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.

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. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. Recording consent

The record must include:

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

18. 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.

19. Staff training

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

Training must be recorded.

20. Audit

The Registered Manager must audit consent records for intimate examinations and procedures at least annually, or more often where the service frequently undertakes this work.

The audit must check:

Findings must be actioned through governance.

21. Related policies

This policy should be read with:

22. 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.

23. 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.

24. 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.

25. Document control

Version Date Author Changes
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 tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

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Last reviewed 10 June 2026