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Use of Chaperons Policy

1. Purpose

The purpose of this policy is to ensure that the use of chaperones within {{org_field_name}} is managed in a manner that protects the dignity, safety, and rights of all individuals during personal care, medical examinations, treatments, or sensitive conversations. This policy supports compliance with the Regulation and Inspection of Social Care (Wales) Act 2016, the Social Services and Well-being (Wales) Act 2014, the Equality Act 2010, and Care Inspectorate Wales (CIW) expectations around safe care, safeguarding, and respect for privacy and choice. The use of chaperones is an essential safeguarding measure that also reassures service users and supports transparency and accountability among staff.

2. Scope

This policy applies to all staff at {{org_field_name}}, including care workers, nurses, health professionals, agency staff, and any visiting medical personnel. It applies to all residents receiving care or support where the use of a chaperone may be appropriate, particularly during personal, intimate, or potentially distressing procedures or examinations. It also includes instances of communication involving sensitive personal issues, complaints of abuse, or where there is a risk of misinterpretation or discomfort.

3. Related Policies

This policy should be read in conjunction with the following:
CHW07 – Person-Centred Care Policy
CHW08 – Dignity and Respect Policy
CHW09 – Consent to Care Policy
CHW11 – Safe Care and Treatment Policy
CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy
CHW16 – Health and Safety at Work Policy
CHW18 – Risk Management and Assessment Policy
CHW27 – Staff Supervision, Training, and Development Policy
CHW30 – Equality, Diversity, and Inclusion Policy
CHW40 – Assisting with Personal Care Policy

4. Policy Statement and Implementation

A. Definition and Role of a Chaperone
A chaperone is a trained individual who is present during personal or clinical interactions to provide support, reassurance, and protection for the person receiving care or treatment. The role of a chaperone is to:

• Offer emotional comfort and support to the service user
• Act as a witness to protect both the individual and the staff member
• Help prevent misunderstandings or allegations
• Ensure that the care being delivered is appropriate and respectful
  A chaperone may be another staff member, preferably of the same gender as the resident where possible and in accordance with their preferences.

B. When a Chaperone Should Be Offered
A chaperone must be offered in the following circumstances:

• During any intimate or personal care procedure that may cause discomfort, embarrassment, or distress
• During physical examinations conducted by external healthcare professionals such as GPs, nurses, or physiotherapists
• When a resident is anxious, has a history of trauma, or makes a request for a second person to be present
• Where care is being delivered in a one-to-one setting and the individual lacks capacity to consent, is particularly vulnerable, or where there may be a safeguarding concern
• During sensitive conversations, complaints involving allegations, or disclosures of harm
  Service users have the right to decline a chaperone, but this must be documented, and staff must assess whether it is still appropriate to proceed or if alternative arrangements are required.

C. Consent and Communication
Before any procedure or intervention begins, the resident must be informed of the option to have a chaperone present. The purpose and role of the chaperone must be clearly explained in accessible language or using appropriate communication aids. Consent must be sought for the procedure and separately for the presence of a chaperone, particularly where the chaperone is of a different gender or is not known to the resident. Where the person lacks capacity, a best interests decision is made following the principles in CHW39 – Mental Capacity and Deprivation of Liberty Safeguards Policy.

D. Chaperone Training and Responsibilities
Only staff who have received appropriate training may act as chaperones. Training includes:

• Confidentiality and professional boundaries
• Safeguarding and reporting concerns
• Understanding dignity and respect in care
• Recognising signs of discomfort, abuse, or distress
• Accurate record keeping
  The chaperone must remain present for the duration of the procedure or examination and must not leave the person unattended. They must not perform clinical tasks unless they are specifically trained and authorised to do so. After the interaction, the chaperone should document their presence in the care record and report any concerns to the senior member on duty.

E. Gender and Cultural Sensitivities
{{org_field_name}} respects the cultural, religious, and gender preferences of individuals in relation to who is present during personal care or examinations. Where possible, a chaperone of the same gender is provided, especially where requested. Staff are trained to be sensitive to gender identity, past experiences of trauma or abuse, and the needs of individuals with communication or cognitive difficulties.

F. Safeguarding and Protection
The use of a chaperone is a proactive safeguarding measure. If the chaperone observes any behaviour, comments, or actions that may be inappropriate or place the resident at risk, they must follow CHW13 – Safeguarding Policy and report the concern immediately. Where there are repeated requests to exclude a chaperone or concerns about the appropriateness of a clinical interaction, this is escalated to the Registered Manager and safeguarding lead. Chaperones also serve to protect staff from unfounded allegations and support a culture of transparency.

G. Recording and Documentation
Whenever a chaperone is present, this must be recorded in the service user’s care notes. The record must include:

• The name and role of the chaperone
• The reason for the procedure or interaction
• Whether the chaperone was offered, accepted, or declined
• Any relevant observations made by the chaperone
  Documentation must be completed immediately following the event to ensure accuracy and transparency.

H. Managing Declined Chaperones
If a resident chooses to decline a chaperone, this decision is respected, documented, and a dynamic risk assessment is completed by the staff member to ensure it is safe to proceed. Where the absence of a chaperone may place the staff member or resident at risk, the procedure may be postponed until a suitable arrangement is made. In such cases, this is discussed with the Registered Manager and communicated sensitively with the resident.

I. Multi-Agency and Visiting Professionals
Where visiting professionals (e.g. GP, district nurse, physiotherapist) attend the service to conduct examinations or assessments, staff ensure that residents are informed of their right to request a chaperone. A member of the care home team may act as the chaperone unless the professional brings their own colleague for this purpose. Staff must ensure that all such visits are properly recorded, including the name of any chaperone present.

J. Audit and Continuous Improvement
The Registered Manager is responsible for monitoring the use of chaperones through audits of care records, feedback from service users, and incident logs. Trends or concerns are reviewed during quality assurance meetings and training plans are updated where necessary. Service users’ experiences are sought through review meetings and feedback tools to ensure that the use of chaperones continues to meet their needs and preferences.

5. Policy Review

This policy will be reviewed annually or earlier in response to changes in legislation, guidance from CIW, or following any incident involving the inappropriate use or absence of a chaperone. The Registered Manager is responsible for ensuring staff awareness and adherence to this policy and for integrating it into ongoing safeguarding and care practice training.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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