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Use of Chaperones Policy in Home Care

1. Purpose

The purpose of this policy is to ensure that all people living at {{org_field_name}} receive care and support that protects their dignity, privacy, autonomy, safety and human rights. The use of a chaperone during intimate, personal, sensitive or potentially distressing care provides reassurance to the person, supports transparency, protects both the person and staff, and helps reduce the risk of abuse, misunderstanding or unsafe practice.

This policy applies a person-centred and rights-based approach. Chaperones must only be used with the person’s informed consent, unless the person lacks capacity to make the specific decision and the use of a chaperone is agreed as being in their best interests in accordance with the Mental Capacity Act 2005. The policy supports compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including Regulations 9, 9A, 10, 11, 12, 13, 17, 18, 19 and 20, and relevant CQC quality statements under the current assessment framework.

The policy also supports compliance with the Care Act 2014 safeguarding duties, the Mental Capacity Act 2005, the Human Rights Act 1998, the Equality Act 2010, UK GDPR and the Data Protection Act 2018.

2. Scope

This policy applies to all staff employed or engaged by {{org_field_name}}, including permanent, temporary, bank, agency, volunteer and student workers, and to any person who may be involved in supporting, observing or chaperoning personal, intimate or sensitive care within the care home.

This policy applies to all people living at the care home, including people receiving residential care, nursing care, respite care, short-term care or end-of-life care. It also informs relatives, representatives, advocates, visitors and visiting professionals of the person’s right to request, accept or decline a chaperone, and of the care home’s responsibility to protect dignity, privacy, consent, safety and safeguarding.

This policy covers all situations where a chaperone is requested, offered, considered necessary following risk assessment, or included within a person’s care plan. It applies regardless of a person’s age, sex, gender identity, sexual orientation, disability, race, religion or belief, communication needs, mental capacity, health condition or personal circumstances.

3. Related Policies

The use of chaperones intersects with a range of other policies to ensure coordinated and consistent care practices. These include:

• CH07 – Person-Centred Care Policy: For tailoring chaperone use based on individual needs and preferences.
• CH08 – Dignity and Respect Policy: Ensures respect for individuals’ wishes and privacy during care.
• CH09 – Consent to Care Policy: Aligns with obtaining informed consent regarding chaperone presence.
• CH11 – Safe Care and Treatment Policy: Supports safe working practices and the prevention of harm.
• CH13 – Safeguarding Adults from Abuse and Improper Treatment Policy: Provides a preventative approach to protect individuals and staff.
• CH39 – Mental Capacity and Deprivation of Liberty Safeguards Policy: Ensures decisions involving chaperones are made appropriately for those lacking capacity.
• CH40 – Assisting with Personal Care Policy: Guides how to provide intimate care sensitively with chaperones.

4. Policy Statement and Principles

4.1 Person-Centred Consent

Every person living at {{org_field_name}} has the right to be offered a chaperone and the right to accept or refuse a chaperone, unless there is a lawful and clearly recorded reason why a chaperone is required to protect the person or others. Staff must always explain the purpose of the chaperone in a way the person can understand, including who the chaperone is, why they are being offered, what they will do, what they will observe, and what information may be recorded.

Consent to the presence of a chaperone must be obtained before the care or support begins. Consent must be voluntary, informed and specific to the situation. Staff must not assume that a person has agreed to a chaperone because a chaperone was used previously.

Where a person has communication needs, staff must make reasonable adjustments to support understanding and decision-making. This may include using accessible information, communication aids, an interpreter, an advocate, additional time, or support from someone who knows the person well, where this is appropriate and agreed by the person.

Where a person lacks capacity to decide whether a chaperone should be present for a specific episode or type of care, staff must follow the Mental Capacity Act 2005. A capacity assessment must be decision-specific and time-specific. Any decision to use, not use, or restrict a chaperone must be made in the person’s best interests, be the least restrictive option, and involve the person and relevant others, such as family, representatives, attorneys, deputies or advocates, where practicable and appropriate.

Where the person has a legally authorised representative, such as a Lasting Power of Attorney for Health and Welfare or a Court of Protection Deputy, staff must involve that representative where the decision falls within their legal authority. Staff must still involve the person as much as possible.

A person’s preferences about the gender, identity, role or individual chaperone must be recorded in their care plan and respected wherever reasonably practicable. Where a preference cannot be met, staff must explain the reason, consider alternatives, and record the discussion and outcome.

4.2 When Chaperones Are Offered, Considered or Required

A chaperone must be offered before any care, treatment, examination or support that may be intimate, personal, intrusive, sensitive, distressing or open to misunderstanding. The offer must be made respectfully and in a way that does not make the person feel pressured or embarrassed.

A chaperone must be offered or considered in the following circumstances:

• bathing, showering or bed bathing;
• toileting, continence care or catheter care;
• dressing, undressing or support with nightwear;
• support with personal hygiene, including washing intimate areas;
• application of creams, dressings or medicines to intimate areas;
• intimate examinations or observations carried out by nurses, GPs, allied health professionals or visiting clinicians;
• moving and handling where clothing, exposure or close physical contact may affect privacy or dignity;
• care involving a person who has expressed anxiety, distress, fear, embarrassment or previous discomfort;
• care involving a person who has requested a specific staff member, a specific gender of staff member, or the presence of another person;
• care provided by a new staff member, agency worker, student, volunteer or staff member unfamiliar to the person;
• care provided after a complaint, allegation, safeguarding concern, unexplained injury or incident;
• care where there is a known risk of misunderstanding, disinhibition, distress, sexualised behaviour, aggression, trauma response or false allegation;
• care where the person, their representative, an advocate, staff member or manager reasonably requests a chaperone.

A chaperone may be required following an individual risk assessment where this is necessary and proportionate to protect the person, staff or others from risk of harm, abuse, misunderstanding or distress. Any requirement for a chaperone must be recorded in the person’s care plan, including the reason, the circumstances in which it applies, the person’s views, consent or best-interests decision, and the review date.

A blanket rule that all intimate care must always be chaperoned must not be applied. Decisions must be person-centred, lawful, proportionate and based on the person’s needs, wishes, risks and rights.

4.3 Visitors, Relatives, Friends and Advocates in Care Homes

People living at {{org_field_name}} have the right to receive visits from people they want to see and to be supported to maintain contact with family, friends and advocates, in line with Regulation 9A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

A visitor, relative, friend or advocate may provide emotional support or act as the person’s chosen supporter during sensitive discussions or care planning. However, they must not automatically be treated as a formal chaperone for intimate care. A family member, friend or advocate may only act as a chaperone where the person gives informed consent, the arrangement is appropriate, confidentiality is protected, there is no conflict of interest or safeguarding concern, and the arrangement has been risk assessed.

The care home must not use chaperone arrangements to prevent, discourage or unreasonably restrict visiting, contact, advocacy or accompaniment. Any restriction on visits, accompaniment or the involvement of a person’s chosen supporter must be exceptional, lawful, necessary, proportionate, least restrictive, individually risk assessed, recorded and reviewed regularly.

Where a person lacks capacity to decide whether a visitor, family member, friend or advocate should be present during care or support, staff must follow the Mental Capacity Act 2005 and make a best-interests decision. The person must be involved as much as possible, and relevant others must be consulted where practicable and appropriate.

4.4 Who Can Be a Chaperone

A formal chaperone will usually be a member of staff employed or engaged by {{org_field_name}} who is suitable, competent, trained and appropriately checked for the role. This may include:

• a care worker;
• a senior care worker;
• a nurse;
• a team leader;
• a deputy manager;
• the registered manager;
• another competent staff member who has received appropriate training.

Staff acting as formal chaperones must have completed the provider’s recruitment checks, including appropriate Disclosure and Barring Service checks, identity checks, references and right-to-work checks, in line with Regulation 19 and the provider’s safer recruitment procedures.

A family member, friend, advocate or representative may support the person if the person wants them present. However, they are not automatically a formal chaperone and must not be asked to undertake staff duties, supervise staff practice, provide regulated care, or replace the provider’s responsibility to deploy suitable staff.

A family member, friend, advocate or representative may act as a chaperone only where this is appropriate, agreed by the person, risk assessed, recorded, and consistent with safeguarding, confidentiality, dignity and the person’s best interests. Staff must not assume that a relative, friend or advocate is willing or suitable to act as a chaperone.

A person must not act as a chaperone where there is a conflict of interest, a safeguarding concern, a complaint or allegation involving them, a concern about coercion or undue influence, or where their presence would compromise the person’s dignity, privacy, consent, safety or wellbeing.

4.5 Role and Conduct of the Chaperone

The role of the chaperone is to provide reassurance, observe the care or interaction, support dignity and privacy, promote transparency, and raise concerns if practice is unsafe, disrespectful, abusive, discriminatory or inconsistent with the person’s wishes or care plan.

The chaperone must:

• introduce themselves and explain their role;
• remain present for the agreed part of the care or interaction;
• position themselves in a way that supports observation while preserving the person’s dignity and privacy;
• avoid unnecessary conversation or actions that may embarrass or distress the person;
• respect confidentiality;
• intervene appropriately if the person becomes distressed, withdraws consent, asks for care to stop, or appears unsafe;
• report and record any concern without delay.

The chaperone must not take over the care unless they are competent and authorised to do so, must not act as a passive observer where harm or poor practice is occurring, and must not discuss the person’s private information outside the agreed care, reporting or safeguarding process.

4.6 Documentation and Record-Keeping

Staff must keep accurate, complete, contemporaneous and detailed records of chaperone discussions, decisions and use. Records must be factual, respectful and proportionate.

The following must be recorded in the person’s care notes and, where relevant, in their care plan:

• whether a chaperone was offered;
• whether the person accepted or declined the chaperone;
• how consent was obtained;
• the person’s preferences, including any preference about gender, role or individual chaperone;
• the name and role of the chaperone;
• the reason the chaperone was present;
• the care, treatment or support being provided;
• any concerns, distress, refusal, withdrawal of consent, incident, allegation or safeguarding concern;
• any action taken during or after the care;
• where the person lacks capacity, the capacity assessment and best-interests decision;
• any involvement of attorneys, deputies, advocates, family members or representatives;
• any reason why a requested chaperone could not be provided and what alternative was offered;
• any decision that a chaperone is required as part of the person’s care plan or risk assessment;
• the date for review of any planned chaperone arrangement.

Where a person refuses a chaperone, staff must record the refusal and consider whether care can safely and lawfully proceed. If there are concerns about safety, safeguarding, consent, distress or staff protection, staff must seek advice from a senior member of staff or the registered manager before proceeding, unless urgent care is required to prevent harm.

Records relating to chaperone use must be audited as part of the provider’s governance arrangements. The registered manager must ensure that records are used to identify themes, training needs, safeguarding risks, complaints, equality issues, staffing concerns and opportunities for improvement.

4.7 Safeguarding, Confidentiality and Information Sharing

Chaperones form part of the care home’s safeguarding arrangements. Their presence can help prevent abuse, improper treatment, neglect, discrimination, avoidable harm, misunderstanding or unsafe practice. The use of a chaperone must never be used to override the person’s rights, dignity, consent, privacy or autonomy.

All staff and chaperones must understand that abuse and improper treatment include neglect, degrading treatment, unlawful discrimination, unnecessary or disproportionate restraint, inappropriate deprivation of liberty, sexual abuse, psychological abuse, organisational abuse and acts that significantly disregard a person’s needs or wishes.

Any concern observed or disclosed during chaperoned care must be acted on immediately. This includes concerns about staff conduct, visitor conduct, unexplained injury, distress, sexual safety, coercion, neglect, poor practice, discrimination, medication errors, unsafe moving and handling, or care provided without valid consent.

Where abuse, neglect or improper treatment is suspected, reported, witnessed or disclosed, staff must follow the Safeguarding Adults from Abuse and Improper Treatment Policy without delay. This may include immediate action to protect the person, reporting to the registered manager, referral to the local authority safeguarding team, notification to CQC where required, contact with the police where a crime may have been committed, and preservation of evidence.

Chaperones must respect confidentiality and must only share information with people who need to know in order to provide safe care, investigate concerns, meet legal duties, protect the person or others, or comply with safeguarding, regulatory or contractual requirements. Confidential information must be handled in accordance with UK GDPR, the Data Protection Act 2018 and the provider’s confidentiality and data protection policies.

4.8 Staff Training and Responsibilities

All staff must receive induction, supervision, competency assessment and refresher training appropriate to their role in relation to chaperone use. Training must include:

• the purpose and limits of chaperones;
• when a chaperone should be offered, considered or required;
• how to explain chaperone use respectfully;
• consent and the right to refuse;
• the Mental Capacity Act 2005 and best-interests decision-making;
• dignity, privacy, equality, diversity and human rights;
• safeguarding adults and recognising abuse or improper treatment;
• sexual safety and professional boundaries;
• confidentiality and information sharing;
• accurate record-keeping;
• how to respond to concerns, incidents, complaints, allegations or withdrawal of consent;
• how chaperone arrangements are reflected in care plans and risk assessments.

Staff must also complete learning disability and autism training appropriate to their role in line with the statutory requirement introduced through the Health and Care Act 2022 and the Oliver McGowan Code of Practice.

The registered manager is responsible for ensuring that staff understand and follow this policy. Senior staff, nurses and team leaders must monitor practice, provide guidance, review care plans, check records, and escalate concerns. Staff must not provide intimate care where they are unsure whether a chaperone is required, where consent is unclear, or where they believe the situation is unsafe, unless urgent action is needed to prevent harm.

4.9 Monitoring and Review of Practice

The Registered Manager {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}} and Nominated Individual {{org_field_nominated_individual_first_name}} {{org_field_nominated_individual_last_name}} are responsible for monitoring the effectiveness of this policy and ensuring that chaperone practice supports safe, effective, caring, responsive and well-led care.

Monitoring will include:

• care plan audits;
• daily note and record audits;
• review of incidents, complaints, safeguarding concerns and allegations;
• supervision and competency checks;
• observation of practice;
• feedback from people living at the home;
• feedback from families, representatives and advocates;
• staff feedback and whistleblowing themes;
• analysis of whether people’s preferences and protected characteristics are being respected;
• review of any restrictions, risks or recurring concerns linked to chaperone use.

Where monitoring identifies gaps, the registered manager must take prompt action. This may include updating care plans, revising risk assessments, providing additional staff training, addressing conduct or competency concerns, making safeguarding referrals, notifying CQC, reviewing staffing levels, or updating this policy.

Evidence from monitoring must be retained as part of the provider’s governance records and used to support continuous improvement and CQC assurance.

4.10 Refusal, Withdrawal of Consent or Unavailability of a Chaperone

A person with capacity has the right to refuse a chaperone or withdraw consent to a chaperone at any time. If consent is withdrawn, staff must stop the care or interaction as soon as it is safe to do so, check the person’s wishes, and agree how to proceed.

Where a person refuses a chaperone but the staff member believes a chaperone is necessary to provide safe, dignified or transparent care, the staff member must explain the concern, consider alternatives, and seek advice from a senior member of staff or the registered manager. Alternatives may include delaying non-urgent care, offering a different chaperone, offering a chaperone of a preferred gender, involving an advocate, or changing the staff member providing care.

Where a chaperone is requested but is not immediately available, staff must consider whether the care is urgent. Non-urgent care should be delayed until a suitable chaperone is available where this is the person’s preference. Urgent care must not be withheld where delay would place the person at risk of harm, but the reason for proceeding without a chaperone must be recorded and reviewed.

Where a person lacks capacity and resists or appears distressed by the presence of a chaperone, staff must consider whether the chaperone arrangement remains in the person’s best interests and whether a less restrictive or less distressing option is available.

4.11 Complaints, Allegations, Incidents and Duty of Candour

Any complaint, allegation, incident, near miss or concern arising before, during or after chaperoned care must be taken seriously, recorded and reported in accordance with the relevant policy. This includes concerns raised by the person, a family member, advocate, visitor, staff member, chaperone or visiting professional.

Where an allegation is made against a staff member, visitor, volunteer, contractor or other person, the registered manager must take immediate steps to protect the person and others, preserve evidence, seek advice where required, and follow safeguarding, disciplinary, police referral, DBS referral and CQC notification procedures as applicable.

Where an incident meets the threshold for a notifiable safety incident, {{org_field_name}} will follow the Duty of Candour Policy. The person, or their relevant representative, must receive a truthful account of what is known, an apology, appropriate support, information about further enquiries, and written follow-up where required.

Chaperone records must be made available to support investigations, safeguarding enquiries, complaints reviews, CQC inspections and legal or professional processes where lawful and appropriate.

4.12 Equality, Diversity, Human Rights and Trauma-Informed Practice

Chaperone arrangements must respect the person’s dignity, privacy, personal identity, culture, faith, gender identity, sexual orientation, disability, communication needs and past experiences. Staff must have due regard to protected characteristics under the Equality Act 2010 and must make reasonable adjustments where needed.

Staff must recognise that intimate care may be distressing for people who have experienced trauma, abuse, sexual violence, discrimination, institutional care, restraint or loss of control. Staff must offer choice, explain each step of care, check consent regularly, preserve privacy, and stop or pause care where the person becomes distressed, unless urgent action is required to prevent harm.

The use of a chaperone must support, not undermine, the person’s human rights. Decisions must balance the person’s right to privacy and family life, autonomy, safety, protection from abuse, and freedom from degrading treatment.

5. Policy Review

This policy will be reviewed at least every 12 months, or sooner where required because of:

• changes in legislation, statutory guidance or CQC guidance;
• changes to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014;
• updates to CQC’s assessment framework, quality statements or inspection expectations;
• changes to the Oliver McGowan Code of Practice or statutory training requirements;
• safeguarding incidents, complaints, allegations or duty of candour events;
• learning from audits, care plan reviews, supervision, incidents or feedback;
• changes in local safeguarding adults board procedures;
• organisational learning or changes in the needs of people living at the home.

The registered manager is responsible for ensuring that this policy remains current, implemented in practice, and understood by staff.

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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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