Freedom of Information Request – Ref: FOI 087-2026
Thank you for your recent Freedom of Information request. Please find our response below.
You asked:
1) Current chaperone policy or policies relating the use of formal and informal chaperones.
Our response:
Please click on following link to access our “Chaperone Guidelines” – 8.1 – CLG013 Chaperone Guideline V3 issued 3.12.25
You asked:
2) Associated procedures & guidelines including:
- a) Guidance on how the offer, acceptance, or refusal of a chaperone must be recorded in patient notes.
- b) Guidance on how the sex of the chaperone is recorded.
Our response:
Please click on following link to access our “Chaperone Guidelines” – 8.1 – CLG013 Chaperone Guideline V3 issued 3.12.25
You asked:
3) If your policy/procedures/guidelines have been withdrawn, please provide:
- a) the most recent version.
- b) the date it was placed under review or withdrawn.
- c) the communications with staff when it was put under review or withdrawn.
- d) the timetable for development and approval of any replacement policy
- e) details of internal and external consultation lists.
Our response:
Please click on following link to access our current “Chaperone Guidelines” – 8.1 – CLG013 Chaperone Guideline V3 issued 3.12.25
You asked:
4) If not included in the policy/procedures/guidelines, please also disclose:
- a) training and competency standards for staff acting as formal chaperones.
- b) training description and provision for chaperones (eg online, in person, what organisations delivers the training and outline).
Our response:
As part of the chaperone guidelines there is now to be an assessment of competence to be completed by unregistered staff so that they can act as a chaperone if required. The course will introduce the role of a chaperone and assess their knowledge to be able to undertake the task.
Aim of Course
To be confident and competent to act as a chaperone when requested and to have a clear understanding of the expectations and role.
Learning outcomes
It is expected that the staff member will be able to: ·
- Explain the role of the chaperone and when one is be required.
- Discuss when a chaperone should be offered to a service user. ·
- Describe what types of chaperones there are and who can act as one.
- Fully discuss the importance of consent and the barriers to gaining consent.
- Demonstrate an understanding about consent for children under 18.
- Describe the process of acting as a chaperone and the expectations.
- Discuss how to report any safeguarding concerns identified.
- Accurately document in the electronic patient records that a chaperone was used in accordance with trust policy.
Discuss understanding of the Chaperone Policy, to include:
- Demonstrate an understanding about why a chaperone may be required, and the barriers
- Demonstrate knowledge of the role, and types of chaperones.
- Demonstrate an understanding of consent and confidentiality
- Demonstrate appropriate behaviour
- Follow instruction from the clinician
- Understand the importance of documenting in clinical records.
(This is taken from the Assessment of Competence form that is attached to the Chaperone Policy as appendix 4.)
Who is this training for?
Registered and non-registered staff including Healthcare Assistants, Admin and Reception staff with competence
You asked:
5) Audit reports, quality assurance reviews, compliance monitoring, and management and/or board reports relating to chaperoning 2024 to date.
Our response:
| Monitoring Requirements and Methodology | Frequency | Further Actions |
| Any service user feedback, complaint or information from Patient and Carer Experience which relates to non-compliance with the standards in this guideline will be subject to DATIX and further investigation | On-Going | Reported to the Trust Board |
| Individual services may wish to audit their own use of chaperones – see appendix 3 for suggested template | Annual | Reported to the Trust Board |
You asked:
6) Related equality impact assessments (EIAs) if separate
Our response:
Please click on link to access – CLG013 Chaperone Guideline V3 EIA
You asked:
7) Datix reports:
a) Number of Datix reports raised related to chaperoning in 2024, 2025 and 2026 Jan & Feb, by sex of patient and chaperone & definition of sex field in Datix.
b) If you record this data by gender, please disclose the Number of Datix reports raised related to chaperoning in 2024, 2025 and 2026 Jan & Feb, by gender of patient and chaperone and definition of gender field in Datix.
Our response:
| Jan-Feb 2024 | Jan-Feb 2025 | Jan-Feb 2026 | |
| Incidents involving male patients | 0 | 1 | 0 |
| Incidents involving female patients | 0 | 0 | 1 |
This is based on incidents where “chaperone” or “chaperoning” is mentioned in the incident description, as we don’t have a specific category of incident related to chaperoning.
You asked:
8) Concerns:
a) Number of concerns raised by chaperones, if not recorded via Datix, in 2024, 2025 and 2026 Jan & Feb, by sex of patient and chaperone & definition of sex field.
Our response:
Zero
You asked:
b) If you record this data by gender, please disclose the number of concerns raised by chaperones in 2024, 2025 and 2026 Jan & Feb, by gender of patient and chaperone and definition of gender field.
Our response:
Not applicable.
You asked:
9) Complaints:
a) Number of complaints raised related to chaperoning in 2024, 2025 and 2026 Jan & Feb, by sex of patient and chaperone & definition of sex field in your complaints system.
Our response:
Zero.
You asked:
b) If you record this data by gender, please disclose the number of complaints raised related to chaperoning in 2024, 2025 and 2026 Jan & Feb, by gender of patient and chaperone and definition of gender field in your complaints system.
Our response:
Not applicable.
You asked:
c) Number of Freedom to Speak Up reports related to chaperones in 2024, 2025 and 2026 Jan & Feb by sex of the reporter.
Our response:
Zero
You asked:
d) If you record this data by gender, please disclose the number of cFTSU reports related to chaperoning in 2024, 2025 and 2026 Jan & Feb, by gender of the reporter.
Our response:
Not applicable.
Next steps:
Should you have any queries in relation to our response, please do not hesitate to contact us. If you are unhappy with the response you have received in relation to your request and wish to ask us to review our response, you should write to:
Louise Moss
Head of Legal Services / Associate Director of Corporate Governance
c/o Gloucestershire Health and Care NHS Foundation Trust
Edward Jenner Court
1010 Pioneer Avenue
Gloucester Business Park
Brockworth, GL3 4AW
E-mail: louise.moss@ghc.nhs.uk
If you are not content with the outcome of any review, you may apply directly to the Information Commissioner’s Office (ICO) for further advice/guidance. Generally, the ICO will not consider your case unless you have exhausted your enquiries with the Trust which should include considering the use of the Trust’s formal complaints procedure. The ICO can be contacted at: The Information Commissioner’s Office, Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF.