Dysphagia and choking: IDDSI levels, the care home risk assessment and what to record

Every resident who has a swallowing difficulty, or a condition that commonly causes one, needs a speech and language therapy assessment, a care plan that states the IDDSI level for food and for drink, and a mealtime routine that makes sure the plate matches the plan. Every choking episode, including near misses, is recorded, reviewed for cause and, where there was serious harm or a failure of care, reported. The risk assessment sits behind all of that and needs reviewing whenever the person's health changes.

The short answer

Dysphagia is difficulty swallowing, and it is one of the most common causes of avoidable death in care homes and the leading one in learning disability services. The IDDSI framework gives everyone the same language for modified food and drink, with levels 0 to 4 for drinks and 3 to 7 for foods, and the speech and language therapist sets the level. The home's job is to assess everyone for risk, get the right people assessed, write the level into the care plan in plain terms, make sure the kitchen and the carers serve exactly that, supervise where the plan says so, and record intake, refusals and any coughing or distress at the time. When someone chokes, staff give first aid, call 999 if the airway does not clear, get a medical check after abdominal thrusts, record the incident, review it and report it where the rules require.

Why choking is treated so seriously

A choking death is nearly always investigated as a possible failure of care. The coroner, the safeguarding team and the inspector will each ask the same questions: was the person known to be at risk, was there an assessment, did the care plan say what texture to serve, was that texture served, was the person supervised, and did staff know what to do. If any of those answers is no, the home is in serious difficulty, whatever the outcome of the first aid.

LeDeR reviews have repeatedly found that people with a learning disability die from choking and aspiration pneumonia at far higher rates than the general population, and that the reasons are usually ordinary: a dysphagia diagnosis nobody acted on, a texture served wrongly by staff who did not know, food given by a visitor, eating unsupervised while distracted. None of these need special equipment to prevent. They need a clear plan and a home that follows it.

The same is true in nursing and residential homes for older people, where stroke, dementia and Parkinson's make dysphagia common and where a resident's swallow can deteriorate over weeks without anyone noticing unless they are looking.

At a glance: IDDSI levels

Who is at risk

The list is longer than most homes assume, and a care home risk assessment for choking should be part of every admission rather than reserved for people already on modified diets.

• Stroke, Parkinson's disease, motor neurone disease, multiple sclerosis, cerebral palsy and dementia.
• Learning disability, particularly Down's syndrome, and autism where sensory issues affect chewing.
• Poor or absent teeth, ill-fitting dentures and dry mouth.
• Sedating medication, antipsychotics and anything that reduces alertness or saliva.
• Eating very fast, cramming food, taking food from others, or pica.
• Reflux, frequent chest infections and unexplained weight loss.
• Any recent change in the person's ability to eat and drink, however small.

Watch for coughing or throat clearing during or after meals, a wet or gurgly voice after drinks, food left pocketed in the cheeks, drooling, meals taking much longer than they used to, avoidance of certain textures, and repeated chest infections. Each of these is a referral trigger. Staff should know them from induction, and the daily log should give them an easy way to record what they saw.

The care home risk assessment for choking

A choking risk assessment is a scored or structured assessment that pulls together the factors above and produces a level of risk and a set of controls. It is not a substitute for a speech and language therapy assessment, which looks at the swallow itself, but it is what tells you who needs SLT and how urgently. Complete it on admission, review it monthly or whenever health changes, and repeat it after every choking episode or chest infection.

Good risk assessment in care homes examples for choking make the link between finding and control explicit. Finding: eats very fast and crams food, has a learning disability, has had two choking episodes in the last year on bread. Controls: level 6 soft and bite-sized food per SLT, bread avoided, meals served in small portions with one course at a time, staff member sitting beside at every meal, verbal prompts to slow down, drinks offered between mouthfuls, review in one month.

Keep each version of the assessment. When the person's swallow deteriorates over six months, the versions show the home noticed and acted. A universal scored risk assessment with version history in your care records does this without extra work.

Referral to speech and language therapy

Any of the signs above, any choking episode, and any resident newly admitted with a known swallowing problem but no current plan, is a referral to SLT. Do not wait for a chest infection to confirm what the mealtime observations are already telling you. The referral should say what you have seen, when, on what textures, and what you have done in the meantime.

While waiting, serve a safer, more modified texture than the person currently has and record that as a temporary measure with the reason. Do not make the food thicker or the pieces smaller than a level below because that carries its own risks; ask the SLT service or the GP for interim advice and record it.

Chase the referral. Waiting times vary and a referral sitting unanswered for two months is a finding against the home, not the SLT service. Record each contact.

What goes in the care plan

The eating and drinking section of the care plan should let a new member of staff serve the person safely on their first shift without asking anyone. A good care plan example includes:

• The IDDSI level for food and the IDDSI level for drink, by number and name, with the date of the SLT assessment.
• Specific foods to avoid, such as bread, rice, hard fruit, nuts or mixed consistencies like soup with lumps.
• Positioning: upright at 90 degrees, head slightly forward, and remaining upright for 30 minutes after eating.
• Pace, portion and supervision: small mouthfuls, one course at a time, a staff member beside the person throughout.
• Equipment: adapted cups, spoons, plate guards, straws where permitted or prohibited.
• Prompts and strategies from the SLT report, such as a clearing swallow or a chin tuck.
• Oral care before and after meals, because poor oral hygiene raises the risk of aspiration pneumonia.
• Signs that something is wrong and what to do about them.
• Choking first aid and who to call.
• Review date and the trigger for an earlier review.

Involve the person and, where relevant, the family. A resident who understands why the bread has gone is more likely to accept it, and a family that knows the plan is less likely to bring in a bag of biscuits.

Making sure the plate matches the plan

The most common cause of a choking death is not a missing assessment but a plate that did not match a plan that existed. The plan said level 5 minced and moist; the plate had a sausage on it. The information failed somewhere between the care plan, the kitchen, the trolley and the table. Build controls at each point.

Kitchen

The cook has a current list of every resident's IDDSI levels and avoid list, updated the same day the plan changes, and the kitchen can produce each level properly. Modified food is made from the same menu, plated to look like food, and labelled with the resident's name and level.

Serving

Whoever serves checks the label against the resident's plan or a photo card before putting the plate down. Nobody assumes.

Table

Residents at risk sit where staff can see them, and residents who take food from others are seated with that in mind.

Visitors and snacks

Families and volunteers know the plan, and the snack trolley and vending machine are not a loophole.

Testing textures and thickening drinks

IDDSI gives simple tests that any member of staff can do. For drinks, the flow test uses a standard 10ml slip-tip syringe: fill to 10ml, release for ten seconds and read the amount left. Under 1ml is level 0, 1 to 4ml is level 1, 4 to 8ml is level 2, more than 8ml is level 3, and no flow is level 4. For foods, the fork pressure test checks that level 4 to 6 foods squash under gentle thumb pressure on a fork without springing back, the fork drip test checks level 3 drips through the prongs, and the spoon tilt test checks level 4 holds its shape and slides off cleanly.

Thickening drinks needs the measured scoop, the stated amount for the level and the stated stirring and standing time. Over-thickened drinks get refused and lead to dehydration; under-thickened drinks are aspirated. Keep the thickener in the resident's room only if it is safe to do so, because thickener powder has caused deaths when eaten, and it needs to be prescribed and recorded like a medicine.

Test a sample of drinks and meals every week as part of the manager's walk round and record it.

Supervision at mealtimes

Supervision means a named person watching the resident eat, not a member of staff in the same room. For anyone at high risk it means sitting beside them, at their level, for the whole meal, with nothing else to do. That takes planning: staggered mealtimes, protected mealtimes with all staff on the floor, or a rota that names who is with whom.

The supervisor's job is to keep the pace slow, prompt the strategies in the plan, watch for coughing, throat clearing, a change in breathing or colour, food pocketing and distress, and stop the meal if any of those appear. They also make sure the person is upright and stays upright afterwards. Supervision is not the same as feeding, and a resident who eats independently may still need someone beside them.

Write the supervision level into the plan in plain words and check at handover that it is being done. A supervision plan that exists on paper and not in the dining room is a common finding after an incident.

Recording at mealtimes

For residents on modified textures, mealtime records should show the texture served, the amount eaten, any coughing or distress, any refusal and what was tried instead, and the position the person ate in. That is more than the usual ate well entry, and it is what shows the plan was followed. Record at the time, not from memory at the end of the shift.

Fluid intake needs particular attention because people on thickened drinks are the most likely to be dehydrated. Run a fluid chart with the IDDSI level of each drink alongside the volume, set a target and a trigger, and total it daily; see nutrition and hydration: fluid charts that get filled in.

Any coughing, wet voice or difficulty during a meal is recorded as an observation and passed on at handover. A pattern of coughing at lunch over a week is exactly the information the SLT needs and exactly what a handover based on memory loses.

Oral care and aspiration

Aspiration pneumonia, where food, drink or saliva enters the lungs and causes infection, kills more people with dysphagia than acute choking does. The bacteria come mostly from the mouth. Good oral care, twice a day with a soft brush and appropriate toothpaste, and after meals for anyone with pocketing, reduces the risk substantially and is one of the cheapest interventions there is.

Put oral care in the care plan with the same weight as the IDDSI level, record it in the daily log, and check dentures fit. Refer to a dentist for anyone with pain, loose teeth or dentures that no longer fit, because those are choking risks in their own right.

Repeated chest infections in a resident with any risk factor should prompt an SLT referral even if nobody has seen them cough at a meal. Silent aspiration is common.

If someone chokes: the first aid sequence

Every member of staff, including night staff, kitchen staff and agency workers, needs to be able to do this from memory. Follow current Resuscitation Council UK guidance and your first aid training.

1. Ask if they are choking and encourage them to cough if they can breathe or speak. Stay with them.
2. If they cannot cough, speak or breathe, give up to five back blows between the shoulder blades with the heel of your hand, supporting the chest and leaning them forward.
3. If that fails, give up to five abdominal thrusts: stand behind, place a fist above the navel, grasp with the other hand and pull sharply inwards and upwards. Adapt for a wheelchair user or a person who cannot stand as your training directs.
4. Alternate five back blows and five abdominal thrusts until the obstruction clears.
5. Call 999 if it does not clear, and shout for help from the start.
6. If the person becomes unresponsive, lower them to the floor and start CPR.
7. After any abdominal thrusts, even if the object cleared, arrange a medical check the same day, because thrusts can cause internal injury.
8. Record everything: what was being eaten, the texture, who was present, what was done and by whom, times and the outcome.

After a choking episode: record, review, refer

A choking episode is an incident, and a near miss where the person coughed and cleared it is also an incident. Complete the incident record on the same shift. Then the manager reviews it within 72 hours with the same questions the coroner would ask: was the person known to be at risk, what did the plan say, what was actually served, who was supervising, did staff act correctly, and what will change.

Refer to SLT for a review of the level, even if the person was already assessed, and make any interim change to a safer texture in the meantime with the reason recorded. Update the risk assessment and care plan. Speak to the person and their family, and where the episode caused harm, follow the duty of candour.

Look for the system failure, not the individual. If the wrong texture was served, the question is how the plan failed to reach the plate, and the answer is usually a kitchen list that was out of date or a handover that did not happen. An incident review that records root cause and flags whether the event is notifiable is part of CQC compliance, not extra paperwork.

Reporting: CQC and safeguarding

Notify CQC where a choking episode caused serious injury, needed hospital treatment or led to death. Deaths are notified regardless of cause. Where the wrong texture was served, the person was left unsupervised against their plan, or a known risk was not acted on, raise a safeguarding concern with the local authority, because each is a possible failure of care. Record the decision either way and keep the references with the incident.

Homes sometimes hold back from notifying because the person recovered fully. That is the wrong test. The test is whether the event met the definition, and a choke that needed abdominal thrusts and an ambulance usually does. See CQC notifications: what to report and when for the full rules, and your incident reporting process should prompt the decision every time.

Coroners may ask for the records after a choking death, so the incident, the plan, the SLT report, the mealtime records and the training records should all be retrievable within a day.

Learning disability and autism services

Choking risk in these services is driven as much by behaviour and communication as by the swallow. Residents may eat very fast, cram, take food from others or from bins, eat non-food items, or refuse the modified texture because it looks and feels wrong. Some cannot tell you they are struggling. Some have been on a modified diet for years with no reassessment.

The plan therefore covers pace, portion size, seating, environment and the person's sensory preferences as much as the IDDSI level. It also covers what happens outside the dining room: day services, trips out, family visits and the shop down the road. A person at level 6 who goes to the cafe on Thursdays needs a plan for that.

Reasonable adjustments apply to the SLT assessment itself. Ask for an assessment in the home at a normal mealtime rather than in a clinic, and for advice in a format the person can understand. Record the discussion and the person's own views, because the right to make choices about food does not disappear with a dysphagia diagnosis.

Mental health services

In mental health homes the risks are sedating medication, antipsychotic side effects such as dry mouth and reduced swallow coordination, eating fast during periods of distress, and residents who eat alone in their rooms. Tardive dyskinesia can affect the tongue and swallow in people on long-term antipsychotics and is often missed.

Include swallowing in the physical health monitoring that goes with antipsychotic prescribing, ask the pharmacist about medicines that dry the mouth or sedate, and be alert to changes in eating pattern during a relapse. A resident who normally eats in the dining room and starts eating in their room is both a mental health observation and a choking risk observation.

Capacity and choice still apply. A resident with capacity may decline a modified diet; record the discussion, the risks explained and the decision, tell the GP and SLT, and keep the offer open.

Training and competence

Every member of staff who serves food or drink needs IDDSI awareness training, and the kitchen needs to be able to prepare and test each level. Every member of staff needs choking first aid within their basic life support training, refreshed at least annually, with a practical element. Agency staff need the resident's plan explained before their first meal on shift.

Test it. Ask a carer what level 5 looks like, how they would check a drink is level 2, and what they would do if a resident started coughing and could not speak. Ask the cook how they know what to send for each resident today. The answers tell you more than the training matrix.

Keep the training records where you can produce them for the staff on shift at the time of any incident. HR and training records linked to the staff member make this quick.

The monthly check

1. Every resident has a choking risk assessment dated within the last month or a documented reason why the interval is longer.
2. Every resident on a modified texture has a current SLT report and the levels in the care plan match it.
3. The kitchen list matches the care plans, and it was updated the day of the last change.
4. Sample drinks and meals tested against the IDDSI level this month, with the result recorded.
5. Every choking incident and near miss in the month has a review, an SLT referral and a care plan update.
6. Referrals outstanding are chased and the chase is recorded.
7. Staff on shift this month all have current first aid and IDDSI awareness.
8. Oral care recorded daily for everyone at risk.

Common mistakes

• A resident with obvious signs of dysphagia who has never been referred because they have not choked yet.
• Care plans that say soft diet or pureed instead of the IDDSI level by number.
• A kitchen list that is weeks out of date, so the plate does not match the plan.
• Thickener kept where a resident can eat it, or not recorded as a prescribed item.
• Supervision that means someone in the room rather than someone beside the person.
• Near misses not recorded because the person coughed and was fine.
• No medical check after abdominal thrusts.
• Visitors bringing in food that is not on the plan because nobody told them.

What good looks like on inspection day

An inspector will ask how many residents are on modified diets and pick one or two. They will read the SLT report, check the care plan states the levels by number, watch the person's meal, and compare what is on the plate with what the plan says. They will ask the cook how they know what to prepare and may ask to see the kitchen list. They will ask a carer what they would do if that resident started choking.

They will look at incidents for choking episodes and near misses and follow one through: the record, the review, the SLT referral, the plan change and any notification. They will check training records for the staff involved.

Be ready to open a record and show the risk assessment history, the plan, the mealtime records and the incident review in one place. Kiwi keeps the scored assessment with its versions, the care plan and the daily mealtime records against the same resident, so that trail is on screen in a minute. If you want to see how it works for your home, book a demo.

Final conclusion

Choking and aspiration are preventable in most cases, and the prevention is not complicated: know who is at risk, get them assessed, write the IDDSI level into the plan in a way nobody can misread, make sure the plate matches the plan every single time, supervise properly, record at the time, and treat every episode, including the ones that ended well, as something to learn from. The homes that get this right are not the ones with the most policies. They are the ones where the cook, the carer and the manager can all say, without looking it up, what each resident at risk eats and drinks today.

Frequently asked

What are the IDDSI levels?

IDDSI uses eight levels from 0 to 7. Drinks run from level 0 thin through 1 slightly thick, 2 mildly thick, 3 moderately thick and 4 extremely thick. Foods run from level 3 liquidised through 4 pureed, 5 minced and moist, 6 soft and bite-sized and 7 easy to chew or regular. Levels 3 and 4 overlap so a level 4 puree and a level 4 extremely thick drink have the same consistency.

Can care staff change a resident's IDDSI level?

No. The level is set by speech and language therapy after an assessment. Staff can and should raise concerns, refer, and serve a safer more modified texture temporarily while waiting for advice, but the plan itself is reviewed and changed by SLT. Record the temporary change and the referral.

What do I do if a resident chokes?

Encourage coughing if they can. If the airway is blocked, give up to five back blows then up to five abdominal thrusts and alternate until the object clears. Call 999 if it does not clear or the person becomes unresponsive, and start CPR if they stop breathing. Anyone who has had abdominal thrusts needs a medical check afterwards.

Does a choking incident need to be reported to CQC?

Notify CQC where the choking caused serious injury, required hospital treatment or resulted in death. Also consider a safeguarding referral where the wrong texture was served, because that is a possible failure of care. Every choking episode, including near misses, is recorded and reviewed internally regardless.

Who is at risk of choking in a care home?

Anyone with dysphagia from stroke, dementia, Parkinson's, MND or a learning disability, and anyone with poor dentition, sedating medication, a history of eating fast or cramming, or reflux. In learning disability services choking and aspiration are leading causes of avoidable death, so the threshold for assessment should be low.

How do I test whether a drink is the right IDDSI level?

Use the IDDSI flow test with a standard 10ml slip-tip syringe. Fill it to 10ml, release for ten seconds and read how much is left: level 0 leaves under 1ml, level 1 leaves 1 to 4ml, level 2 leaves 4 to 8ml, level 3 leaves more than 8ml, and level 4 does not flow at all. Foods are tested with the fork pressure, fork drip and spoon tilt tests.

What should a choking care plan example include?

The IDDSI level for food and drink, positioning, pace and supervision, what to avoid, the signs that something is wrong, the first aid response, who to call and when to review. It should be specific enough that agency staff can serve the person safely on their first shift.

Sources

• IDDSI framework (International Dysphagia Diet Standardisation Initiative)
• Resuscitation Council UK: adult choking guidance
• NHS Improvement Patient Safety Alert: Resources to support safer modification of food and drink (2018)
• Royal College of Speech and Language Therapists: dysphagia guidance
• LeDeR: Learning from lives and deaths of people with a learning disability and autistic people
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 14 Meeting nutritional and hydration needs
• CQC: Statutory notifications guidance for providers