Chaperones and intimate examinations policy (sexual health)

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))

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

Regulation 13 adds the safeguarding duty this policy supports:

Service users must be protected from abuse and improper treatment in accordance with this regulation. (Regulation 13(1))

any behaviour towards a service user that is an offence under the Sexual Offences Act 2003, (Regulation 13(6)(a))

Regulation 17 requires the governance and records that evidence this policy:

Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part. (Regulation 17(1))

The full text of these regulations is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/10, https://www.legislation.gov.uk/uksi/2014/2936/regulation/11, https://www.legislation.gov.uk/uksi/2014/2936/regulation/13 and https://www.legislation.gov.uk/uksi/2014/2936/regulation/17. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

Service users must be treated with dignity and respect, including protecting their privacy and having due regard to their protected characteristics. Care and treatment may only be provided with the consent of the relevant person. For intimate examinations this means explaining the examination, gaining and recording consent, offering a chaperone every time, protecting the patient's dignity and privacy, and stopping if the patient asks. Doing this well protects both the patient and the clinician, and the records show that the patient's dignity and choice were respected.

3. Purpose

Sexual health care involves intimate examinations. Done well, with consent, dignity and the offer of a chaperone, they are safe and respectful and protect both the patient and the clinician. This policy sets out how the Service carries out intimate examinations and offers chaperones.

The Service must verify this policy against current GMC guidance on intimate examinations and chaperones before adoption.

4. Scope

This policy applies to:

• every intimate examination the Service carries out
• the offer and use of chaperones
• the clinicians who examine and the staff who act as chaperones

5. Explaining and consenting before the examination

Before any intimate examination the clinician:

• explains why the examination is needed, what it involves and what the patient will feel
• gains the patient's consent and records it
• stops if the patient asks to stop, at any point

The examination is limited to what is clinically necessary.

Where the patient is under 18, the clinician assesses Gillick competence and, for advice and treatment, applies the Fraser guidelines, and follows the local safeguarding children procedures and Working Together to Safeguard Children 2026. Where an adult may lack capacity to consent, the clinician follows the Mental Capacity Act 2005.

6. Offering a chaperone

• a chaperone is offered for every intimate examination, regardless of the genders of the patient and clinician
• the offer, and whether the patient accepts or declines, is recorded, along with the name of the chaperone where one is present
• a chaperone is an impartial person, trained for the role, whose job is to support and reassure the patient and to observe the examination; a family member or friend is not a substitute for a trained chaperone, though the patient may also wish them present
• where the patient declines a chaperone but the clinician feels one is needed, the clinician explains why and may decline to proceed without one, offering to rearrange

7. Dignity and privacy

• the patient undresses and dresses in private, and is kept covered as much as possible, exposing only the area being examined
• the examination takes place in a private space free from interruption
• the patient's cultural, religious and personal preferences are respected, including a request for a clinician or chaperone of a particular gender where that can be met

8. Protecting patient and clinician

The offer of a chaperone, the explanation and consent, and a respectful technique protect the patient from harm and the clinician from misunderstanding. Where a concern about conduct arises, on either side, it is recorded and raised through the Service's safeguarding and incident routes.

9. Recording

For every intimate examination the Service records: the consent, the chaperone offer and the patient's choice, the chaperone's name where present, and the examination findings. The record shows the patient's dignity and choice were respected.

Operational controls to adapt

Roles and responsibilities

• Registered Manager: owns this policy, confirms there is enough trained chaperone cover, and reviews intimate-examination complaints, incidents and audit findings.
• Examining clinician: explains the examination, confirms consent, offers a chaperone, preserves dignity, stops if the patient asks, and records the chaperone decision.
• Trained chaperone: supports the patient, observes the examination, understands how to raise a concern, and does not act as a clinical assistant unless separately trained for that task.
• Reception or booking staff: give neutral information about the chaperone offer, book a suitable appointment where a chaperone is needed, and protect confidentiality in waiting and call areas.
• Safeguarding lead: advises where age, capacity, coercion, alleged misconduct or a distressed patient creates a safeguarding question.

Intimate-examination procedure

1. Confirm the clinical need. The clinician records why the intimate examination is necessary and whether a less intrusive option was considered.
2. Explain before starting. The patient is told what will happen, what clothing needs to be removed, what they may feel, who will be present and that they can stop at any time.
3. Offer a trained chaperone. The offer is made for every intimate examination. The patient's acceptance or refusal is recorded before the examination begins.
4. Check consent and capacity. Under-18s, adults who may lack capacity, patients with communication needs and patients who appear distressed or coerced receive the extra checks set out in the linked policies.
5. Protect privacy. The patient undresses and dresses in private, is covered as much as possible, and is not interrupted during the examination.
6. Pause if anything changes. The examination stops if the patient withdraws consent, becomes distressed, asks a question that changes their decision, or if the chaperone or clinician has a concern.
7. Record the outcome. The record includes the chaperone offer, the patient's decision, the chaperone's name and role where present, and any refusal, deferral, safeguarding concern or conduct concern.
8. Escalate concerns. Alleged misconduct, unexplained distress, coercion, under-18 safeguarding concerns, capacity concerns, and chaperone availability failures are opened on the relevant register.

Records and register links

The intimate-examination record should include:

• clinical reason for the examination and the body area examined
• explanation given, consent obtained and whether consent was withdrawn or limited
• chaperone offer, patient choice, chaperone name and chaperone role or training status
• any same-gender clinician or chaperone request and whether it was met
• privacy steps taken, including curtains, covering, interruptions avoided and support person present if relevant
• under-18, safeguarding, capacity, interpreter or accessible-information checks where relevant
• reason for deferring or declining to proceed where a chaperone was unavailable or the clinician considered one necessary
• incident, complaint, safeguarding, risk or improvement-action reference where the control failed

Chaperone refusals do not automatically create an incident. A missing offer, missing record, conduct concern, safeguarding concern or repeated chaperone availability gap does.

10. Training

Clinicians are trained in carrying out intimate examinations respectfully, and chaperones are trained for the role, both refreshed on a stated cadence. The Service records who is trained and the next refresher date.

11. Audit cadence

The Service checks, on a stated cadence, that:

• intimate examinations were explained and consented, and the consent recorded
• a chaperone was offered every time, with the offer, the patient's choice and the chaperone's name recorded
• dignity and privacy, and patients' gender and cultural preferences, were respected
• chaperones are trained and conduct concerns were raised and acted on

The Registered Manager and the clinical lead review the results and record the improvement actions that follow.

12. 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.

• GMC, guidance on intimate examinations and chaperones: https://www.gmc-uk.org/
• Royal College of Nursing, chaperoning guidance: https://www.rcn.org.uk/
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 10 (dignity and respect) and Regulation 12 (safe care and treatment): https://www.legislation.gov.uk/uksi/2014/2936/regulation/10
• CQC Regulation 10: Dignity and respect
• CQC Regulation 11: Need for consent
• CQC Regulation 13: Safeguarding service users from abuse and improper treatment
• CQC Regulation 17: Good governance
• Safeguarding adults and children procedures, including local Safeguarding Children Partnership procedures, Working Together to Safeguard Children 2026, Fraser guidelines and Gillick competence
• Mental Capacity Act 2005, where an adult may lack capacity to consent

Related reading

• Related policy: Chaperone policy
• Related policy: Consent to intimate examinations and procedures policy
• Related policy: Dignity, privacy and respect policy
• Related policy: Under-18s and safeguarding policy

13. 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.

14. Document control

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.