Version: 1
Review date: 01/11/2022
Edited by: Steph Nicholson
Approved by: Steph Nicholson
Comments: N/A
The purpose of this document is to ensure conformity in order to achieve a common standard of medical practice. This is achieved by enabling the patient to have a chaperone present during the consultation and clinical examination of the patient. Medical examinations can, at times, be perceived as intrusive by the patient so having a chaperone present protects both the patient and staff member.
This document and any procedures contained within it are non-contractual and may be modified or withdrawn at any time. For the avoidance of doubt, it does not form part of your contract of employment.
The Care Quality Commission (CQC) would expect any primary care organisation to have a policy to support this process and this should be used as evidence of compliance against the CQC Key Lines of Enquiry (KLOE).
Specifically, Lamberhurst Surgery will need to answer the CQC Key Questions on “Safe”, “Effective”, “Caring” and “Responsive”.
The following is the CQC definition of Safe:
By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse.
CQC KLOE S1
How do systems, processes and practices keep people safe and safeguarded from abuse?
S1.2
How do systems, processes and practices protect people from abuse, neglect, harassment and breaches of their dignity and respect? How are these monitored and improved?
S1.4
How is safety promoted in recruitment practice, arrangements to support staff, disciplinary procedures,
and ongoing checks?
(For example, Disclosure and Barring Service checks.)
S1.5
Do staff receive effective training in safety systems, processes and practices?
The following is the CQC definition of Effective:
By effective, we mean that people’s care, treatment and support achieve good outcomes, promote a good quality of life and are based on the best available evidence.
CQC KLOE E1
Are people’s needs assessed and care and treatment delivered in line with current legislation, standards and evidence-based guidance to achieve effective outcomes?
E1.4
Are the rights of people subject to the Mental Health Act 1983 (MHA) protected and do staff have regard to the MHA Code of Practice?
CQC KLOE E6
Is consent to care and treatment always sought in line with legislation and guidance?
E6.5
When people lack the mental capacity to make a decision, do staff ensure that best interests’ decisions
are made in accordance with legislation?
The following is the CQC definition of Caring:
By caring, we mean that the service involves and treats people with compassion, kindness, dignity and respect.
CQC KLOE C1
How does the service ensure that people are treated with kindness, respect and compassion and that they are given emotional support when needed?
C1.1
Do staff understand and respect the personal, cultural, social and religious needs of people and how these may relate to care needs and do they take these into account in the way they deliver services?
Is this information recorded and shared with other services or providers?
C1.5
Do staff understand the impact that a person’s care, treatment or condition will have on their wellbeing and on those close to them, both emotionally and socially?
CQC KLOE C2
How does the service support people to express their views and be actively involved in making decisions about their care, treatment and support as far as possible?
C2.1
Do staff communicate with people so that they understand their care, treatment and condition and any
advice given?
C2.2
Do staff seek accessible ways to communicate with people when their protected equality or other characteristics make this necessary?
CQC KLOE C3
How are people’s privacy and dignity respected and promoted?
C3.1
How does the service and staff make sure that people’s privacy and dignity needs are understood and always respected, including during physical or intimate care and examinations?
The following is the CQC definition of responsive:
By responsive, we mean that services meet people’s needs.
CQC KLOE R1
How do people receive personalised care that is responsive to their needs?
R1.3
Are the facilities and premises appropriate for the services that are delivered?
[Insert organisation name] will provide guidance and support to help those to whom it applies to understand their rights and responsibilities under this policy. Additional support will be provided to managers and supervisors to enable them to deal more effectively with matters arising from this policy.
Chaperone awareness training is available on blue stream
This document applies to all employees of the organisation and other individuals performing functions in relation to the organisation, such as agency workers, locums and contractors.
Furthermore, it applies to clinicians who may or may not be employed by the organisation but who are working under the Additional Roles Reimbursement Scheme (ARRS).
It is a requirement that, where necessary, chaperones are provided to protect and safeguard both patients and clinicians during intimate examinations and or procedures.
All clinical staff may at some point be asked to act as a chaperone at Lamberhurst Surgery. Therefore, it is essential that clinical personnel are fully trained and aware of their individual responsibilities when performing chaperone duties.
The organisation aims to design and implement policies and procedures that meet the diverse needs of our service and workforce, ensuring that none are placed at a disadvantage over others, in accordance with the Equality Act 2010. Consideration has been given to the impact this policy might have with regard to the individual protected characteristics of those to whom it applies.
A chaperone can be defined as ‘an independent person, appropriately trained, whose role is to observe independently the examination/procedure undertaken by the doctor/health professional to assist the appropriate doctor-patient relationship’.
The term implies that the person may be a healthcare professional. However, it can also mean a specifically trained non-clinical staff member.
At Lamberhurst Surgery, a chaperone poster is clearly displayed in the waiting area, in all clinical areas and annotated in the practice leaflet as well as on the practice website.
All patients should routinely be offered a chaperone, ideally at the time of booking the appointment and the importance of a chaperone should not be underestimated or understated.
A chaperone poster is available at Annex A
It is policy that any member of the practice team can act as a chaperone provided that they have undertaken appropriate chaperone training. If a chaperone is not available, the examination should be postponed until a suitable chaperone is present.
Patients must be advised that a family member or friend is not permitted to act as a chaperone as they are not deemed to be impartial even if they have the requisite training or clinical knowledge. However, they may be present during the procedure/examination if the patient is content with this decision.
It may be appropriate to offer a chaperone for a number of reasons. All clinicians should consider using a chaperone for some or all of the consultation and not solely for the purpose of intimate examinations or procedures. This applies whether the clinician is of the same gender as the patient or not.
Before conducting any intimate examination, the clinician must obtain the patient’s consent and:
Ensuring that the patient fully understands the why, what and how of the examination process should mitigate the potential for confusion.
The role of the chaperone varies on a case-by-case basis taking into consideration the need of the patient and the examination or procedure being carried out. A chaperone is present as a safeguard for all parties and is an impartial witness to continuing consent of the examination or procedure.
Expectations of chaperones are listed in the GMC guidance. It states chaperones should:
In addition, the chaperone may be expected to:
Chaperones should undergo training which enables them to understand:
Training will be undertaken by all staff who may be required to act as a chaperone at Lamberhurst Surgery.
Training is provided by blue stream e-learning. The practice manager will provide information on this training.
In addition to training, employees conducting chaperone duties should have a Disclosure and Barring Service (DBS) Certificate as below.
To act as a chaperone, staff who undertake this role should have a Disclosure and Barring Service (DBS) Certificate. This is further supported and is detailed in GP Mythbuster 2.
Whilst clinical staff who undertake this role will already have a DBS check, the CQC has recently determined that non-clinical staff may also need a DBS check in order to act as a chaperone due to the nature of chaperoning duties and the level of patient contact.
It should be noted that if Lamberhurst Surgery decide that a DBS check will not be conducted for any non-clinical staff, then the organisation needs to provide a clear rationale for the decision. This should be supported by an appropriate risk assessment and as further detailed within the DBS Policy.
It is also the case that once a member of staff has a DBS check in place, there is no requirement to repeat it as long as there are no changes to their employment and it is up to this organisation to decide if and when a new check is needed.
For any staff that has not received a repeat DBS check, this organisation will provide evidence that they have appropriately considered this and that it is supported by a risk assessment that details any mitigating actions.
In a diverse multicultural society, it is important to acknowledge the spiritual, social and cultural factors associated with the patient population. Clinicians must respect the patient’s wishes and, where appropriate, refer them to another practitioner to have the examination or procedure undertaken.
Local guidance should be sought regarding patients suffering from mental illness or those with learning difficulties. A relative or carer will prove to be a valuable adjunct to a chaperone.
Chaperones are to ensure that they adhere to the Caldicott and information governance policies. The clinician carrying out the examination or procedure should reassure the patient that all clinical staff within the practice fully understand their obligation to maintain confidentiality at all times.
See extract from CQC Nigel’s surgery 15.
Many intimate examinations will not be suitable for a video consultation. Where online, video or telephone consultations take place, GMC guidance explains how to protect patients when images are needed to support clinical decision making. This includes appropriate use of photographs and video consultations as part of patient care.
Where intimate examinations are performed, it is important that a chaperone is offered. Documentation should clearly reflect this. It is important to document who provided the chaperoning. It should also state what part of the consultation they were present for. For further advice on audio and video consultations, plus the management of any imagery, refer to the Audio visual and photography policy.
If a chaperone was not requested at the time of booking the appointment, the clinician will offer the patient a chaperone explaining the requirements:
Detail
SNOMED CT Code
The patient agrees to a chaperone
1104081000000107
Refusal to have a chaperone present
763380007
No chaperones available
428929009
There may be, on occasion, a need to ensure that appropriate measures are in place to escort visitors and guests including Very Important People (VIPs). Lamberhurst Surgery will follow the recommendations outlined in the Lampard Report (2015):
The relationship between the clinician and patient is based on trust and chaperones are a safeguard for both parties at Lamberhurst Surgery.
The role of a chaperone is vital in maintaining a good standard of practice during consultations and examinations. Regular training for staff and raising patient awareness will ensure that this policy is maintained.
