clinical intimate personal care and chaperoning policy - NHS Scotland

CLINICAL
INTIMATE PERSONAL CARE AND
CHAPERONING POLICY
Authors: Kathryn Bailey &
Kevin Hurst
Review Group:
Last Updated: July 2009 Review Date: July 2011
Document No: Issue No:
UNCONTROLLED WHEN PRINTED
Signed: Executive Lead
Officer
(Authorised Signatory)

CONTENTS
Section Title Page Number
1. PURPOSE AND SCOPE 3
2. STATEMENT OF POLICY 3
3. DEFINITIONS 3-4
4. RESPONSIBILITIES AND ORGANISATIONAL 4-6
ARRANGEMENTS
5. FLOW CHART 7
6. REFERENCES 8
7. BIBLIOGRAPHY AND FURTHER READING 8
8. RAPID IMPACT CHECKLIST 9-14
9. POLICY APPROVAL CHECKLIST 11
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1. PURPOSE AND SCOPE
The purpose of this policy is to set out the standards, which must be adhered to when providing
intimate personal care and chaperoning to patients. Through this policy staff will be able to offer a
co-ordinated service and approach, which acknowledges their responsibilities and protect the rights
of everyone involved. This policy will enable the service to comply with; The Children (Scotland) Act
1995, Adults with Incapacity (Scotland) Act 2000, and Human Rights Act 2000. It gives specific
guidance regarding babies, children and individuals with special needs, adults at risk, and those
whose first language is not English, and pre verbal infants. This policy also adheres to the human
rights principles found in the Mental Health (Care and Treatment) (Scotland) Act 2003.
2. STATEMENT OF POLICY
NHS Tayside attaches the highest importance to ensuring a culture that values the privacy and
dignity of all patients who are cared for within the organisation. Staff have a professional duty of care,
and have responsibilities to act in the patients best interest and are accountable for their actions.
Staff must be sensitive to differing expectations associated with race, ethnicity, age, gender,
disability, religion/faith, and sexual orientation.
The policy applies to the care of patients who require support of an intimate nature, including
examinations, procedures and interventions. Intimate and personal care is an important area of an
individual’s self image and respect. The apparent nature of many care interventions, if not practised
in a sensitive and respectful manner, can lead to misinterpretation and occasionally allegations of
abuse. Not understanding an individual’s specific needs can lead to confusion and misunderstanding.
It is therefore important that healthcare professionals are sensitive to these issues and alert to the
potential for individuals, especially children, young people and other ‘at risk’ groups to become the
victims of abuse.
A relationship of trust is required to ensure that all patients receive the same degree of care and
support, (Children (Scotland) Act, 1995; Adults with Incapacity (Scotland) Act, 2000). A relationship
of trust can be described as one in which one party is in a position of power or influence over the
other by virtue of their work or the nature of their activity. Relationships developed by professions
such as medicine, nursing and allied health professionals are all founded on trust (Home Office,
1999).
The Adult Support & Protection (Scotland) Bill as passed, is intended to give greater protection to
adults at risk of abuse. This includes those who are mentally unwell. The new Bill gives new powers
and a statutory responsibility to local agencies to investigate any risk of harm or abuse to adults living
in care homes or in the community. Part 1 of the Bill is concerned with adult protection. Within
Tayside, there is a multi-agency protocol to guide and inform local inter-agency procedures &
practice concerning the protection of vulnerable adults – Protecting Vulnerable Adults in Tayside.
3. DEFINITIONS
WHAT IS INTIMATE CARE?
Intimate care covers all areas of personal care that most individuals learn to carry out independently
as they grow and develop, but some are unable to do so because of impairment or
disability/age/understanding due to communication difficulties. Individuals may require help with
eating and drinking, washing and dressing and toileting. Help may also be required to change stoma
bags, manage urinary catheters or administer rectal medication (Scottish Executive, 1999).
Other procedures such as intimate examinations undertaken whilst an individual is in hospital also
require the same degree of respect.
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WHAT IS A CHAPERONE?
An individual who acts as an advocate for the patient during examination or procedure, providing
explanation and reassuring the patient whilst safeguarding against unnecessary discomfort, pain,
humiliation or intimidation (Royal College of Nursing, 2002).
AT RISK GROUPS
Any individuals dependent on others for care are vulnerable. Factors, which may increase this
vulnerability, may include:
• Reduced control over their lives or decisions due to their disability or lack of understanding
• Lack of sex education which can lead to difficulty in children recognising abusive behaviour
• Reduced communication skills to let someone know they are not happy
• Multiple carers due to hospital admissions or respite/residential care
• Differences in appearance or behaviour may be attributed to a child’s disability/age and not to the
possibility that something may be wrong
• Discrimination against children and adult with disabilities in society
• Individuals whose first language is not English
• Pre Verbal infants and children
• Individuals suffering from a mental illness including people with dementia
(Scottish Executive, 1999; Scottish Executive, 2000)
From a child protection perspective, intimate personal care involves risks for both the child and the
adult providing the care as it may involve the adult touching intimate parts of the child’s body. By
addressing the issue we create an awareness of the importance of maximising safety for all
concerned and promote the best interest of the child. This will not completely eliminate the risk but
will minimise the potential of its occurrence.
While this is an important issue when caring for children, the same risks are present when providing
care to vulnerable adults. To ensure staff protect the rights of everyone involved, all staff providing
care within NHS Tayside must comply with the following principles for practice.
4. RESP0NSIBILITIES AND ORGANISATIONAL ARRANGEMENTS
4.1 PRINCIPLES FOR PRACTICE
All staff must ensure that they promote and enable each individual to be part of the decision making
process in relation to their intimate and personal care, giving all relevant information, to ensure
patient choice and that informed consent has been obtained, in adherence with NHS Tayside’s
Informed Consent Policy. In the event that the patient does not have the capacity to consent to
treatment, The Adults with Incapacity (Scotland) Act 2000 provides a comprehensive framework to
ensure equity of treatment and choice for adults with incapacity, and makes provision for decisions to
be made on behalf of an adult, subject to safeguards and in specific and well-defined situations.
Incapacity is defined within that Act as being incapable of: acting, making decisions, communicating
decisions, understanding decisions or retaining the memory of decisions, by reason of mental
disorder or of inability to communicate because of physical disability. If required, an incapacity
certificate must be completed prior to any intervention or treatment. Independence must still be
promoted, and consideration given to additional needs, communication methods or tool that maybe
required.
Consent for a child can be given by a variety of individuals depending on the circumstances
regarding their care. In most cases consent if given by the mother, father if married to the mother or
has been or a legally appointed guardian. Staff should refer to the Children Scotland Act 1995 for
further guidance. Individuals working with children must also be aware that a person under the age
of 16 years shall have a legal capacity to consent on his/her own behalf to any surgical, medical or
dental procedure or treatment where, in the opinion of a qualified medical practitioner attending
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him/her, he/she is capable of understanding the nature and possible consequences of the procedure
and treatment. (The Age of Legal Capacity, 1991)
The following principles for good practice should assist in this matter:
• Allow the individual to care for him/herself as far as possible
• Allow an individual wherever possible to express a preference for his/her carer
• Where the individual is unable to give consent, discussions must take place with themselves,
their parent/carer or other legally appointed representative as to their preferences
• Allow the individual a choice in the sequence of care they receive, where possible.
• Ensure the privacy and dignity of the individual
• Be aware of and responsive to the individual’s reactions
• If carrying out intimate care away from the ward area/respite/residential facility/individuals home,
ensure the privacy and safety of the individual.
• Any individual carrying out intimate personal care to children and young people must have an
enhanced disclosure Scotland check undertaken
All staff should be familiar with the following documents:
The Age of Legal Capacity (Scotland) Act, 1991
Children (Scotland) Act, HMSO, London, 1995
Protecting Children A shared Responsibility, Scottish Executive, 2000
Human Rights Act, The Home Office, 2000
Adults with Incapacity (Scotland) Act, 2000
Mental Health (Care & Treatment) (Scotland) Act 2003
The Adult Support & Protection (Scotland) Bill
A Multi-Faith Resource for Healthcare Staff, NHS Education Scotland
NHS Tayside Informed Consent Policy, 2007
Protecting Vulnerable Adults in Tayside: A Multi-Agency Protocol
4.2 PROVIDING INTIMATE CARE
In the provision of health care, staff are in a position of trust and responsibility. This trust and
responsibility is heightened when providing intimate care. It is neither practical nor possible to
eliminate the fact that intimate care may be provided by a member of staff of the opposite gender.
However, in order to safeguard patients, staff must practice in accordance with the following
statements: -
4.2.1 If any personal care support is to be given by a member of the opposite sex, the individual
must be offered the option of a chaperone. The chaperone must be wherever possible, the same sex
as the individual receiving the care (RCN, 2002; GMC, 2006). The name of any chaperone must be
documented in the individuals care plan (NMC, 2005). If a chaperone is not available and care is not
urgent this must be explained to the patient to ascertain if they would prefer to proceed without a
chaperone or offer to delay the care until such time as a chaperone is available (RCN, 2002).
Nurses and other health care professionals should also consider being accompanied by a chaperone
when undertaking intimate examinations and procedures to avoid misunderstanding and, in rare
cases, false accusations of abuse. If the patient prefers to undergo an examination/procedure
without the presence of a chaperone, this should be respected (RCN, 2002).
Wherever possible, a chaperone should be a healthcare professional, but it is recognised that in
some areas or situations an additional healthcare professional may not be available. If this occurs,
and if the examination/procedure cannot be safely postponed, then the patient must be offered to
invite a relative, carer or friend to be present. If this is not possible, then a non-clinical member of
staff from the healthcare team may be asked to undertake the role of chaperone. The patient must be
made aware of the fact that the chaperone is a non-clinical member of staff and again given the
opportunity to refuse or delay the procedure. All non-clinical members of staff undertaking this
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esponsibility such as administration and clerical staff, will have undergone chaperone training and
are aware of the role expected of them, how to raise concerns and also their contractual obligations
regarding issues of confidentiality.
Staff must record discussions and outcomes of any of the above in the individuals care plan (GMC,
2001; NMC, 2005).
4.2.2 In areas where intimate personal care may be given on a regular basis by members of the
opposite sex, information must be given and where possible discussion and agreement should take
place with the individual, parent/carer, their family or where appropriate legally appointed
representative. This information must be recorded in the individual’s care plan (NMC, 2005).
4.2.3 When a chaperone has been required and a member of staff of the same gender has been
requested but not available this must be brought to the attention of the nurse/midwife in charge. In
addition a brief note should be made in the individual’s notes for each occasion and must include:
Date/Time/Care given/Immediate necessity that led to opposite sex personal care
being given or details of what care was omitted or delayed plus reason why member of
same gender was not available.
It is the responsibility of staff, through record keeping to monitor the frequency of same gender staff
not being available for intimate personal care needs.
4.2.4 Religious views of families must be taken into account. It may be the case that males can only
have intimate care provided by another male, therefore involvement of the family in the care of the
individual is important.
NHS Education for Scotland (NES) has produced a booklet called Spiritual Care: A Multi-Faith
Resource for Healthcare Staff through its Healthcare Chaplaincy Training and Development Unit in
consultation with a multi-faith group which represents the main faith and belief groups in Scotland.
Although it cannot cover every group, this booklet contains information for most of the smaller faith
communities on issues such as:
• Attitudes to healthcare staff and illness
• Washing and toilet
• Ideas of modesty and dress
Each ward or department has a hard copy of this booklet or it can be found on staffnet under Spiritual
care or Diversity and Equality or online at http://www.nes.scot.nhs.uk/publications.
The Department of Spiritual Care can contact any faith community if you require further information.
4.2.5 Apart from in emergency situations, staff must get to know the child/ vulnerable adult before
being involved in any intimate or personal care. They must also reach agreement with the child and
family/vulnerable adult and carer/family on the names used for intimate body parts.
4.2.6 Whilst children must be protected from receiving inappropriate touches, it is important that
touch is not withdrawn completely from infants and children with profound disabilities for whom it will
always be essential for providing reassurance and personal and social development. Massage is
commonly used to develop sensory and body awareness for infants and children with complex needs
as well as a means of relaxation.
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5. INTIMATE PERSONAL CARE AND CHAPERONING FLOW CHART
When intimate and personal care is required, assessment must take place as to who is the most appropriate person to undertake this care, taking
cognisance of the patients wishes.
Same sex individual is available to undertake care
YES NO
Undertake care as required
Provide care with chaperone present.
Document the full name of the
chaperone in the patient care plan
Chaperone available
YES NO
Explain the required procedure to patient and its
urgency. If the patient continues to refuse consent
to the procedure without a chaperone, and the
treatment is necessary to preserve life, care may
be provided
Chaperone to be offered to the
patient
Patient refuses chaperone
Ascertain if the care is urgent
YES NO
Document clearly in the care plan the patient’s
decision not to have a chaperone present. Undertake
care as required
Explain to the patient the lack of an appropriate
chaperone and discuss the options of: (a)
undertaking care without a chaperone present, or
(b) delaying the care until later in the day.
Option A preferred by patient Option B preferred by patient
Document in the patients care plan an agreed time to
undertake the care with chaperone present

6. REFERENCES
Adults with incapacity (Scotland) Act, The stationery Office, Edinburgh, 2000
Caring for Young People and the Vulnerable, Home Office, 1999
Chaperoning: The role of the nurse and the rights of patients, RCN, 2002
Children (Scotland) Act, HMSO, London, 1995
Good Medical Practice – Maintaining Boundaries, General Medical Council 2006
Guidelines for records and record keeping, Nursing & Midwifery Council, 2005
Guidelines for staff who provide intimate care for children and young people with disabilities, Scottish
Executive 1999
Human Rights Act, The Home Office, 2000
Mental Health (Care and Treatment) (Scotland) Act 2003
NHS Tayside Informed Consent Policy, 2007
Protecting Children A shared Responsibility, Scottish Executive, 2000
Spiritual Care: A Multi-Faith Resource for Healthcare Staff, NHS Education for Scotland 2007
The Adult Support & protection (Scotland) Bill, Scottish Executive
The Age of Legal Capacity (Scotland) Act, HMSO, 1991
7. BIBLIOGRAPHY AND FURTHER READING
Illness and disability in Children and Young People, Action for Sick Children, 1996
Practitioner-client relationships and the prevention of abuse, Nursing & Midwifery Council, London, 2002
Protection of nurses working with children and young people: Guidance for nursing staff, RCN 2001
The essence of Care, Department of Health, London, 2001
The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives, Nursing & Midwifery
Council, London, 2008
The Same As You, Scottish Executive, 2001
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Name of Function/Policy/Strategy
EQUALITY AND DIVERSITY RAPID IMPACT ASSESSMENT
Intimate Personal Care & Chaperoning Policy
Workstream
Clinical
Location of Function/Policy/Strategy
What are the main aims of your function/policy/strategy
To provide clear guidance with regard to the requirement to provide patients with informed choices
regarding their intimate personal care & chaperoning, & therefore provide a framework to ensure that
patient’s dignity, privacy & respect is maintained at all time.
Is this a new/existing policy/function/strategy?
New
What are the intended outcomes from the proposed function/policy/strategy?
To enhance & improve the patients experience of healthcare within NHST.
Priority: state whether high/low?
High
Review Team: who is assessing or considering the assessment?
Nursing & Patient Services
Names and titles of team members
Kevin Hurst – Senior Nurse Practice Development
Role of assessment team
To impact assess the policy
When completed please this form to be emailed to ……………………………………
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Item
No
Considerations Detail Impact and Identify
Groups Affected
1. Which groups of the population will be affected
by the function/policy?
1.1 Will it impact on the whole population? Yes
1.2 If not which groups of the population do you think will
be affected by this function/policy?
Item
No
• Minority ethnic population (including
refugees, asylum seekers&
gypsies/travellers)
• Women and men
• People in religious/faiths groups
• Disabled people
• Older people, children and young people
• Lesbian, gay, bisexual and transgender
people
• People with mental health problems
• Homeless people
• People involved in criminal justice system
• Staff
All groups will be affected, as
the six equality strands apply to
all patients admitted to NHS
Tayside
Considerations Detail Impact and Identify
Groups Affected
2. What impact will the function/policy have on
lifestyles?
For example will the changes affect:
• Diet & nutrition
• Exercise & physical activity
• Substance use: tobacco, alcohol or drugs
Whilst the Policy should have
no impact on lifestyle, the policy
will promote informed choices
for patients in relation to their
intimate & personal care. The
policy will also provide a
framework for the promotion of
the patient’s rights to privacy,
dignity & respect.
Document the
Evidence/Research
Performance Through Inclusion
documentation.
Fair For All
Document the
Evidence/Research
Actions Taken/To be Taken
Awareness of the Policy will
need raising with staff, & will be
achieved through the
implementation plan
Actions Taken/To be Taken
Review implementation plan
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Item
No
• Risk taking behaviours
• Education & learning or skills
• Other
Considerations Detail Impact and Identify
Groups Affected
3. Does your function/policy consider the impact on
the social environment?
Item
No
Things that might be affected include:
• Social status
• Employment (paid/unpaid)
• Social/family support
• Stress
• Income
The Policy does consider the
impact on the social
environment. Wellbeing is
increasingly being recognised
as central to health and
therefore in-patients who feel
comfortable within their
environment will have a better
sense of wellbeing and
therefore better clinical outcome
when privacy and dignity are
respected.
Patient’s wishes must be
respected when intimate care is
being carried out or during
examination, procedures &
interventions of a personal
nature.
Considerations Detail Impact and Identify
Groups Affected
4. Will the proposal have any impact on:
5.
• Discrimination
• Equality of opportunity
• Relations between groups
• Other
Will the function/policy have an impact on the
physical environment?
Adherence with the Policy will
have a positive impact on
privacy, dignity and respect
therefore improving the patient
experience.
No
Document the
Evidence/Research
Better Together SGHD Patient
Experience Programme
Chaperoning: The role of the
nurse & the rights if the
patients, RCN 2002
Document the
Evidence/Research
Actions Taken/To be Taken
Actions Taken/To be Taken
11

Item
No
For example will there be impacts on:
• Living conditions
• Working conditions
• Pollution or climate change
• Accidental injuries/public safety
• Transmission of infectious diseases
• Other
Considerations Detail Impact and Identify
Groups Affected
6. Will the function/policy affect access to and
experience of services?
For example:
• Healthcare
• Social services
• Education
• Transport
• Housing
7. Consultation
1) What existing consultation data do we have
or need?
• Existing consultation sources
• Original consultations
• Key learning
2) What new consultation, if any, do you need
to undertake?
The Policy will improve patient’s
experience of healthcare,
through assuring privacy,
dignity and respect, in addition
to providing informed choices to
patients regarding their care.
The following groups have been
consulted with and advice
incorporated into the
development of the Policy:
• Public Partnership (Health)
Group
• NHST staff from a range of
professional backgrounds
including medical,
NMAHPs, A&C staff groups
• Dept of Spiritual Care
Document the
Evidence/Research
Better Together – SGHD
Patient Experience Programme
NHST Informed Consent Policy
Chaperoning: The role of the
nurse & the rights if the
patients, RCN 2002
Performance Through Inclusion
documentation.
Fair For All
Better Together – SGHD
Patient Experience Programme
NHST Informed Consent Policy
Human Rights Act 2000
Actions Taken/To be Taken
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Item
No
Considerations Detail Impact and Identify
Groups Affected
8. In relation to the groups identified:
Item
No
• What are the potential impacts on health?
• Will the function/policy impact on access to
health care? If yes – in what way?
• Will the function/policy impact on the
experience of health care? If yes – in what
way?
The Policy will improve patient’s
experience of healthcare,
through assuring privacy,
dignity and respect, in addition
to providing informed choices to
patients regarding their care.
Considerations Detail Impact and Identify
Groups Affected
9. Have any potential negative impacts been
identified?
• If so, what action has been proposed to
counteract the negative impacts? (if yes state
how)
For example:
• Is there any unlawful discrimination?
• Could any community get an adverse
outcome?
• Could any group be excluded from the
benefits of the function/policy? (consider
groups outlined in item 3)
• Does it reinforce negative stereotypes? (For
example, are any of the groups identified at
item 3 being disadvantaged due to
perception rather than factual information?)
The impact of patients refusing
urgent treatment, examinations
& interventions when a same
sex chaperone has been
requested but not available has
been considered.
Document the
Evidence/Research
Better Together – SGHD
Patient Experience Programme
Document the
Evidence/Research
Chaperoning: The role of the
nurse & the rights if the
patients, RCN 2002
Actions Taken/To be Taken
Actions Taken/To be Taken
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Item
No
Considerations Detail Impact and Identify
Groups Affected
10. Data & Research
11. Monitoring
• Is there need to gather further
evidence/data?
• Are there any apparent gaps in
knowledge/skills?
• How will the outcomes be monitored?
• Who will monitor?
• What criteria will you use to measure
progress towards the outcomes?
12. Recommendations
Item
No
(This should include any actions required to address
negative impacts identified)
No
If non-clinical staff are required
to act as a chaperone, training
is required. Training is not
currently available for this
Outcomes will be monitored
locally & any issue that gives
cause for concern will be acted
on
Complaints that result from
patients regarding intimate
personal care & chaperoning
will be monitored, as the
anticipated outcome of
implementation of this policy will
lead to a reduction in the
number of these
Considerations Detail Impact and Identify
Groups Affected
13. Is a more detailed assessment needed?
• If so, for what reason?
14. Completed function/policy
15.
• Who will sign this off?
• When?
Publication
No
Medical Director
August2009
Staffnet
Document the
Evidence/Research
Document the
Evidence/Research
Actions Taken/To be Taken
Identify any sources of training
available, & develop training if
required.
Complaints are monitored by
the organisation.
Actions Taken/To be Taken
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9. NHS TAYSIDE - POLICY APPROVAL CHECKLIST
This checklist must be completed and forwarded with policy to the appropriate
forum/committee for approval: the Delivery Unit Executive Management Team and the
Improvement and Quality Committee.
POLICY AREA: Clinical
POLICY TITLE: Intimate Personal Care & Chaperoning Policy
LEAD OFFICER: Andrew Russell
Why has this policy been developed?
Has the policy been developed in
accordance with or related to
legislation? – Please give details of
applicable legislation.
Has a risk control plan been
developed? Who is the owner of the
risk?
Who has been involved/consulted in
the development of the policy?
Has The policy been assessed for
Equality and diversity in relation to:-
Race/Ethnicity
Gender
Age
Religion/Faith
Disability
Sexual
orientation
Yes
Yes
Yes
Yes
Yes
Yes
Does the policy contain evidence of
the Equality & Diversity Impact
Assessment Process?
There is no existing policy. This policy will ensure
that health professionals are able to comply with
Legislation & recommendations from National
Bodies.
Adults with Incapacity (Scotland) Act 2000
Age of Legal Capacity (Scotland) Act 1991
The Children (Scotland) Act 1995
Mental Health (Care and Treatment) (Scotland) Act
2003
Human Rights Act, 2000
The Adult Support & Protection (Scotland) Bill
NHS Tayside Informed Consent Policy 2007
Protecting Vulnerable Adults in Tayside: A Multi-
Agency Protocol
A Multi-Faith Resource for Healthcare Staff, NHS
Education Scotland
Yes, Dr Andrew Russell
Various groups of health care staff within NHST,
including patient & public groups.
Has the policy been assessed For Equality and
Diversity not to disadvantage the following
groups:-
Minority Ethnic
Communities
(includes
Gypsy/Travellers,
Refugees & Asylum
Seekers)
Women and Men
Religious & Faith Groups
Disabled People
Children and Young
People
Lesbian, Gay, Bisexual &
Transgender Community
YES
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Is there an implementation plan? YES
Which officers are responsible for
implementation?
The Medical Director is ultimately responsible
but delegated responsibility lies with General
Managers and CHP Managers.
When will the policy take effect? Immediately following approval
Who must comply with the policy? All health care practitioners who undertake any form
of treatment, intervention or therapy
How will they be informed of their The policy will be widely disseminated and
responsibilities?
discussed within clinical governance forums,
management meetings and be available on staffnet
Is any training required? No
If yes, has any been arranged? YES
Are there any cost implications? NO
If yes, please detail costs and note
source of funding
Who is responsible for auditing the
implementation of the policy?
What is the audit interval?
Who will receive the audit reports?
When will the policy be reviewed and
by whom? (please give designation)
Annual
Medical Director
Two years (July 2011) by the Medical Director
Name: _____________________________ Date: __________________
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