Intimate Care Policy

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.

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.[1]

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.

[1] Policy for the Chaperoning of Patients During Examination, Investigation or Clinical Recording, The Leeds Teaching Hospital Trust

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.

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.

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. 

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.

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? 

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. 

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.

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.

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.

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.

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.

• 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

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

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.