TRUST Chaperone Policy

CHAPERONE POLICY- TELEREHAB LTD
Policy Date: August 2025
Author: S Paddison Director
Review Date: August 2026

Equality Impact Assessment (EIA) Disclosure Statement

This policy was assessed on the 01 August 2025 for its impact on equality. The assessment determined that the policy
will not have a significant negative impact on equality in relation to each of the protected staff/patient groups below:

i.) Age; The policy promotes safety, privacy, dignity, choice and respect for all patients. Children may require support from a parent/significant other with appropriate explanation of the procedure to gain understanding.
ii.) Sex (Male and Female); The policy promotes safety, privacy, dignity, choice and respect for all patients.
iii.) Disability (Learning Disability/Physical or Sensory Disability); It is essential that patients understand their care so they are able to make informed decisions and express their needs, preferences and concerns. Therefore patients/relatives who have specific communication needs may require the support of an interpreter or communication aide to consent.
iv.) Race or Ethnicity; The policy promotes safety, privacy, dignity, choice and respect for patients from all racial backgrounds.
v.) Religion and Belief; Religion and culture should be considered. Where appropriate assessments should be conducted by practitioner of the same sex if requested.
vi.) Sexual Orientation (gay, lesbian or heterosexual); The policy promotes safety, privacy, dignity, choice and respect for all patients.
vii.) Gender Reassignment (The process of transitioning from one gender to another); The policy promotes safety, privacy, dignity, choice and respect for all patients.
viii.) Pregnancy, Maternity, Marriage and Civil Partnership; The policy promotes safety, privacy, dignity, choice and respect for all patients.

1. Summary

This policy applies to all clinicians directly working for the organisation.

To produce a co-ordinated approach to the use of chaperones during consultations and visual examinations carried out by Telerehab Ltd. All healthcare professionals have a responsibility to ensure they work in line with their own professional code of conduct.

The patient will be in their own home and may feel a sense of safety but it is essential that they are provided with the opportunity to have someone with them acting as their chaperone.

The relationship between a patient and their healthcare professional is based on trust. The healthcare professional may not have doubts about a patient they have known for a long period of time and feel it is not necessary to offer a formal chaperone. This should not detract from the fact that any patient is entitled to the right to request / be offered an opportunity to arrange a chaperone (of the same sex) being present during any consultation, within the boundaries of each individual service or planned appointment made and especially when an individual may need to remove clothing for any part of an assessment.

A chaperone will act as a safeguard for both patient and clinician, and their role will depend on the needs of the patient.

 

2. Introduction and Aims

The aim of this policy is to raise staff awareness of the use of chaperones and to provide a coordinated approach to the use of chaperones during Digital Health consultations, and visual
examinations, carried out when working with Telerehab Ltd, providing the protection of both patient and healthcare professional.

Telerehab Ltd is committed to providing a safe, comfortable environment where patients and staff can be confident that best practice is being followed at all times and the safety of everyone is of paramount importance.

Patients can find some consultations or visual examinations distressing and may prefer to have a chaperone present in order to support them. It is good practice to offer all patients a chaperone for any consultation, examination or procedure, or where the patient feels one is required.

Any consultations or examinations involving the need to undress, and may make the patient feel particularly vulnerable.In these circumstances the patient must be asked whether they wish to arrange a chaperone to be present to act as a safeguard for both patient and clinician.

All patients have the right, if they wish to have a chaperone present during an assessment, examination or treatment or any care irrespective of organisational constraints or settings in which they are carried out.

Staff should be sensitive to differing expectations with regard to race, culture, ethnicity, age, gender and sexual orientation, and wherever possible, the chaperone should be of the same gender as the patient.

3. Definitions

For this policy, the following definitions are used:

CHAPERONE
The Oxford dictionary defines a chaperone as, a person who accompanies and looks after another
person or group of people. There is no common definition of a ‘chaperone’ in healthcare and the
role varies according to the needs of the patient, healthcare professional, and the 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 patient. This should be documented.

INFORMAL CHAPERONE
Informal chaperones include family members, friends, carers, legal guardian, non -clinical staff or
care assistants. Many patients may feel reassured by the presence of a familiar person i.e. a
family member or a friend and this in almost all cases should be accepted, as the Chaperone.
The patient will be in their own home and an informal chaperone will be there to provide emotional
support and reassurance to the patient/service user. It is inappropriate to expect an informal
chaperone to take an active part in the examination. The examiner must also feel safe with the
informal chaperone.

FORMAL CHAPERONE
Formal Chaperones can include all medical, registered Healthcare professionals and healthcare
support workers. They have a specific role to play in the consultation and this role should be made
clear to both the patient and the person undertaking the chaperone role. This role may include
assisting with undressing or assisting in the procedure. In this situation, the chaperone will be
invited to be present by the patient and it will be their decision whether the healthcare professional
participates in the consultation and assessment.

4. Duties and Responsibilities

Chief Executive and Clinical Governance Lead
Have ultimate responsibility for the implementation and monitoring of the policies in use in the organisation- Trust. This responsibility may be delegated to an appropriate colleague.

All Executive Directors
Will support the implementation of the chaperone policy and ensure their colleagues/Associates
abide.

5. Body of Policy

Key Messages:
Patients
● All patients have the right, if they wish to have a chaperone present during an examination and treatment.
● Patients should be given the opportunity to state their preferences in relation to the sex of the chaperone. This must be documented in their Telerehab Ltd health records.
● The patient will be completely responsible for the choice of their chaperone in their own home. If a chaperone is desired but is unavailable, the patient must then decide if they wish the consultation and assessment to proceed or be re-scheduled and this documented decision should be recorded in the Telerehab Ltd health records.

● Patients should be informed of the Telerehab Ltd Chaperone Policy Healthcare professionals

Healthcare Professionals

● All Telerehab Ltd healthcare professionals must be aware of and comply with the Chaperone Policy
● It is mandatory within Telerehab Ltd that a formal chaperone is present for any parts of the consultation that may require the patient to undress, in order to carry out the assessment.
● Staff should be sensitive to differing expectations with regard to race, culture, ethnicity, age, gender and sexual orientation and where ever possible the chaperone should be of the same gender as the patient. As the patient is within their own home they will choose their appropriate chaperone.
● The need for emergency care will take precedence over the request and/or requirement for a chaperone
● Professionals may be asked to justify any failure to follow this policy.

6. THE ROLE OF THE EXAMINER

Before conducting an examination that will require a patient to uncover part of their body to be seen by the Telerehab UK clinical professional, the examiner should:
● Explain to the patient why an examination is necessary and give the patient an opportunity to ask questions
● Explain what the examination will involve, in a way the patient can understand, so that the patient has a clear idea of what to expect. Clarify that no images will be stored from the examination. If an image will be beneficial to record, the patient will provide the image independently to Trust Telerehab Ltd using a secure link, provided by the clinician.
● Get the patient’s consent before the examination and record that the patient has given it via the Telerehab consent record.
● Protect the patient from vulnerability and embarrassment. Patients should be offered the choice of the gender of their chaperone.
● From 16 years, a person can be presumed to have the capacity to consent depending on their maturity and ability to understand what is involved.

7. THE EXAMINATION PROCESS

● Patients will arrange someone in their own home, if they need to be assisted in removing clothing. Trust Tele-rehab clinicians should be aware and sensitive to religious customs and beliefs, when asking a patient to remove clothing to reveal a body part.
● Direct the patient that they should keep themselves covered as much as possible to maintain their dignity.
● The patient will not be asked to take off more clothing than is necessary.
● Telerehab Ltd professionals will ensure that any examinations should take place in an appropriate situation in the patient’s home and the chaperone must be present if appropriate. Ensure the environment supports privacy and dignity.
● During the examination, you must explain what you would like to observe clearly, explain why and seek the patient’s permission
● Stop the assessment if the patient asks you to.
● Keep discussion relevant and don’t make unnecessary personal comments
● Following any examination, patients will have an opportunity to re-dress before the consultation continues.
● Document the interventions, details of the chaperone patient consent and outcome in the Telerehab Ltd patient’s electronic records.
● It is important that chaperones should place themselves within the same room and not just be within earshot of the consultation, (as they are then not technically chaperoning).
● Provide protections to healthcare professionals against unfounded allegations or improper behaviour

8. DOCUMENTATION

The name and role of the chaperone present, and whether ‘formal’ or ‘informal’, must be documented in the patient’s notes or electronic record. If the patient is offered a chaperone and declines the offer, this must also be documented.

9. WHERE A CHAPERONE IS DECLINED BY A PATIENT

● If a patient prefers to undergo an examination/ assessment without the presence of a chaperone this should be respected and their decision documented in their clinical record.
● The only exclusion to this is when a patient is asked to reveal a more private area of their body, such as their buttock to reveal a pressure ulcer or a catheter area issue. In this case it is mandatory to ask a patient to arrange to have a chaperone, as outlined in this policy
● If the patient has declined a chaperone for the assessment, the practitioner must explain clearly to the patient why a chaperone is necessary. In this case, the examination should not proceed without a chaperone and request that the appointment is rearranged when a chaperone is available.
● Any discussion about chaperones and the outcome should be recorded in the patient’s notes or electronic record. That the offer of a chaperone was made and declined should always be recorded.

10. PATIENTS WITH INDIVIDUAL NEEDS

Patients with communications needs or learning disabilities must have a formal chaperone for all examinations/assessments. Family or friends who understand their communications needs and are able to minimise any distress, should be invited to be present throughout any examination. Tele-rehab Ltd practitioners must be aware of the implications of the Mental Capacity Act (2005)
(‘MCA’) and cognitive impairment. If a patient’s capacity to understand the implications of consent to proceed with a consultation, with or without the presence of a chaperone, is in doubt, the consultation should not be carried out. This should be fully documented in the patient’s Telerehab Ltd electronic record, along with the rationale for the decision.

11. INDUCTION OF CLINICAL STAFF

All clinical professionals should provide evidence of formal training in Safeguarding and MCA & DoLS. All staff should have an understanding of the role of the chaperone and the procedures for raising concerns.