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Inspection report

Date of Inspection: 23 September 2011
Date of Publication: 14 October 2011
Inspection Report published 14 October 2011 PDF


Inspection carried out on 23 September 2011

During an inspection looking at part of the service

We carried out this unannounced inspection visit to check on the service�s compliance with two warning notices that we had issued in August 2011. The notices were issued following a visit we made, on 25 July 2011, at the request of the coroner under Rule 43 of the Coroner's Rules. The coroner had asked us to look at how the risks to people who were assessed to be at risk of choking were being managed. When we did this, we found that they were not being managed sufficiently to ensure people's safety, and so we issued notices requiring the service to take prompt action to address these risks.

On this visit, we looked at the support given to five people who staff had assessed as being at high risk of choking because of swallowing difficulties they had. These difficulties were due to a range of causes. The people lived on �Shillingford� or �Ide�, the two units for older adults. We met them and, in some cases, their visiting relatives. We observed the support they received over a mealtime, looked at their care records, and spoke with staff who supported them.

Some people living at the home had various communication needs and were thus not able to give us their views directly. We observed staff interacting with people in a kindly, patient, calm and respectful way. When we asked one person what they thought of the food provided, they said they liked it and the quantity was right for them. We saw people were served good sized portions. Most people appeared to enjoy their food, and were offered �seconds� as well as more to drink.

We saw that the mealtime was managed in a skilful way, ensuring that all people were attended to and that people were not rushed by staff supporting them to eat or drink.

Two visitors we met said they knew about the risk to their relative of choking. One told us they had no concerns and considered the care to be �very good indeed�.

We found that staff knew who was at high risk of choking. They could describe the individualised support required by the people we followed up, to reduce their risk of choking when eating or drinking. We saw they provided the required support, to promote people's safety. Daily records reflected that people were given appropriate foods as indicated by advice from a Speech and Language Therapist, to avoid causing choking.