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March 2019

Dear Home Manager,

Please find enclosed information from the Speech and Language therapy department to help support staff in managing individuals with any swallowing difficulties. The information attached is as follows:

Minimising risks of aspiration, including when and how to refer to Speech and Language Therapy

Details of diet and fluid consistencies, including the new International Dysphagia Diet Standardisation Initiative (IDDSI) terminology (for further information on IDDSI, please refer to https://iddsi.org).

This information has been provided to help you and your staff support and identify people with swallowing difficulties. Staff members who prepare meals are also likely to find the information useful as there are some ideas for meals and snacks for each of the diet consistencies.

It is important that all staff are aware of this information and where it is kept. A signing sheet (titled ‘Confirmation that information has been read’) has therefore been provided. Please ensure all staff complete this to demonstrate they have read the documentation. Please retain this for your records.

Please note, this information does not replace the individual advice given following a Speech Therapy assessment. If a resident has a dysphagia regime, then please follow this. The documentation is instead an extra copy for reference. Replacement copies of this information will be available via the Locala website https://www.locala.org.uk

Please complete and return the ‘Confirmation of Receipt’ form and return it to the address detailed at the bottom of the form.

Also included on the ‘Confirmation of Receipt’ form is a table of different types of thickener. We are aware that there are a number of different types of thickener currently being used and we would be grateful if you could also complete the table detailing which thickeners are being used and by how many of your residents.

If you have any queries please do not hesitate to contact the Speech and Language Therapy service on 0300 304 5555.

https://www.locala.org.uk/

https://iddsi.org/

Yours Sincerely,

Locala Speech and Language Therapy Service

Confirmation of Receipt

Please complete the details below to confirm receipt of the following information:

Minimising risk of aspiration, including when and how to refer to Speech and Language Therapy

Diet and fluid consistencies

Name of home: …………………………………………….

Signature: ………………………………………………….

Print name: …………………………………………………

Designation: ………………………………………………..

Types of thickenerWe are aware that there are a number of different types of thickener currently being used and we would be grateful if you could complete the table below detailing which thickeners are being used and by how many of your residents.Types of thickener Please tick which

thickener appliesNumber of residents using this thickener

Thick n EasyThick n Easy ClearNutilisNutilis ClearResource Thicken UpResource Thicken Up ClearAymesOther (please give details)

Please return the completed form to the following address:FAO: Speech and Language Therapy TeamEddercliffe Health CentreBradford RoadLiversedgeWF15 6LP

Confirmation that information has been readPlease sign to confirm that you have read the information.

Date Signature Print Name

April 2019The Basics of Minimising the Risk of Aspiration

The following are some basic strategies and advice to help maintain safe swallowing and minimise the risk of aspiration. Please note the list is not exhaustive!

In the first instance, check to see if the patient has been previously seen by a Speech and Language Therapist and commenced on a plan to manage their swallowing problems.

If not, refer the patient for an assessment (see below).If so, ensure that the person is:

- Taking the appropriate diet and fluid recommendations.- Being provided with the correct level of support and assistance. - Prompted to use the strategies advised for all oral intake (e.g.

double swallow, chin-tuck posture, small sips etc). If adaptive cutlery or specific recommendations regarding cutlery size has been recommended, then ensure this is used for all oral intake (e.g. all diet/ fluids from a teaspoon).

Alertness- If the patient is drowsy or asleep, they should not be offered any

oral intake- The patient may fatigue over the course of a drink/meal; if so you will

notice that they slow down with their eating/drinking, and it may appear more effortful for them as the meal/drink progresses. They may show adverse signs such as coughing, wet breath sounds, wet voicing or choking, which will not occur earlier on in the meal. In this instance encourage the patient to have a rest and return to the meal/drink later.

Positioning- The patient should be FULLY UPRIGHT when eating and drinking to

reduce aspiration risk. If the patient cannot be fully upright for medical reasons (e.g. spinal issues, fractures) or because positioning is difficult, they should at least be as upright as possible.

- If positioning changes during a meal, then re-position as appropriate.- Food, drink and all required utensils should be within easy reach of the

patient.

Encourage self-feeding- The patient should be encouraged to self-feed wherever possible. If

they are noted to rush, they should be supervised and prompted to slow down

- If the patient requires assistance, the individual assisting needs to ensure they are offering food/drink at the patient’s pace rather than their own. Ask the patient if they are ready for the next sip/ mouthful if they are able to tell you, and if not ensure their mouth is empty and they have swallowed (up-down movement of the voice box) before offering any more.

- Ensure the patient has any adapted utensils that they need.- If you are assisting, make sure you are approximately the same height

where possible (e.g. sat down or stood up if the individual is in bed and the bed height is high). Do not stand when a person is sat, as this can feel quite intimidating and off putting for the patient when trying to eat. Offer small mouthfuls and try to avoid having a conversation throughout the meal to allow the patient to concentrate on the meal. Ensure the

temperature of the food is appropriate and reheat if necessary so that it stays palatable.

Spouts & straws- Beaker spouts and straws should be avoided whenever possible.

Spouts encourage the patient to tip their head back (opening the airway) and also make the size of the sip difficult to control. Straws direct fluids to the back of the patient’s mouth very rapidly which can frequently result in coughing. They can also encourage a patient to take rapid, consecutive sips, rather than one sip at a time which can be more difficult for them to manage. Only use either if previously recommended by a Speech and Language

Therapist.

Oral hygiene- Patients should receive daily oral hygiene to ensure that their mouth and

teeth are clean.- If a patient requires thickened fluids or is nil by mouth, then ensure the

toothbrush is just damp and any excess water is removed. A patient can easily aspirate on toothpaste/ water if it is too wet.

- Any evidence of oral thrush should be assessed and treated by the GP.- If the patient wears dentures these should be securely attached using a

fixative if necessary – effective chewing of solids is difficult with loose dentures.

- Oral hygiene should be undertaken after meals, especially if you are aware that the patient can ‘pocket’ food in their mouths without swallowing it.

- When carrying out oral hygiene ensure all the surfaces of the teeth, tongue and palate are brushed, which should take about two minutes. Remember to brush the inside surfaces, outside surfaces and the chewing surfaces of the teeth.

- Apply a pea sized amount of a fluoride-containing toothpaste (try a low foaming toothpaste) onto a soft or medium bristled toothbrush.

- If you are supporting someone to perform oral hygiene tilt their head forward slightly to reduce the risk of aspiration.

- If the patient wears dentures, ensure these are cleaned daily and removed at night.

Medication- If there are any concerns regarding difficulty with tablet medication, then

please contact the GP in the first instance for an alternative preparation.- If the patient is on thickened fluids and liquid or dispersible medication,

then ensure the medication is thickened appropriately.

Clinical signs that indicate a swallowing problem/ aspiration:- Frequent coughing/ choking with signs of struggle during or after meals - Sudden change in breathing pattern such as wheezing or sounding chesty

during or following oral intake- Wet /gurgled voice quality - Excessive drooling - Holding/ pocketing food in the mouth for more than 20 seconds and not

swallowing

- Sudden change of colour around the lips and face - Needing many swallows to try and clear food/ fluids- Reporting the sensation that food is sticking in the throat- Watering eyes - Gagging - Facial grimacing - Recurrent chest infections (even if coughing on oral intake does not seem

to occur)

If any of the above occur then clearly document the incident in the patient care plan including detail on: time of day, type of food/ fluids, positioning, environment and presentation of swallowing problem.

If there are any concerns that a patient is no longer tolerating their recommendations, has developed a new swallowing problem, or their swallowing has improved and so their recommendations need reviewing, then always contact the Speech and Language Therapy team for advice and support on 0300 304 5555 or refer through the Locala website - www.locala.org.uk

National Descriptors for Texture Modification in Adults July 2002Stage 3 Needs to be taken with

a spoonStage 2 Leaves a thick coat on

the back of a spoonStage 1 Leaves a thin coat on

the back of a spoon

Naturally thick

Product leaves a coating on an empty glass

Thin Still water

Dysphagia Diet and Food Texture Descriptors March 2012Normal This was not used

E – Fork Mashable

Soft, tender, moist, needs some chewing, can be mashed with a fork

D – Pre mashed

Soft, tender, needs very little chewing

C – Thick puree

Smooth, no bits, no lumps

B – Thin puree

Does not require chewingDoes not hold its shape on a plate

Name…………………………………….. Date………………….

LEVEL 3 LIQUIDISED (MODERATELY THICK)(previously texture/category, B thin puree diet)

This sheet offers general guidance, please refer to other Speech and Language Therapy information sheets provided.If this is for a resident in a care home, this will be found in their care plans.

If you have any questions, please contact Speech and Language Therapy on 0300 304 5555.

Name…………………………………….. Date………………….

Level 4 – PUREED DIET (EXTREMELY THICK)

General DescriptionAll items listed to be prepared as follows: Food has been puréed or has purée texture It does not require chewing It is smooth throughout with no ‘bits’ (e.g. lumps,

fibres, shell, skin, husk, gristle or bone etc.) It may need to be sieved to achieve this

smoothness It is moist Can be poured Does not hold its shape on a plate or when

scooped, it spreads out if spilled. Cannot be eaten with a fork because it slowly

drops through the prongs The prongs of a fork do not make a clear pattern

on the surface It cannot be piped, layered or moulded A light, disposable plastic teaspoon must be

able to stand upright when the head is fully covered. If not the texture is too thin.

Check before serving: No hard pieces e.g. garnish, crust or skin have

formed during cooking / heating / standing Any fluid (e.g. gravy, sauce, custard) in or on the

food is as thick as the purée itself and has not thinned out or separated off

If food is too thin, thickener can be added

Ideas for Main Meals

Puréed meat with thin gravy Puréed cooked fish (no bones or skin) with

thin, smooth sauce e.g. cheese, white Pureed pasta with sauce Pureed boiled white rice with sauce e.g. puréed curry, puréed mince and gravy Pureed meat or vegetable casserole Pureed cauliflower cheese

Ideas for Breakfast

Ready Brek or smooth porridge Well soaked Weetabix Pureed scrambled eggs Pureed and sieved baked beans Pureed tinned fruit Pureed fresh fruit which has been peeled first.

Add fruit juice to thin the puree if needed. Smooth thin yoghurt Thin milkshakes or fruit smoothies

Ideas for Desserts and Snacks Angel Delight, Instant Whip, mousse, blancmange Custard Smooth yoghurt or fromage frais Puréed semolina, rice or other milk pudding Puréed stewed fruit and custard (fruit may need sieving) Smooth fruit fools Cake puréed with custard or cream Thin smooth or creamy soup

Tips Purée each part of a meal separately and

keep them separate on the plate Some foods are difficult to purée e.g. stringy,

crunchy or chewy food Vegetables with shells (e.g. peas, sweetcorn)

will need to be sieved after pureeing Be careful with dried herbs as these are ‘bitty’ Add extra milk, cream, juice or sauces to

achieve correct consistency Ideas for Vegetables Puréed lentils e.g. dahl Pureed potato, smooth mashed potato Pureed root vegetables

(previously texture/category C, thick puree diet)



Name…………………………………….. Date………………….

Level 5 – MINCE & MOIST

General Description Are usually eaten with a spoon Cannot be drunk from a cup or sucked

through a straw

Do not require chewing Have a smooth texture with no lumps Hold shape on a spoon Fall off a spoon in a single spoonful when tilted Are not sticky

Check before serving: No hard pieces e.g. garnish, crust or skin have

formed during cooking / heating / standing Any fluid (e.g. gravy, sauce, custard) in or on the

food is as thick as the purée itself and has not thinned out or separated off

If food is too thin, thickener can be added

Ideas for Main Meals Puréed meat with thick gravy

Puréed cooked fish (no bones or skin) with thick, smooth sauce e.g. cheese, white

Pureed pasta with sauce

Pureed boiled white rice with sauce e.g. puréed curry, puréed mince and gravy Pureed meat or vegetable casserole; potted meat; paté Cheese soufflé Pureed cauliflower cheese

Ideas for Breakfast Ready Brek or smooth porridge Well soaked Weetabix Pureed scrambled eggs Pureed and sieved baked beans Pureed tinned fruit Pureed fresh fruit which has been peeled first Smooth yoghurt or fromage frais Thick milkshakes or fruit smoothies

Ideas for Desserts and Snacks Angel Delight, Instant Whip, mousse, blancmange Custard Smooth yoghurt or fromage frais Puréed semolina, rice or other milk pudding Puréed stewed fruit and custard (fruit may need sieving) Crème caramel Cheese cake topping Smooth fruit fools Cake puréed with custard or cream Thick smooth or creamy soup

Tips Purée each part of a meal separately and keep

them separate on the plate Some foods are difficult to purée e.g. stringy,

crunchy or chewy food Vegetables with shells (e.g. peas, sweetcorn)

will need to be sieved after pureeing Be careful with dried herbs as these are ‘bitty’

Ideas for Vegetables Puréed lentils e.g. dahl Pureed potato, smooth mashed potato Pureed root vegetables

(previously texture/category D, premashed diet)



Name…………………………………….. Date………………….

General DescriptionAll items listed to be prepared as follows: Soft and moist, but with no liquid

leaking/dripping from the food Biting is not required Minimal chewing required Lumps of 4mm in size Lumps can be mashed with the tongue Food can be easily mashed with just a little

pressure from a fork Should be able to scoop food onto a fork,

with no liquid dripping and no crumbles falling off the fork

Check before serving: No hard pieces, crust or skin have formed

during cooking / heating / standing Fluid / gravy / sauce / custard in or on the

food has not thinned out or separated off

Ideas for Breakfast

Porridge or Ready Brek Weetabix well soaked with milk (no dry bits or

excess milk) Mashed banana Egg (i.e. scrambled, poached, boiled) mashed

and sauce added Stewed or mashed fruit with smooth yoghurt Custard See also Ideas for Desserts & Snacks below

Ideas for Vegetables

Mashed potato, sweet potato or yam with topping e.g. well mashed tuna mayonnaise or cottage cheese Mashed soft root vegetables Mashed well cooked broccoli or cauliflower Mashed butternut squash Mashed avocado Mashed courgettes or aubergine Mushy peas

Ideas for Desserts & Snacks Stewed fruit with thick custard or cream (excess juice drained away) Soft tinned or fresh fruit, mashed (excess juice drained away) Rice pudding, semolina Mashed trifle (no hard bits of fruit) Plain cake (no bits e.g. fruit, chocolate chunks) mashed into custard or cream Mashed Tiramisu Angel Delight Cold pudding pots e.g. chocolate mousses, yoghurts and desserts Houmous, Guacomole, other dips


Well-flaked fish [with a sauce] Mashed fish pie, cottage pie [with a sauce or

gravy] Minced or puréed meats with thick gravy Mashed potato or inside of a jacket potato

with smooth humous or cream cheese, tuna mayonnaise, grated cheese

Dahl Eggs (see breakfast ideas) Mashed Avocado

Unsuitable FoodsAvoid:

Floppy, fibrous or stringy foodsSticky or cloggy foodsBitty foodsDry, crispy or crumbly foodsCrunchy, chewy or hard foodsFood with skins (e.g. grapes, mandarin oranges)

Be careful with:Mixed consistencies

Bread NOT allowed

Level 6 – SOFT & BITE-SIZED (previously texture/category E, fork mashable diet)



Name…………………………………….. Date………………….

General DescriptionAll items listed to be prepared as follows: Food is soft, tender and moist Food could be broken up easily with the flat

edge of a fork into small, soft lumps Can be held on a fork Does not need to be pureed or sieved May be served or coated with a thick gravy

or sauce All items must be cut into bite-sized pieces

no bigger than 1.5cm x 1.5cm in size, unless otherwise specified

Ideas for Breakfast

Porridge, Ready Brek or instant oat cereal Weetabix well soaked in milk Egg (i.e. scrambled, poached, boiled and

mashed, omelette, egg mayo) Whole tinned tomatoes Soft fruit – tinned or fresh with no skins

e.g. chopped banana, ripe peaches


Any tough meats blended but minced/casserole meats are ok with thick gravy/sauce.

Steamed, poached or baked fish e.g. cod, haddock in sauce. Only offer with batter if thin and light e.g. on a fishcake.

Fish / Shepherd’s / Cottage Pie / Lasagne Cauliflower cheese Well-cooked soft pasta and sauce

e.g. macaroni cheese, Ravioli (cut into bitesize pieces no bigger than 1.5cm x 1.5cm in size)


Floury and crumbly boiled potatoes with butter

Lumpy mashed potato, sweet potato or yam Inside of a well-cooked jacket potato (no

skin) with a soft filling e.g. tuna mayo Softly cooked root vegetables e.g. peeled

and stewed pumpkin, squash Softly cooked vegetables e.g. broccoli tops,

cauliflower, mushy peas, courgettes, aubergine

Chopped tinned tomatoes Pulses e.g. chickpeas, lentils, dahl [with a

sauce added to moisten]

Ideas for Desserts & Snacks Steamed pudding , sponge cake, cake bars

or sponge fingers with a lot of custard or cream

Soft fruit – tinned or fresh with no skins e.g. chopped banana or ripe peaches

Lumpy stewed fruit with yoghurt, ice cream, cream or evaporated milk

Yoghurt with fruit lumps Milky way (cut into bitesize pieces no bigger

than 1.5cm x 1.5cm in size) Chopped baked apple Rhubarb crumble with lots of custard Soft, maize-based crisps e.g. Skips,

Quavers (broken into bitesize pieces no bigger than 1.5cm x 1.5cm in size)


Floppy, fibrous or stringy foodsSticky or cloggy foodsBitty foodsDry, crispy or crumbly foodsCrunchy, chewy or hard foodsFoods with skins (e.g. grapes, mandarin oranges etc)

Be careful with:Mixed consistencies

Bread NOT allowed

LEVEL 7 - EASY TO CHEW (previously normal diet avoiding high risk food textures)



General Description

Food is soft, but needs some chewing Meat is cut into small pieces (no bigger than

15mm) Food requires cutting up Can be held on a fork Does not need to be pureed or sieved May be served or coated with a thick gravy

or sauce You should be able to ‘bite off’ pieces of soft

and tender food and choose bite-sizes that are safe to chew and swallow

Can also offer soft items that can be mashed

Ideas for Breakfast

Porridge, Ready Brek or instant oat cereal Weetabix soaked in milk Egg (i.e. scrambled, poached, boiled and

mashed, omelette, egg mayo) Whole tinned tomatoes (with extra juices

drained off) Bread and butter/ jam/marmalade Pancakes with a soft topping Soft fruit – tinned or fresh with no skins

e.g. chopped banana, ripe peaches

Ideas for Main Meals Bite sized pieces of skinless sausages/soft

meat. Including minced meat in gravy Casseroles or curry (meat, fish or vegetable

based) with a sauce and chapatti/naan Steamed, poached or baked fish including

fish in a soft batter/soft fishcakes Fish/Cottage Pie / Lasagne Meat/Vegetable Pie / Quiche (extra sauces

to moisten any pastry/crust) Cauliflower cheese, vegetable bakes Risotto Pasta and sauces, including small pieces of

soft meat/fish/vegetables


Boiled potatoes with butter Mashed potato, sweet potato or yam Soft chips/ potato wedges Inside of a well-cooked jacket potato (no

skin) with a soft filling e.g. tuna mayo, egg mayo, cheese and beans

Softly cooked root vegetables e.g. peeled and stewed pumpkin, squash, carrots

Softly cooked vegetables e.g. broccoli tops, cauliflower, mushy peas, courgettes, aubergine

Whole tinned tomatoes Pulses e.g. chickpeas, lentils, dahl [with a

sauce added to moisten]

Ideas for Desserts & Snacks

Soft, maize-based crisps e.g. Skips, Quavers

Crustless sandwiches with soft, moist fillings e.g. tuna mayonnaise, egg mayonnaise

Soft, well-buttered toast, crusts removed Steamed pudding, sponge cake, cake bars

or sponge fingers, jaffa cakes Dunked plain biscuits e.g. rich tea Soft fruit – tinned or fresh with no skins

e.g. chopped banana or ripe peaches Stewed fruit with yoghurt, ice cream, cream

or evaporated milk Yoghurt with fruit lumps Milky way Chopped baked apple Fruit pie with extra sauces to moisten a hard

crust. Rhubarb crumble with lots of custard


Floppy, fibrous or stringy foodsSticky or cloggy foodsBitty foodsDry, crispy or crumbly foodsCrunchy, chewy or hard foodsFoods with skins [e.g. grapes, mandarin oranges]

Be careful with:Mixed consistencies e.g. breakfast cereals such as cornflakes, muesli, rice crispies etc

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