Sample policy · Reg 11

Consent to Intimate Examinations and Procedures Policy

Statutory anchor: Regulation 11 (need for consent), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 10 (dignity and respect), Regulation 12 (safe care and treatment), Regulation 13 (safeguarding service users from abuse and improper treatment), and the Mental Capacity Act 2005. · primary source

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Verivius pack version v1, 2026-06-10

1. What the regulation says

Care and treatment of service users must only be provided with the consent of the relevant person. (Reg 11(1): the headline duty)

Regulation 10 adds the dignity-and-respect duty that this policy also operationalises:

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

The full text is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/11 and https://www.legislation.gov.uk/uksi/2014/2936/regulation/10. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

You can only provide care or treatment with the consent of the relevant person. If the service user is 16 or over and lacks capacity, follow the Mental Capacity Act 2005. If Parts 4 or 4A of the Mental Health Act 1983 apply, follow that instead. Section 5 of the MCA (acts done in connection with care or treatment) still applies underneath. For intimate, sensitive or distressing examinations and procedures, this means consent must be valid, informed and voluntary, and the person's dignity, privacy and right to refuse or stop must be protected throughout.

3. Purpose

The purpose of this policy is to make sure that people using [Service Name] give valid, informed and voluntary consent before any intimate examination, intimate procedure or sensitive care is provided.

Intimate examinations and procedures can affect a person's dignity, privacy, bodily autonomy, trust and sense of safety. The service must make sure that people understand what is proposed, why it is needed, what it involves, what alternatives exist, what risks are relevant, and that they may refuse or stop the examination or procedure.

This policy supports Regulation 11 need for consent, Regulation 10 dignity and respect, Regulation 12 safe care and treatment, Regulation 13 safeguarding, the Mental Capacity Act 2005 and relevant professional standards.

Before adoption, the Service must define which examinations, procedures and images fall within its local scope, who may perform them, which staff may act as chaperones, where consent is recorded and how an urgent concern is escalated.

4. Policy warning

An intimate examination or procedure must not take place unless valid consent has been obtained, or there is a lawful basis for proceeding where the person lacks capacity.

Consent must not be assumed because the person attended the appointment, entered the room, undressed, remained silent, did not object, or has had the same procedure before.

The person must be able to pause, refuse or withdraw consent at any time. If consent is withdrawn, or the person appears distressed, resistant or unsure, the examination or procedure must stop unless there is an immediate and lawful emergency reason to continue.

5. Scope

This policy applies to:

It applies to adults, children and young people, and to people who may lack capacity for the decision.

6. Definitions

An intimate examination is any examination of breasts, genitalia, rectum or other intimate areas, or any examination the person may reasonably experience as intimate or sensitive.

An intimate procedure is any procedure involving intimate areas, exposure, touch, photography, instrumentation or intervention that may affect privacy, dignity or bodily autonomy.

Valid consent means consent that is given voluntarily, by a person with capacity for the decision, after receiving enough information in a way they can understand.

A chaperone is a trained person present to support the person, observe the process, protect dignity and provide a safeguard for the person and practitioner.

7. Principles

The service will make sure that:

8. Roles and responsibilities

9. Operational procedure

  1. Prepare before exposure. Confirm the person's identity, clinical purpose, communication needs, privacy arrangements and whether the proposed examination is within the practitioner's competence.
  2. Explain what will happen. Describe why it is needed, which body area will be examined, the steps, likely discomfort, material risks, alternatives and the right to refuse or stop.
  3. Offer a chaperone. Explain the chaperone's role and record whether the person accepts or declines. If a suitable chaperone is requested but unavailable, rearrange unless delay would create a significant clinical risk.
  4. Obtain consent. Check understanding and voluntariness, address questions and complete any decision-specific capacity or safeguarding assessment.
  5. Protect dignity throughout. Keep exposure to the minimum, explain each next step and seek permission before proceeding. Stop if the person asks, withdraws agreement or shows distress or resistance.
  6. Close the interaction safely. Allow the person to dress in privacy, explain findings and next steps, provide safety-netting and document the examination, consent and chaperone decision.
  7. Escalate any exception. Record and report inappropriate conduct, unclear consent, unexpected distress, image-handling concern or a mismatch between the record and what happened.

10. Information before consent

Before asking for consent, the practitioner must explain:

The explanation must be given by a person with enough knowledge to answer questions.

11. Communication needs

The service must support the person to understand the information.

This may include:

Staff must not rely on family members to interpret sensitive information unless this is appropriate, safe and the person agrees.

12. Voluntary consent

Consent must be free from pressure, coercion or manipulation.

Staff must not pressure a person by:

Where the person appears unsure, the practitioner must pause and check understanding and willingness.

13. Right to refuse or stop

The person has the right to refuse an intimate examination or procedure.

The person also has the right to stop once the examination or procedure has started.

If the person refuses or withdraws consent, staff must:

Refusal must not be treated as a behaviour problem.

14. Chaperone offer

A chaperone must be offered where an intimate examination or procedure is proposed, unless the service has a clear and documented reason why the offer is not required for that type of interaction.

The record must show:

The Chaperone Policy must be followed.

15. Children and young people

For children and young people, the practitioner must consider:

If a child or young person refuses, appears distressed or does not understand, the practitioner must stop and reassess unless there is an immediate emergency requiring lawful action.

Any safeguarding concern must be escalated without delay.

16. Adults who may lack capacity

Where there is reason to doubt an adult's capacity to consent to the intimate examination or procedure, the Mental Capacity Act process must be followed.

The record must show:

A person who lacks capacity must still be involved as far as possible. Staff must pay attention to verbal and non-verbal signs of objection, discomfort or distress.

17. Intimate photography and images

Intimate or sensitive images must only be taken where there is a clear clinical, care or governance reason and valid consent has been obtained, unless another lawful basis clearly applies.

The person must be told:

Images must be stored securely and must not be kept on personal devices.

18. Emergencies

In an emergency, treatment may be required where a person cannot give consent and delay would place them at serious risk.

The practitioner must act within the law, professional standards and the person's best interests.

The record must explain:

Emergency action must not be used to justify poor planning for routine intimate examinations or procedures.

19. Recording consent

The record must include:

For higher-risk procedures, written consent may be required. Written consent does not replace the discussion.

20. Concerns and escalation

Staff must escalate immediately where:

Escalation may include incident reporting, safeguarding referral, complaint process, professional-regulator referral, police contact or CQC notification consideration.

The concern is entered in the appropriate incident, safeguarding or complaints register on the same working day. Any corrective work is recorded in the improvement action plan with an owner, due date and evidence required for closure. Serious or repeated concerns are reviewed by the Registered Manager without waiting for the routine governance meeting.

21. Staff training

Staff involved in intimate examinations or procedures must receive training appropriate to their role on:

Training must be recorded.

22. Audit

The Registered Manager audits 10 consent records each quarter, or all records if fewer than 10 intimate examinations or procedures occurred. The sample includes a range of practitioners and, where available, one declined chaperone, one image, one capacity or communication adjustment and one refusal or stopped procedure.

The audit must check:

Findings must be actioned through governance with an owner, due date and closure evidence. A concern about consent, conduct, safeguarding or image security is escalated immediately. A follow-up sample must show whether the change worked.

23. Related policies

This policy should be read with:

24. Review

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

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
v1.1 2026-07-19 Verivius (sample) Added local adoption prompts, named roles, the operating procedure, register links and quarterly audit sampling.
v1 2026-06-10 Verivius (sample) Initial sample template, conformed to the Verivius policy standard.

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 the point where clinical need and a person's bodily autonomy meet most directly, and it happens when the person is undressed, often alone with a practitioner, and least placed to object. The specific risk here is not that consent is refused, it is that consent is inferred: the person attended, they undressed, they said nothing, the examination proceeded and the record captured only that it was done. That silence is exactly what a person who is frightened, in pain, without the language or communication support they need, or under pressure from somebody else will produce, and it is also what a practitioner crossing a professional boundary relies on. A record that shows what was explained, that a chaperone was offered, that the person was told they could stop, and that somebody noticed and acted when they flinched or went quiet, is what separates a service where people feel safe from one where they simply comply. It is also the trail that protects a practitioner when an allegation is raised months later, and the only way a Registered Manager sees a pattern forming while it is still a consent problem rather than a safeguarding investigation.

  1. Consent is recorded and valid, not inferred from attendance or silence. The record shows the information given, the person's questions and the consent obtained, and treats consent as valid rather than assumed because the person attended, undressed, stayed silent or had the same procedure before.

    Strong evidence: The consent record showing information given, questions asked, consent given, the name and role of the practitioner and the date and time (section 19), against the warning in section 4 that consent must not be assumed; Reg 11(1) requires that care and treatment 'must only be provided with the consent of the relevant person'.

    Weak evidence: The entry reads "consent obtained" or a single ticked box, with nothing showing what was explained, which body area was involved, what the person asked or that they were told they could stop at any point. Records that read word for word the same across every practitioner and every person, or that lean on the person having had the same examination before, evidence a routine being documented rather than a conversation being had.

    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); reg 17(2)(c)

  2. Withdrawal of consent stops the examination. The person's right to pause, refuse or stop is explained and honoured, and the examination stops when consent is withdrawn or distress, resistance or uncertainty appears, rather than being carried through to completion.

    Strong evidence: The record of consent refused or withdrawn and of any distress, objection or concern (section 19), with the procedure stopped unless there was an immediate and lawful emergency reason to continue (sections 4 and 13).

    Weak evidence: Across the whole sample nobody has ever paused, hesitated, refused or stopped, which in a service carrying out these examinations routinely is not credible and usually means only completed procedures get written up. Where distress does appear it is recorded as the person being anxious or uncooperative, the examination is still logged as completed, and nothing shows the person was asked whether to carry on.

    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), with the exceptions in reg 11(3)-(4)

  3. Where capacity is in doubt, the Mental Capacity Act process is decision-specific and on the record. A capacity assessment is done for that specific decision, with a best-interests decision, less-restrictive options, a necessity check and attention to verbal and non-verbal objection, rather than a blanket assumption of capacity or a best-interests shortcut.

    Strong evidence: The Mental Capacity Act record showing the specific decision, capacity assessment, who was consulted, best-interests decision, less restrictive options considered, whether the examination is necessary and whether the person objects or appears distressed (section 16).

    Weak evidence: A general note that the person lacks capacity, or a diagnosis of dementia or a learning disability standing in for an assessment, carried forward from a decision made months earlier and applied to this examination. Nothing records how the person was supported to make the decision themselves before capacity was doubted. Best-interests entries that name nobody consulted, weigh no less restrictive option and never say whether the examination was necessary now, with no record of whether the person pulled away, tensed, went quiet or said no while it was happening.

    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 ss.1(3), 1(6), 2(1) and 4 (incl. s.4(4), s.4(6)); HSCA 2008 (Regulated Activities) Regulations 2014, reg 11(3)

  4. Intimate images rest on specific consent and are stored securely off personal devices. Any image has a clear clinical, care or governance reason and valid consent covering storage, access, sharing and retention, and images are held securely and never on personal devices.

    Strong evidence: The consent record for the image covering why it is needed, what is photographed, who takes it, where it is stored, who may see it, whether it may be shared and how long it is kept (section 17), and the storage arrangement showing images are not kept on personal devices.

    Weak evidence: Consent for the image is folded into the general treatment consent, so nothing shows the person was told where it would be stored, who could see it, whether it might be shared or how long it would be kept. The common failure is an image taken on a staff member's own phone and moved to the record later: there is no evidence the copy on the device was deleted, and nobody can say today where every copy of that photograph is.

    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.

  5. Consent concerns are logged promptly and acted on, not left to the next meeting. An unclear-consent, distress, image-handling or record-mismatch concern is entered in the incident, safeguarding or complaints register and given a corrective action with an owner and due date, and serious or repeated concerns are reviewed by the Registered Manager without waiting for routine governance.

    Strong evidence: The incident, safeguarding or complaints register entry with corrective work recorded in the improvement action plan carrying an owner, due date and closure evidence (section 20).

    Weak evidence: The concern first appears in the minutes of a governance meeting weeks after the event, with no register entry carrying the date it was raised, so the delay itself is invisible. Actions written as "staff reminded" or "discussed at team meeting", with no named owner, no due date and nothing showing what closed them. Entering the concern on the same working day is a Verivius default rather than a statutory deadline, but a gap of weeks between the event and any written trace tells you the escalation route is not actually being used.

    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. The consent audit deliberately samples the hard cases and checks the change worked, rather than pulling only clean records. The audit is sampled across practitioners including a declined chaperone, an image, a capacity or communication adjustment and a refused or stopped procedure, plus a follow-up sample showing whether corrective action held.

    Strong evidence: The quarterly audit of consent records (10 per quarter, or all if fewer than 10 intimate examinations or procedures occurred) with the specified sample, checking consent recorded, risks and alternatives explained, chaperone offered, refusal or withdrawal respected, capacity considered, best-interests records complete and images handled correctly, followed by a repeat sample (section 22).

    Weak evidence: The sample is the first ten records in date order, every one a straightforward examination where a chaperone was offered and accepted, so it is a sample that cannot fail. No declined chaperone, no image, no capacity or communication adjustment, no refused or stopped procedure, and often the same two practitioners throughout. The audit closes with a percentage score and no repeat sample, so nothing shows whether last quarter's corrective action changed anything at the point of care.

    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.

Related

Last verified 20 July 2026

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Last reviewed 10 June 2026