The purpose of this document is to set out the minimum standards for the offer and delivery of ear checks to children and young people attending special residential schools and colleges. The intention is to support local integrated care boards (ICBs) and service providers to implement an effective ear checks programme locally. The document is to be used in combination with the ‘service specification for ear checks for children and young people attending residential special schools and colleges in England.

Background

The purpose of the ear checks in the residential special schools and colleges service is to support access to ear and hearing healthcare. The service is part of a wider sensory check programme that includes vision and dental health checks, which is being introduced by NHS England.

It is widely documented that hearing loss can have a significant impact on the development and wellbeing of children and young people, especially for children and young people with additional needs. There is however limited literature and data documenting the prevalence of hearing loss and unmet need amongst autistic children and young people, and children and young people with a learning disability. Evidence suggests that autistic children and young people and children and young people with a learning disability are at greater risk of permanent hearing loss and ear health issues than their typically developing peers.

Ear checks are important for children and young people with SEND (special educational needs and disabilities) attending residential special schools as they may be less likely to access hearing testing if there is a concern about their hearing and ear health. Many children and young people attending residential schools may not be able to easily describe any discomfort or hearing problems because of communication difficulties. In addition, there are some overlapping presentations associated with learning disability, autism, and hearing loss and as a consequence children and young people attending residential special schools are at risk of diagnostic overshadowing. Diagnostic overshadowing is when certain symptoms or behaviours may be mistakenly judged to be inherent in someone’s condition or impairment, without exploring other factors. It is therefore important to take a whole school approach to checking ear health in children who have high levels of need.

In 2023, NHS England conducted a national pilot to offer and deliver ear checks in residential special schools and colleges. The pilot highlighted three key findings:

• there was considerable unmet ear health and hearing need amongst children and young people attending residential special schools and colleges
• individualised and flexible approaches to ear checks helps support acceptability and successful uptake of ear checks
• interdisciplinary working supports obtaining a meaningful check, encourages better communication and a person-centred approach, and facilitates appropriate access to any additional investigation required and onward care

The system facing summary of the Ear checks pilot programme evaluation report summary can be accessed here.

Section 1: Ear check clinical requirements

Governance

Ensuring appropriate clinical governance and oversight rests with the contracted provider of the service. This includes but is not limited to clinical input during the set-up of the ear checks service, practical training and competency assessment, service maintenance, clinical peer review and audit.

Eligibility

The service scope is to detect external and middle ear health issues and check peripheral auditory function in children and young people aged 4-24 years (24yrs and 364 days) attending residential special schools and colleges.

Children and young people with a diagnosed hearing loss and/or are under the care of audiology and/or Ears, Nose and Throat services (ENT) for ear and hearing related issues are not eligible for this service, as the purpose is to identify unmet need.

Frequency of ear checks

Ear checks should be offered within the first year that the child or young person enters the residential special school system. The check should be repeated when the child or young person transitions to secondary school, and from secondary school to college. Only half of childhood permanent hearing loss is identified at birth, therefore multiple checks ensure that an acquired or progressive permanent hearing loss is detected prior to entering the next stage of education and appropriate care provided in a timely way [1][2].

Ear health issues are more common in children and young people and for those with complex needs. Checking ear health at these key points in education ensures that unmet need does not go undetected [3].

If there is concern about the child or young person’s hearing between or after checks, they should be referred directly to audiology. If the concern is that there is an infection or outer ear abnormality the child or young person should be referred to their general practitioner (GP) or follow local guidelines.

If an external ear condition results in being unable to complete the check, such as occluding wax, infection or other abnormality, the ear check should be repeated following resolution, to ensure permanent hearing loss is not missed.

Clinical standards

Design and delivery of ear checks standard operating procedures should be in line with the most recent British Society of Audiology Standards and Recommended Procedures for Ear Examination OD104-54 [4], Clinical Application of Otoacoustic Emissions (OAEs) in Children and Adults BSA OD104-120 [5] (screening) and Tympanometry OD104-35 [6].

The ear checks questionnaire Part 1 (P1) and Part 2 (P2) should be completed in advance.

• P1 identifies reasonable adjustments and supports individualised care, to facilitate preparation for, and the delivery of, the ear check
• P2 assesses auditory behaviours and supports joint decision about making an onward referral when a check is not accepted

Local standard operating procedures (SOP) should be developed between the contracted service provider and the local audiology and ENT services. Where delivery of the ear checks is undertaken by non-audiology staff, this should include clear guidance on arrangements and responsibilities associated for clinical peer review, by both non-audiology staff and clinical reviewers and should include local referral pathways for each potential outcome. The service provider is responsible for procuring suitable medical equipment, ensuring that algorithms are appropriate, and that devices are serviced and calibrated as set out in appropriate ISO standards.

Referral on the basis of concern

When the check cannot be undertaken, fully completed, or is deemed not appropriate, questionnaire Part 2 (P2) should be used to identify if a child or young person would benefit from a referral to audiology for diagnostic assessment.

If there is concern about a child or young person’s ear health or hearing they should be referred to the appropriate service, in line with local referral procedures.

The limitations of the check should be acknowledged: the ear check procedure does not rule out central auditory processing issues, including Auditory Neuropathy Spectrum Disorder (ANSD). Therefore, if there is concern, a child or young person should be referred even if the check provides a clear response.

Section 2: practising standards

Section 2 sets out the “practising standards” for the delivery of ear checks in residential special schools and colleges to support quality assurance. These standards may be used as guidance to develop person specifications and/or support amendments to current roles.

1. Training and accreditations

Staff undertaking the ear checks should:

• work in either health, education, or social care: this can be at assistant level if the person has experience working in special residential schools and colleges
  • education staff should have expertise in special educational needs and disability (SEND) and staff should have direct experience of working with SEND children and young people[7]
  • when external staff (health, education or social care) are delivering the checks, they should have experience of working with children and young people who have complex and additional needs and should spend at least one day at the school or college to familiarise themselves with the students, staff and school procedures before undertaking ear checks
• have completed the e-learning for health (eLfH) knowledge-based training package for Ear checks in residential special schools and colleges and the Delivering sensory health services course
• have completed the Oliver McGowan Part 1 and Part 2 Tier 1 training (1 hour online interactive session)
• have met the minimum training requirements for ear examination (otoscopy) set out by the British Society of Audiology (BSA) standards[8] and certified as competent (arranged locally) This could be evidenced by:
  • completing an accredited ear examination training course
  • having completed an accredited degree in audiology
• have completed local skills-based and equipment specific training in line with BSA standards, with local quality assurance. This should include a period of observed practice, agreed locally, including completing at least 10 supervised ear checks (OAE, ear examination and tympanometry) independently, where no prior audiology qualification has been completed. Competency should be checked annually, and all training records should be documented
• all staff are expected to maintain their knowledge, skills and training through regular revision of the e-learning materials in order to undertake ear checks appropriately and safely and ensure results are reviewed and acted on in the recommended way
• local guidelines should be developed and followed for the revision of practical and equipment-specific training, and supervised delivery. It is recommended that non-audiology staff undertake annual revision of e-learning materials and audiology staff every 2 years
• all training and observed practice should be documented and recorded
• complete appropriate safeguarding training, including level 2 safeguarding training
• receive appropriate supervision in their role to ensure they demonstrate and maintain competence in understanding the needs of SEND children and young people, including knowing how to support them in the best way.

2. Values

Staff undertaking the ear checks should:

Apply the six values of the NHS Constitution[9]

• working together for patients
• respect and dignity
• commitment to quality of care
• compassion
• improving lives
• everyone counts

3. Shared decision making and communication

Staff implementing ear checks should adopt a person-centred approach and take account of any necessary reasonable adjustments in order to ensure ear checks are accessible.

Adapt communication strategies to accommodate diverse backgrounds, communication needs, styles and preferences, and levels of understanding.

1. use effective communication skills to engage and interact with children and young people, families and guardians, in a compassionate and empathetic manner
2. recognise that every child and young person has unique needs and preferences and put the needs, preferences, and ambitions of the child or young person at the centre of all that they do, including the planning and decision making before, during and after an ear health check
3. include the views of the child and young person, family/carers and legal guardians and anyone else who has parental responsibility (e.g. if the child is looked after)
4. where children and young people are unable to actively participate in planning surrounding ear checks, consider the views of the people who know them best
5. adopt a flexible approach, understanding that a variety of factors may impact or change the readiness of the child or young person to undergo an ear health check and ensuring that their wellbeing is maintained
6. work as part of an interdisciplinary approach to deliver ear checks. The person delivering the check needs to liaise closely, plan and work in association with families and carers, education and learning support, health, and/or care staff who have the most in-depth knowledge and understanding of the child or young person’s needs
7. ensure that decision-making is in line with those who are legally able to make decisions on behalf of the child or young person, where they are not Gillick competent
8. ensure the outcome of the ear check and referral process is communicated effectively in the preferred communication style of the child or young person, and/or where appropriate to their parent carer or guardian. This should include formal notification by letter to the child, young person and/or where appropriate their parent carer or guardian and their registered general practitioner

4. Safety, quality, and clinical governance

Staff undertaking the ear checks should:

• work within their scope of practice, following local guidelines and operating procedures
• be aware of and actively implement infection control procedures
• refer the child or young person to the appropriate professional following an ear health check, when additional investigation or follow up is required
• understand the importance of:
  • facilitating clinical peer review of ear check results (in line with local procedures)
  • supporting clinical audit
• understand that equipment requires daily checks and regular calibration. Actively document and record calibration
• be able to trouble shoot issues with equipment and ask for support when equipment appears to have an error
• understand and act on incident reporting procedures, within the health, education and social care system in which they operate and in line with contractual requirements
• safeguard and promote the welfare of children and young people in line with the provisions of the Children Act 2004 [10]
• ask for help and assistance when needed, seek support and guidance from the audiology service providing governance and quality assurance

 5. Knowledge and skills

Staff undertaking the ear checks should:

a. Have knowledge of the theoretical and practical skills involved in delivering ear checks in line with British Society of Audiology standards, as set out in the training (Section 1 a), service specification and local standard operating procedures.

This includes:

• Ear checks questionnaire Part 1 (preferences) and Part 2 (auditory profile)
• external visual check of the outer ear, face and mastoid for signs of inflammation, discharge or other abnormalities
• Transient Evoked Otoacoustic Emissions (TEOAE) or Distortion Production Otoacoustic Emissions (DPOAE)
• ear examination using video otoscope
• understand that an ear check does not result in clinical diagnosis and is a check to support appropriate onward referral

b. Have knowledge of local referral pathways into primary, community and secondary care.

• wax removal/aural care
• outer ear infection (otitis externa) /other identifiable abnormalities
• suspected permanent and/or conductive hearing loss
• acute otitis media/Otitis media with effusion (glue ear)

c. Have knowledge of local support services to signpost children, young people, and families when necessary.

d. Understand the impact of hearing loss and ear health issues on the individual, and how ear health can affect health, education and wellbeing. It is particularly important to recognise the importance of ear and hearing health for children and young people attending residential special schools and colleges who may be non-verbal communicators.

e. Be aware of symptoms and various impact of diseases and hearing loss sub-types.

f. Be aware of the wide range of needs of children and young people who attend residential special schools and colleges.

g. Have knowledge of strategies for effectively working with children and young people in residential special schools and colleges, considering their unique needs such as:

• social stories
• role play with replica equipment
• picture exchange communication system (PECS)

h. Be aware of legal (Mental Capacity Act 2005 [11]) and ethical considerations related to consent and best interest when working with vulnerable populations.

• understand the concept of consent and its significance in providing ear checks and procedures to children and young people
• apply strategies for obtaining informed consent and making decisions in the best interest of the child or young person

i. Be familiar and compliant with safeguarding policies and be able to identify a Safeguarding Lead to contact where safeguarding concerns arise and be Disclosure and Barring Service (DBS) checked.

j. Be aware of the NICE guidelines for disabled children and young people up to 25 with severe complex needs NICE guideline [NG213][12].

Section 3: framework and guidance for standard operating procedure development

Section 3 is a framework and guidance that can be used to support the development of local standard operating procedures (SOP). 

1. Check for eligibility

1.1 Ear check offer

1.1.1 aged 4-24 years (24yrs and 364 days).of age and attending a residential school or college (day or residential pupil).

1.2 Exclusion criteria

1.2.1 Children and young people who have a known hearing loss. Children and young people who are under review with audiology or ear, nose, and throat (ENT) service.

1.1.2 Unless the equipment used has been verified as safe to be used with a programable ventriculo-peritoneal (PVP) shunt, the child or young person should be excluded from an ear check at school. In this instance, complete the Ear check questionnaire, and if there is concern, make an appropriate referral to Audiology or ENT.

2. Consent

2.1 Ensure that informed consent for pre-assessment, ear checks and any further management must be obtained from the child or young person if Gillick competent, and those with parental or legal guardian responsibility where not

2.2 Meet requirements set out within the Mental Capacity Act 2010 for those young people aged over 16 years of age

2.3 Acquire appropriate consent for ear check, data sharing and for making onward referrals where needed

3. Child or young person’s history

3.1 Support/ensure questionnaire P1 (preferences) and P2 (auditory profile) have been completed

3.2 Register whether there is concern about a child or young person’s ears and hearing

3.3 Check for red flags

3.3.1 Pain in or around the ear

3.3.2 Discharge from the ear canal

3.3.3 Evidence of ear canal blockage

3.3.4 Atresia (closed ear canal).

4. Planning

4.1 Preparation

4.1.1 Communication

4.1.2 Familiarisation techniques.

4.2 Environment

4.2.1 Consider appropriate and calming environments e.g., sensory room.

4.2.2 Consider day and time of day

4.3 People present

4.3.1 It is important that someone who knows the child well and is trusted, is present during the check

4.3.1.1 This can help reduce anxiety

4.3.1.2 The person who knows the child well may be able to interpret certain cues that indicate if the child or young person is uncomfortable or would like the check to stop

5. Ear and hearing health checks

5.1 Infection control: hand washing and disinfection

5.2 Initial examination of the outer ear and surrounding area to check for red flags and identify contraindications prior to conducting the initial check (if present refer directly and urgently to GP)

5.2.1 Discharge

5.2.2 Evidence of blockage or foreign body

5.2.3 Inflammation of the ear or mastoid

5.2.4 Atresia

5.2.5 Evidence of abnormal skin lesion (e.g. basal cell carcinoma (BCG))

5.2.6 Pain

5.3 TE/DP Screening OAE

5.3.1 In line with standards set out for screening in BSA recommended procedures Clinical Application of Otoacoustic Emissions (OAEs) in Children and Adults OD104-120

5.3.2 As a minimum, the screening algorithm should meet UK standards set for newborn hearing screening including sensitivity and specificity

5.3.3 OAE check may be performed before (less contact time if OAE passed, more information should only one check be accepted) or after video-otoscopy. However, decision on order can be agreed locally and based on each child or young person’s level of acceptance of OAE checks

5.3.4 Checks should be carried out in both ears for check to be considered complete

5.3.5 If the check is inconclusive or incomplete, a re-check should only be performed three times on each ear

5.3.6 Results should be captured, and local standard operating procedures should be followed

5.3.7 A clear response in both ears should be obtained for the check to be considered complete and no need to proceed to the next set of checks

5.4 Ear examination using video otoscopy

5.4.1 Carried out in line with BSA recommended procedures for Ear Examination OD104-54.

5.4.2 A video assisted otoscope should be used, that can record and save examination.

5.4.3 All ear examinations should be recorded, and video/images should be stored securely.

5.4.4 Ear specific examination should be saved for governance and additional clinical review purposes.

5.4.5 If wax, blockage, infection or abnormality is present, stop and follow local standard operating procedures, including clinical peer review as required and onward referral.

5.4.6 If clear, and no contraindication present, continue and perform tympanometry.

5.5 Tympanometry

5.5.1 Carried out in line with BSA recommended procedures Tympanometry OD104-35.

5.5.2 Capture all check data, including number of attempts and date.

5.5.3 If type B tympanogram present, indicating glue ear, repeat full check procedure in six weeks under guidance provided by governing audiology department, to ensure pupils with self-limiting otitis media are not referred unnecessarily to audiology- if type B is still present refer for management following guidelines within local standard operating procedures.

5.6 When a check is not accepted or successful

5.6.1 Additional attempts to familiarise and prepare the child or young person should be made.

5.6.1 When a child or young person does not accept the check and it is unlikely that the child or young person will accept the check with additional preparation and:

5.6.1.1 There is concern about ear health or hearing, the child or young person should be referred to the most appropriate service based on that concern via local referral pathways.

5.6.1.2 There is no concern, the outcome of the questionnaire P2 should be used to support decision making about whether a child or young person would benefit from a referral to audiology. This tool helps to ensure that children and young people have equal access to onward care and diagnostic services.

6. Clinical peer review and onward referral

6.1 It is essential that clinical peer review is provided for ear check assessments and by all staff delivering ear checks who do not hold an accredited degree in audiology

6.2 Where ear check delivery is provided in schools and colleges by non-audiology staff, the process by which clinical peer review occurs should be agreed locally. It should include capturing both “checker” and “reviewer” data, enable external audit and case tracking, and have local Standard Operating Procedures developed

6.3 Clinical peer review should be considered and planned for as part of the planning and commissioning of the ear checks service and where possible be provided by the local audiology service to ensure appropriate quality assurance

6.3.1 Where non-audiology staff are providing ear checks, all children and young people who require onward referral should be reviewed by the agency commissioned to undertake the clinical peer review to ensure referrals are appropriate.

6.3.2 In in the first year of the service, reviewing all results, including passes, will add additional quality assurance, and should continue until quality levels are met consistently.

6.4 The service providing the clinical peer review process should support in the provision of training, in the specific requirement of observed practice and supervised ear check, as outlined in Section 1 -Training and Accreditation

6.5 Referral pathways should be mapped locally

6.5.1 Specialist pathways should be developed to ensure children and young people with complex needs receive person-centred care and any reasonable adjustments they might need.

6.5.2 The school or college should be fully informed as to where and how children and young people from their setting can receive care.

6.6. Referral

6.6.1 It is the responsibility of the person carrying out the check to follow local procedures that ensure the outcome of the ear check, and the referral process is communicated effectively in the preferred communication style of the child or young person, and/or where appropriate to their parent, carer or guardian. This should include formal notification by letter to the child, young person and/or where appropriate their parent carer or guardian and their registered General Practitioner.

7. Data capture and audit

7.1 Data capture

7.1.1 Data should be captured in line with requirements set out in the service specification.

7.1.2 Data should be stored in line with Data Protection Act 2018 [13].

7.1.3 Data should be submitted in line with local requirements and DAPB1069: Community Services Data Set requirements.

7.2 Audit

7.2.1 Service providers should ensure data is available for clinical audit.

7.2.2 Service providers should conduct and support clinical and service delivery audit to the best of their ability.

7.2.3 Clinical audit should be conducted in line with local and national guidance, as per the requirements of the responsible commissioner [14].

7.2.4 Undertake any additional service delivery and service user review and audit as per the requirements of the responsible commissioner and service specification.

References

[1] Bamford J, Uus K, Davis A. Screening for hearing loss in childhood: issues, evidence and current approaches in the UK. J Med Screen 2005; 12(3): 119-24.

[2] Fortnum HM, Summerfield AQ, Marshall DH, Davis AC, Bamford JM. Prevalence of permanent childhood hearing impairment in the United Kingdom and implications for universal neonatal hearing screening: questionnaire based ascertainment study. BMJ (Clinical research ed) 2001; 323(7312): 536-40.

[3] Bennett FC, Ruuska SH, Sherman R. Middle Ear Function in Learning-Disabled Children. Pediatrics 1980; 66(2): 254-60

[4] British Society of Audiology (BSA) 2022, Recommended Procedure: Ear Examination OD104-54, [Online] Available: https://www.thebsa.org.uk/wp-content/uploads/2022/02/OD104-54-BSA-Recommended-Procedure-Ear-Examiniation-February-2022.pdf

[5] British Society of Audiology (BSA) 2023, , Recommended Procedure: Clinical Application of Otoacoustic Emissions (OAEs) in Children and Adults BSA OD104-120, [Online] Available:  https://www.thebsa.org.uk/wp-content/uploads/2022/09/OD104-120-Recommended-Procedure-Clinical-Application-of-Otoacoustic-Emissions-OAEs.docx.pdf

[6] British Society of Audiology (BSA) 2024, Tympanometry and Acoustic Reflex Thresholds. OD104-35, [Online].  Available:  https://www.thebsa.org.uk/wp-content/uploads/2013/10/OD104-35-BSA-Recommended-Procedure-Tympanometry-and-ART.pdf

[7] The purpose of this is to build on evidence that trusted relationships aid the reduction of anxiety and support an individualised approach.

[8] British Society of Audiology (BSA) 2022, Minimum training guidelines: Ear Examination, [Online]  Available:  https://www.thebsa.org.uk/wp-content/uploads/2022/02/OD104-50-BSA-Minimum-Training-Guidelines-Ear-Examination-Feb-2022.pdf

[9] NHS 2015. The NHS values. Health Careers NHS [Online] Available: https://www.healthcareers.nhs.uk/working-health/working-nhs/nhs-constitution

[10] Children Act 2004, UK Government Legislation.Gov, [Online] Available: https://www.legislation.gov.uk/ukpga/2004/31/contents

[11] Mental Capacity Act 2005, UK Government, Legislation.gov, [Online] Available: https://www.legislation.gov.uk/ukpga/2005/9/contents

[12] NICE 2022. NICE guideline [NG213] Disabled children and young people up to 25 with severe complex needs: integrated service delivery and organisation across health, social care, and education. NICE. [Online]  Available: https://www.nice.org.uk/guidance/ng213/chapter/Recommendations-on-support-for-all-disabled-children-and-young-people-with-severe-complex-needs#principles-for-working-with-children-young-people-and-their-families

[13] Data Protection Act 2018, UK Government. Legislation.Gov, [Online] Available: https://www.legislation.gov.uk/ukpga/2018/12/contents/enacted

[14] NHS England Clinical Audit [Online] Available: https://www.england.nhs.uk/clinaudit/

Publication reference: PRN01338_iii