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It is recommended that where children require intimate care, good practice guidelines are drawn up within the establishment and disseminated to all staff. Parents / carers should also be made aware of how intimate care for their child will be managed. 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 this in a constructive manner.

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 to 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.

The following is an example of good practice guidelines from Chailey Heritage, a nationally recognised centre for the education, assessment, treatment and support of children with physical and multiple disabilities. Whilst these are considered to be “best practice”, individual establishments may wish to adapt them to suit their particular circumstances.

Guidelines for good practice (adapted from the Chailey Heritage centre)

1. 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. Kent and Medway LSCPs believe this practice should be 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. 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 although it is recognised that there will be 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 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;
2. Involve the child as far as possible in his or her own intimate care. 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. If a child is fully dependent on you, talk with her or him about what you are doing and give choices where possible;
3. 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. Conversely, if a child has a “grudge” against you or dislikes you for some reason, ensure your line manager is aware of this;
4. Make sure practice in intimate care is as consistent as possible. Line managers have a responsibility for ensuring their 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 to intimate care are not markedly different between individuals. 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?
5. 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. Other 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;
6. 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);
     
     Report any such incident as soon as possible to another person working with you and make a brief written note of 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.
     
     Additionally, if you are a member of staff who has noticed that a child’s demeanour has changed directly following intimate care, e.g. sudden distress or withdrawal, this should be noted in writing and discussed with your designated person for child protection.
7. 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 important. As far as appropriate and keeping in mind the child’s age, routine care of a child should be enjoyable, relaxed and fun;
   
   Intimate care is to some extent individually defined, and varies according to personal experience, cultural expectations and gender. Kent and Medway LSCPs 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 “invasion” of body space for physical or medical 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.

The above is taken largely from the publication 'Abuse and children who are disabled: a training and resource pack for trainers in child protection and disability, 1993'.

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