CPOL39 Chaperone Policy by Provide Community

Chaperone Policy

Version: V6

Ratified by: Clinical Reference Group

Date ratified: 13/01/2023

Job Title of author:

Named Nurse safeguarding Adults and Children

Reviewed by Committee or Expert Group Strategic Safeguarding Group

Equality Impact Assessed by:

Provide Group Safeguarding Assurance Oversight Structure

Provide Group Business Board Meets Bi -Monthly

• Receives escalations from QSC

• Discusses risks and areas for action where gaps in performance are identified with due regard to risk appetite and tolerance

Provide Group Business Quality & Safety Committee Meets Bi -Monthly

• Receives escalations from QPLT

• Identifies risks and areas for action where gaps in performance are identified

• Escalates exceptions to the Board

Provide Group Quality Provide Leadership Team Meets Monthly

• Reviews Quarterly Safeguarding Report from SSG quarterly

• Makes recommendations for action and monitors where gaps in performance are identified

• Escalates exceptions to QSC

Provide Group Strategic Safeguarding Group Meets Quarterly

• Reviews performance against safeguarding standards and statutory and regulatory compliance

• Devises and maintains oversight of safeguarding strategy for the Provide Group

• Agrees and Ratifies policies and training Produces a quarterly assurance report for QPLT

•

1. Introduction

Provide Community Group is committed to offering a safe, compassionate and comfortable environment where people using our services and staff can be confident that best practice is always followed and the safety of everyone is of paramount importance.

People can find some care, consultations, examinations, investigations or procedures distressing and may prefer to have a chaperone present in order to support them. It is good practice for staff to offer all people using their services a chaperone for any care, consultation, examination or procedure, or where the person feels one is required.

Examples of care, consultations or procedures which may make the service user feel particularly vulnerable include the need to undress, the use of dimmed light or intimate examinations involving the breasts, genitalia or rectum.

The intimate nature of many care, nursing, midwifery and medical interventions, if not practised in a sensitive and respectful manner, can lead to misinterpretation and the potential for allegations of sexual assault or inappropriate examinations.

All people using our services have the right, if they wish, to have a chaperone present during an examination, procedure, or treatment. Staff should be sensitive to differing expectations regarding race, culture, ethnicity, age, gender and sexual orientation, and wherever possible, the chaperone should be of the same gender as the person using the service

The presence of a chaperone ensures the protection of both people using our services and staff from any allegations of misconduct and preserves dignity, privacy and safety.

2. Purpose

This policy sets out the requirement for all Provide CommunityGroup staff to befamiliar with the use of chaperones during consultations, examinations and procedures carried out with people using our services

All Provide Community Group staff need to be aware of the requirement to have a formal chaperone present when performing intimate examinations and to offer a chaperone for all other consultations.

3. Definitions

Chaperone

There is no common definition of a ‘chaperone’ and the role varies according to the needs of the person using the service, the health or care practitioner and the care, examination or procedure being carried out. It is acceptable for a friend, relative or carer to be present during a procedure if that is the wish of the person using our service, as well as a formal chaperone.

Formal Chaperone

A Formal Chaperone would be a Provide Community Group employee with the knowledge and skills to recognise any safety implications for the person using our

services during the examination, consultation or treatment. This would usually be a health or care practitioner who may also assist in the procedure and support the person with any care needs such as undressing, dressing and attending to personal hygiene.

A chaperone will be able to identify any unusual or unacceptable behaviour on the part of the health or care professional, and should immediately report any incidence of inappropriate behaviour, including inappropriate sexual behaviour to their line manager or manager on call.

A chaperone will also offer protection to health or care practitioners against unfounded allegations of improper behaviour made by people using our services

Informal Chaperone

An informal chaperone would not be expected to take an active part in the examination or witness the procedure directly. An example is a family member or friend i.e., a familiar person who may be sufficient to give reassurance and emotional comfort to the service user

4. Duties

Chief Executive Officer

The Group Chief Executive Officer is ultimately responsible for ensuring effective corporate governance assurance within Provide Community Group

Chief Officers

The Chief Nurse & Operations Officer, and The Chief Medical Officer are responsible for endorsing the full implementation of this policy and its relevance to everyday practice

Senior Managers

The Senior Manager’s role is to ensure implementation of this policy and that all staff understand how the Chaperone Policy applies to them and to the people using their services Senior Managers are also responsible for ensuring that where necessary, local processes are developed and training is given to ensure all staff are competent to offer people using our services a chaperone. Managers should review the effectiveness of the policy, and take appropriate action to investigate any incidents relating to the use of chaperones.

Line Managers

The Line Manager has a responsibility for ensuring chaperones are available within their respective areas, and that chaperones work within their scope of practice and are fully aware of this and associated policies. They also have responsibility for informing the senior manager if no suitable chaperone is available. They have responsibility for Training all chaperones to ensure that they are aware of their responsibilities and that appropriate use of chaperone posters are made available within their practice areas if required.

Health and Care Practitioners

All health and care practitioners are responsible for ensuring that people using our services are offered a chaperone and for respecting the individual’s choice to request or decline a chaperone. They are responsible for maintaining accurate documentation including the consent given to proceed without a chaperone.

They are also responsible for escalation of concerns should these emerge during this process. Health and care practitioners are also responsible for reporting any incidents or complaints relating to the use of chaperones, via the Datix Incident reporting system.

5. Training for Chaperones

Training should be given to any staff required to act as a Chaperone within their role and they should be assessed as competent before they are required to fulfil this role.

They should receive training on the role of the Chaperone, including why a Chaperone is required and their duties, a knowledge of procedures so that they can spot if a practitioner is acting inappropriately and how to escalate their concerns to safeguard the person using the service from abuse.

6. Role of the Chaperone

The role of the chaperone may vary according to the situation and can include:

• providing the person using the service with physical and emotional support and reassurance

• ensuring the environment supports privacy and dignity

• providing practical assistance with the examination

• safeguarding service users from humiliation, pain, distress or abuse

• providing protection to health and care practitioners against unfounded allegations of improper behaviour or abuse

• identifying unusual or unacceptable behaviour on the part of the health or care practitioner

• escalating any breaches of professional conduct to the line manager and completing a Datix incident report

• ensuring that their presence is documented in the person’s record by the practitioner completing the examination

• to be prepared to ask the practitioner to stop the examination if the person using the service requests this

• being sensitive and respectful of the patient’s dignity and confidentiality

7. Chaperone Process

It is good practice to offer all people using our services a chaperone for any care, consultation, examination or procedure where the person using the service feels one is required.

If a person using the service prefers to undergo an examination or procedure without the presence of a chaperone this should be respected and their decision documented

in their clinical record, unless the examination is an intimate examination or procedure, when a chaperone is mandatory.

An intimate examination is defined as an examination of the breast, genitalia or rectum and applies to both female and male patients. (An exception to this may be made for the examination of male breast tissue, decided on a case-by-case basis and in consultation with the person).

For people using our services to exercise their right to request the presence of a chaperone, a full explanation of the examination, procedure, care or treatment to be carried out should be given to the person using the service. This should be followed by a check to ensure that the person has understood the information and gives consent.

To protect the person using the service from vulnerability and embarrassment, consideration should be given to the chaperone being of the same sex as the person using the service, wherever possible.

Facilities should be available for people using the service to undress in a private, undisturbed area. There should be no undue delay prior to examination once the person has removed any clothing.

During the examination the practitioner should:

• be courteous at all times

• offer reassurance

• keep all discussion relevant to the examination and avoid personal comments

• remain alert to any verbal and non-verbal signs of distress from the person

• respect any requests for the examination to be discontinued

• document the name and presence of the chaperone in the person’s electronic record

8. When there is no Chaperone available

Every effort should be made to provide a chaperone. If either the practitioner or the person using the service does not want the examination to go ahead without a chaperone present, or if either is uncomfortable with the choice of chaperone, the examination may be delayed to a later date when a suitable chaperone will be available, if the delay would not adversely affect the person’s health.

Where a suitable formal Chaperone cannot be provided, a Datix incident report should be completed outlining the reasons and action taken. The immediate line manager must be notified and any adverse implications this will have on the person’s care or treatment discussed with them. In all circumstances the person must be notified that a chaperone is not available and this should be recorded in their electronic record.

If the seriousness of the condition would dictate that a delay would have a negative impact then this should be explained to them and recorded in their electronic record. All attempts must be made to locate a suitable chaperone before a decision to continue or otherwise should be jointly reached and recorded in the person’s records.

9. Where a Chaperone is declined by the patient

If the person using the service has declined a chaperone for an intimate examination, the practitioner must explain clearly to them why a chaperone is necessary. In this case, the person may wish to consider requesting referral to an alternative care provider. The examination should not proceed without a chaperone. Exceptions to this are specified within this policy.

Any discussion about chaperones and the outcome should be recorded in the person’s electronic record. That the offer of a chaperone was made and declined should always be recorded.

10.Patients with individual needs

Consent is a person’s agreement for a health or care professional to provide care. All staff must adhere to QSPOL07 Policy for Consent to examination or treatment.

Before health or care professionals examine, treat or care for any person they must obtain valid consent. The person using the service must be fully informed of the procedure and why the examination is required to enable the person to ask any questions and make an informed decision.

Staff must be aware of the implications of the Mental Capacity Act (2005) and may need to complete a Mental Capacity Act Assessment if they think that the person is unable to consent due to a disturbance in the functioning of the mind or brain that affects their ability to give valid consent. If the person is assessed as lacking capacity to consent to a specific procedure and then a Best Interests Decision needs to be made before proceeding and the option of a formal chaperone should be considered within this.

People with a disturbance in the functioning of the mind or brain which may impact on their ability to make a decision must have formal chaperone support from health or care professionals. Family or friends who understand their communication needs and are able to minimise any distress caused by the procedure, could also be invited to be present throughout any examination.

11. Lone Working

Health and care professionals who are working alone in community and domiciliary settings should still offer a formal chaperone for all intimate examinations. If this is a planned intervention then two members of the team should attend.

Where it is appropriate family members/friends may take on the role of informal chaperone only. In caseswhere a formalchaperone would be appropriate, i.e., intimate examinations, the health or care professional would be advised to reschedule the examination.

Health and care professionals should note that they are at an increased risk of their actions being misconstrued or misrepresented if they conduct intimate examinations where no other person is present.

12. Children and Young People

All children and young people under 16 years must have a formal chaperone for any intimate examination. A parent or informal chaperone must be present for any other physical examination.

For children under 16 consent must be obtained from the parent unless the young person is over 13 and has been assessed as competent to give their own consent using Frazer Guidelines.

If a young person has been assessed as able to give consent and they then decline a chaperone this should be recorded in their records.

13. Intimate Personal Care

‘Intimate personal care’ is defined as the care associated with bodily functions and personal hygiene, which require direct or indirect contact with, or exposure of, the sexual parts of the body. It is recognised that much day-to-day care by health and care practitioners is delivered without a chaperone, as part of the unique and trusting relationship between people using our services and practitioners.

However, staff must consider the need for a chaperone on a case-by-case basis, mindful of the special circumstances outlined within this policy, and people should always be offered the opportunity to have a chaperone if they wish.

Staff must be aware that people from diverse cultures may interpret other parts of the body as intimate. The cultural values and religious beliefs of people can make intimate examinations and procedures difficult and stressful for themselves and health or care professionals.

The cultural needs and specific requirements of people using our services should be understood and whenever possible complied with by all Provide Community Group staff

Professional interpreters should always be used if required, rather than family members who may have a vested interest in mistranslating what is asked.

14.Record Keeping

In line with the Record Keeping Policy, details of the care, treatment or examination, must be documented in the person’s record. Requests to discontinue with any care examination or treatment including the reasons given, should be clearly documented

The full name and contact details of any chaperone present, must be recorded including if the chaperone has been offered but declined

15.Policy Statement

The relationship between a person using Provide Community Services and a Health or Care Professional is based on trust. They may not have any doubts about a person

they have known for a long time and feel it may not be necessary to offer a formal chaperone.

Similarly, there is evidence that many people are not concerned whether a chaperone is present or not. However, this should not detract from the fact that any person, of any gender, using our services are entitled to a chaperone if they feel one is required.

This policy is also for the protection of staff and as such should always be followed. The key principles of communication and record keeping will ensure that the health or care practitioner and their relationship with people using their service is maintained and will act as a safeguard against formal complaints, or in extreme cases, legal action against the organisation or the individual staff member.

Appendix 1 : Staffchecklist for consultations involving intimate investigations or procedures.

i. Establish there is a genuine need for an intimate examination and discuss this with the person prior to the procedure taking place.

ii. Explain to the person why an examination is necessary and give the person an opportunity to ask questions, and full explanation of what this involves.

iii. Offer a formal chaperone to support them through this or invite the person to have a family member/friend present to act in informal chaperone capacity if this is relevant (i e , leading up to the intimate procedure) If the person does not want a chaperone, record that the offer was made and declined by the individual in the patients’ notes.

iv. Obtain the person’s consent before the examination, and record that permission has been obtained in the person’ record. Follow Mental Capacity Act where there are issues related to the person’s capacity to give valid consent

v. Be prepared to discontinue the examination at any stage should the person request this and record the reason.

vi. Children should be given the opportunity to have parents present if they wish during the any medical procedure. If a child does not wish a nurse to be present during an intimate examination, then the parents can also be present, however a professional chaperone must be present.

vii. A Chaperone must always allow people privacy to undress and dress through the use of drapes, screens, blankets.

viii. Explain what you are doing at each stage of the examination, the outcome when it is complete and what you /or the health or care professional propose to do next. Keep discussion relevant and avoid personal comments at all times.

ix. If a chaperone has been present throughout the process, record that fact and the identity of the chaperone in the person’s notes.

x. Record any other relevant issues and escalate concerns immediately following the consultation.

xi. Ensure the individual is supported to dress fully after the procedure always maintaining their full dignity and privacy.

Appendix 2: Escalation of concerns

Actions to be taken by the Chaperone if a Provide Community Group practitioner does not adhere to the Chaperone Policy.

Concern by the Chaperone that the practitioner is not adhering to policy or an inappropriate examination is taking place

Requesttheexaminationtobe postponedortostop

Reassurethepersonusingtheservice

Informlinemanager/seniormanager/OnCallManagerimmediatelyofconcerns(managerwill followsafeguardingandHRpoliciesinrelationtodiscinplainaryandinappropriateconduct)

Requestperson'sappointmentis rearrangedwithanotherpractitioner.

Contactthesafeguardingteamtooffer supportifrequired

Chaperone/informanttodocumentincidentandcompletedatixform

SupporttobeofferedtoChaperone throughlinemangement

Supporttobeofferedtothe practitionerthroughHRprocesses.

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 1: ‘Screening’

Name of project/policy/strategy (hereafter referred to as “initiative”):

CPOL39 Chaperone Policy

Provide a brief summary (bullet points) of the aims of the initiative and main activities:

People using services delivered by Provide Community Group have a right to be offered a chaperone for intimate examinations.

The presence of a chaperone ensures the protection of both service users and staff from any allegations of misconduct and preserves their dignity, privacy and safety.

Project/Policy Manager: Named Nurse safeguarding Adults and Children

Date: November 2022

This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community – i.e. on the grounds of race (incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equality neutral” (i.e. have no effect either positive or negative). In the case of gender, consider whether men and women are affected differently.

Q1. Who will benefit from this initiative? Is there likely to be a positive impact on specific groups/communities (whether or not they are the intended beneficiaries), and if so, how? Or is it clear at this stage that it will be equality “neutral”? i.e. will have no particular effect on any group.

Neutral

Q2. Is there likely to be an adverse impact on one or more minority/under-represented or community groups as a result of this initiative? If so, who may be affected and why? Or is it clear at this stage that it will be equality “neutral”?

Neutral

Q3. Is the impact of the initiative – whether positive or negative - significant enough to warrant a more detailed assessment (Stage 2 – see guidance)? If not, will there be monitoring and review to assess the impact over a period time? Briefly (bullet points) give reasons for your answer and any steps you are taking to address particular issues, including any consultation with staff or external groups/agencies.

Guidelines: Things to consider

Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.

The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.

Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.

Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan.

Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?

It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.

It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 2:

(To be used where the ‘screening phase has identified a substantial problem/concern)

This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.

Q1. What data/information is there on the target beneficiary groups/communities? Are any of these groups under- or over-represented? Do they have access to the same resources? What are your sources of data and are there any gaps?

Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations? If yes, how? Which are the main groups it will have an impact on?

Q3. Will the initiative have an adverse impact on any particular group or community/community relations? If yes, in what way? Will the impact be different for different groups – e.g. men and women?

Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative? Summarise (bullet points) any important issues arising from the consultation.

Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact? Are there specific factors which need to be taken into account?

Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required.

Guidelines: Things to consider

An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised. It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations, and could form a specific part of the initiative. The consultation process should form a meaningful part of the initiative as it develops, and help inform any future action. If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.

Further information:

Useful Websites www.equalityhumanrights.com Website for new Equality agency www.employers-forum.co.uk – Employers forum on disability www.efa.org.uk – Employers forum on age

‘Screening’