Sample policy · Reg 10

Chaperone Policy

Statutory anchor: Regulation 10 (dignity and respect), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 11 (need for consent), Regulation 12 (safe care and treatment), Regulation 13 (safeguarding service users from abuse and improper treatment), and Regulation 17 (good governance). · primary source

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Verivius pack version v1.1, 2026-07-19

1. What the regulation says

Service users must be treated with dignity and respect. (Regulation 10(1))

...having due regard to any relevant protected characteristics (as defined in section 149(7) of the Equality Act 2010) of the service user. (Regulation 10(2)(c))

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/10. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

Service users must be treated with dignity and respect. In particular, you have to protect their privacy, support their autonomy, independence and involvement in the community, and have due regard to any relevant protected characteristics under the Equality Act 2010. For intimate, sensitive or distressing examinations and procedures, offering, recording and properly using a chaperone is one of the clearest ways a service protects dignity and privacy, evidences valid consent, and keeps both the person and the practitioner safe.

3. Purpose

The purpose of this policy is to protect the dignity, privacy, safety and rights of people using [Service Name] during intimate, sensitive or potentially distressing examinations, procedures or care.

A chaperone is not a formality. A chaperone helps support the person, protects dignity, provides reassurance, witnesses the process, and supports safe professional practice.

This policy supports Regulation 10 dignity and respect, Regulation 11 consent, Regulation 12 safe care and treatment, Regulation 13 safeguarding, Regulation 17 good governance and professional standards.

4. Policy warning

An intimate examination or procedure must not take place unless the person has given valid consent and has been offered a chaperone where appropriate.

Refusal of a chaperone must be respected, but the practitioner must consider whether it is safe and appropriate to proceed.

A family member or friend may support the person if the person wishes, but they should not normally replace a trained chaperone where a chaperone is clinically or professionally required.

5. Scope

This policy applies to:

It applies regardless of the sex, gender, age or background of the person using the service.

Local adoption decisions

Before adoption, the provider defines:

6. Definitions

A chaperone is a trained person who is present during an examination, procedure or care episode to support the person, observe the process, help maintain dignity and provide a safeguard for the person and practitioner.

An intimate examination includes examination of breasts, genitalia, rectum or other intimate areas, and any examination that the person may reasonably experience as intimate, embarrassing, intrusive or distressing.

A support person is someone chosen by the person using the service, such as a relative, friend, advocate or carer. A support person is not automatically a trained chaperone.

7. Principles

The service will ensure that:

Chaperone operating procedure

  1. Plan the appointment. The booking or clinical team identifies whether the examination may be intimate or sensitive and arranges a trained chaperone where one is likely to be needed.
  2. Explain and offer. Before consent, the practitioner explains the examination and the chaperone's role in a way the person can understand, then records the person's decision.
  3. Confirm the safeguard. The practitioner confirms the chaperone's identity, training and role. A support person may also attend if the person wishes, but does not replace a required trained chaperone.
  4. Conduct and observe. The practitioner protects privacy, explains each step and stops if consent is withdrawn. The chaperone remains able to observe the examination and challenge concerns.
  5. Record. The clinical or care record is completed at the time, including the offer, acceptance or refusal, chaperone identity, consent and any departure from the usual procedure.
  6. Escalate. Any distress, objection, unexpected conduct or safeguarding concern is acted on immediately and linked to the appropriate incident, safeguarding or complaint record.

8. When a chaperone must be offered

A chaperone must be offered for:

The offer must be made in a way that the person can understand.

9. Consent

Before an intimate examination or procedure, the practitioner must explain:

Consent must be voluntary, informed and specific to the examination or procedure.

If the person lacks capacity for the decision, the Mental Capacity Act process must be followed and the least restrictive option considered.

10. Refusal of chaperone

If the person declines a chaperone, the practitioner must record the offer and refusal.

The practitioner must consider whether to proceed. Factors to consider include:

If the practitioner believes it is not safe or appropriate to proceed without a chaperone, they should explain this to the person and arrange an alternative unless urgent clinical need requires immediate action.

11. Request for a specific chaperone

The service will try to meet reasonable requests for a chaperone of a particular sex or gender where possible.

Where this cannot be arranged immediately, the person should be offered the option to wait or rebook where clinically safe.

The service must not discriminate or make assumptions about who needs a chaperone.

12. Children and young people

Children and young people must be offered privacy, dignity and appropriate support.

Where intimate examination or procedure is needed, the practitioner must consider:

A parent or carer may support the child or young person, but the practitioner must consider whether a trained chaperone is also needed.

Any safeguarding concern must be escalated immediately.

13. Adults who may lack capacity

Where an adult may lack capacity to consent to the examination or procedure, the practitioner must follow the Mental Capacity Act. The record must show:

If the person objects or appears distressed, the practitioner must stop and reassess unless there is an immediate serious risk that requires urgent action.

14. Intimate examinations under sedation or anaesthesia

Where an intimate examination or procedure may take place while the person is sedated, anaesthetised or otherwise unable to give or confirm consent at the time, the practitioner must make sure that valid consent has been obtained beforehand for all relevant aspects of the examination or procedure.

The record must show what was explained, what was agreed, whether a chaperone was required or present, and any limits placed by the person.

An intimate examination must not be carried out for teaching, training or assessment purposes unless this has been specifically explained and the person has given explicit consent, recorded in writing or clearly documented in the clinical record.

The person's privacy and dignity must be protected even when they are sedated, anaesthetised or unable to participate actively.

15. Role of the chaperone

The chaperone must:

The chaperone must not simply wait outside the room or act as an unrelated assistant.

16. Who may act as chaperone

A chaperone should normally be a trained member of staff. The chaperone must:

A family member, friend or interpreter may support the person, but should not normally replace a trained chaperone.

17. Privacy and dignity

The practitioner and chaperone must protect privacy and dignity by:

18. Recording

The clinical or care record must show:

The record must be factual and contemporaneous.

19. Concerns during or after examination

If the chaperone, practitioner, person using the service, family member or staff member has concerns about the conduct or appropriateness of an examination, they must raise this immediately. Concerns may require:

The service must not dismiss concerns because a chaperone was present.

The concern is entered in the incident register and cross-linked to any safeguarding, complaint, professional-conduct or police record. The decision to refer or not refer, immediate protection and follow-up owner must be recorded.

20. Chaperone training

Staff acting as chaperones must receive training covering:

Training must be recorded and refreshed at intervals set by the service.

21. Availability of chaperones

The service must plan for chaperone availability.

Where intimate examinations or procedures are part of routine service delivery, the rota or appointment system must ensure that a trained chaperone is available.

If a chaperone is not available and the examination is not urgent, the person should be offered the option to wait or rebook. Where the examination is urgent, the practitioner must record why it proceeded and what safeguards were used.

22. Audit

The Registered Manager must audit chaperone records at least annually, or more often where the service frequently undertakes intimate examinations or procedures. The audit must check:

Findings must be recorded in the audit register. Corrective actions are assigned in the improvement-actions register, repeated risks are linked to the risk register, and training gaps are linked to the training matrix.

23. Related policies in this pack

This policy should be read with:

24. Review

This policy will be reviewed annually, or sooner following a complaint, safeguarding concern, incident, CQC finding, professional-regulatory concern, change in clinical practice, or change in legal or professional guidance.

25. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

26. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

27. Document control

Version Date Author Changes
v1 2026-06-10 Verivius (sample) Initial sample template, conformed to the Verivius policy standard.
v1.1 2026-07-19 Verivius (sample) Added the appointment-to-escalation operating procedure, local adoption decisions and links from concerns and audit findings to the provider's governance registers.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the provider's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

An intimate examination is one of the very few moments in care where a person is undressed, alone with a practitioner and least equipped to object, and the chaperone is often the only independent person who will ever see what happened. That makes this policy unusual: the safeguard is a human being in the room, and it fails silently. A chaperone who waits outside the curtain, who has never been trained to watch for distress, or who is too junior to say "stop" leaves a record that looks complete while the person was in fact on their own. People carrying a history of trauma, those who asked for a chaperone of a particular sex, and those with a communication difficulty feel that failure first, and they rarely complain about it at the time. The risk runs both ways, because the same contemporaneous note is the only account the practitioner will have if an allegation is made months later, and the only account the person will have if something did go wrong. Getting this right decides whether someone felt safe enough to say what was actually wrong with them and to come back next time, which is why the offer, the decision and the chaperone's name matter more than the neatness of the form.

  1. The chaperone offer and the person's decision are recorded at the time, not reconstructed afterwards. The clinical or care record shows the offer, acceptance or refusal, and the chaperone's name and role contemporaneously, so a colleague reading it later can see who was in the room and what was agreed, not a blank field or a note added later.

    Strong evidence: The contemporaneous clinical or care record showing that a chaperone was offered, accepted or declined, the name and role of the chaperone if present, and the reason if the examination proceeded without a chaperone where one would normally be expected (sections 7 step 5, and 18).

    Weak evidence: The record carries a pre-printed "chaperone offered" tick box with nothing beside it, or a free-text line reading "chaperone present" with no name and no role, so nobody can say afterwards who was in the room. Weaker still is a clinic where the chaperone fields are completed in a batch at the end of the session, or where the entry only appears once a concern has been raised and the notes are revisited. Where an examination went ahead without a chaperone that would normally be expected, no reason is written down at all.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  2. The chaperone was trained and actually able to observe and challenge, not a bystander outside the room. The recorded chaperone had completed chaperone training, understood safeguarding escalation and stayed present for the relevant part, able to raise concerns, not an untrained assistant who waited outside or felt unable to speak up.

    Strong evidence: Chaperone training records (section 20) against the role expectations in sections 15 and 16, including no conflict of interest and not being under pressure to remain silent.

    Weak evidence: The training evidence is an attendance signature for a general induction morning that listed chaperoning as one bullet among twelve, with nothing showing the person understood the observing and challenging part of the role. In practice the named chaperone had no chaperone training on file, or was an agency member of staff nobody had briefed, or stood on the other side of the curtain rather than where they could see what was happening, and a junior colleague said afterwards that they would not have felt able to question the practitioner. The training record also shows no refresher interval set for the role.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  3. Valid consent was obtained and the right to stop was real. The person was told what would happen, who would be present, the chaperone's role and their right to decline the chaperone or stop the examination, and the practitioner stopped when consent was withdrawn or distress appeared.

    Strong evidence: The record of the explanation and consent, and of any distress, objection or pause (sections 9 and 18), with the examination stopped on withdrawal unless an immediate serious risk required urgent action.

    Weak evidence: Consent appears as the single word "consented", or as a template phrase that fires automatically when the examination code is entered, with no trace of what was explained, who would be present or that the person was told they could decline the chaperone and stop at any point. The give-away is a record that describes the clinical findings in detail and the conversation before them in five words, and no entry at all where the person hesitated, flinched or asked to pause.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 11(1) and (2)

  4. Where capacity is in doubt, the Mental Capacity Act process is on the record, not assumed away. An adult who may lack capacity for the decision has a decision-specific capacity assessment, a best-interests decision, a least-restrictive consideration and an assessment of distress or objection, not an inference of consent because the person did not resist.

    Strong evidence: The Mental Capacity Act record showing the decision being considered, the capacity assessment, people consulted, the best-interests decision, the least restrictive option and whether a chaperone was present (section 13).

    Weak evidence: The file carries a blanket "lacks capacity" flag from an assessment done months earlier for a different decision, rather than a capacity assessment for this examination on this day, and nothing shows what was done to help the person decide for themselves first. The best-interests section names nobody consulted, records no less restrictive alternative such as deferring or using a different position or approach, and treats the fact that the person did not pull away as if it were agreement.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Mental Capacity Act 2005 s.2(1), s.1(6) and s.4; reinforced by Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 11(3)

  5. A concern about an examination is acted on even when a chaperone was present. A concern raised by the chaperone, practitioner, person or a relative is escalated and recorded, not dismissed on the grounds that a chaperone was in the room.

    Strong evidence: The incident register entry cross-linked to any safeguarding, complaint, professional-conduct or police record, with the decision to refer or not refer, immediate protection and follow-up owner recorded (section 19).

    Weak evidence: The concern was handled as a quiet word with the practitioner and never reached the incident register, so there is no record of what was said, who decided what, what immediate protection was put in place, or whether a safeguarding referral to the local authority and a referral to the practitioner's professional regulator were each considered and ruled out. A common pattern is a note closing the matter with "a chaperone was present throughout", treating the chaperone's presence as the answer rather than asking the chaperone what they saw.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  6. Intimate examinations under sedation, or for teaching, rest on explicit prior consent. Valid consent was obtained beforehand for all relevant aspects where the person could not confirm it at the time, and any examination for teaching, training or assessment had specific, explicitly recorded consent.

    Strong evidence: The record showing what was explained and agreed before sedation or anaesthesia, whether a chaperone was required or present, and explicit written or clearly documented consent for any teaching, training or assessment examination (section 14).

    Weak evidence: The consent form covers the main procedure and says nothing specific about the intimate examination carried out while the person was sedated, so nobody can show it was explained and agreed before the person lost the ability to confirm it, and no limits the person set are written down. Teaching evidence is thinner again: the record says "student present" or "trainee assisted", with no separate, explicit consent to being examined for teaching, training or assessment.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

Related

Last verified 20 July 2026

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Last reviewed 19 July 2026