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ADULT SERVICES DEPARTMENT PROCEDURE 15/15

Supporting People at Risk of Choking Policy

Effective date January 2016

Category Adults

Summary This policy provides the framework for use within Hampshire County Council as well as for those commissioned to provide services by Hampshire County Council to support individuals at risk of choking.

Keywords Choking, SALT, dysphagia, pica

Approved by

Date Approved

Procedures cancelled or amended

N/A

Author Karen Alexander, Governance Manager

Sponsor Jo Lappin, Head of Safeguarding and Governance

Contact [email protected]

Signed

Designation

Date

Version control change record (inside first page)

Date Version Reviewed

Author Reason for change Approved by

10.05.2016

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PURPOSE

This policy gives practice guidance for Hampshire County Council staff who directly provide care, or who commission care, for people who may be at increased risk of choking. This guidance has been built on the document, Reducing the risk of choking for people with a learning disability: a multi-agency review in Hampshire produced by Hampshire Safeguarding Adults Board Multi-Agency Partnership (2012). The main purpose of this document is to offer guidelines for staff to follow when a person may be suspected to be or is known to be at risk of choking. For staff working in Hampshire County Council residential or nursing homes this policy should be used in conjunction with the Quality Standard – Care of people at risk of choking.

SCOPE

This policy is relevant to all Hampshire County Council staff providing care to people who are or who may be at risk of choking. This policy applies to staff employed by Hampshire County Council and to those services which have been commissioned by Hampshire County Council.

This policy has considered a number of areas including:

Commissioning and monitoring of food provision, mealtime supervision / support and environments Screening for the increased risk of choking Care planning and risk management Training and health promotion Going into hospital Reporting choking episodes/incidents Capacity / best interests issues.

CONTRIBUTIONS

The following organisations and staff made valuable contributions to the content of this policy:

Southern Health NHS Foundation Trust Speech and Language Therapists

Solent NHS Trust Speech and Language Therapists

AS staff in HCC Care units and Day Services

AUTHORITY TO VARY

Graham Allen, Interim Director of Adult Services

Care Governance Board

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CONTENTS

pageDuties/Responsibilities/Roles 4

Introduction 4

Main content 5

Requirements for Hampshire County Council staff 6

Training for HCC staff 6

Screening the risk of choking 6

Managing care 8

Hospital stays 11

Requirements for providers of commissioned care 11

Training 11

Screening the risk of choking 12

Managing care 12

Requirements for those commissioning services 12

Implementation considerations 13

Monitoring compliance 13

Document review 13

References 13

Appendices 14

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DUTIES/RESPONSIBILITIES/ROLES

All Hampshire County Council staff providing care for people to adhere to the guidance laid out in this policy to ensure the safety of those people with an increased risk of choking. This policy also applies to services commissioned by Hampshire County Council.

INTRODUCTION

Definition of choking: Choking is the inability to breathe because the trachea is blocked, constricted, or swollen shut. Choking is a medical emergency. When a person is choking, air cannot reach the lungs. If the airways cannot be cleared, death follows rapidly.

The document, Reducing the risk of choking for people with a learning disability: a multi-agency review in Hampshire (2012) was aimed at people who are working with those who have a learning disability, in the role of commissioners or providers of services. A number of recommendations are made at the end of the report as a result of the findings which are all based on a common sense approach and good practice.

The recommendations made in Reducing the risk of choking for people with a learning disability: a multi-agency review in Hampshire cover a wide range of issues including understanding of causes of choking; recognition of choking risk; emergency response to someone who is choking; training for staff commissioning placements and supporting people to keep healthy. This policy has been written in response to the recommendations made and to ensure that they are implemented across all client groups.

Definition of Pica: People eating items compulsively of no nutritional value. People may eat relatively harmless items of potentially dangerous items.

Definition of dysphagia: reduction or loss of oral or pharyngeal skills can impact on risks of choking. The term dysphagia is used to describe swallowing disorders characterised by difficulty in oral preparation for the swallow or in moving the bolus from the mouth to the stomach. Subsumed in this definition are problems in positioning food in the mouth and in the oral movements, including suckling, sucking and mastication. Early identification of the symptoms of dysphagia is essential.

Acute symptoms of dysphagia include:

coughing during or immediately after drinking and/or eating

choking

wet vocalisations after drinking

change of skin colour

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watering eyes

refusal of food before or during meal

increased anxiety at drink/meal times

behavioural difficulties at drink/meal times

Chronic symptoms of dysphagia include:

chest infections

signs of malnutrition – as identified by MUST assessment, weight loss, skin

breakdown, hair loss

signs of dehydration – constipation, strong urine, urinary tract

infections, dry skin

Above information taken from Southern Health Dysphagia (Swallowing Disorder) Policy

MAIN CONTENT

All providers and staff need to be aware of the catastrophic consequences that occur if the person chokes. Recognition of choking (airway obstruction by a foreign body) is the key to a successful outcome, it is important not to confuse this emergency with fainting, heart attack, seizure or other conditions that may cause sudden respiratory distress, cyanosis or loss of consciousness.

For greater clarity, this policy has separate sections for those employed directly by Hampshire County Council, and for those who are commissioned by Hampshire County Council to provide a service. There is an additional section for the commissioners of services.

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Requirements for Hampshire County Council staff

TrainingAs a provider of services to adults, Hampshire County Council will ensure that:

All Hampshire County Council staff providing care will receive emergency aid choking response training as part of the Stepping forward, Stepping Back induction programme

Hampshire County Council staff directly providing or commissioning care to persons who may be at risk of choking will receive training in managing the risk of choking.

Screening the risk of chokingWhilst it is not possible to prevent all episodes of choking, reducing the risk of choking and improving the safety of individuals who have a risk of choking is essential.

It is important that staff recognise that choking risks can result in fatal choking incidents. Choking can occur as a result of either a single medical problem, e.g. stroke, progressive neurological condition, or as a result of:

oropharyngeal structural problems

motor processing difficulties

central nervous system disorders

pharyngo-oesophageal problems

poor oral health

the psychological effects of institutionalisation

mental health problems

deliberate self harm

the effects of medication

Pica

Eating too fast or cramming food into the mouth

Epilepsy – risks are increased immediately before, during and after a seizure.

Hampshire County Council staff must use the Solent NHS Trust Choking Screen as part of the assessment process to determine if professional advice is required from a speech and language therapist. Following the completion of the choking screen, if

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there are concerns relating to questions 1-6, then pre-referral liaison will help staff identify if a referral to SLT is appropriate. Staff will receive local guidance from their head of service / service manager as to which staff will carry out these assessments. For questions 7 – 10 there should be consultation with other relevant health professionals e.g. GP/community nurse etc.

Staff must gain the consent of the person wherever possible, before any screening, assessment or medical investigation is undertaken. Numerous guidelines regarding the assessment of consent are available and it is essential that all decisions are clearly documented. When the person is unable to give informed consent best interest decisions are made using the guidelines in the Mental Capacity Act and best interest guidance.

Some people may exhibit challenging behaviours e.g. putting non-food items into their mouth, swallowing non-food items or deliberately trying to choke themselves through self-harm. Some people also may cram food into their mouth or eat their food very fast so increasing their risk of choking. If this occurs, staff should immediately seek a multi-disciplinary assessment and also ensure that a robust risk assessment and support plan is in place.

When behaviours and/or choking episodes occur these should be reported through Hampshire County Council internal reporting systems and well documented in care plans in order that frequency and severity can be determined and action (what staff did) reviewed so that assurance can be given that care is delivered safely.

All services should use the Solent NHS Trust Choking Screen or similar to indicate the risk of choking and whether a referral / further discussion with SLT or another health professional is required.

This checklist must be completed:

at initial assessment or

each time a carer is concerned about a person’s eating and drinking / swallowing ability or

if the person is believed to be at risk of choking

if there has been a significant change in the person’s condition or social situation which might increase their risk of choking

if a person has been identified as being at increased risk of choking then each meal-time should be recognised as an opportunity for reassessing the risk

routinely as part of a regular review.

Staff must ensure that they follow the recommendations set out by professionals, including speech and language therapists in order to reduce the risk.

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Managing care and care planning

Different professionals or care givers will often have their own care plans for the people they are supporting. For example a self-directed support plan, a speech and language therapy care plan, and caregivers may have their own individual care plans. If a person has increased risks around eating and drinking this must be considered and reflected consistently throughout the care planning process by those involved in specialist advice giving, or day to day care provision. A consistent approach across all care givers is very important for keeping the person safe and reducing the risk of choking.

The development of individual care plans must, wherever possible, include the person and those who provide care. The principles and requirements of the Mental Capacity Act 2005 must be considered and implemented when developing an individual care plan.

Each person for whom a service is provided must have an individual first aid treatment plan so that those who are wheelchair users or cared for in bed are treated by first aid appropriate to their needs and staff must be aware of this plan and understand how to execute it if required. In day services, such a plan would only be developed for those people who are both wheel chair users and also identified as at risk of choking.

Where a risk of choking / problems with eating, drinking, medication and pica is identified, the plan must include what the concern is and what needs to be done:

to support the person to eat, drink and take medication safely and minimise the risk of choking

if the person’s risk of choking increases as a result of their behaviour – what this is and how and when the person needs to be supported

if an incident of choking or aspiration occurs if there is a change in the risk of choking.

It is important that the risk plan considers the risk of choking presented by both edible and non-edible items.

A person’s care plan and any decisions outlined in it must be checked regularly for any changes. Assessments and decisions must be actively revisited following any change or deterioration in the person’s health or behaviour.

While regular reviews are of course necessary, staff must remain vigilant and responsive to the individual’s needs on a daily basis, during all oral intake, including meals, drinks, snacks and medications.

If a person is unable to make an informed decision about their own care a best interest meeting must be held. This must include the person, if appropriate and a range of people who are able to contribute to the decision making process on behalf of that person and in their best interests. This provides an opportunity to consider all possible options of care and through discussion reach a decision as to what the course of action will be in the “best interest” of the person concerned.

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In circumstances where care workers or family members disagree with any decision reached regarding the person’s care, it is up to the decision maker (usually, the commissioning body or relevant health care professional or advocate) to weigh up the views of the different parties and make a best interest decision when developing the care plan. In the event of a significant dispute regarding the best interest’s decision made, every effort should be made to resolve it through discussion, negotiation or mediation. In the event of irresolvable disputes about best interests, an application may need to be made to the Court of Protection for a decision about the person’s welfare best interests.

It may be necessary to restrict access to certain environments, foods or objects for some people due to a risk of choking. In all cases this must be taken as a best interest decision and be documented in the usual way. On occasions it may be appropriate to consider whether this is a Deprivation of Liberty and the appropriate process undertaken to assess this i.e. referral as a Deprivation of Liberty Safeguards application to the funding authority if within residential care or an application to the Court of Protection if not within a residential setting.

Any professional has a responsibility to screen for the risk of choking where it is thought that a person may be at risk.

A person’s care plan must:

Clearly document all health care that is relevant for the person, such as an annual health or dental check and when and where the care should be sought. It must inform the care givers of what they must do to support the person in their care to visit the GP, dentist etc.

Clearly reference any clinical guidelines and the people who have been consulted in developing the support plan around choking. The ideal is that where health professional guidance has been given relating specifically to Dysphagia, then the care plans that are in place are those of the health professional

Document any medication or treatments prescribed to them. Some medications can have an impact on a person’s swallowing functioning and it is important that any changes are considered before a medication change. Any identified risks following a change in medication must be clearly documented within the person’s care plan.

Be reviewed should any changes in medication occur. Clearly document any signs and symptoms of swallowing difficulties or

dysphagia that may be relevant to an individual’s health care and condition, and that can assist care givers in identifying an emerging risk of, or change in risk of choking.

Clearly document any risk to an individual due to them easting too fast or cramming food in to their mouth and how they should be supported

Clearly document any risk due to Pica and how the individual is to be supported

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Document the likely prognosis for the individual deemed to be at increased risk of choking so that care givers will not make false assumptions which might place the individual at risk.

Clearly document any consideration to the individual accessing the food of others and the risk and management around this

Clearly document the high risk foods for a person and likely access to these Provide detailed contingency plans should emergency intervention be

required. Detail first aid care that is appropriate to the person should choking or

aspiration occur. This must take into account any wheelchair users or those who are cared for in a bed.

Clearly state that the care giver must immediately notify emergency health care services, the GP and Local Authority of any choking incident that may have resulted in harm to the person or if the provision of care is suspected to have resulted in a choking incident.

Include information about the person’s mental capacity to be able to understand their risk of choking and their ability to understand and agree to the protective actions which may be put in place to reduce that risk. There should be a statement about individual’s capacity and awareness of choking risk.

All staff involved in the person’s care must:

be informed of the care plan and any changes to it in relation to eating, drinking and taking medication

be involved in the care planning process for people at risk of choking be aware of the consequences of not following an agreed eating and

drinking plan (see details on training) complete a swallowing checklist every time concerns are raised or a risk of

choking is suspected on current oral intake and be completed every six months after initial completion/initial SLT recommendations are made

understand what they are required to do if the swallowing checklist indicates there is a risk of choking or an increased risk of choking for the person

be able to recognise and know how to prepare/present food and fluids to the person, in keeping with their eating and drinking recommendations

follow instructions in the care plan for giving medications; including correct positioning and making sure medications are in the appropriate format

must follow instructions regarding how a person should be supported at meal times or whenever there is access to food and drink

Where a person experiences a choking episode or a near miss choking episode, this must always be recorded on an incident form

The incident must also be fully recorded in the daily notes for that person (where relevant) and consideration should be given to whether a referral or re-referral to an appropriate professional is required

Consideration should also be made as to whether a safeguarding concern needs to be raised.

The Quality Standard, Care of people at risk of choking, has been developed for Hampshire County Council staff working in HCC Care residential and nursing homes

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to guide them in the practical steps required to aid them reduce the risks of choking among the people they deliver care to. See Appendix 2

When a service user has a stay in hospitalIf a person is going into hospital for any reason, their eating and drinking needs must be communicated verbally or through a document such as their hospital passport. It is of paramount importance that this information goes with the person to hospital to detail the person’s most up to date eating and drinking recommendations. The hospital passport should include risk of the person choking due to eating too fast or cramming food in their mouths and also re PICA

Where the individual is open to speech and language therapy and they are aware of the hospital admission, best practice would be for the community services and acute services for SLT to liaise regarding any changes to the eating and drinking recommendations during the hospital admission and following discharge. When an individual is acutely unwell, their eating and drinking skills often will require assessing within the hospital setting.

This does not negate the importance of clear communication and handover between the hospital, provider, family carers and any Adult Social Care practitioner who may be involved.

It is recommended that hospitals consider whether there are any training needs identified for the provider staff and / or family carers following the discharge of the person back to their care.

Requirements for providers of commissioned care

TrainingProvider services regulated by the Care Quality Commission are required to meet a number of essential quality outcomes in order to register to provide services. As part of this arrangement providers must only accept people whose assessed needs can be met safely and in line with the agreed person-centred care plan. This requirement extends to the care of people assessed as at risk of choking.

In order to do this, those providing a commissioned service must ensure that their employees and / or subcontractors who give care have adequate training on the recognition of choking, the use of appropriate choking risk screening tools and must also understand how and when to make referrals to specialist services.

Providers must ensure that their employees and / or subcontractors have sufficient training to:

be able to safely deliver care to any person at risk of choking be able to respond to an episode of choking by administering the correct first

aid care and then seeking appropriate aftercare.

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Screening the risk of chokingProviders must:

ensure that their employees and / or subcontractors who give care are fully aware that choking risks can result in fatal choking incidents

ensure their employees and / or subcontractors have an adequate understanding of the varied conditions and circumstances which can place a person at risk of choking

provide an appropriate screening tool for employees and / or subcontractors to use when they are concerned that a person may be at risk of choking

should we be stating that risk around eating and drinking should be a part of their initial and on going assessment of individuals

ensure that their employees are suitably trained to provide support at mealtimes and to observe and assess eating and drinking skills at each and every meal

ensure their employees and / or subcontractors know when and how to escalate concerns to a specialist service – for example, speech and language therapy, when this has been indicated by the screening tool.

Managing care and care planning

Providers must have robust processes to ensure that an appropriate eating and drinking care plan is in place for any person who is at risk of choking.

Providers must make sure there is a process in place to prompt regular reviews by the care provider and for the risk to be re-assessed as the needs of the person change, for example if there is a medication or physiological change.

The provider must monitor that staff are fully competent to recognise and assess risk and deliver safe care to those at risk of choking, in line with the agreed care plan.

Requirements for those commissioning servicesCommissioners of services must ensure that there is sufficient

speech and language therapy resource within the community to respond in a timely / efficient manner to appropriate requests for assessments and advice of those identified as having a risk of choking related to dysphagia, irrespective of health status.

Those responsible for commissioning services must ensure that all contracts with providers include the same specification for safe and effective screening, adoption of common sense approaches, a well defined process for onward referral where appropriate, assessment and management pathways of those at risk of choking for all client groups as defined throughout this document and that those contracts are effectively monitored.

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IMPLEMENTATION CONSIDERATIONS (TO INCLUDE PUBLICITY AND TRAINING REQUIREMENTS)

Training requirementsWorkforce Development Team and PaCT (Partnership in Care Training) regularly review the provision of training courses for Hampshire County Council employees and for provider organisations in the area of caring for a person with at risk of choking. They do so to ensure that the content is fit for purpose and is aligned with policy and current practice and also to ensure sufficient course are provided.

Policy implementation planStaff will be advised of the introduction of this policy by an item in Team Brief. Additionally, Safeguarding and Governance Team members will attend relevant manager’s meetings to ensure that all teams are informed of this policy. A copy of the policy will be sent to Hampshire County Council Commissioning Team to ensure they are aware of it and it’s implications for commissioning.

PaCT will be advised of this policy and will be asked to direct providers to it at any provider events they are attending.

MONITORING COMPLIANCE

Unit Managers will monitor episodes of choking and near miss choking to ensure that the guidance in this policy is routinely followed. Where guidance is not followed, managers will assess staff competence and consider retraining or other appropriate measures.

DOCUMENT REVIEW

This policy will be reviewed at the end of one year as is standard practice with all new and revised policy documents issued by Adult Services.

REFERENCES

Quality Outcomes Monitoring Framework Policy

Reducing the risk of choking for people with a learning disability: a multi-agency review in Hampshire

Multi-agency Safeguarding Policy, Practice Guidance and Toolkit 2015

Royal College of Speech and Language Therapists Resource Manual for Commissioning and Planning Services – Dysphagia

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APPENDICES

APPENDIX 1 SOLENT RISK OF CHOKING SCREEN

RISK OF CHOKING SCREEN FOR ADULTS

Client Name: …………….……………………………….Date of Birth: ………….……..…….NHS Number:……………………..…………………Has consent been gained to complete this screen? Yes/No (give details)

………………………………………………………………………Have the next of kin been informed where appropriate? Yes/No (give details)

………………………………………………..……………

COLUMN A COLUMN B1. Does the person frequently or continually cough before, during or after eating and/or drinking?

Yes No

2. Has the person already got a known diagnosis of ‘Dysphagia’?If ‘Yes’, when were they last assessed by a Speech & Language Therapist?..............................

Yes No

3. Has there been a choking (partial or complete obstruction affecting respiratory function) incident in the last 12 months?If ‘Yes’: Number of occasions …………………………………………….…………………………………….…………. On what? ………………………………………………………..………………………………….………….….…...

Yes No

4. Has the person had pneumonia or recurrent chest infections in the last 12 months?If ‘Yes’: Number of occasions ………………………………………………………….………………………………… Known respiratory conditions……………………………………………………..…………………….….

Yes No

5. Has there been a significant change in the last 12 months in any of the following: (Please provide details for any ‘Yes’ responses)

a) Unplanned weight loss………..……………………………………………………………………b) Fluid intake……………………………………………………………………………………………….c) Time taken to complete meal/drink………………………………………………………….d) Self feeding skills………………………………………………………………………………………e) Environment…………………………………………………………………………………………….f) General health………………………………………………………………………………………….

YesYesYesYesYes

Yes

NoNoNoNoNoNo

6. Oral skills:a) Are they able to chew a normal diet? If ‘No’, give details………………………………………………

………………………………………………………………………………………………………………………………………………….b) Is their food and/or drink currently modified? If ‘Yes’, how and why?................................……………………………………………………………………………………………………………………………………………….

No

Yes

Yes

No

7. Oral Health: Does the person have good oral hygiene/healthy teeth? If ‘No’, please provide details……………….………………………………………………………………………………………………………………………..

No Yes

8. Does the person have a diagnosis of Pica (a persistent craving & compulsive eating of non-food substances)?

Yes No

9. Does the person have any other behaviours (including self harming) that may increase their risk of choking e.g. fast pace or food cramming?If ‘Yes’, please provide details………………………………………………………………………………………...……………………………………………………………………………………………………………………………………………………….

Yes No

10. Is the person currently experiencing any of the following side effects from their medication: relaxed muscle tone; drowsiness; dryness of the mouth; increased saliva?If ‘Yes’, please provide details………………………………………………………………..……………………………….……………………………………………………………………………………………………………………………………………….

Yes No

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If you have circled an answer in Column A – further action is required. A new care plan, adopting a common sense approach, maybe required to

manage the risk of choking. For additional advice - questions 1-6 liaise with Speech & Language Therapy,

questions 7-10 liaise with an appropriate health professional or GP.

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Agreed action/outcome of liaison:

Name of person completing form: Signature:

Information provided by: Date completed:

APPENDIX 2 – Care of people at risk of choking – Quality Standard xx

Care of people living in HCC Care homes who at risk of choking

Category

CQC Outcome number Outcome 4, CARE AND WELFARE OF PEOPLE WHO USE SERVICES

PurposeThis Quality Standard explains what staff in HCC Care need to do to care for service users who have been identified as being at increased risk of choking, in relation to food or non-food items. HCC Care has a duty of care to our service users and there is an expectation that we will look after their best interests at all times.

Risk assessment and planning for all residents All individuals will have an eating and drinking care plan which includes

references to the risk of choking and how this should be managed.

All staff will attend training around First Aid response to someone who is choking as part of the Stepping Forward, Stepping Back induction programme.

All new admissions to the home / day service will be assessed with regard to their risk of choking and the outcomes of the assessment will be recorded in their care plan at the earliest opportunity. It is the expectation of HCC that any risks to a person should be identified prior to admission and if a choking risk becomes apparent once the person has been admitted then staff must make referrals to the appropriate services and seek to actively reduce any risk to the person depending on what the cause of the choking risk is.

If a service user is at increased risk of choking

If the person is assessed to be at an increased risk of choking, this should be explained to the person or to their relative, carer or advocate if they lack the mental capacity to understand this.

The individual’s consent must be sought over matters that affect their chosen ways of eating and drinking, e.g. for regulating types of food to be eaten, meal portions, liquid diets, presentation and cutting up of foods.

People who are unable to give their consent on these matters must be assessed on a “best interests” basis in line with policy on mental capacity.

The eating and drinking support plan must give details about how food, drinks and medicines must be prepared and given to the person at risk of

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choking. For example “all food should be cut into pieces no larger than a ten pence piece”.

The eating and drinking support plan must also say if the person needs to be positioned in a particular way to receive medications, drinks and food.

If the Solent Choking Screen indicates that a Speech and Language Therapy (SLT) assessment is required this must be organised by staff.

SLT plans for reducing the risk of choking must be used to rewrite the eating and drinking support plan, which must include how to safely give food, drinks and medications.

If staff feel the SLT plans are not clear enough they should refer back to SLT for further clarification.

Information about food requirements (puree/ soft diet etc.) must be given to kitchen staff and all care staff caring for the person.

All care staff must monitor the food, eating, drinking and taking of medication of residents known to be at increased risk of choking.

All staff must attend the managing the risk of choking training.

If the resident is admitted to hospital, information about the choking risk and how it is to be managed must be passed to the hospital on admission.

Information about how to manage the choking risk should also be shared with family where appropriate.

If a service user has an episode of choking An urgent referral to SLT must be made by staff

If a resident chokes on a non-food item an urgent Multi Disciplinary Team referral should be made.

The eating and drinking care plan for that person must be reviewed immediately.

The changes made to the eating and drinking care plan must also be made to other parts of the support plan so that they are all consistent.

If a resident has a choking episode or near miss choking episode staff must use the incident reporting system to record this.

A referral to safeguarding should be considered.

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