Leeds SCP Children and Young People’s Intimate Care Good Practice Guidelines

If you are the safeguarding leading for your organisation, please ensure that you disseminate and implement this policy throughout your organisation as per the following JFDI. 

Residential settings, Health (LTHT, LCH, LYPFT), Education (SILCs), Nurseries and Childrens Centres):

  • Review own agency intimate care guidance in line with this document and update (or adopt this document) as appropriate.
  • Ensure all staff aware of any updates to own agency guidelines, and that LSCP guidance has been updated, via appropriate communication channels.
  • Place within own websites / link across to LSCP website as appropriate
  • Update any other relevant in-house policies and procedures to reflect process
  • Update in-house training to reflect and changes in guideline


All other partner agencies and clusters:

  • Disseminate process to all staff via appropriate communication channels for information
  • Place within own websites / link across to LSCP website as appropriate
  • Update in-house polices and procedures to reflect process as appropriate
  • Update in-house training to reflect process as appropriate.


When the above has been completed please update your Section 11 Audit to provide assurance that this local protocol has been disseminated and implemented.

 

Introduction

What are these guidelines? This document provides all agencies who may provide a level of intimate care to children and young people with clear guidance when developing an internal set of good practice guidelines.

Why do we need these guidelines? Children and young people who receive intimate care have the right for this to be provided in a dignified and appropriate way consistent with their level of need and is agreed by everyone involved (agency/organisation, child or young person and their parents or carers). These guidelines provide an overview of things to be considered in order to provide consistent and appropriate levels of intimate care.

Who are these guidelines aimed at? Organisations which deliver a level of intimate care to children and young people including those with a disability up to their 25th birthday. 
    
The key contact for comments about this policy is: lscp.info@leeds.gov.uk

 

Definitions

The following definitions are based on those with the document “Intimate care and toileting; Guidance for early years settings and schools” 2014, Surrey Council.

Definition of intimate care
Intimate care can be defined as care tasks of an intimate nature, associated with bodily functions, bodily products and personal hygiene, which demand direct or indirect contact with, or exposure of, the sexual parts of the body. Help may also be required with changing colostomy or ileostomy bags, managing catheters, stomas or other appliances. In some cases, it may be necessary to administer rectal medication on an emergency basis.

Intimate care tasks include:

  • Dressing and undressing (underwear)
  • Helping someone use the toilet
  • Changing continence pads/nappies (faeces and urine) 
  • Bathing/ showering
  • Washing intimate parts of the body
  • Changing sanitary wear
  • Inserting suppositories
  • Giving enemas
  • Inserting and monitoring pessaries.

Definition of personal care
Personal care generally carries more positive perceptions than intimate care. Although it may often involve touching another person, the nature of this touching is less intimate and usually has the function of helping with personal presentation and hence is regarded as social functioning. These tasks do not invade conventional personal, private or social space to the same extent as intimate care and are certainly more valued as they can lead to positive social outcomes.

Personal care tasks include:

  • Skin care/applying external medication
  • Feeding
  • Administering oral medication
  • Hair care
  • Dressing and undressing (clothing)
  • Washing non-intimate body parts
  • Prompting to go to the toilet.

Personal care encompasses those areas of physical and medical care that most people carry out for themselves but which some are unable to do because of disability or medical need.

Definition of intimate examination - includes examinations of breasts, genitalia and rectum. Cultural and diversity influences may affect what is deemed ‘intimate’ to a patient and particular regard should be taken of social, ethnic and cultural perspectives.

This document is specifically concerned with providing best practice in relation to intimate care, however it should be recognised that the definitions are potentially interchangeable depending on the needs of the child and their parents.

 

Vulnerability to abuse 

By its definition intimate care may involve touching the private parts of the child / young person’s body, increasing the vulnerability of the child / young person. Leeds SCP recognise that children who experience intimate care may be more vulnerable to abuse:-

  • Children with additional needs are sometimes taught to do as they are told to a greater degree than other children. This can continue into later years. Children who are dependent or over-protected may have fewer opportunities to take decisions for themselves and may have limited choices. The child may come to believe they are passive and powerless.
  • Increased numbers of adult carers may increase the vulnerability of the child, either by increasing the possibility of a carer harming them, or by adding to their sense of lack of attachment to a trusted adult.
  • Physical dependency in basic core needs, for example toileting, bathing, dressing, may increase the accessibility and opportunity for some carers to exploit being alone with and justify touching the child inappropriately.
  • Repeated intimate care may result in the child feeling ownership of their bodies has been taken from them.
  • Children with additional needs can be isolated from knowledge and information about alternative sources of care and residence. This means, for example, that a child who is physically dependent on daily care may be more reluctant to disclose abuse, since they fear the loss of these needs being met. Their fear may also include who might replace their abusive carer.

Abuse and children who are disabled: a training and resource pack for
trainers in child protection and disability, 1993.

 

Good Practice Guidelines

It is recommended that where children require intimate care, good practice guidelines are drawn up within the establishment and disseminated to all staff, children and young people and parents / careers.

When developing intimate care policies and / or individual intimate care plans practitioners should be aware of these increased vulnerabilities and seek to address these.

It is unrealistic to eliminate all risk but this vulnerability places an important responsibility on staff to act in accordance with agreed procedures, and where possible and appropriate for children, adolescents and or parents / carers to be involved in the development of their intimate care plan so they know where it may have been deviated from. There should also be clear escalation routes should a practitioner, parent/carer or child or young person believes that intimate care is not being undertaken in line with the agency’s intimate care policy, the individual care plan or with dignity and respect.

These guidelines should be viewed as expectations upon staff, which are designed to protect both children and staff alike. In situations where a member of staff potentially breaches these expectations, other staff should be able to question and consider this in a constructive manner, through discussing concerns with line managers, or other colleagues and their own organisations whistle blowing procedures.

Staff should be advised that if they are not comfortable with any aspect of the agreed guidelines, they should seek advice within the establishment. For example, if they do not wish to conduct intimate care on a 1:1 basis, this should be discussed, and alternative arrangements considered. For example, it may be possible to have a second member of staff in an adjoining room or nearby so that they are close to hand but do not compromise the child’s sense of privacy.

Intimate care plans should have the child’s safety, privacy and dignity at its centre.

Guidelines for good practice (adapted from the Chailey Heritage Centre).

1. Involve children, young people and parents / cares in devising intimate care plans
Parents / carers and the child or young person should be involved in individual discussions and decisions in relation to how intimate care will be managed in order to draw up an agreed plan. The wishes and feelings of both the child and the parents / carers including cultural and religious beliefs should be sought and plans should be respectful and responsive to these, reflecting where possible usual home routines. A copy of this should be given to the parents and the child or young person as well as being held within the child’s records.

The agency’s intimate care plan should be reviewed regularly (at least annually), and any individual intimate care plans should have an agreed regular review to ensure needs or requests have not changed. Any changes should be communicated to staff, children, young people and parents / carers.

Intimate care plans should be linked (where present) to a child / adolescent’s Education Health Care Plan, Individual Health Care Plan and/or Health and Safety Risk Assessment.

2. Treat every child with dignity and respect and ensure privacy appropriate to the child’s age and the situation
Privacy is an important issue. Much intimate care is carried out by one staff member alone with one child. Leeds SCP believes this practice should be actively supported unless the task requires two people (for example lifting or moving), however the need for a chaperone should be considered, and offered, on a case by case. Intimate examinations should adhere to the medical agencies chaperone policy.

Where appropriate a named member of staff who is familiar to the child / adolescent should carry out intimate care routines.  Wherever possible the member of staff should be a permanent staff member / somebody that the child knows and is familiar with, especially for younger children/children with autism/learning needs / disabilities. There should be a named second person (significant other) in case of staff absence / to cover breaks.

Having people working alone does increase the opportunity for possible abuse. However, this is balanced by the loss of privacy and lack of trust implied if two people have to be present. It should also be noted that the presence of two people does not guarantee the safety of the child or young person, organised abuse by several perpetrators can, and does, take place. Therefore, staff should be supported in carrying out the intimate care of children alone unless the task requires the presence of two people. Leeds SCP recognises that there are partner agencies that recommend two carers in specific circumstances.

Where possible, the member of staff carrying out intimate care should be someone chosen by the child or young person. For older children (eight years and above) it is preferable if the member of staff is the same gender as the young person. However, this is not always possible in practice. Agencies should consider the implications of using a single named member of staff for intimate care or a rota system in terms of risks of abuse.

3. Involve the child as far as possible in his or her own intimate care
Children / adolescents should be supported to be as involved as possible with their personal care. The intimate care plan should clearly state what the child can do independently. This will give the child some control over the process and promote the child’s independence. It should be regularly updated to reflect progress (at least termly). Try to avoid doing things for a child that s/he can do alone and if a child is able to help ensure that s/he is given the chance to do so. This is as important for tasks such as removing underclothes as it is for washing the private parts of a child’s body. Support children in doing all that they can themselves. Explain to children the tasks that you are undertaking and give choices where possible. It is good practice to take into consideration the views of the CYP offering choices where appropriate. For example, getting changed lying or standing up, which cubicle etc. Ensure that children/adolescents can communicate wishes / views in a variety of ways including those who are non-verbal’. Where possible complete personal/ intimate care routines at appropriate times to minimise children missing out on social break times, consider quieter times of day and a recognised prompt to allow children/adolescents privacy and dignity in this support.

4. Be responsive to a child’s reactions
It is appropriate to “check” your practice by asking the child, particularly a child you have not previously cared for, “Is it OK to do it this way?”; “Can you wash there?”; “How does mummy do that?”. If a child expresses dislike of a certain person carrying out her or his intimate care, try and find out why and record this in their notes / care plan. Senior leaders must ensure that intimate care is as positive experience for children and adolescents as possible. Due consideration must be given to the suitability of staff responsible for undertaking intimate / personal care i.e. if a child / adolescent is anxious around specific individuals, due to their individual needs/experiences. Or if a child/adolescent does not have a positive relationship with a specific individual.

5. Make sure practice in intimate care is as “care planned” as possible
Line managers have a responsibility for ensuring their staff have a “care planned” approach. This means that there is a planned approach to intimate care across the agency, but which is also flexible enough to be planned to meet the specific needs (and wishes as appropriate) of individuals. It is important that approaches to intimate care are not markedly different between individuals, but also reflect individual needs and wishes. For example, do you use a flannel to wash a child’s private parts rather than bare hands? Do you pull back a child’s foreskin as part of daily washing? Is care during menstruation consistent across different staff?

6. Never do something unless you know how to do it
If you are not sure how to do something, ask. If you need to be shown more than once, ask again. Certain intimate care or treatment procedures, such as rectal examinations, must only be carried out by nursing or medical staff. Medical procedures, such as giving rectal valium, suppositories or intermittent catheterisation, must only be carried out by staff who have been formally trained and assessed as competent.

7. Report and record any concerns
If you are concerned that during the intimate care of a child:

  • You accidentally hurt the child
  • The child seems sore or unusually tender in the genital area
  • The child appears to be sexually aroused by your actions
  • The child misunderstands or misinterprets something
  • The child has a very emotional reaction without apparent cause (sudden crying or shouting)
  • You suspect FGM has taken place

Report any such incident as soon as possible to the manager or designated person in charge, inform parents / carers and record it. This is for two reasons: first, because some of these could be cause for concern, and secondly, because the child or another adult might possibly misconstrue something you have done.

If a member of staff notices that a child’s demeanour has changed directly following intimate care, e.g. sudden distress or withdrawal, this should be recorded in writing and discussed with the designated person for child protection who will advise on the next steps. The child should be spoken to by the designated person for child protection as soon as possible in order to ascertain the reason behind the child’s change in demeanour. Any issues / concerns arising from this discussion should be addressed immediately without delay. Parents / carers must be notified of any such issues / concerns in a timely fashion.

8. Supporting children/adolescents who are resistant to intimate care.

In cases where children / adolescents are extremely resistant to intimate care and become distressed, staff must always use agreed strategies / techniques as outlined in the intimate care plan which will be informed by an understanding of their wider needs. At no point must staff forcibly hold children down to undertake intimate care, as this could result in injury / distress / trauma and / or increased anxiety for all parties concerned.

The intimate care plan should clearly identify an agreed plan of action between parents / carers and the setting on how to support the child / adolescent who is likely to be extremely resistant to intimate care, which could include, distraction techniques, notifying parents / carers of the situation, and an agreed way forward that is in the best interest of the child, without compromising their safety, dignity, health or causing emotional harm. This could include the name and de tails of an emergency contact(s) who will be asked to attend without delay. All behaviour should be understood as communication.

9. Dealing with allegations of abuse against staff
Should a child disclose abuse or harm as a result of intimate care this should be responded to in line with the agency’s child protection procedures. If a member of staff has concerns about the way in which another practitioner is undertaking intimate care these should be recorded and escalated to the organisation’s manager, giving consideration for LADO procedures. Due to the nature and degree of contact intimate care may also leave staff more vulnerable to accusations of abuse. Any allegations against a member of staff should be considered in line with the agency’s allegations management procedures and LADO procedures.

10. Encourage the child to have a positive image of her or his own body
Confident, assertive children who feel their body belongs to them are less vulnerable to abuse. As well as the basics like privacy, the approach you take to a child’s intimate care can convey lots of messages about what her or his body is “worth”. Your attitude to the child’s intimate care is very important.

11.Training
The requirement for staff training in the area of intimate/personal care will vary greatly between settings and will be largely influenced by the needs of the children / adolescents for whom staff have responsibility. Consideration should be given, however, to the need for training on an individual setting basis and for individual staff who may be required to provide specific care for an individual child/young person or small number of children / young people.

All members of staff responsible for intimate care should have appropriate training in good         
Health and Safety practices around hygiene, Safeguarding Training, Intimate Care Training and Positive Handling.

Whole staff group training should provide staff with opportunities to work together on the range of issues covered within this document thus enabling the development of a culture of good practice and a whole setting approach to personal care. Training should provide disability awareness, and opportunities for staff to increase knowledge and enhance skills.

More individualised training will focus on the specific processes or procedures staff are required to carry out for a specific child / young person. In some cases this may involve basic physical care which might appropriately be provided by a parent or carer. In cases of medical procedures, such as catheterisation, qualified health professionals should be called upon to provide training.

Designated staff may require training in safe moving and handling. This will enable them to feel competent and confident and ensure the safety and well-being of the child / adolescent. It is imperative for staff to keep a dated record of all training undertaken.

For intimate care needs, training and advice should be included for staff on how to deal with sexual arousal in the child / young person, if appropriate.

12.   Other practical considerations

  • Is a risk assessment for Moving and Handling required?
  • There should be sufficient space, heating and ventilation to ensure safety and comfort for staff and child / young person.
  • Facilities with hot and cold running water. Anti-bacterial hand wash should be available.
  • Items of protective clothing, such as disposable gloves and aprons should be provided. No re-use of disposable gloves.
  • Special bins should be provided for the disposal of wet and soiled nappies / pads. Soiled items should be “double-bagged” before placing in the bin.
  • There should be special arrangements for the disposal of any contaminated waste/clinical materials.
  • Seeking advice on general continence issues through the school nurse or health visitor. For specific conditions, the school nurse, health visitor and / or parents / carers should be able to provide links with relevant specialists.
  • Supplies of suitable cleaning materials should be available. Anti-bacterial spray should be used to clean surfaces.
  • Supplies of clean clothes (the child or young person’s own where possible) should be easily to hand to avoid leaving the child unattended while they are located.
  • Adolescent girls will need arrangements for menstruation in their plan.
  • Settings should have a supply of sanitary wear which can be provided for girls in a sensitive and discreet way

 

Assessing toileting support

When a child is soiling / wetting consider if this is a relatively isolated / new incident or if this is a recurring incident. The following pathways provide support in assessing toileting support:

Relatively isolated / new incident

Practitioner to consider:

  • Is there a developmental delay?
  • Is there a medical problem?
  • Is there a concentration problem?
  • Is there an underlying emotional problem?
  • Does the child have special educational needs?
  • Is there a possibility of a child protection issue?

Speak to parent:

  • Is this a problem   at home?
  • Has medical advice been sought? Parent to consult GP or Health Visitor
  • Is there a referral to a Paediatrician or incontinence nurse?
    • If yes advice / information to be provided to school via School Nurse or Health Visitor and discuss with parent regarding management plan (see below).
    • If no, discuss with parent regarding management plan (see below).

Discussion with parent – consultation on management plan:

  • Toilet training if appropriate
  • Facilities in school
  • What is reasonable
  • Staff involved – who
  • Staff training
  • Record keeping

Recurring incident

Practitioner to determine if the child has been toilet trained.

If the child has been toilet trained practitioner to consider if the child has special educational needs.

  • If yes, involve the SENCO / School Nurse / Health Visitor / Area Sector and discuss with parent regarding management plan (see below).
  • If no, speak to the parent:
    • Is this a problem   at home?
    • Has medical advice been sought? Parent to consult GP or Health Visitor
    • Is there a referral to a Paediatrician or incontinence nurse?
      • If yes advice / information to be provided to school via School Nurse or Health Visitor and discuss with parent regarding management plan (see below).
      • If no, discuss with parent regarding management plan (see below).

Discussion with parent – consultation on management plan:

  • Toilet training if appropriate
  • Facilities in school
  • What is reasonable
  • Staff involved – who
  • Staff training
  • Record keeping


NB: always be aware of the possibility of Child Protection issues (in which case follow Child Protection Procedures

 

Forms to support care 

The following forms are available on request from lscp.info@leeds.gov.uk. They can be used / adapted for individual settings as required.

  1. Intimate Care Good Practice Guidelines; Record of other agencies involved
  2. Intimate Care Good Practice Guidelines; Personal care management checklist (to inform the written Personal Care Management Plan)
  3. Intimate Care Good Practice Guidelines; Personal Care Management Plan
  4. Intimate Care Good Practice Guidelines; Toileting Plan
  5. Intimate Care Good Practice Guidelines; Record of Personal Care Intervention
  6. Intimate Care Good Practice Guidelines; Agreement of Intimate Care Procedures for a Child or Young Person with Complex Needs