Personal Care and Relationships

1. Principles

Sexuality and sexual relationships are a normal part of human development across the life span.

All children and young people, including those who are in care, should be supported in developing healthy attitudes and behaviours with regards to sexuality and relationships. The welfare of children and young people is paramount.

Carers, social workers, and other professionals involved in the care, education, and support of Children in Care must support these children and young people to make informed choices with regards to their sexuality. The best outcomes for individual children and young people are achieved through the co-operation of each different agency, which is the essence of corporate parenting.

Children in Care and young people must be enabled to make independent decisions, within the boundaries of the law. This is balanced by the duty placed on carers, social workers, and other professionals to work to prevent inappropriate sexual behaviour particularly where such behaviour may negatively affect another person or themselves.

Children and young people should have equal access to relationships and sex education regardless of race, culture, religion, sexual orientation, disability, or legal status.

Children in Care and young people have the same rights and responsibilities with regards to sexuality and relationships as others in their peer group, and their rights to privacy and confidentiality must be respected except in situations where to do so would place them or others at risk of harm.

2. Confidentiality, Consent and Communication

Confidentiality in accessing Health Care - Children in Care need to feel safe and confident about asking for advice and support. They need to be clearly informed about the boundaries of confidentiality and should be advised that they can consult doctors, nurses and other specialist services independently if they do not wish to discuss issues with their social worker or carer. Explanation should be given that this consultation will be kept confidential where the young person is aged 16 or over, or where Health professionals are satisfied that the criteria set out in the Fraser Guidelines are met (also known as “Gillick competence”).

While assuring the young person of confidentiality in most situations, he or she should be informed that confidentiality cannot be kept if there is a risk of Significant Harm to themselves or another.

Communicating about relationships and sexual health - Children in Care should be consulted before information about their sexuality or relationships, whether oral or written, is shared with others, and encouraged to share information with adults where this is desirable or necessary.

It is important that staff and carers work together to promote the health and well-being of Children in Care. At the outset of any placement, the carer, child/young person, allocated worker, and, where appropriate, parent, must meet to agree a plan for communication about health matters, including relationships and sexual health.

Additionally, all Health assessments of Children in Care should include, among other aspects, reference to the young person's sexual health and education.

Respecting the rights of children and young people in Reviews - children and young people should choose the extent and nature of any discussion regarding their relationships and sexuality at Statutory Reviews and in written information about them. Chairpersons should meet with children and young people prior to the Review, to establish their views on, and clarify, what will be discussed within the Review.

Supporting Children in Care when information is disclosed - if a member of staff or carer has reason to believe that a child or young person is being abused or exploited, or is at risk of Significant Harm, or that they may be harming someone else, they should work with the young person to encourage them to allow the relevant information to be passed on, unless to do so would place them or others at further risk or could compromise any criminal investigation.

If the child or young person refuses and the carer or staff member believes the involvement of others is essential to their best interests, they may disclose information without the young person's consent. Information shared with colleagues, line managers and relevant agencies should be on a strictly “need to know” basis and governed by the principle of promoting and safeguarding the health and welfare of the child or young person, or any one else at risk of harm.

Where appropriate, the child/young person should be kept informed about what information will be given, to whom and for what purpose. They should be informed where the information will be recorded and who will be able to see it. Such information should be securely stored.

When confidentiality is broken, staff and carers should ensure that the young person has access to appropriate support. Examples of such support could include involvement with Upfront, being accompanied to relevant meetings by a friend or advocate, therapeutic support, or the provision of an Independent Visitor.

The child or young person should also have support both during and after any Child Protection Investigation (Section 47 Children Act 1989) and police investigation.

Competence and Consent - Any act of sexual intercourse with boys or girls under the age of 13 is legally rape under the Sexual Offences Act 2003.

Once adolescents reach the age of 16, they are presumed in law to be competent to give consent for themselves for their own surgical, medical or dental treatment, and any associated procedures, and can legally consent to sexual activity. However, it is still good practice to encourage 16 and 17 year olds to seek the support of trusted adults with regards to sexuality and relationships.

3. Physical Contact

Carers/residential staff must provide a level of care, including physical contact, which is designed to demonstrate warmth, friendliness and positive regard for children.

Physical contact should be given in a manner which is safe, protective and avoids the arousal of sexual expectations, feelings or in any way which reinforces sexual stereotypes.

4. Intimate Care

Children must be supported and encouraged to undertake bathing, showers and other intimate care of themselves without relying on carers/ residential staff.

Such arrangements must emphasise that children's dignity and their right to be consulted and involved will be protected and promoted; and, where necessary, carers/ residential staff will be provided with specialist training and support.

5. Bedrooms

Each child over 3 will have their own bedroom or, where this is not possible, the sharing of the bedroom will have been agreed by the placing authority and the foster carers' Fostering Social Worker must have conducted a risk assessment and any arrangements must be outlined in the child's Placement Plan.

Children should be encouraged to personalise their bedrooms, with posters, pictures and personal items of their choice.

Children of an appropriate age and level of understanding should be encouraged and supported to purchase furniture, equipment or decorations. For older children this should be part of a plan to prepare the child for independence.

Children's rooms should be kept in good structural repair and be clean and tidy. The furniture should conform to standards of flame retardant materials as advised by trading standards.

Children's privacy should be respected. Unless there are exceptional circumstances, carers/ residential staff should knock the door before entering children's bedrooms; and then only enter with their permission. The exceptional circumstances where carers/ residential staff may have to enter a child's bedroom without asking permission include:

• To wake a heavy sleeper, undertake cleaning, return clean or remove soiled clothing; though, in these circumstances, the child should have been told/warned that this may be necessary;
• To take necessary action, including forcing entry, to protect the child or others from injury or to prevent likely damage to property. NB The taking of such action is a form of Physical Intervention.

6. Puberty and Sexual Identity

Carers/residential staff must adopt a non-judgemental attitude toward children, particularly as they mature and develop an awareness of their bodies and sexuality.

Carers/residential staff must adopt the same approach to children who explore or are confused about their sexual identity or who have decided to embrace a particular lifestyle so long as it is not abusive or illegal.

Children who are confused about their sexual identity or indicate they have a preference must be afforded equal access to accurate information, education and support to enable them to move forward positively. As necessary this must be addressed in Placement Plans.

7. Pornography

All materials published, circulated or available to children (including the internet) must promote and encourage healthy lifestyles and images of men and women that are positive and encouraging.

Children must be positively discouraged from obtaining material that is potentially offensive or pornographic.

If they obtain such material that is suspected to be illegal it must be confiscated. This should be discussed by the carers/residential staff with the child's social worker and their manager/supervision social worker. If there are concerns that the child has been exposed to extreme pornography, the concerns should be shared by the carers/residential staff with the child's social worker and their manager/supervision social worker who will consider with their managers what additional action is required.

If children obtain material legally they should be required to keep it private.

8. Role of Carers and Social Workers in Relationships and Sex Education

It is the duty of social workers and foster carers to promote and safeguard the health and welfare of young people. Young people need to feel comfortable with their emerging sexuality and to develop self-esteem and positive self-image. This needs to be supported by accurate information to help them establish positive relationships and enable them to make informed decisions about becoming sexually active. Talking about relationships and sex is a key part of helping young people to do this. The role of foster carers and social workers is vital in enabling children and young people to build relationships with adults they can trust, respect, and talk to.

They can also offer young people support in developing assertiveness and negotiation skills to help them resist pressure to become involved in aspects of relationships that are unhelpful or unwanted. This is particularly important for vulnerable young people who through lack of self-esteem, poor social skills, or disability may feel less able to make their own choices.

Talking about sex and relationships is important because it enables young people to:

• Build self-esteem;
• Explore their values and attitudes;
• Make informed decisions about their behaviour personal relationships and sexual health;
• Develop social skills including assertiveness and negotiation skills, which can then be generalised to other areas of their lives and may enhance their ability to recognise and protect themselves from potentially abusive situations;
• Enable them to protect themselves against sexually transmitted infections and unwanted pregnancy;
• Prepare for independent living.

Foster carers and social workers need to be able to:

• Share age appropriate information with the children and young people in their care;
• Talk about issues in simple, easy to understand language and be prepared to answer questions in a non-judgemental manner;
• Talk about body changes and feelings before they happen and prepare children and young people for them;
• Be aware of the things that young people need to learn if they are to make safe and positive choices about sex and relationships;
• Explore a range of values and attitudes;
• Provide opportunities for children and young people to make informed choices within age-appropriate boundaries;
• Talk about the emotional implications and responsibilities of entering into a sexual or romantic relationship with another person;
• Talk about the need to treat sexual partners with consideration and not as objects to be used;
• Be aware of leaflets and other information, as well as the direct health care available to young people through local health and health promotion services;
• Understand the risks for young people around maintaining sexual health and the need for appropriate information about sexually transmitted infections including HIV;
• Respond sensitively to a young person who may tell them they are gay, lesbian or bisexual or that they are confused about their sexuality and unsure of how they would identify themselves. Be able to provide practical support to counter prejudice from others;
• Understand that religion and culture may be important influences which will affect young people's attitudes and values towards sex and relationships;
• Understand the needs of disabled children and young people they are caring for, how society may deny their sexual identity and how their dependency on others may increase their vulnerability;
• Talk about the responsibilities, emotional, and practical implications of becoming a parent.

It is not appropriate or helpful for foster carers or social workers to share sexual information about themselves.

9. Working with Parents

Parents and carers are key to helping children learn about relationships and sex. Young people growing up in families where sex and relationships are discussed without embarrassment delay their first experience of intercourse and are more likely to use contraception when they become sexually active.

Most Children in Care experience some difficulties in their relationships with parents, and this can affect parents' opportunities for providing guidance and support around sexuality.

10. Sexual Activity in Homes

Children under the age of 13 are deemed to be incapable of giving consent to sexual activity. Therefore, children of this age who engage in sexual activity must be referred under Safeguarding Children Procedures (as a Child Protection Referral) as potentially suffering from Significant Harm.

Children's social workers, pla10. Sexual Activity in Homes10. Sexual Activity in Homes10. Sexual Activity in Homescement officers and care providers must be alert to such relationships when considering the placement of children under 13. Children of this age who are likely to be at risk from each other (or from older children) should not be placed together.

When considering the placement (or ongoing placement) of children over the age of 13, managers must assess the risk of sexual relationships developing and should ensure strategies are in place to reduce or prevent these risks if they are likely to be exploitative or abusive.

Where children aged 13 - 18 are placed together with no identified risk of exploitative or abusive behaviour, carers/ residential staff must monitor any developing relationships, sensitively but positively discouraging children from engaging under aged sexual relationships.

Overall, carers/ residential staff should be mindful of their duty to consider the overall welfare of children and this may mean recognising that illegal activity is taking place and working to minimise risks and consequences. If there is any suspicion that a child is engaging in illegal behaviour it must be discussed with the child's social worker who will consider what further action is required under the Safeguarding Children Procedures.

Any actions taken in this respect will be subject to consultation and must be addressed in Placement Plans.

Should carers/ residential staff suspect children are engaging in sexual relationships, they should:

1. Ensure the basic safety of all the children concerned;
2. Inform the child's social worker and their manager/supervision social worker.

11. Contraception and Pregnancy

There are many forms of contraception available free of charge through the National Health Service. These vary in their effectiveness and the manner in which they work, and all have both advantages and disadvantages.  

Access to contraceptives will not be conditional on children giving information about their lifestyles and contraception will never be withdrawn as a punitive measure.

Whilst not encouraging it, it is understood that children may engage in sexual activity; some before they reach the age of consent.

In such circumstances the carers' Fostering Social Worker/residential manager should consult the social worker to agree what reasonable steps can be taken to minimise risk of pregnancy or infection, including facilitating contact with relevant agencies providing contraceptive advice; such as the Brook Advisory Service.

12. Sexual Exploitation

Children may have previously exchanged sex for rewards, gifts, drugs, accommodation and money. Some maintain this lifestyle whilst continuing to be accommodated by the authority. Such situations must be reported to by the carers/residential staff to their managers and the child's social worker to decide on the actions that should be taken.

Carer/residential staffs must be alert to such behaviours and should do all they can to create an environment which encourages children to be open about their past or present attitudes and behaviours and which demonstrates they will be supported to guide them away from such lifestyles.

Where there is any suspicion that a child is engaged in such behaviour it should be addressed in the child's Placement Plan together with strategies to be adopted to help the child find alternative lifestyles need to be identified.

In addressing these behaviours consideration must be given to the extent to which the child is suffering Significant Harm and whether it is necessary to refer the child under Safeguarding Children Procedures in the area where the child is living.

13. Sexually Transmitted Infections

An STI is any infection that is spread through sexual contact. It is important to realise that:

• Many sexually transmitted infections have no obvious symptoms of illness;
• STI's occur in both males and females;
• Many STI's are curable and all are preventable;
• Delaying treatment could mean that the infection gets worse and other problems can occur;
• Untreated STI's, including HIV, can be passed to a foetus during pregnancy and birth.

Whenever a Child in Care or young person is sexually active, or may become so, or where there is a possibility of sexually transmitted infection, the young person should be encouraged to seek advice and if necessary treatment from a suitable health professional.

How/Where are Services Provided?

Contraception and treatment for STI's are available free of charge from local GP surgeries and sexual health clinics. Many clinics offer advice and treatment for young people only. Children and young people may register with a GP other than their own for contraceptive and sexual health services only.

As explained under the sections on Confidentiality, Competence, and Consent above, in many situations the young person's carer and/or social worker will not need to be aware of such a consultation, although the young person will be encouraged to seek the support of a trusted adult.

For service information see For Young People website - information on drugs, alcohol and sexual health in Kent.

If it is known or suspected that a child has a sexually transmitted infections (including HIV), carers/residential staff must notify their managers and the child's social worker, who will decide what measures to take.

14. Peer Group Abuse

The possibility of peer abuse will always be taken seriously but we recognise it is equally important not to label or stigmatise normal sexual exploration and experimentation between children.

Behaviour is not a cause for concern unless it is compulsive, coercive, age-inappropriate or between children of significantly different ages, maturity or mental abilities.

If at any time carers/residential staff suspect children are engaged in abusive sexual relationships as perpetrators and/or victims, they must immediately inform their managers and the child's social worker and make a referral under the Safeguarding Children Procedures.

15. Menstruation

Young women should be supported and encouraged to keep their own supply of sanitary protection without having to request it from carers.

There should also be adequate provision for the private disposal of used sanitary protection.

16. Enuresis and Encopresis

If it is known or suspected that a child is likely to experience enuresis, encopresis or may be prone to smearing it should be discussed openly, with the child if possible, and strategies adopted for managing it; these strategies should be outlined in the child's Placement Plan.

Carers/residential staff, their managers and the child's social worker should consider the reasons for enuresis and encopresis there may be a variety of reasons but it is likely that such behaviour is symptomatic of anxiety and worries about previous experiences including abuse and neglect.

It may be appropriate to consult a Continence Nurse or other specialist, who may advise on the most appropriate strategy to adopt. In the absence of such advice, the following should be adopted:

1. Talk to the child in private, openly but sympathetically;
2. Do not treat it as the fault of the child, or apply any form of sanction;
3. Do not require the child to clear up; arrange for the child to be cleaned and remove then wash any soiled bedding and clothes;
4. Keep a record, either on a dedicated form or in the child's Daily Record with detail, if necessary, in a Detailed Record;
5. Consider making arrangements for the child to have any supper in good time before retiring, and arranging for the child to use the toilet before retiring; also consider arranging for the child to be woken to use the toilet during the night;
6. Consider using mattresses or bedding that can withstand being soiled or wetted.

17. Guidance in Relation to Personal Care and Relationships

The term 'Touch' is used throughout this manual in two different contexts.

'Touch' as a form of physical intervention designed to prevent a child or others from being injured or to protect property from being damaged; and the use of 'Touch' to enable carers/residential staff to demonstrate affection, acceptance and reassurance.

This section provides guidance relating to the demonstration of affection, acceptance and reassurance.

It is acknowledged that touch raises particular issues for those working with children. Some people have views about applying a "hands off" or "hands on" policy with children result from scandals of child abuse, or fear of violence from children. Carers may be anxious about allegations of inappropriate physical contact with children.

However, touch is acceptable; but carers should consider the following:

The Child's Background and Previous Experiences

The child may have had particular experiences which make it difficult to accept touch from an adult; or the child's experiences may lead to a need for more touch than is acceptable.

It is therefore important for carers to obtain information about the child's background before acting, in any way not just in terms of the use of touch.

If there are particular needs that the child has or if it appears that the child may respond more or less favourably to touch, this must be reflected in the planning process.

Dependent on the age and level of understanding of the child, (s)he should be involved in this assessment and planning; and should be encouraged to consent to being touched; or to place conditions on it.

The Child's Culture and Boundaries

The culture or values of the household should be such that touch is encouraged; as a positive and safe way of communicating affection, warmth, acceptance and reassurance.

Carers/residential staff and children should be encouraged to use touch, positively and safely.

But it is important for carers and children to know if boundaries exist within the home or for individual children.

If boundaries or expectations exist for individual children they should be set out in their Care Plan and Placement Plan.

If boundaries or expectations exist for the home, they should be clear. For example, if carers are not expected to allow children to sit on their laps, or to carry children, this should be stated, preferably in writing.

In the absence of any plan or expectation, the following should be taking into consideration

1. When thinking about who is an appropriate person to touch a child, it is vital to consider what the adult represents to the particular child. Personal likes and dislikes will play a part in any relationship;
2. In addition, many factors influence the power relationship between adult and child, including gender, race, disability, age, sexual identity and role status;
3. The background of the child will also influence any decision about who represents a 'safe' adult in the eyes of the child;
4. Children from ethnic minority backgrounds may be used to different types of touch as part of the culture;
5. Children who have been subject to physical or sexual abuse may be suspicious or fearful of touch. This is not to say that children who have experienced abuse should not be touched, it may be beneficial for the child to know different, safer and more reliable adults who will not use touch as a form of abuse;
6. For each child, what constitutes an intimate part of the body will vary; but generally speaking it is acceptable to touch children's hands, arms, shoulders. It may be appropriate to hug or cuddle children, or carry or give them 'piggy backs';
7. Other parts of the body are less appropriate to be touched, by degrees. Some parts of the body are 'no go areas';
8. Therefore, it may be appropriate to touch a child's back, ears or stroke their hair or knees - if the child indicates such touch is acceptable. To go beyond this would be unacceptable, even if the child appeared to accept it;
9. In any case, no part of the body should be touched if it were likely to generate sexualised feelings on the part of the adult or child;
10. Also, no part of the body should be touched in a way which appeared patronising or otherwise intrusive;
11. Therefore, the context in which touch takes place is usually a decisive factor in determining the emotional and physical safety for both parties;
12. What message is being sent out to the child? If the intention is to positively and safely communicate affection, warmth, acceptance and reassurance it is likely to be acceptable;
13. A fleeting or clumsy touch may confuse a child or may feel uncomfortable or even cause distress. Carers should touch with confidence, and should verbalise their affection, reassurance and acceptance; by touching and making positive comments. For example, by touching a child's arm and saying "Well Done";
14. Where children indicate that touch is unwelcome carers should back off and apologise if necessary;
15. Carers should talk to colleagues and record their interactions with children. If particular strategies work, or not, colleagues should be informed so they can build on or avoid making the same mistake;
16. Touch of an equally positive and safe nature is acceptable between carers; demonstrating positive role models for children. Showing that adults can get along and use touch in non abusive or threatening ways;
17. It is also acceptable to talk about how touch feels, about acceptable boundaries and expectations; doing so in 'house meetings' or key worker sessions;
18. Play fighting is no alternative for this. It is unacceptable;
19. The key is for carers to help children experience and benefit from touch, positively and safely; as a way of communicating affection, warmth, acceptance and reassurance.

18. Appropriate Language

It is essential that all carers/residential staff are aware, that the use of foul and abusive language directed towards children is totally inappropriate and unnecessary. This will only have the effect of demeaning children, have a negative effect on child/carer relationship and lead to an escalation of disruptive and challenging behaviour.

All carers/residential staff need to be aware that any complaints relating to foul and abusive language will be treated seriously and may lead to disciplinary measures.

19. Friendship and Support

Confidence in and good rapport with particular adults is a fundamental element in good care practices. Whilst children are in foster or residential care a variety of problems will arise, at times of stress or crisis every child needs an adult to turn to.

Warmth and understanding are essential, but everyone needs to know and understand when a relationship is inappropriate. The fine line between what is "proper" warmth and understanding and what is regarded as "improper" is likely to vary depending on the needs and experiences of the individual child.

Where it is known that a child has been a victim of sexual abuse and it is likely he or she will behave towards carers in a sexual manner, particular rules will have to be drawn up for carers/residential staff. This may involve the need to avoid being alone with the child, by always having a third person present.

What is important is that carers and residential staff need to be putting the children's interests first and always considering what is appropriate in any given situation with a particular child.

Interaction on a One To One Basis

Carers/residential staff must have knowledge and understanding of the child and his or her background, and be able to recognise and respect any emotional 'barriers' the child has 'erected'.

Carers/residential staff should be sufficiently aware of their own feelings, so that they can recognise the dangers of a relationship with a child becoming sexualised and stop to consider what is happening and what they are doing.

Other people's feelings and views, of both adults and children, need to be taken into account. If there is any indication that a relationship could be viewed as inappropriate, the carers/residential staff should discuss the issues with their managers/supervisors and the child's social worker.

It is not a matter of carers never becoming involved in close one to one relationships with a child, it is a vital part of the 'caring' task, however, carers must be aware of the dangers, which this type of work can bring and be clear where the boundaries in such relationships lie.

Additional Support

Consideration should be given to the need for each child to have an Advocate or Independent Visitor - see Advocacy and Independent Visitors Procedure.

Appropriate support must be provided to all children including those who are refugees or asylum seekers, and those who are disabled children and with communication difficulties.