Chaperone Policy
Last reviewed 28/01/2026
Next review date 01/01/2027
1.Policy Purpose and Scope
This policy ensures all patients attending this GP practice are informed of their right to be offered a chaperone for consultations, examinations, or procedures, particularly those that could be perceived as intimate. It supports patient safety, dignity and privacy, enhances patient choice and protection for both patients and staff, and aligns with the NHS England national principles for chaperoning practice.
This policy applies to all staff, including clinicians and non-clinical team members who may act as chaperones.
2. Definition and Role of a Chaperone
A chaperone is an appropriately trained member of practice staff present during an examination or treatment to support the patient and act as the patient’s advocate, maintaining their privacy, dignity and comfort. Local policy clearly defines who is eligible to undertake chaperoning duties and ensures they have received suitable training.
The primary role of a chaperone is to:
- Support and reassure the patient throughout the examination.
- Observe the process for safeguarding purposes.
- Facilitate communication between the patient and clinician.
- Act respectfully towards patient dignity and cultural needs
3. Offer of a Chaperone
- All patients must be offered a chaperone before any relevant examination or procedure, whether intimate or not. The offer should ideally be made early in the care pathway (e.g., at appointment booking) and reiterated immediately before the examination.
- Patients have the right to accept or decline a chaperone; this decision is respected and documented in the clinical record.
- The offer and provision of a chaperone should be communicated using culturally appropriate, clear language, considering preferences including gender, religion and communication needs.
4. Intimate Examinations
- In line with national guidance, a chaperone should be offered and consent obtained for intimate examinations (e.g., of genitalia, breast or rectum) unless emergent clinical circumstances make this impractical.
- Clinicians may proceed without a chaperone if all reasonable attempts to provide one have been made, the patient chooses to decline, or in urgent clinical situations provided this is documented.
- A patient’s relative or friend does not usually replace a formal chaperone, as they may not have the impartial training required, but we should comply with patient request assuming there are no safeguarding concerns in doing so.
5. Documentation and Record Keeping
Accurate documentation is required for every offer and use of a chaperone:
- Clinical entries must be made by both the clinician and the chaperone.
- The clinician mustrecord that the offer of a chaperone was made and whether it was accepted or declined; if accepted, include the chaperone’s name and role.
- The chaperone must record the event using the relevant chaperone template.
- The practice uses the Ardens Chaperone Template to record all chaperoning details directly in the patient’s medical record, including:
- Date and time of examination/procedure.
- Explanation of purpose of the examination.
- Details of the offer, acceptance/decline, and identity of the chaperone.
- Any issues or concerns raised during or after the examination.
- Documentation must allow audit and review to promote continuous quality improvement.
6. Training and Competency
The Practice is responsible for ensuring that all staff who may undertake chaperoning duties:
- Receive adequate training (internal or external) in line with national guidance and are deemed competent.
- Understand their role, responsibilities, and boundaries, including safeguarding, patient dignity and confidentiality.
- Are aware of the practice chaperone processes and documentation requirements, including use of the Ardens Chaperone Template.
- Records of training and competency assessments are maintained by the practice for governance and audit purposes.
- A member of staff who has not received training should not be asked and should not volunteer to act as a chaperone.
7. Communication of the Policy
- The chaperone policy is made readily available to patients and the public through the practice website, in waiting rooms, and in accessible formats (e.g., easy-read versions).
- All staff are informed of this policy and regularly updated through practice meetings and training.
8. Escalation and Raising Concerns
- The practice ensures clear routes for raising concerns about chaperoning practice or conduct, including internal escalation and safeguarding processes.
- Chaperones and any practice staff are encouraged to report concerns promptly to clinical leads or management.
9. Governance and Review
- The practice designates responsibility for oversight of chaperone practice to the Management Team and Partners.
- This policy is reviewed regularly and updated in line with evolving national guidance, service needs, audit outcomes, and patient feedback.