Sample policy · Sexual health

Chaperones and intimate examinations policy (sexual health)

Statutory anchor: Regulation 10 (dignity and respect) and Regulation 11 (need for consent), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 13 (safeguarding from abuse and improper treatment) and Regulation 17 (good governance). The professional primary for intimate examinations and chaperones is the GMC guidance on intimate examinations and chaperones. · primary source

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:

5. Explaining and consenting before the examination

Before any intimate examination the clinician:

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

7. Dignity and privacy

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

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:

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:

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.

Related reading

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

Version Date Author Changes
v1.1 2026-07-14 Verivius (sample) Added role ownership, intimate-examination procedure, record fields, register links and related reading.
v1 2026-06-10 Verivius (sample) Conformed to the Verivius policy standard: added statutory anchor, verbatim regulation quotes, plain-English summary, and the standard sources and document-control blocks, additively over the original draft.

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.

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 moment a sexual health service asks the most of a patient's trust: often someone attending alone, anxious about a result, partly undressed and not well placed to object. The specific risk here is that the chaperone offer becomes a habit spoken aloud rather than a recorded choice, so nothing survives to show the patient was given control over who was in the room and told they could stop. That matters for care long before it matters for inspection. This is the room in which coercion by a partner, exploitation of someone under 18, or a cultural or gender preference quietly going unmet is most likely to first show itself, and a record that captures only findings lets all three pass unnoticed. A well-run service treats the offer, the patient's answer, the chaperone's name and training status, and the privacy steps taken as part of the clinical record rather than as administration around it. Done that way the record protects the patient's dignity and the clinician's position equally, and gives the Registered Manager something real to audit when a concern surfaces months after the appointment.

  1. A chaperone is offered for every intimate examination and the patient's acceptance or refusal is recorded before the examination begins, with the chaperone's name where one was present. The failure that matters is an intimate examination carried out with no record the offer was ever made, so nobody can later say whether the patient was given the choice or who was in the room with them.

    Strong evidence: The intimate-examination record: chaperone offer, patient's choice, chaperone name and role or training status, tested against the audit that a chaperone was offered every time with offer, choice and name recorded; a missing offer or missing record is itself logged as an incident (section 6, procedure step 3, Records and register links, Audit cadence).

    Weak evidence: The clinical note describes the examination findings in detail but says nothing at all about a chaperone, or carries a pre-filled template line such as "chaperone offered" that appears identically on every record, including those from sessions when no chaperone was available. Weak too where the offer is recorded but the patient's actual answer is not, or where a chaperone was present and the record names no one, so months later nobody can say who was in the room.

    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. Consent is explained and recorded, the clinical reason for the examination is documented, and the examination is limited to what is clinically necessary, with the patient able to stop at any point. The failure that matters is consent assumed rather than recorded, or an examination going beyond what the note justifies.

    Strong evidence: The record: clinical reason and body area examined, explanation given, consent obtained and whether it was withdrawn or limited (section 5, procedure steps 1 to 2 and 6, Recording, Records and register links).

    Weak evidence: Consent appears only as the single word "consented" or a tick, with no record of what the patient was told, no clinical reason for the examination and no note that a less intrusive option was considered. Weak too where the findings describe a body area wider than anything the stated reason justifies, or where a patient became distressed mid-examination and the record runs on as though nothing changed, showing no evidence the patient knew they could stop.

    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 reg 17(2)(c) for the record)

  3. The chaperone is an impartial person trained for the role, not a family member or friend standing in, and chaperone training is current. The failure that matters is an untrained person, or a relative, recorded as the chaperone, which leaves the patient without the independent presence the offer was meant to give them.

    Strong evidence: The chaperone role or training-status field on the record, and the training record showing who is trained with the next refresher date (section 6, section 10, Records and register links, Audit cadence).

    Weak evidence: The chaperone field holds a first name only, with no role and no training status, so the person cannot be matched to the training record. Weak too where the named chaperone turns out to be the patient's partner, parent or friend who was already in the room, or where the training record shows a cohort trained once at induction with refresher dates long past and no plan to bring them back.

    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.

  4. Dignity and privacy are protected, and any request for a clinician or chaperone of a particular gender, or a cultural or religious preference, is recorded along with whether it was met. The failure that matters is a preference that went unrecorded, or unmet with no explanation given to the patient.

    Strong evidence: The record: privacy steps taken (covering, interruptions avoided, support person present where relevant), and any same-gender clinician or chaperone request and whether it was met (section 7, Records and register links, Audit cadence).

    Weak evidence: Privacy is asserted in a policy paragraph but never appears in a single record: no note of covering, of the patient dressing and undressing in private, or of the room being kept free from interruption. Weak too where a request for a clinician or chaperone of a particular gender was made at the desk and never reached the record, or where the record shows the request was not met but gives no reason and no offer to rearrange, so the answer reads as a shrug.

    What the regulator expects to see. Not a law in itself, but CQC judges you against it, so an inspector will look for it and expect a reason where you depart from it.

  5. An alleged conduct concern, unexplained distress or coercion noticed during an intimate examination is recorded and raised through the service's own safeguarding and incident routes, not left in the clinical note alone. The failure that matters is a concern that never leaves the consulting room.

    Strong evidence: The record and register entry: conduct or safeguarding concern reference where the control failed, and the escalation of alleged misconduct, coercion or under-18 concerns onto the relevant register (section 8, procedure step 8, Records and register links).

    Weak evidence: A note reading "patient upset, reassured" or "partner insisted on being present throughout" that sits in the clinical record and appears on no register, with no safeguarding lead consulted and no incident opened. Weak too where a concern was raised verbally to a colleague and remembered by both, but there is no dated entry, no decision about whether a local authority safeguarding referral was due, and no record of what happened next.

    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 13(2) and reg 13(3)

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Last verified 20 July 2026

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Last reviewed 10 June 2026