1 Introduction

1.1 Policy statement

It is a requirement that, when necessary, chaperones are provided to protect and safeguard both patients and clinicians during intimate examinations and or procedures. All clinical and non-clinical staff may at some point be asked to act as a chaperone at this organisation. Therefore, it is essential that training is given and trained chaperones are aware of their individual responsibilities when performing chaperone duties.

The CQC GP Mythbuster 15: Chaperones advises that for children and young people, their parents, relatives and carers should be made aware of the policy and why this is important.

To raise awareness, the chaperone policy should be clearly advertised. At this organisation, a chaperone poster is clearly displayed in the waiting area, in all clinical areas and annotated in the organisation leaflet as well as on the organisation website.

1.2 Status

The organisation aims to design and implement policies and procedures that meet the diverse needs of our service and workforce, ensuring that none are placed at a disadvantage over others, in accordance with the Equality Act 2010. Consideration has been given to the impact this policy might have regarding the individual protected characteristics of those to whom it applies.

This document and any procedures contained within it are non-contractual and may be modified or withdrawn at any time. For the avoidance of doubt, it does not form part of your contract of employment.

Furthermore, this document applies to all employees of the organisation and other individuals performing functions in relation to the practice such as agency workers, locums and contractors.

2 Policy

2.1 Who can act as a chaperone

The GMC Intimate examinations and chaperones guidance explains that the patient should be given the option of having an impartial observer (a chaperone) present whenever possible. As per the GMC guidance, relatives or friends of the patient are not considered to be an impartial observer so would not usually be a suitable chaperone but staff at this organisation should comply with a reasonable request to have such a person present in addition to the chaperone.

It is policy that any member of the organisation team can act as a chaperone only if they have undertaken appropriate chaperone training as detailed in CQC GP Mythbuster 15: Additionally, all staff must complete chaperone awareness training which covers the role of the chaperone.

2.2 General guidance

The GMC guidance states that before conducting an intimate examination, the clinician should:

• Explain to the patient why the particular examination is necessary and give the patient the 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 including any pain or discomfort
• Get the patient’s permission before the examination and record that the patient has given it
• Offer the patient a chaperone
• If dealing with a child or young person:
• Assess their capacity to consent to the examination
• If they lack the capacity to consent, seek parental consent
• Give the patient privacy to undress and dress and keep them covered as much as possible to maintain their dignity; they should not help the patient to remove clothing unless they have been asked to or they have checked with the patient that they want help

During the examination, the clinician should:

• Explain what they are going to do before they do it, and if this differs from what they previously told the patient, explain why and seek the patient’s permission
• Stop the examination if the patient asks them to
• Keep discussion relevant and not make unnecessary personal comments
• When a chaperone is present, the details of the chaperone must be recorded in the patient’s clinical record.

2.3 Expectations of a chaperone

At this organisation, chaperones will adhere to the GMC guidance which states chaperones will:

• Be sensitive and respect the patient’s dignity and confidentiality
• Reassure the patient if they show signs of distress or discomfort
• Be familiar with the procedures involved in a routine intimate examination
• Stay for the whole examination and be able to see what the doctor is doing, if practical
• Be prepared to raise concerns if they are concerned about the doctor’s behaviour or actions

The CQC advises that for most patients and procedures, respect, explanation, consent and privacy are all that are needed. These take precedence over the need for a chaperone. A chaperone does not remove the need for adequate explanation and one

If the clinician does not want to proceed with the examination without a chaperone but the patient has refused a chaperone, the clinician must clearly explain why they want a chaperone present. The GMC states that ultimately the patient’s clinical needs must take precedence. The clinician may wish to consider referring the patient to a colleague who would be willing to examine them without a chaperone as long as a delay would not adversely affect the patient’s health.

Any discussion about chaperones and the outcome should be recorded in the patient’s medical record, and in particular:

• Who the chaperone was
• Their title
• That the offer was made and declined

2.6 Disclosure and Barring Service (DBS) check

Clinical staff who undertake a chaperone role at this organisation will already have a DBS check. The CQC states that non-clinical staff who carry out chaperone duties may need a DBS check. This is due to the nature of chaperoning duties and the level of patient contact. Should the organisation decide not to carry out a DBS check for any non-clinical staff, then a clear rationale for this decision must be given including an appropriate risk assessment.

2.7 Using chaperones during a video consultation

CQC GP Mythbuster 15 explains that many intimate examinations will not be suitable for a video consultation.

When online, video or telephone consultations take place, GMC guidance explains how to protect patients when images are needed to support clinical decision making. This includes the appropriate use of photographs and video consultations as part of patient care.

When intimate examinations are performed, it is important that a chaperone is offered. Documentation should clearly reflect this. It is important to document who provided the chaperoning and this should also state what part of the consultation they were present for.

This guidance explains how to conduct intimate examinations by video and the use of chaperones.

2.8 Practice procedure (including SNOMED codes)

If a chaperone was not requested at the time of booking the appointment, the clinician will offer the patient a chaperone explaining the requirements:

• Contact reception and request a chaperone
• Record in the individual’s healthcare record that a chaperone is present and identify them
• The chaperone should be introduced to the patient
• The chaperone should assist as required but maintain a position so that they are able to witness the procedure/examination (usually at the head end)
• The chaperone should adhere to their role at all times
• Post procedure or examination, the chaperone should ensure they annotate in the patient’s healthcare record that they were present during the examination and there were no issues observed
• The clinician will annotate in the individual’s healthcare record the full details of the procedure as per current medical records policy

2.9 Escorting of visitors and guests (including VIPs)

There may be, on occasion, a need to ensure that appropriate measures are in place to escort visitors and guests including VIPs. On such occasions, this organisation will follow the recommendations outlined in the Lampard Report (2015).

If media interest is likely, the Practice Manager is to inform the local ICB, requesting that the communication team provides guidance and/or support where necessary

Under the Data Protection Act 2018 you have a right to know who holds personal information about you. This person or organisation is called the data controller. In the NHS, the data controller is usually your local NHS board and your GP surgery. The NHS must keep your personal health information confidential. It is your right.

Please be aware that our staff are bound to the NHS code of confidentiality. Our staff are therefore not permitted to discuss any of our patient’s medical history, this includes their registration status, without their written consent to do so.

Once we have received their written consent and verified this with the patient, then we can provide you with this information, this includes complaining on behalf of a patient, but excludes patients who are unable to act on their own behalf and already have a designated person or carer responsible for their medical care.

We therefore respectfully ask parents and guardians not to request information regarding their relatives or to complain on their behalf unless we have their written consent to do so.

Suggestions and Complaints

Your comments and suggestions are welcome to improve the quality of our service.

Friends and Family Test

The Friends and Family Test (FFT) is an important feedback tool that supports the fundamental principle that people who use NHS services should have the opportunity to provide feedback on their experience. Listening to the views of patients and staff helps identify what is working well, what can be improved and how.

The FFT asks people if they would recommend the services they have used and offers a range of responses. When combined with follow-up questions, the FFT provides a tool to highlight both good and poor patient experience. This kind of feedback is vital in transforming our service and supporting patient choice.

So far, the FFT has produced more than 48 million pieces of feedback across England – and the total rises by around 1.2 million more every month – making it the biggest source of patient opinion in the world. Scores so far have told us that at least nine out of ten patients would recommend the NHS services they used to their loved ones.

Patient comments also identify areas where improvements can be made so that providers can make care and treatment better for everyone.

The feedback gathered through the FFT is being used in NHS organisations across the country to stimulate local improvement and empower staff to carry out the sorts of changes that make a real difference to patients and their care.

Your Feedback

How to share your feedback

We want your feedback – whether good or bad.

We care about what you think and we want to make sure you are happy with the service you receive.

You can provide feedback using one of our ‘We care about what you think!’ leaflets in the surgery or online by filling out the Friends & Family form.

Where you have a concern we want to sort this for you. We would encourage you to talk to a member of staff as soon as possible.

What to do if you are unhappy with the service

If you are unhappy with the service we provide to you, please speak to a member of our team as soon as possible.

If you decide that you need to make a complaint, this page outlines your rights and how to make a complaint. It also provides you with contact details for a number of organisations that can help you.

How to make a complaint

If you are not happy with how we resolve your concern, you can make a formal complaint either in writing or verbally. We would encourage you to do this as soon as possible.

If you make a complaint verbally, a record of your complaint will be made and you will be provided with a written copy.

When emailing or writing to us, please mark your email or letter for the attention of the Practice Manager of the surgery.

What information should you provide?

However you choose to contact us, it is important to provide as much information as you can, especially dates, times and venues.

The sort of thing to include is:

• Your name, address and telephone number
• The nature of your complaint:
  • details of what happened, when it happened and where it happened (it helps to include
  • the names or titles of members of staff if you know them);
  • details of what you want to complain about; and
  • details of what you would like the outcome of the complaint to be if you can. For example, an apology or tell us what we could do to improve things.

What are your rights?

If you are not happy with the care or treatment you’ve received or you’ve been refused treatment or a condition, you have the right to complain, have your complaint investigated and be given a full and prompt reply.

The NHS Constitution explains your rights when it comes to making a complaint. You have the right:

• to have any complaint you make about NHS services acknowledged within three working days and to have it properly investigated;
• to discuss the manner in which the complaint is to be handled, and to know the period within which the investigation is likely to be completed and the response sent;
• to be kept informed of progress and to know the outcome of any investigation into your complaint, including an explanation of the conclusion and confirmation that any action needed in consequence of the complaint has been taken or is proposed to be taken;
• to take your complaint to the independent Parliamentary and Health Service Ombudsman or Local Government Ombudsman, if you are not satisfied with the way your complaint has been dealt with by the NHS;
• to make a claim for judicial review if you think you have been directly affected by an unlawful act or decision of an NHS body or local authority; and
• to compensation where you have been harmed by negligent treatment.

The NHS also commits:

• to ensure that you are treated with courtesy and you receive appropriate support throughout the handling of a complaint; and that the fact that you have complained will not adversely affect your future treatment;
• to ensure that when mistakes happen or if you are harmed while receiving health care, you receive an appropriate explanation and apology, delivered with sensitivity and recognition of the trauma you have experienced, and know that lessons will be learned to help avoid a similar incident occurring again; and
• to ensure that the organisation learns lessons from complaints and claims and uses these to improve NHS services.

Who else can help me?

Making a complaint can be daunting, but help is available.

Making a complaint

If you have a complaint relating to the way an NHS service has been commissioned by the LLR ICB, or you have been directly affected by a commissioning decision made by us, you can contact us in the following ways.

Phone: 0116 295 7572

Email: llricb-llr.enquiries@nhs.net

Write: Corporate Affairs Team,
Leicester, Leicestershire ICB
Room G30,
Pen Lloyd Building,
County Hall,
Glenfield,
Leicester,
LE3 8TB

Your complaint should be made as soon as possible. This should be within a year of the event or as soon as it came to your attention. You can make a complaint on your own or on behalf of someone else if you have their permission.

NHS ENGLAND

NHS England welcomes concerns, compliments and complaints as valuable feedback that will help the NHS learn from your experiences and make improvements to services it commissions.

Telephone: 0300 311 2233
Email: england.contactus@nhs.net
By Post: NHS England, PO Box 16738, Redditch, B97 9PT

Can I get help to make my complaint?

POhWER NHS Complaints Service can support you to make a complaint and offer a free and confidential service that is independent of the NHS.

Telephone: 0300 200 0084
Website: http://www.pohwer.net/in-your-area/where-you-live/leicester-city
Email: pohwer@pohwer.net
Post: PohWER, PO Box 14043, Birmingham, B6 9BL
Text: send the word ‘pohwer’ with your name and number to 81025
Fax: 0300 456 2365
Minicom: 0300 456 2364

The support centre is open Monday to Friday from 8am to 6pm.

THE PARLIAMENTARY AND HEALTH SERVICE OMBUDSMAN (PHSO)

If you are not content with the response you receive to your formal complaint, the next step is to escalate your complaint to the PHSO.

Telephone: 0345 015 4033
Email: phso.enquiries@ombudsman.org.uk
By Post: Millbank Tower, Millbank, London SW1P 4QP

YOUR LOCAL CITIZENS ADVICE BUREAU

The Leicester Citizens Advice Bureau (CAB) is a source of advice and support if you want to make a complaint about the NHS, social services or local authorities. Wherever you live in Leicestershire, you can contact their General Advice Service.

Monday – Friday, between 9am – 4pm:
Telephone: 0300 330 1025
Website: www.leicscab.org.uk to find a local branch

HEALTHWATCH

Healthwatch is the independent consumer champion organisation created to gather and represent the views of the public. Healthwatch plays a role at both a national and local level and makes sure that the views of the public and people who use services are taken into account.

You can contact Healthwatch Leicester:

Helpline: 0116 251 8313
General Enquiries: 0116 251 0601
Email: information@healthwatchleicester.co.uk
By Post: Clarence House, Humberstone Gate, Leicester  LE1 3PJ
Website: www.healthwatchleicester.co.uk

We comply with the General Data Protection Regulation 2016 and the Data Protection Act 2018.

We use your information to provide you with Health Care services, and share your information with other organisations involved in your care.

We do this under Article 6(1) and Article 9(2)(h) of the GDPR.

For further information please see the Privacy Notice document below.

You are entitled to see what information we hold about you on request.

• Please keep your appointment or cancel it well in advance to allow other people to see us
  
• Please book urgent appointments for emergencies only
• If you feel you need a longer appointment for your problem, please tell reception at the time of booking the appointment
• If you change your name, address or telephone number please inform us as soon as possible
• Only call the Doctor out of hours if you can’t wait
• For minor ailments and injuries try the ‘Urgent Care Centre’ in Oadby: Oadby Urgent Care Centre, 18 The Parade, Oadby LE2 5BJ
• Be polite to the staff as they are just doing their job
  • The practice operates a zero tolerance policy, any patient that is violent or abusive to any member of staff may risk being removed from the practice list

There is a new Central NHS Computer System called the Summary Care Record (SCR). It is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had.

Why do I need a Summary Care Record?

Storing information in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.

This information could make a difference to how a doctor decides to care for you, for example which medicines they choose to prescribe for you.

Who can see it?

Only healthcare staff involved in your care can see your Summary Care Record.

How do I know if I have one?

Over half of the population of England now have a Summary Care Record. You can find out whether Summary Care Records have come to your area by asking your GP.

Do I have to have one?

No, it is not compulsory. If you choose to opt out of the scheme, then you will need to complete a form and bring it along to the surgery. Please contact reception for the relevant form.

More Information

For further information visit the NHS Digital website.

All telephone calls to and from the surgery are recorded to protect our patients and healthcare professionals. Patients are protected by the practice having a record of our conversations with patients, staff and other health workers to protect from potential abuse. We also occasionally use recordings for staff training and quality control.

For new patients, when you register with us, we will make it clear that all inbound and outbound calls from the surgery are recorded.

Calls, or transcripts of calls, audio or audio-visual recordings or elements of the discussion you have with the clinicians that contain clinical information may be added to your medical records, but this will be clarified with you at the time.

The recordings are stored securely on a system provided by X-on and are protected through the company’s Data Protection Policy, which is complaint with GDPR legislation. These recordings will not usually be shared outside the practice.

If we hold recordings that have not been deleted, you can ask for a copy. In order to do this, you must put the request in writing to the Practice Manager via a Subject Access Request.

The practice will not tolerate violent or abusive behaviour.

Anyone verbally abusing either a member of staff or the public, or using inappropriate language, will be asked to leave the premises and requested to find another GP.

Anyone who is violent or causes damage will be removed from our list immediately.

Patients will also be removed from the list in the following circumstances:

• Violence and aggression towards staff or members of the public;
• Damage to practice property or equipment;
• Change of residence to outside of the practice area;
• Persistent misuse of the system; or
• Patients who the doctors are unable to manage clinically e.g. breach of contract with doctor regarding use of prescribed medicine, break down in patient communication.

Members of our team are instructed to dial 999 for police assistance if patients are disruptive and display aggressive and/or intimidating behaviour and refuse to leave the premises when asked. Charges may then be brought against these individuals.

We ask you for information and keep it together with details of your care. We may use some of this information to help us to protect the health of the Nation, to help plan the future of the NHS, to train tomorrow’s clinical staff and to carry out research for the benefit of everyone.

You have a right of access to your health records. Please ask at the reception for further details on how you can access your health records online.

Everyone working for the NHS has a legal duty to keep information about you confidential.