Chime Social Enterprise NewApproachComprehensive Report ... · PDF file1 Chime Social...

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Overall summary

Chime Social Enterprise provides audiology assessmentand treatment for adults, and children and young people.Only audiology services for children were included as partof this inspection as audiology services for adults are notcurrently required to be registered with the Care QualityCommission. This report includes the communitychildren and young people core service.

The regulated activities are diagnostic and screeningprocedures and treatment of disease, disorder or injury.

Chime is a community interest company. This means thatany surplus of funds is reinvested into the organisation toimprove NHS services. Chime has a contract to offer NHSchildren’s audiology services, free at the point of deliveryon behalf of NHS Northern, Eastern and Western DevonClinical Commissioning Group. At the time of ourinspection a re-tendering process was underway.

Chime accepts referrals from health, social care oreducation professionals for children living in Exeter, Mid-and East Devon. It provides detailed hearingassessments, advice and appropriate management ofpermanent hearing loss. This includes fitting hearing aidsand other appropriate listening devices together withspecialist advice and information. Chime carries out avariety of different tests, depending on the age and abilityof the patient and whether they have any complex

hearing problems, including hearing loss and tinnitus.Some children under three years of age are seen as partof the new-born hearing screening programme. Oncetests are completed the team make recommendationsand provide appropriate treatment. Patients attend theaudiology service as outpatients or are seen in their ownhomes. Staff also visit schools and a community groupsetting.

During April 2016 to March 2017, Chime carried out a totalof 51,689 episodes of care. Of these, 7,216 (14%) werewith children and young people.

We regulate this service but we do not currently have alegal duty to rate it. We highlight good practice and issuesthat service providers need to improve and takeregulatory action as necessary. We found the followingareas of good practice:

• Staff were confident to identify and reportsafeguarding concerns.

• Staff knew how to report incidents. There had beenprompt investigation and learning from a seriousincident that was shared within the team and withother audiology services.

• Facilities were clean and equipment was in calibrationand well maintained.

ChimeChime SocialSocial EntEnterpriseerpriseQuality Report

CHIME SOCIAL ENTERPRISEROYAL DEVON & EXETER HOSPITALBARRACK ROADEXETEREX2 5DWTel: 01392 402223Website: www.chimehealth.co.uk

Date of inspection visit: 23-28 June 2017 and 3 July2017Date of publication: 21/09/2017

1 Chime Social Enterprise Quality Report 21/09/2017

• There was sufficient staffing and fluctuations indemand were anticipated effectively.

• There was good compliance with mandatory trainingfor safeguarding level two and three and for movingand handling, conflict resolution and prevention ofradicalisation training.

• The service had recently been awarded ImprovingQuality in Physiological Services (IQIPS) accreditation.IQIPS is a professionally led programme with the aimof improving services, care and safety for patientsundergoing physiological tests, examinations andprocedures.

• All staff were qualified to carry out their role and weregiven opportunities to develop and share their skills.

• Current evidence based practice was used to developand deliver treatment. The service used up to datetechnology to obtain good outcomes for patients.

• Teams worked effectively with other services for thebenefit of patient care.

• Patients who moved from children’s to adults serviceswere prepared for this transition in a coordinated way.Staff respected the confidentiality of patients and theirfamilies.

• Staff involved parents of patients throughout theconsultations and provided comprehensiveexplanations of symptoms and treatment options.

• Information leaflets for patients and their families hadbeen upgraded to explain what to expect from thehearing assessment and how parents could helpchildren to benefit from their audiology treatment.

• Patients were offered appointments at a range oflocations including home visits for very young babies.

• When paediatric patients required audiologyassessment or intervention, they were assessed withinsix weeks and treated within 18 weeks. This met thestandards set by the clinical commissioning group.

• Staff viewed the leaders of the service asknowledgeable, approachable and supportive.

• Leaders were focussed on the forward vision for theservice.

• Staff demonstrated the values of the organisation andwere engaged with the service strategy.

• Staff enjoyed their work and were committed toproviding effective and patient centred care.Teamwork was valued and nurtured both within theservice and with external agencies.

However, we also found the following issues that theservice provider needs to improve:

• Not all staff were up to date with mandatory training;in particular there was low compliance with fire safety,infection prevention and control, basic life supportand paediatric life support.

• There was a detailed risk register but this did notcontain clear arrangements for reducing the impact ofrisks and timeframes for when this should becompleted and by whom.

• There was no documented method by which keysafety and quality information was regularly reportedon and challenged by the board as part of the boardassurance process

• Staff did not always comply with the organisationalpolicy for infection prevention and control

• Staff had not participated in duty of candour training• In waiting rooms at locality clinics there no toys or

diversional activities for children.• Children were not always encouraged to voice their

opinions during audiology appointments• The provider did not always signpost children and

their families to resources for emotional supportwhere applicable

• Patients and their families were not routinely providedwith information about how to complain aboutservices

Following this inspection, we told the provider that itmust take some actions to comply with the regulationsand that it should make other improvements, to help theservice improve. We also issued the provider with tworequirement notices that affected the children’s services.Details are at the end of the report.

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Communityhealthservices forchildren,young peopleand families

• Staff were confident to identify and reportsafeguarding concerns.

• Staff knew how to report incidents. There had beenprompt investigation and learning from a seriousincident that was shared within the team and withother audiology services.

• Facilities were clean and equipment was incalibration and well maintained.

• There was sufficient staffing and fluctuations indemand were anticipated effectively.

• There was good compliance with mandatorytraining for safeguarding level two and three and formoving and handling, conflict resolution andprevention of radicalisation training.

• The service had recently been awarded ImprovingQuality in Physiological Services (IQIPS)accreditation. IQIPS is a professionally ledprogramme with the aim of improving services, careand safety for patients undergoing physiologicaltests, examinations and procedures.

• All staff were qualified to carry out their role andwere given opportunities to develop and share theirskills.

• Current evidence based practice was used todevelop and deliver treatment. The service used upto date technology to obtain good outcomes forpatients.

• Teams worked effectively with other services for thebenefit of patient care.

• Patients who moved from children’s to adultservices were prepared for this transition in acoordinated way. Staff respected the confidentialityof patients and their families.

• Staff involved parents of patients throughout theconsultations and provided comprehensiveexplanations of symptoms and treatment options.

• Information leaflets for patients and their familieshad been upgraded to explain what to expect fromthe hearing assessment and how parents could helpchildren to benefit from their audiology treatment.

Summary of findings


• Patients were offered appointments at a range oflocations including home visits for very youngbabies.

• When paediatric patients required uni-disciplinaryassessment or intervention, such as an audiologyassessment or provision of a hearing aid, they wereassessed within six weeks and treated within 18weeks. This met the standards set by the clinicalcommissioning group.

• Staff viewed the leaders of the service asknowledgeable, approachable and supportive.

• Leaders were focussed on the forward vision for theservice.

• Staff demonstrated the values of the organisation intheir work and were engaged with the servicestrategy.

• Staff enjoyed their work and were committed toproviding effective and patient centred care.Teamwork was valued and nurtured both within theservice and with external agencies.

However, we also found the following issues that theservice provider needs to improve:

• Not all staff were up to date with mandatorytraining, in particular there was low compliancewith fire safety, infection prevention and control,basic life support and

• There was a detailed risk register but this did notcontain clear arrangements reducing the impact ofrisks and timeframes for when this should becompleted and by whom.

• There was no documented method by which keysafety and quality information was regularlyreported on and challenged by the board as part ofthe board assurance process

• Staff did not always comply with the organisationalpolicy for infection prevention and control

• Staff had not participated in duty of candourtraining

• In waiting rooms at locality clinics there no toys ordiversional activities for children.

• Children were not always encouraged to voice theiropinions during audiology appointments

• The provider did not always signpost children andtheir families to resources for emotional supportwhere applicable

Summary of findings


• Patients and their families were not routinelyprovided with information about how to complainabout services

Summary of findings


Contents

PageSummary of this inspectionBackground to Chime Social Enterprise 8

Our inspection team 8

Why we carried out this inspection 8

How we carried out this inspection 8

What people who use the service say 9

The five questions we ask about services and what we found 10

Detailed findings from this inspectionOutstanding practice 25

Areas for improvement 25

Action we have told the provider to take 26

Summary of findings


Chime Social Enterprise

Services we looked atCommunity health services for children, young people and families;

ChimeSocialEnterprise


Background to Chime Social Enterprise

Chime is a staff owned social enterprise registered toprovide regulated activities of diagnostic and screeningprocedures plus treatment of disease disorder or injury.At the time of our inspection, Chime was commissionedby Northern, Eastern and Western Devon ClinicalCommissioning Group to provide audiology services toadults and children living in Mid Devon, East Devon andExeter areas. This service includes paediatric hearingtesting, fitting, paediatric hearing aid habilitation andrehabilitation and diagnostic follow-up of all babiesidentified through the New-born Hearing ScreeningProgramme

The audiology service for children and young people isprovideded at several different locations including bothsites of the local acute hospital, community hospitals,special schools and a parent and toddler group forhearing impaired children. Services are provided on anoutpatient basis with some domiciliary visits.

• Chime has been registered with the CQC since 21March 2011. This service was previously inspected inJanuary 2013 and again in January 2014 and wasjudged to be compliant in all core standards.

• The registered manager at the time of our inspection,Jonathon Parsons, had been in post since March 2011.

Our inspection team

The inspection was led by : Helen Rawlings – InspectionManager CQC

The team that inspected the service comprised of oneCQC inspector and one specialist advisor; an audiologist.

Why we carried out this inspection

We inspected this service as part of our ongoingcomprehensive independent health inspectionprogramme. The service was not rated as part of thisinspection.

How we carried out this inspection

To fully understand the experience of people who useservices, we always ask the following five questions ofevery service and provider:

• Is it safe?• Is it effective?• Is it caring?• Is it responsive to people’s needs?• Is it well-led?

Before the inspection visit, we reviewed information thatwe held about the location, asked a range of otherorganisations for information and sought feedback frompatients using comments cards

During the inspection visit, the inspection team:

• Visited five locations where audiology clinics forchildren were being held during the week of ourinspection. These included a main hospital site andsmall community hospital locality clinics. We looked atthe quality of the clinic environment and observedhow staff were caring for patients.

• Returned for an unannounced visit to the second mainhospital site.

• Spoke with four relatives of patients who were usingthe service.

• Spoke with the registered manager and the cliniciansat each of the locations we visited.

Summaryofthisinspection

Summary of this inspection


• Spoke with other staff members; includingadministration and reception staff and assistanttechnical officers.

• Received feedback about the service from one clinicalcommissioning group.

• Looked at five care and treatment records of patients.• Looked at a range of policies, procedures and other

documents relating to the running of the service.

What people who use the service say

We did not receive any comments cards in relation to thisservice.

Healthwatch had not received any feedback related topaediatric audiology services.




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?We found that

• Staff knew how to report incidents. There had been promptinvestigation and learning from a serious incident that wasshared within the team and with other audiology services.

• Staff were confident to identify and report safeguardingconcerns.

• Facilities were clean and equipment was in calibration and wellmaintained.

• There was sufficient staffing and fluctuations in demand wereanticipated effectively.

• There was good compliance with mandatory training forsafeguarding level two and three and for moving and handling,conflict resolution and prevention of radicalisation training.

However,

• Many staff were not up to date with mandatory training in firesafety, basic life support and children’s life support.

• Operational staff showed very limited understanding of theduty of candour regulations.

• Not all protocols for infection prevention and control werefollowed consistently by staff.

Are services effective?We found that:

• Current evidence based practice was used to develop anddeliver treatment. The service used up to date technology toobtain good outcomes for patients.

• The service had recently been awarded Improving Quality inPhysiological Services (IQIPS) accreditation. IQIPS is aprofessionally led programme with the aim of improvingservices, care and safety for patients undergoing physiologicaltests, examinations and procedures.

• All staff were qualified to carry out their role and were givenopportunities to develop and share their skills.

• Teams worked effectively with other services for the benefit ofpatient care.

• Patients who moved from children’s to adults services wereprepared for this transition in a coordinated way.

Are services caring?We found that:




• Staff respected the confidentiality of patients and their families.• Staff involved parents of patients throughout the consultations

and provided comprehensive explanations of symptoms andtreatment options.

• When children became distressed, staff adapted their approachand provided reassurance to parents.

However,

• Audiologists did not always support older children to engage inconsultations

• Audiologists did not always directly engage in a comforting waywith children who became distressed during appointments

• When audiologists identified that a patient had an emotionalneed, they did not always signpost that child for additionalsupport.

Are services responsive?We found that:

• Information provided to patients was focussed on the needs ofchildren and their families and presented in a child friendlyway.

• Patients were offered appointments at a range of locationsincluding home visits for very young babies.

• When paediatric patients required audiology assessment orintervention, such as provision of a hearing aid, they wereassessed within six weeks and treated within 18 weeks. Thismet the standards set by the clinical commissioning group.

However,

• Patients were not routinely advised how to make a complaintabout the service.

• Some clinic waiting areas in community hospital clinics werenot equipped with toys or books for children and some clinicareas contained minor hazards for children such as sharp tableedges at head height.

Are services well-led?We found that:

• The oversight of safety and quality were disjointed. Seniorclinicians did not regularly report on their specific area ofresponsibility. There was no regular mechanism by which theboard received and challenged reports of safety performanceother than when the managing director chose to raiseconcerns.




• The risk register did not adequately or comprehensively reflectcurrent risks, mitigations, responsibilities or time frames.

However,

• Staff viewed the leaders of the service as knowledgeable,approachable and supportive.

• Leaders were focussed on the forward vision for the service.• Staff demonstrated the values of the organisation in their work

and were engaged with the service strategy.• Staff enjoyed their work and were committed to providing

effective and patient centred care.• Teamwork was valued and nurtured both within the service and

with external agencies.




Safe

EffectiveCaringResponsiveWell-led

Are community health services forchildren, young people and families safe?

Safety performance

• The standard measures of safety performance suchas pressure ulcers, falls and urinary tract infections werenot relevant to this audiology service. Chime monitoredsafety parameters such as equipment calibration,mandatory training compliance, safeguarding andinfection prevention and control. There were no similarorganisations against which Chime could benchmark itsperformance.

Incident reporting, learning and improvement

• Staff told us they felt confident to report incidents butwere rarely required to do so in the paediatric service asvery few occured. During the twelve months precedingour inspection, there had been one incident reported inthe paediatric service in February 2017.

• At the time of our inspection, this incident was notclassified as a serious incident but was classified as anaccident. This classification was given based on advicefrom their clinical commissioning group (CCG) .Wereviewed the incident information and following ourinspection this incident was reclassified as a seriousincident. We asked for assurance that the appropriateinvestigations would take place following thereclassification, in line with best practice guidance fromthe National Patient Safety Agency. An update wasreceived and we were satisified the investigation hadcommenced.

• Considerable effort had been made to manage futurerisks associated with the incident to prevent ithappening again. This included communicating withthe manufacturer about a problem associated with

custom made paediatric ear moulds so changes couldbe made, and liaison with regional and nationalpaediatric audiology interest groups to raise awarenessof the concern nationally.

• At a department level, details of the incident wereemailed to staff immediately and were discussed at thepaediatric service team meeting one week after theincident and then at all paediatric team meetingsthereafter. The format of the paediatric individualmanagement plan template was amended to include awarning about the risks. Audiologists then highlightedthis risk to parents of children who were less than threeyears of age.

Duty of Candour

• The duty of candour is a regulatory duty that relates toopenness and transparency and requires providers ofhealth and social care services to notify patients (orother relevant persons) of certain ‘notifiable safetyincidents’ and provide reasonable support to thatperson.

• During our inspection we noted that operational staffand the clinical manager we spoke with were aware ofthe requirement to be open and honest with patients.However staff did not demonstrate knowledge of thefull requirements of duty of candour regulations and didnot see this as within their remit of responsibility. Theydid not participate in specific duty of candour trainingand at the time of our inspection there was no duty ofcandour policy. Following our inspection themanagement team took immediate action to draft andcirculate a duty of candour policy.

Safeguarding

• There were reliable systems to ensure that staff had theknowledge and skills to identify safeguarding concerns.

Communityhealthservicesforchildren,youngpeopleandfamilies

Community health services forchildren, young people andfamilies


Paediatric staff were trained in safeguarding to leveltwo. Paediatric leads were trained in safeguarding tolevel three. Staff told us they were able to access advicefrom a paediatric lead at all times.

• There were reliable systems for staff to reportsafeguarding concerns. Staff demonstratedunderstanding of how to identify safeguarding concernssuch as neglect. Any concerns were discussed with oneof the lead paediatric audiologists and referrals weremade directly to the multi-agency safeguarding hub.

• Safeguarding practices were incorporated intoadministrative protocols. For example, when childrendid not attend three consecutive appointments, staffraised a safeguarding alert with the local safeguardinghub.

• There was a lack of reliable systems to alert Chime staffto an existing safeguarding or child protection concerns.The patient database did not include an alert to identifyif a child had a safeguarding or were under childprotection. During the initial interview with the patient,staff asked parents or carers if the child was known toany other health or social care services and relied onthis as their source of information. When Chime staffreceived this information they added it to the patientrecord as free text. This meant there was potential forstaff to not have a comprehensive or accurateunderstanding of the child’s safeguarding needs.

• Chime used a reliable system to improve the likelihoodof making safe recruitment decisions and preventingunsuitable people from working with children.Disclosure and barring service checks were completedfor all staff employed in the paediatric service

Medicines

• No medicines were used by the provider. There were nomedical or non-medical prescribers on the staff team.

Environment and equipment

• The furniture and layout of treatment environmentswere safe for children. In four of the five locations wevisited, the environment was designed to be safe forchildren, for example table edges were rounded,electrical sockets covered. This was not the case in thefifth location, a community hospital clinic. Staff ensuredthat children were not left alone and an audiologist wasalways with the child within clinic rooms.

• In the main hospital site, receptionists were positionedto allow adequate oversight of children and young

people in the waiting area. However, this was notconsistent in all clinic locations. Waiting rooms incommunity hospital clinics were not observed byreception staff. This meant that staff relied upon parentsor carers to ensure the well-being of patients whilstwaiting for their appointments

• The equipment available to children was adequate tokeep them safe. For example paediatric resuscitationequipment was available in all clinic locations. Howevernot all staff were up to date with the training needed toensure they were competent to use the equipment.

• Equipment was maintained and used appropriately.Equipment that came into contact with children wassingle use and all consumable equipment was in date.All equipment used for testing children’s hearing hadbeen calibrated within the 12 months preceding ourinspection. All portable electrical equipment had beentested for safety during the 12 months preceding ourinspection.

• Staff followed safe systems and protocols for disposal ofwaste. For example, clinical waste was segregated andbins were not overflowing.

Quality of records

• Individual care records were written and managed in away that kept people safe. We reviewed five patientrecords and saw that records were accurate, complete,legible, and up to date. Staff stored all records securelyon the electronic drive, and did not use paper records;this meant that records were easily accessible for clinicsand always available when required.

• Records were audited to check the quality of recordkeeping. During 2016, a documentation audit wascompleted which looked at seven random sets ofrecords from 10 staff. In total 70 records were reviewed.The audit showed some records had informationmissing and these concerns were clearly identified anddiscussed at staff meetings to ensure improvementswere made.

Cleanliness, infection control and hygiene

• The clinic environments were visibly clean and staffdecontaminated equipment prior to patient use.

• Staff did not consistently follow protocols for infectionprevention and control. There was an increased risk ofhealthcare related infections because staff did notcomply with the organisational uniform policy. Forexample, during patient consultations we observed one




clinical member of staff wearing chipped nail varnish onboth days we visited, and one clinical member of staffwore sleeves below their elbow. We observed eightpatient appointments. None of the audiologistsdecontaminated their keyboard and mouse betweenappointments. Computers were not fitted with wipeclean keyboards.

• The service had taken some action to improvecompliance with infection prevention and control. Anaudit of treatment protocols was carried in 2016. Seniorstaff observed audiologists carrying out treatment. Thisidentified concerns regarding infection prevention andcontrol and as a result further training in local infectioncontrol processes was given at a staff training day inMarch 2017 and reminder notices were placed in allclinic rooms.

Mandatory training

• Not all staff were up to date with essential training forsafety systems, processes and practices. At the time ofour inspection, not all staff had completed theirmandatory training within the twelve months precedingour inspection. For example, less than 30% of staff hadcompleted fire safety training, less than 50% of staff hadcompleted basic life support, less than 60% of staff hadcompleted children’s life support, and less than 70% ofstaff had completed training in infection prevention andcontrol. There had been some delay in provision oftraining due to a change of supplier. Following theinspection we were provided with evidence that futureattendance had been arranged for some of these staff.

• However, compliance with other training such assafeguarding level two and three, moving and handlingand prevention of violent extremism (PREVENT) trainingwere all 100% and compliance with conflict resolutiontraining was 94%.

Assessing and responding to patient risk

• Staff used available information to assess and respondto patient risk. Prior to the appointment, audiologistswere reliant on the information in the referral letter toidentify risks as they were unable to access informationfrom other health or social care providers. During theappointment, staff asked parents about the child’shealth and involvement of other services in order to

identify known risk factors and flagged these on thepatient record where necessary. Staff took care toensure that patient details held on the patient recordwere correct.

• Staff told us that they were rarely required to respond tohigh risk situations. Staff were aware how to respondappropriately when children’s health and well-beingdeteriorated. However staff we spoke with had notexperienced this situation. In emergency situations, staffknew to telephone for an ambulance.

• All staff were aware of techniques to resolve conflicts. Allstaff had been issued with a personal alarm.

Staffing levels and caseload

• The paediatric audiology service had the correctnumber of staff, with the right skills, to deliver safe careand treatment at all times. At the time of our inspectionthere were 56 members of staff employed by ChimeSocial Enterprise. These included audiologists, assistanttechnical officers, and administrative staff. There weresix audiologists plus two team lead audiologists whoworked primarily in the paediatric service. Two of thepaediatric audiologists were on maternity leave at thetime of our inspection. Several other members of staffwere involved in the service to a lesser extent, such asbooking appointments, taking calls, repairing hearingaids, assisting in consultations.

• Leaders of the paediatric service responded proactivelyto anticipate changes to staffing requirements. Therewere no vacancies in the paediatric audiology team butthere were two members of staff on maternity leave.Leaders had anticipated the need for maternity leavecover prior to their absence and to bridge this gapsenior audiologists were training less experiencedaudiologists to act as assistants in paediatric clinics.

• Patients received continuity of care because there weresystems in place to cover staff absence. Many staff werepart time and some worked full time hours over fourdays. This meant that several staff were available tocover at short notice for enhanced pay on their days off.The service did not use any agency or bank staff.

Managing anticipated risks

• Potential risks were taken into account when planningservices. Administrative staff who scheduled patientsplanned for fluctuations in demand for the paediatric




service. For example, there was high demand forpatients with ‘glue ear’ during colder weather and lowerdemand on the paediatric service during schoolholidays.

Are community health services forchildren, young people and familieseffective?(for example, treatment is effective)

Evidence based care and treatment

• Current evidence based guidance and standards wereused to develop and deliver treatment. For example,special interest groups such as the bone anchoredhearing aid group met regularly to discuss newdevelopments or changes to practice.

• The managing director informed audiologists whenrelevant clinical guidance was published. Protocolswere put in place that reflected evidence based practice.These were available for staff to access electronicallyfrom all clinic locations. The paediatric audiologyservice reviewed protocols in line with best practice asdiscussed at the paediatric audiology interest group. Forexample, Chime had changed the protocol forconducting visual reinforcement audiometry (VRA) forinfants to include use of a different method ofinteraction and a more simple recording method. VRA isa test that allows an audiologist to assess hearing ininfants and toddlers too young for normal tests. VRAuses behavioural conditioning to train very youngchildren to respond to sounds.

Technology and telemedicine

• The paediatric service was using up to date technologyto enhance the delivery of accurate and effectiveassessment and treatment of children’s hearingimpairment. For example, working in pairs, audiologistsused visual reinforced audiometry with puppet boxes togain the attention of young children to effectivelyestablish hearing thresholds. The service was in theprocess of installing visual display unit screens to add toand/or replace the puppet boxes. This meant thataudiologists had a more flexible range of treatmentoptions available to meet the individual needs ofpatients.

Patient outcomes

• Information about patient outcomes was collected andmonitored and used to make improvements. Thepaediatric team conducted an audit of the serviceprovision to children aged over three who had theirappointments at locality clinics. Recommendationsidentified from this audit had been discussed with thewider team and in some instances actions completed.For example, plans were in place to upgrade facilities toinclude visual reinforcement audiometry at the localityclinics. The paediatric service completed a clinical auditof services in August 2016. This report identified severalareas for service improvement and action had beentaken to address these. For example changes had beenmade to the booking process to ensure all hearing aidswere fitted within four weeks of diagnosis.

• The service participated in accreditation schemes. In2015, Chime was granted United Kingdom AccreditationService (UKAS) accreditation against the ImprovingQuality in Physiological Services (IQIPS) standard for itsfull range of adult and children’s hearing services. Chimewas reaccredited in June 2017. The IQIPS scheme is aprofessionally led assessment and accreditationprogramme that is designed to help healthcareorganisations ensure that patients receive consistentlyhigh quality services, tests, examinations andprocedures delivered by competent staff working in safeenvironments. IQIPS accreditation was a contractrequirement for all audiology contracts commissionedby the clinical commissioning group.

• The service participated in regional audits andbenchmarking projects. In November 2016, Chimepublished the paediatric audiology report for Devon andCornwall in collaboration with four acute trusts. Thispresented the results of a joint retrospective audit ofquality measured against standards identified in theNew-born Hearing Screening Programme (NHSP). Thisreport was circulated to staff. Some of these actions hadbeen taken forward, for example the requirement forinformation to be provided for patients and parents.

• The service participated in peer review. Chime SocialEnterprise was part of the South West PaediatricAudiology Interest Group. As part of this group, thepaediatric audiology service participated in monthlypeer review of all new-born hearing screeningprogrammes Auditory Brainstem Response (ABR) tests.ABR tests give information about the inner ear and brain




pathways for hearing. The peer review process providedassurance of the quality of the ABR tests as measuredagainst national standards set by the new-born hearingscreening programme

• There is a national expectation that regional paediatricaudiology services report on the quality of their servicein a number of aspects. The Devon and Cornwallpaediatric audiology interest group (PAIG) had agreed acommon set of reporting standards against which allservices audited their records. These results thencombined to create an annual regional hearing servicesaudit.

Competent staff

• All staff had the relevant skills and competencies to treatpatients safely and effectively. The assessment andtreatment skills of all paediatric audiologists wereobserved by a senior clinician once per year. Paediatricaudiologists frequently worked alongside clinicians of ahigher grade and this was seen as a positive learningopportunity. When staff were underperforming, bespokecoaching was delivered to meet their needs, forexample, communication skills training.

• Staff were given adequate support when they startedtheir employment. Staff who were on a substantive orfixed term contract attended a corporate inductionwithin 12 weeks of starting employment andparticipated in a workplace induction facilitated by theirmanager within eight weeks of starting employment. Atthe time of our inspection, there was a 97% compliancewith completion of appraisals.

• All staff were suitably qualified to carry out their role.Some staff had undertaken additional post graduatetraining to extend their specialist knowledge. Anaudiologist from Chime Social Enterprise was takingpart in the NHS Scientist Training Programme (STP). TheSTP is a postgraduate training programme providing anaccredited MSc in Clinical Science that leads to eligibilityto apply for clinical scientist status. Two of the six seniorpaediatric audiologists had undertaken study atmasters’ level as recommended in British Association ofAudiology scope of practice for career level six.

• Staff were given opportunities to develop theirexpertise. The service had approved funding for a rangeof external courses during the twelve months precedingour inspection. These included administrative, clinicaland managerial/business courses. Senior audiologists

had a specialist area of expertise, for example tinnitus,or bone anchored hearing aids. There were plans foraudiology technical officers to develop skills to take earmould impressions.

• All staff were invited to an internal study day every threemonths during working hours that included a staffmeeting plus training sessions. No staff were required torun clinics during this time except for a small team whotook turns to support the ear nose and throat clinic andthe repair service. This forum was also used to shareknowledge via a presentation of case studies.

• Audiologists shared their knowledge with other teams. Asenior audiologist had provided training regarding theAuditory Brainstem Response (ABR) audiometry test tothe local neonatal unit of an acute trust. ABR is aneurologic test of auditory brainstem function inresponse to auditory (click) stimuli. Two audiologistshad presented at a regional conference regarding theimplementation of the transition service.

Multi-disciplinary working and coordinated carepathways

• The audiology team worked with other services in acoordinated way. The clinical commissioning groupreported that Chime was committed to working with thewider audiology network, nationally and locally. Leadaudiologists from Chime attended the Children’sHearing Services Working Group (CHSWG). This was aregional multi-disciplinary forum includingrepresentatives from health, social care, charities andpatients who worked together to make sure that deafchildren and their families had good quality localsupport which met their needs.

• Where appropriate, staff involved teams from otherservices to assess and plan and deliver patient care. Forexample, staff worked with the Exeter Deaf Academy tofacilitate effective communication between the twoservices and to ensure that children attending theschool were provided with timely and effectiveaudiological care. Paediatric audiologists regularlyvisited three schools for children with special needs inorder to assess new intakes of students and follow upthe needs of children known to the service.

• Audiologists at Chime communicated effectively withthe wider multi-disciplinary team. With parents’permission, a copy of the patient’s individualmanagement plan was sent to external agencies whereappropriate, such as an advisory service for hearing




impaired children and a regional careers service forchildren moving from children’s to adults services.Paediatric audiologists contributed reports tomultidisciplinary meetings regarding specific patients.

• There were multi-disciplinary care pathways. Forexample audiologists contributed to the glue earpathway in conjunction with the ear, nose and throatteam at a local acute hospital. The paediatric audiologyservice provided annual reviews for patients withchronic conditions such as cystic fibrosis, visualimpairment, downs syndrome and cleft palette.

• In 2016, Chime was a case study of good practice in theNHS England commissioning framework for services forpeople with hearing loss. It was recognised as a fullyintegrated specialist hearing care service that alsosupported the wider network in which it was positioned.

• In the survey of children’s services completed in Marchand April 2017, all patients said they felt there had beenappropriate involvement of other services in their carewhere appropriate

Referral, transfer, discharge and transition

• Staff worked together to assess and plan on-going careand treatment in a timely way. Patients who were due tomove from children’s to adult services were prepared forthis transition in a coordinated and seamless way. Therewas a policy, pathway and protocol to support thesepatients and this was regularly discussed at thechildren’s hearing services working group. Thepaediatric team were planning improvements to thisservice to increase uptake, including starting theprocess earlier, i.e. in year seven, using activity bookletsto encourage engagement of young people.

• Audiologists referred to other services whereappropriate, such as the ear nose and throat specialistsat the local acute trust. The process of referral onwardswas streamlined to avoid delays. Audiologists workingin locality clinics emailed referrals to the centraladministration team who immediately printed them offand forwarded to the relevant department.

Access to information

• All clinical audiology information needed to delivereffective on-going care and treatment for patients wasavailable to staff. The paediatric audiology service useda comprehensive clinic management solution designedspecifically for audiology clinics. This included patientdemographics, test results, hearing aid programming,

appointments and all other documentation. Using theirself-managed server and computers, staff were able toaccess the necessary information from all cliniclocations.

• However, the systems that managed information did notsupport audiologists at Chime to view informationsystems outside of their organisation. This meant thatimportant background information was not alwaysavailable in advance of initial appointments. Forexample, staff were not always aware of child protectionorders unless this information was provided at referralor volunteered by families during the consultation. Staffattempted to mitigate this by asking parents/carers ifthe child was known to other health and social careservices.

• There were systems to flag on records where a child hadparticular needs. These ‘flags’ did not include childprotection orders, learning disability or complex needs,but relevant information was included as a journalentry. Staff told us that they planned all appointmentswith the expectation that the child may have a learningdisability or complex needs as this was often the realityfor patients with hearing loss.

• There were systems in place to enable audiologists toshare information with other professionals involved inpatients care. Staff shared details of attendance andoutcome with GPs, school nurses, health visitors forexample in the form of an individual management plan.The service encouraged the use of personal child healthrecords (‘red books’) as recommended by the RoyalCollege of Paediatrics and Child Health. The PersonalChild Health Record is a national standard health anddevelopment record given to parents/carers at a child'sbirth and is the main record of the child’s health anddevelopment. The record is retained by the parent/carerand health professionals should update the record eachtime the child is seen in a healthcare setting.

Consent

• Audiologists had a practical understanding of theconsent and decision making requirements oflegislation. Staff enabled parents and young people togive informed consent. We saw that audiologistsexplained assessment and treatment procedures withpatients and families during their consultations

• Audiologists accepted that continued consent wasgranted because all parties, i.e. patients, parents andcarers, engaged in the process of assessment and




treatment. Audiologists did not proceed withassessments and interventions unless children and theircarers were fully engaged with the process. Staff wespoke with had never been required to make a decisionto assess or to treat without the parent or youngpersons consent. There was a checkbox documentavailable to staff to help them to assess Gillickcompetence if required.

• Some aspects of consent were recorded explicitly usingspecific consent forms, such as permission to shareinformation, or permission to commence on a specifictreatment pathway such as the auditory processingpathway. However, for routine assessments andtreatments, explicit consent was not formally signed bythe responsible adult. Instead, parents or carers gaveverbal consent which audiologists recorded in thepatient record.

Are community health services forchildren, young people and familiescaring?

Compassionate care

• Staff interactions with patients were encouraging,sensitive and considerate. Staff spoke calmly and softlyto small children and used a friendly approach to putthe children at ease.

• In a patient satisfaction survey completed for thechildren’s service in March and April 2017, all patientswere satisfied with the welcome they received at theclinics and with the professionalism of the receptionstaff and audiologists. All patients said that audiologistswere approachable and they were given opportunitiesto discuss problems or difficulties.

• Staff respected confidentiality at all times. Staff closedclinic room doors during consultations and did notleave computer screens unattended.

Understanding and involvement of patients andthose close to them

• During our inspection we saw that parents and carerswere always involved in consultations with audiologists.Parents were asked to expand upon the informationwithin the patient referral and asked to describe thechild’s hearing difficulties from their perspective.

• In six of the eight consultations we observed, staffdirectly engaged with children and offered opportunityfor children to give information regarding theirperspective of their condition. In two of theconsultations we observed that a member of stafffocussed entirely on the adult carer accompanying thechild. This meant that during those encounters the childwas not encouraged to be an active partner in theassessment and treatment process.

• Older children were offered support to manage theirown condition as they made the transition fromchildren’s to adult services.

• In a patient satisfaction survey completed for thechildren’s service in March and April 2017, all patientswere satisfied with the explanations given to them byaudiologists. All patients were happy with theirexperience of communicating with the service.

Emotional support

• Staff did not always provide comfort to children whowere distressed during their consultations withaudiologists. In two of the eight consultations weobserved, children became distressed during theirappointment. In one of these, staff directly engaged withthe child and offered comfort to the child when theybecame tearful. In the other consultation, we observeda member of staff did not offer comfort to the child.

• In all the consultations we observed, staff offeredreassurance to their carers. Audiology staff were heardto be supportive towards parents on the telephone whowere anxious regarding appointments they were unableto keep for their children.

• For younger children, a member of staff coordinated theHappy Hands support group which providedopportunity for children and parents and grandparentsto meet together to learn sign language, learn songs andhave new ear mould impressions made.

• Staff showed understanding of the short-term anxietiesand forms of distress that children and families mightexperience when attending the audiology appointment.Staff were aware of the complex factors that affectedchildren’s experience of hearing loss.

• In one of the eight consultations we observed, anaudiologist treated an older child who presented withcomplex emotional needs. That member of staff agreedthat the child may benefit from professional support forthis emotional need. However that member of staff did




not raise this with the patient or their family during theconsultation. Staff we spoke with were unclear aboutwho they might signpost patients to for emotionalsupport.

Are community health services forchildren, young people and familiesresponsive to people’s needs?(for example, to feedback?)

Planning and delivering services which meetpeople’s needs

• The services provided by Chime reflected thegeographical spread of the population it served.Audiologists ran clinics from 14 sites located in the localacute hospital sites, several small community hospitalsplus three schools and a baby and toddler group.

• The facilities available at clinic locations varied in theirsuitability for children. These premises were leased fromother providers. At the main clinic location, ChimeSocial Enterprise had access to the paediatricoutpatient service waiting room of the local acute trustwhere a separate play area was available for children.However, waiting rooms in the locality clinics weremulti-purpose and did not contain any toys or books forchildren.

• The facilities available at clinic locations varied in theirsuitability for audiology testing and treatment. We sawthat clinic rooms at the main acute hospital site werewell insulated from sound. Clinic rooms at the localityclinics were double glazed and had secondary glazing,however external noises such as banging doors wereevident during some hearing assessments. Leaders wereaware of the variability in ambient noise levels at localityclinics which may have affected the quality of hearingtest results obtained. The need for staff guidanceregarding how to measure and mitigate this was raisedin a recent IQIPS inspection. Plans to address this wereon hold during the tendering process.

• The facilities available at the clinic locations we visitedwere suitable for people with mobility impairment. Wesaw that clinics were accessible for patients usingwheelchairs and there was sufficient car parkingavailable at the majority of the sites we visited.

• Patients were satisfied with the facilities available tothem at clinic locations. In the patient survey of the

paediatric service carried out in March and April 2017, allpatients were satisfied with the comfort of the clinicrooms, 94% of patients were satisfied with the childfriendliness of the waiting areas, 96% of patients weresatisfied with the accessibility of the clinic from theirhome. All patients were satisfied with the signs directingthem to the audiology service.

• Where possible, audiologists brought the service tofamiliar settings where patients and carers werecomfortable. For example, a member of staffcoordinated the ‘Happy hands’ support group where

• Audiologists worked together to meet the individualneeds of children. For example, when children struggledto participate in formal assessments, they werere-booked for an appointment with two audiologists,allowing one to focus on the needs of the child whilstthe other performed test procedures. Audiologistsadapted their approach to meet the needs of differentage groups.

• When children’s needs were not being met, this wasidentified and used to develop the service. For examplethe paediatric team had upgraded their informationservice to meet the needs of families. In November 2016,the Devon and Cornwall paediatric audiology reportidentified that parents and patients were not givensufficient information. The paediatric team hadresponded positively to this finding and had puttogether useful information to help parents and childrento get the most from their assessment and treatmentexperience. This included a patient information leafletdesigned specifically for children to describe what toexpect during a hearing test and an information pack forchildren diagnosed with permanent hearingimpairment. Audiologists included relevant informationin the management plans that were sent to familiesafter their consultations.

Equality and diversity

• Staff ensured that all patients had equal access to careand treatment. For example, when a patients languagewas a barrier to engagement in the assessment ortreatment process, administrative staff contactedinterpreting services and arranged for interpreters to beavailable for appointments when necessary. Forpatients who needed assistance to express their views,staff enabled patients to access advocates whenrequired.




• Chime had not yet focussed due attention to theworkforce race equality standard which brings togetherorganisations to provide leadership on equality andinclusion. The organisation reported on the workforcerace equality standard indicators for the first time in May2017. Prior to this date the clinical commissioning grouphad not required this information to be submitted aspart of their contract. Of the 57 members of staffemployed at Chime, 9% described themselves as Blackor minority ethnicity (BME). These included 17% of staffat band six and 42% of staff at band 5 level. In the twoyears preceding our inspection, Chime had recruitedstaff from overseas to fill audiology vacancies. At thetime of our inspection an action plan was notformulated.

• Staff were not routinely asked whether they felt theywere offered equal opportunities for career progression,however a higher percentage of BME staff (60%) wereoffered non-mandatory training than non BME staff(35%). There had been no reported incidences ofdiscrimination or harassment from staff during thetwelve months preceding our inspection.

Meeting the needs of people in vulnerablecircumstances

• The service was flexible in its approach to delivery ofcare. The paediatric team delivered the service at arange of locations and situations to reach out to thosepatients who might struggle to attend regular hospitalappointments. This included domiciliary visits to veryyoung babies.

• The paediatric team recognised that young teenagersmay disengage with the service at a time when theymost needed support to plan for their future as a personwith permanent hearing loss. For this reason thetransition service had a plan to reach out to youngpeople earlier in order to encourage a two-wayengagement with the adjustment process.

Access to the right care at the right time

• The paediatric service offered flexibility regarding choiceof appointments. Appointments were rearranged whenfamilies could not accommodate prior commitments.There were out of school hours and Saturday clinic slotsavailable. When necessary, children were prioritised andoffered urgent appointments if specially requested bythe referrer.

• Effort was made to minimise the time people had towait for treatment or care. Chime offered a drop in clinicfor hearing aid repairs. Parents could access this withoutan appointment and without the need for children toattend if they were at school. In the 2017 survey of thepaediatric service, all patients were satisfied with thehearing aid repair and battery replacement service.

• There was an easy–to-use appointments system. Whenfamilies telephoned with general enquiries or to changeappointments, their call was placed in a queueingsystem and promptly answered. There were twotelephone lines manned during working hours by ateam of administrative staff.

• At the time of our inspection, the majority of patientshad timely access to an initial audiology assessmentand subsequent treatment. There had been nobreaches of waiting time standards expected by theclinical commissioning group, for example all childrenhad been treated within 18 weeks of referral. In thepatient survey conducted in March and April 2017, 98%of patients were satisfied with the time that the childwaited to be allocated an appointment.

• In some instances, effective action had been taken toaddress previous delays to treatment. For example, inAugust 2016, a clinical audit of the paediatric audiologyservice reported that only 58% of patients were fittedwith a hearing aid within four weeks of diagnosis.Administrative staff now ensured that assessmentappointments and fitting appointments were bookedconcurrently upon receipt of the referral to avoid delay.This had resulted in a clear improvement in responsetimes and since October 2016; all patients were fittedwith a hearing aid within four weeks of diagnosis.

• The paediatric service was not reaching all children whoneeded audiology services. A high percentage ofpatients did not attend their planned appointments. InMay 2017, 12% of patients missed their initialassessment appointment, 36% missed their paediatricvisual reinforcement audiometry appointments, and29% missed their pre-reassessment appointments.

• Action was taken to address the rate of non-attendance.Administrative staff sent text reminders prior toappointments and sent pre-appointment letters forlonger appointments. To encourage re-attendance, staffinformed referrers and sent follow up letters to familieswhen children missed an appointment.

Learning from complaints and concerns




• There was a low rate of complaints. In the twelvemonths preceding our inspection there had been onecomplaint regarding the children’s audiology services.

• When complaints were received, the paediatric teamresponded effectively and there was organisationlearning as a result. Following the complaint, Chimereviewed and amended their procedure for sendingletters to patients who did not attend theirappointment.

• Parents we spoke with were not aware how to make acomplaint about the service. Information about how tocomplain was not routinely sent to patients and theirfamilies prior to or after their appointment. This meantthat the service was missing an opportunity to gainfeedback on the quality of the service.

• However, there was a child friendly comments processavailable at the main hospital clinics. Patients couldchoose from three postcards depicting emoticon facesto write on and post in a comments box in the waitingarea.

Are community health services forchildren, young people and familieswell-led?

Leadership of this service

• Leaders had the capacity, capability and experience toeffectively lead .Two lead audiologists were responsiblefor a clinical caseload plus the day to day running of thepaediatric audiology service and the line managementof the six audiologists in the paediatric team. Thedeputy clinical director had a clinical role and was theline manager for the two lead audiologists. The deputyclinical director reported to the managing director.

• Staff were able to approach leaders and leaders werevisible at the frontline of service delivery. The managingdirector also worked as a clinical consultant in theadult’s service one or two times per week and thedeputy clinical director worked regularly in a clinicalcapacity.

• When spoken to, leaders at all levels could giveexamples of challenges to good quality care. Themanaging director and the deputy clinical directorattended band seven meetings where operationalconcerns were discussed.

• Leaders encouraged appreciative and supportiverelationships amongst the teams. Staff told us they feltcomfortable to approach leaders of the service todiscuss concerns. Less experienced staff consulted moreexperienced staff for clinical advice.

• In the most recent staff survey completed in January2016, 87.2% of staff felt their immediate line managerwas effective and 87.2% of staff felt their immediate linemanager was approachable.

Service vision and strategy

• There was a clear vision and set of values. Chimedescribed its values as ‘professional’, ‘caring’,‘committed’, ‘united’ and ‘pioneers’. Although staff wereunable to list these values, we saw that these valueswere evident in their work.

• Chime was in the process of tendering for a renewal oftheir contract for audiology services with the clinicalcommissioning group. The managing director had aclear vision of how to ensure the sustainability ofregional audiology services and was fully involved inengaging with commissioners and other providers tosecure this vision. Much of the vision for the service wasdependent upon the future shape of the servicecommissioned.

• All grades of staff were committed to moving the serviceforward. There were several improvement projectsunderway in frontline services that continuedirrespective of uncertainties regarding the futurecontract

Governance, risk management and qualitymeasurement

• There was not an effective governance framework tosupport the delivery of the strategy and good qualitycare. The oversight of quality and safety was not joinedup.

• Senior audiologists retained individual oversight ofsome aspects of service provision, such as responsetimes, compliance with mandatory training, audit,health and safety. These staff met regularly with thedeputy clinical director and the managing director todiscuss operational issues. We saw in the minutes fromsenior audiologists meetings (known as band sevenmeetings) that safety and quality concerns werediscussed, however this did not include regularreporting from senior clinicians regarding their specificareas of responsibility. This meant that not all of the




senior clinicians and the management team were fullybriefed regarding clinical governance.For example, theminutes of these meetings showed no evidence ofdiscussion of the non-compliance with mandatorytraining.

• The managing director monitored data to anticipatepotential breaches of waiting times. Data in relation topatient outcomes in the children’s service was reportedto the clinical commissioning group every three months.

• The board consisted of the chair, managing director,finance director, and four non-executive directors thatincluded a staff council representative and a patientrepresentative, a GP and a marketing and businessdevelopment advisor.

• There was not a comprehensive assurance system atboard level. In the twelve months preceding theinspection, the minutes of the board meetingscontained reference to clinical and quality issuesraised by the managing director, such as the outcomesof complaints, breaches to the response times, futureaccreditation inspections, risks identified to patientswith pacemakers. However, there was no standardagenda item for patient safety at the board meeting.This meant there was no guarantee that clinical andquality issues would be considered or that the boardwould receive reports of safety performance, otherthan if the managing director chose to raise issues or ifthe board asked for specific information.

• Poor compliance with mandatory training had notbeen highlighted by senior audiologists at the bandseven meeting, senior managers had not identifiedthis as a safety concern and subsequently the issuehad not been raised at board level. This meant therewas potential for safety concerns to remainundetected and unchallenged.

• There was a detailed risk register but this did notcontain clear arrangements reducing the impact of risksand timeframes for when this should be completed andby whom. The risk register contained 74 risks; nine ofthese risks were rated red. These included risk ofeviction with high costs of relocation, lack of acontingency plan for absence of key senior staff,robustness of income with one major contract,insensitive handling of press invitations, stress onfinances as a result of high growth, changes inexpectations of the service with regard to politicalchange, the need to maximise the Chime Social

Enterprise brand. However, there were omissions in thisdocument. The risk register did not identify clear actionplans, lead person responsible for ensuring risks weremanaged, dates for completion or sources of assurance.

• The risk register did not include reference to the issuesidentified by senior staff at the time of the inspection,for example it did not refer to poor compliance withmandatory training. We did not see evidence that therisk register was used as a working document and/orreviewed regularly by the management team or theboard.

Culture within this service

• Staff felt respected and valued. In the most recent staffsurvey completed in January 2016, 92% of staff felt thatthe organisation treated them with fairness and respect.

• The culture of the organisation was centred on theneeds and experience of patients. Staff we spoke withtold us they were given the time and resources toprovide a high quality service for children and parents/carers. Staff said they were proud to work for Chime.

• We saw that staff valued teamwork and told us how theybenefitted from the experience of other audiologists intheir team. The paediatric team collaborated to improveservice performance. For example, at the time of ourinspection, the team was working on the developmentof a patient satisfaction questionnaire. All staff wereinvited to an annual away day to encourage teambuilding and bonding.

• The safety and well-being of staff was promoted. Staffwere sometimes required to work remotely either incommunity hospital clinics or when carrying outdomiciliary visits. Systems were in place to support loneworking.

• Chime had been awarded the social enterprise mark.This is an accreditation that recognises characteristics ofthe business model as ethical, credible and commercial.

Public engagement

• The views and experiences of parents and otherprofessionals were gathered and acted upon to shapeand improve the service. A member of staff from Chimeattended inter-agency children’s hearing aid servicesworking group (CHSWG). This was a group of health,education and social care professionals, parents and




voluntary sector. This group worked together to agreedterms of reference to improve services for deaf andhearing impaired children and their families in the area,and encouraged user feedback via online forums.

• To some extent, patient representatives were activelyengaged and involved in decision making. There was anadult patient representative on the board ofnon-executive directors. A patient user group in adultservices was consulted regarding changes to protocolssuch as the revision of the letter sent to patients who didnot attend appointments.

Staff engagement

• Staff were involved in making decisions that affected thefuture of the company. There was a staff council. Thisconsisted of six staff representatives and the group metwith the managing director present every two months.This council had clearly defined terms of reference.Representatives from each staff group were voted ontothe council by employees. We saw that the staff councilensured that the voice of the employees was listened to.For example, the staff council were reviewing thequestion format of the staff survey to ensure thatsubsequent surveys reflected the needs of staffcorrectly.

• There were adequate forums for staff to engage with themanagement team. Staff told us they were fullyinformed regarding the vision of the service. All staffwere invited to attend a staff meeting every threemonths, where operational concerns and updates werediscussed. An online question and answer session‘Question Chime’ was facilitated every two months;however not all staff we spoke with were aware of this.

• There were some themes of concern that arose from thestaff survey conducted in January 2016. For example,38% of staff stated that morale was not high, 12.8% ofstaff felt that their views were not listened to, 38.5% ofstaff stated that they had not received useful feedback

on their performance, 20.5% of staff stated that theirworking environment did not allow them to completetheir work effectively, 35.9% of staff said there were notopportunities for personal development, 29% of stafffelt that the organisation was not united, 30.8% of staffadmitted to being stressed at work and 18.9% of staffsaid it was not safe to challenge the ways things weredone within the organisation.

• Action was taken as a result of the staff engagement. Forexample, following the staff survey the senioraudiologists had attended management training tosupport their development.

• At the time of our inspection, the format of the staffsurvey was under review. A staff survey had beencompleted sixteen months prior to our inspection andthere were plans to repeat the survey following ourinspection.

Innovation, improvement and sustainability

• Clinicians showed creativity in their approach toimproving the service for children and young people.For example, the team planned to produce a video forthe website to show what to expect during audiologyappointments. The team supporting children totransition to adult services were designing an activitybooklet for school children aged 12 and 13 to encouragethem to engage with the support and transitionresources available to them.

• Despite financial pressures, leaders were focussed oncontinually improving the quality and responsiveness ofthe service offered to children. A business case hadbeen submitted to equip three community localityclinics with visual reinforcement audiometry equipmentand facilities.

• Chime Social Enterprise had been recognised locally forits innovation. Chime was shortlisted in the ‘health’category for the Exeter Living Awards which celebrateinnovative business and enterprise in Exeter.




Areas for improvement

Action the provider MUST take to improve

• Ensure that all staff are appropriately trained toundertake their roles. This includes meeting theorganisational target for mandatory training

• Ensure that the risk register is complete and used toreflect and manage live risks

• Ensure that the board is cited on key quality and safetyinformation in order to assure themselves of thequality and safety of the services they are providing

Action the provider SHOULD take to improve

• Put systems in place to meet statutoryrequirements including the duty of candourregulations and the workforce race equality standard

• Put systems in place to ensure that staff consistentlyfollow the protocols for infection prevention andcontrol

• Mitigate where possible the environmental risks of alllocality clinic rooms in relation to child safety, forexample table corners, plug sockets

• Consider providing diversional toys/activities forchildren in waiting rooms at locality clinics.

• Encourage children whenever possible to participatein consultations during appointments

• Signpost children and families to resources foremotional support where applicable

• Consider methods by which children can offerfeedback regarding service delivery and direction

• Routinely provide patients and their families withinformation about how to complain about services

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activity

Treatment of disease, disorder or injury Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

17 (1) Systems or processes must be established andoperated effectively to ensure compliance with therequirements in this Part.

Not all systems and processes were fully established andoperated effectively to ensure compliance with goodgovernance. The processes for monitoring quality andsafety information were not robust. At operational level,regular reports on quality and safety metrics were notregularly presented to the senior management team.

There was insufficient assurance of clinical governanceat board level. The risk register was not adequatelymaintained to provide comprehensive identification ofcurrent risks and their mitigation. Quality and safetyinformation was not regularly reported on or challengedat board level.

This was a breach of regulation 17 (1)

Regulated activity

Treatment of disease, disorder or injury Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

Regulation 12 (2) (c) Care and treatment must beprovided in a safe way for service users. The registeredperson must ensure that persons providing care ortreatment to service users have the qualifications,competence, skills and experience to do so safely.

Regulation

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


The provider had not ensured that all staff providing careand treatment to patients had received essentialmandatory training with regards to fire safety, basic lifesupport, children's life support, infection prevention andcontrol.

This was a breach of regulation 12 (2) c.


Requirement noticesRequirementnotices


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.


Enforcement actionsEnforcementactions


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