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Inspection report

Date of Inspection: 25 July 2012
Date of Publication: 28 September 2011
Inspection Report published 28 September 2011 PDF


Inspection carried out on 25 July 2012

During an inspection in response to concerns

We carried out this inspection at the request of the coroner under Rule 43 of the Coroner's Rules. The coroner asked us to look at how the risks to people who are assessed as being at risk of choking were being managed. Concerns were also raised with us that safeguarding procedures were not being followed.

We carried out the inspection on Shillingford Unit where people with dementia are cared for. We identified three people who had been assessed as being at risk of choking due to swallowing problems. We read their care records, spoke with them, and/or observed their care over a mealtime period, and talked to staff about their needs.

During our visit the majority of people living here could not speak with us directly. However, we observed staff interacting with people in a kindly, discreet, calm and respectful way. We were told by one person that they enjoy the meals here and we saw people enjoyed their food. We also saw that people had choices about what to eat, including both hot and cold food choices. We saw that the mealtime in the dining room was managed in a skillful way ensuring that all people were attended to and that the experience for people was calm and relaxed. People are receiving a nutritious diet.

We found that staff knew people's needs well. However some records relating to people'sffluid and food intake were not completely accurate and therefore could not always demonstrate that people were receiving the appropriate care. We also found that some plans in place to manage people's risk of choking were not being completely followed, which meant that this risk was not being fully managed. We saw that some people were eating some foods or food and drink combinations which were associated with an increased risk of choking.

We found that people are not fully safeguarded because actions that were to be taken against a member of staff had not been actioned, and locally agreed safeguarding procedures had not been followed.