Intimate/Personal Care Good Practice Guidance

Children and young people are entitled to respect and privacy at all times and especially when in a state of undress, changing clothes, bathing or undertaking any form of personal care. There are occasions where there will be a need for an appropriate level of supervision in order to safeguard children and young people and/or satisfy health and safety considerations. This supervision should be appropriate to the needs and age of the children and young people concerned and sensitive to the potential for embarrassment.

Staff need to vigilant about their own behaviour, ensure that they follow agreed guidelines and be mindful of the needs of the children and young people with whom they work.

All the children and young people we work with have a right to be treated with dignity and respect. These guidelines are designed to safeguard both children and staff, and apply to every member of staff involved with the intimate care of children. They aim to support good practice in intimate care.

Children, particularly those with disabilities, can be very vulnerable. All staff involved with their intimate care need to be sensitive to the child's needs and also be aware that some care tasks or treatments could be open to possible misinterpretation. False allegations of sexual abuse are extremely rare, but certain basic guidelines will safeguard both children and staff. Everyone is safe if expectations are clear and approaches are consistent as far as possible. If you cannot work within these guidelines for any reason please consult with your line manager.

Please also see: Safer Working Practice Guidance: Safe Touch/Safe Care, Supervision of Children (Staff Presence in Bedrooms, One to One Situations and Lone Working).

Within children's homes there may be occasions when intimate care is part of the staff member's responsibilities in order to meet a child's needs, for example assisting young children with toileting, providing intimate care for children/young people with disabilities or in the provision of medical care. The nature, circumstances and context of such contact should comply with professional codes of practice and guidance and/or be part of a formally agreed plan, which is regularly reviewed. The additional vulnerabilities that may arise from a physical or learning disability should be taken into account and be recorded as part of the agreed care plan. The emotional responses of any child to intimate care should be carefully and sensitively observed, and where necessary, any concerns passed onto the homes managers and/or parents.

All children and young people have a right to safety, privacy and dignity when contact of a physical or intimate nature is required and depending on their abilities, age and maturity should be encouraged to act as independently as possible. It is important to remember that all children and young people regardless of disability have emotional and sexual needs and therefore have the right to be dealt with sensitively and with respect with an emphasis being placed on providing and promoting safe emotional, physical and sexual health.

The views of the child/young person should be actively sought, wherever, possible, when drawing up and reviewing formal arrangements. As with all individual arrangements for intimate care needs, agreement between the child/young person, parents/carers and the organisation must be negotiated and recorded. Processes for this include review and care planning meetings where a record will be held on the child's/young person's personal/care plan and risk assessment/safe care plan.

The guidelines are designed to safeguard children/young people and staff, in an area where it would not be possible to eliminate all risk. They apply to every member of staff involved in the intimate care of children and young people who works in the Disabled Children's Homes and Children's Resource Service. They aim to support good practice in intimate care, however, Intimate care is hard to define and will have a different meaning to individuals. These guidelines are designed to cover some of the most vulnerable situations. This does not exclude the fact that there may be many other circumstances which could be defined as intimate, to the child/young person if not to you. Always ensure that you talk to children/young people or have their permission, where possible, before undertaking any task. If you find it difficult to work within these guidelines please discuss this with your homes manager in order to find an appropriate way forward.

Managers have a responsibility for ensuring that staff have a consistent approach. This does not mean that everybody has to do things in an identical fashion, but it is important that approaches are not markedly different between different staff. It is also important that children are familiar with the member of staff who carries out the intimate care. Try to avoid too many staff changes; preferably the same staff member should do all intimate care throughout a shift, including feeding.

All children and young people are individuals with a range of differing needs. Please acknowledge that the guidelines are general and that some children/young people may have slightly differing needs. As a protective measure, all children/young people who we work with will have an individual placement care plan detailing their specific intimate care needs where they differ from these guidelines. Staff are responsible for ensuring that they are familiar with a child's placement care plan before undertaking any intimate care with them. Plans will be updated as six monthly reviews or earlier if necessary.

Students and volunteers will normally not be involved in the intimate care of any children who use the services. For students on longer term placements and where the undertaking of intimate care is a specific learning need to be met whilst on placement, this will be carefully planned and discussed with the homes manager and supervisor.

However, account is taken of the job description and the actual job that staff do, as the job does carry an element of risk, in that male workers may occasionally find themselves in situations with females, whereby they must assess the degree of intimate care and ensure every effort is made to protect themselves and the child - these situations should always be recorded and reported to your line manager. Residential homes can be high risk area for abusive behaviour, or accusations of abusive behaviour to occur - we must always be aware that these situations may arise between staff and children, regardless of their gender. A male worker should not undertake any intimate care with a female, unless he is required as a co-worker with a female worker. Where possible, male young people should be cared for by male staff.

Privacy is an important issue. Much intimate care is carried out by one staff member alone with one child. This practice is actively supported unless the task requires two people. Having people working alone does increase the risk of possible abuse, however this is balanced by the loss of privacy and lack of trust implied if two people have to be present - quite apart from the practical difficulties. Staff are therefore supported in carrying out intimate care alone unless the task requires the presence of two people. This must be recorded in the child/young person's Individual Placement Care Plan.

Pre admission information will be gathered to assess the child's ability to express preference as to how their intimate care needs can be best met whilst in our care. However, whilst valuing the child's choice of carer, it has to be acknowledged that current staff ratios may mean that we are not always able to offer the choice of a same sex carer to boys. Discuss with carers and the child's intimate care needs and how these will be met whilst in our care which will be updated and discussed again at review meetings - or earlier if necessary.

If staff are not sure how to do something, Ask. If staff feel that they need to be shown more than once, ask again.

Certain intimate care or treatment procedures such as rectal examinations or enemas must only be carried out by nursing or medical staff.

Procedures such as giving rectal valium or suppositories must only be carried out by staff who have been authorised by the child's carer or homes manager, and have had approved training in these procedures.

There are times when staff have to go into the bathroom with young people

• When the child/young people need assistance with bathing/showering;
• To teach and assist with personal hygiene;
• To supervise children/young people and ensure their safety i.e. supervise them when they are running the bath and check the temperature;
• Assist with mobility in and out of the bath/shower;
• Assist with dressing/undressing;
• Supervising a child/young person who has epilepsy. For safety reasons these young people should not be left alone in the bath or shower.

Time and privacy are of utmost importance when staff are supporting young people to use the toilet, bathe or shower. Some children may wish to be alone in the toilet; you may be able to put a towel over their lap. Others may need encouragement or observation. Whatever the situation, ensure dignity at all times:

• Never leave vulnerable children alone, As above when toileting, bathing or showering either close the door and wait outside or have the door slightly ajar;
• Where possible children should be encouraged to close the door when using the toilet or bathing/showering;
• Always knock when entering a bathroom and ask permission to enter wherever possible;
• Only one child/ young person should be in the bathroom at any one time;
• Only one staff member should be in the bathroom unless assistance is required for lifting or a staff member is querying bruising/marks on a child/young person and requires a senior staff member (or colleague if no senior is available) to witness and look at the mark;
• If you need to help with washing, then talk or sign to the child/young person and let them know what you are going to do before you do it;
• Be responsive to their reactions and check out what you are doing by asking "how do you do it at home" and "is it okay for me to do it this way";
• Encourage the child/young people to do as much for themselves as possible;
• Ensure that sanitary equipment is readily available. Please don't leave children/young people in vulnerable situations whilst you go off to find equipment;
• Allow choice over bathing and showering. Children/young people don't always need to be bathed/ showered every day. If a child has communication difficulties, check their daily log;
• Don't force children/young people to bath/shower. If you feel that they need to (e.g. if incontinence is an issue), try to encourage but remember that a 'strip wash' would suffice;
• Encourage children/young people to check water temperatures;
• Check children/young people regularly when left alone in the bath. Always knock and wait for a reply before entering, unless you feel that there may be a problem when a child/young person is not answering;
• If you need to be in the bathroom to help with washing, bathing, showering etc., be receptive to a child's reactions. Check your practice by asking "is it OK to do it this way" - "how do you do this at home?" - Always tell a child/young person what you are doing. Encourage the child/young person to help themselves - use verbal prompts;
• If a child/young person expresses dislike of a certain person carrying out their intimate care, try to find out why. If a child appears to have a 'grudge' against you for some reason, ensure that the homes manager is aware of this;
• When out with children/young people endeavour to use 'in store' toilets or disabled facilities. Children/young people should not be sent into public toilets alone;
• Ensure and encourage female young people who use sanitary towels/tampons are aware of appropriate means of using and disposing of sanitary towels and that the homes toilets are equipped for this, i.e. small bags/bins;
• N.B. Always use gloves and aprons when doing personal care and if a young person needs to have cream rubbed into them. This stops any skin to skin contact. It also stops the staff absorbing any of the cream which could be steroid based or have side effects if absorbed by people it is not prescribed for.

See also: Relationships and Physical Contact with Children Procedure, Menstruation and Enuresis and Encopresis.

• It is important to remember that when working with children and young people with disabilities, especially those with Autism and Learning Difficulties, that soiling and smearing can be sensory (enjoy the feel of their faeces), learnt behaviour, constipation as well as the fear of using toilets and not being able to wipe themselves properly.

• Children/young people should be encouraged to dress themselves where possible;
• Allow time for privacy;
• Children/young people should wear their own clothing and night wear. If a child is incontinent or has not brought nightwear, it would be acceptable to use something from the homes clothing, however, ensure child's agreement to this;
• Where possible children/young people should be given a choice as to what they would like to wear and encouraged to dress appropriately for the weather, time of day, or outings;
• Children/young people with communication difficulties may be able to point, or look toward the clothing of their choice if you hold it up for them;
• Children/young people should not get into nightwear until day care children/young people have left. Ensure children/young people are appropriately covered (dressing gown, underwear etc.) if they are going to watch television or eat supper in their nightwear;
• Where teenage young people of mixed gender are in the building, encourage them not to get into nightwear until they go to bed.

• Ensure continuity - same person throughout shift;
• Never start to assist a young person with their meal, then pass to someone else;
• Utensils used at mealtimes should be appropriate for the individual young person, this should be recorded in their care plan. Plastic spoons should always be used when feeding, to prevent accidental damage to gums or mouth;
• Allow time and choice;
• Tell children what they are eating;
• Mealtimes should not be interrupted e.g. phone-calls etc.

It is important that staff understand and report any of the following incidents as soon as possible to another colleague who is on duty at the same time and make a brief written note of it on the child's file or in the incident book. Bring this to the attention of your line manager as soon as possible, if during the intimate care of a child/young person:

• The member of staff accidentally hurts them, or;
• The child/young person seems unusually sore or tender in the genital area, or;
• The child/young person appears to be sexually aroused by that staff members actions or;
• The child/young person misunderstands or misinterprets something, or;
• The child/young person has a very emotional reaction without apparent cause or anything else which seems unusual.

Staff should:

• Adhere to the organisation's intimate care guidelines and code of practice;
• Make other staff aware of the task being undertaken;
• Explain to the child what is happening with senior managers and parents/carers where any variation from the agreed procedure/care plan/safe care plan is necessary;
• Record the justification for any variation to the agreed procedure/care plan/safe care plan and share this information with parents/carers;
• Ensure that any changes to the agreed care plan are discussed, agreed and recorded;
• Avoid any physical contact when children are in a state of undress;
• Avoid any visually intrusive behaviour;
• Announce the intention of entering the child or young person's bedroom by knocking on the bedroom door and asking if it is OK to enter and waiting for their response before entering (where possible, some young people may not respond);
• Try to avoid doing things for a child/young person that he/she can do alone. If a child/young person is able to help, ensure that they are given the chance to do so. Support the child/young person in doing all that they can for themselves. If a child/young person is fully dependent on you talk with them about what you are doing and give choices where possible;
• Encourage children/young people to have a positive view of their body and image.

Treat every child with dignity and respect and ensure privacy appropriate to the child's age and situation:

Privacy is an important issue. Much intimate care is carried out with one staff member alone with one child/young person. This practice is actively supported unless the task requires two people. 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 - quite apart from the practical difficulties. So, staff are supported in carrying out the intimate care of children alone unless the task requires the presence of two people.

Involve the child as far as possible in their intimate care:

Try to avoid doing things for a child/young person that he/she can do alone, and if a child/ young person is able to help then ensure they are given chance to do so. Support the child in doing all that they can for themselves. If the child is fully dependent upon you, talk with them about what you are doing and give them choices where possible.

Be responsive to a child's reactions:

Check your practice by asking the child/young person, particularly a child/young person you have not previously cared for - e.g. "is this OK to do it this way?" or "can you wash there?", "How does mummy do this?" If a child expresses dislike of a certain person carrying out their intimate care, try and find out why. If a child appears to have a grudge against you, ensure your line manage is aware of this.

Make sure practice in intimate care is as consistent as possible:

Line managers have a responsibility to ensure staff have a consistent approach. This does not mean that everyone has to do things in an identical fashion, but it is important that approaches are not markedly different between different staff.

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. Nursing or medical staff must only carry out certain intimate care or treatment procedures.

If you are concerned, report it:

If during intimate care of a child any of the following occur, report the incident as soon as possible to another person working with you and make a brief written note:

• You accidentally hurt them;
• The child seems unusually sore or tender in the genital area;
• The child appears to be sexually aroused by your actions;
• The child misunderstands or misinterprets something, or has a very emotional reaction without apparent cause.

Some of these could be cause for concern about the child, or alternatively the child or another adult might possibly have misunderstood what has happened.

Encourage the child to have a positive image of their own body:

Confident, assertive children/young people, who feel their body belongs to them, are less vulnerable to sexual abuse. As well as basics such as privacy, the approach you take to a child's intimate care can convey lots of messages to them about what their body means. Your attitude to a child'/young person's intimate care is important. Keeping in mind the child's age, routine care should be enjoyable, relaxed and fun.

Staff should not:

• Change in the same place as children and young people;
• Shower or bathe with children or young people;
• Assist with any personal care task which the child or young person can undertake themselves;
• Enter a bathroom or toilet area unless there is evidence of health and safety and/or safeguarding issue, for example, attempted suicide, if the child/young person is unconscious.