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The Royal College of Speech and Language therapist outlines these 5 'Good Communication Standards' for all the people we work with and care for. If you need specific advice for a resident with communication difficulties, contact your local SALT team to find out what support might be available.

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These resources may be updated at times. If you are considering downloading and printing a resource, please do so only at the time you need it to make sure you have the latest information.

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Uploaded 20.9.2024

This is really useful information for non SLTs working with people who may need thickened fluids.

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East: 03000 848 166

Centre: 03000 855 972

West: 03000 851 758

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We encourage all organisations to complete the free Communication Access training to show that you support people with communication difficulties more effectively.

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Millions of people across the UK experience communication difficulties every day. The Communication Access Symbol and training will support inclusive communication for all.

What is Communication Access?

What is Communication Access?

Communication Access means supporting people with communication difficulties more effectively.

Once an organisation commits to our free training and standards to become Communication Accessible, we will include them in our national directory.

Organisations can then display the Communication Access Symbol.

When people with communication difficulties see your organisation displaying the symbol, they will use your services with greater confidence.

Sign up to Communication Access UK today

Sign up to Communication Access UK today

The process is simple and 100% free

Communication Accessible Organisations

Communication Accessible Organisations

These are some of the organisations accredited as Communication Accessible across the UK:

Why is Communication Access important?

Why is Communication Access important?

Communication is not simply about the ability to speak but also the ability to hear and understand what is said to us.

This lies at the very core of human dignity.

Millions of people across the United Kingdom have communication difficulties, including both adults and children.

Communication difficulties can occur for a range of reasons and leave millions without a voice, denying them equality of access and opportunity.

1 in 5

of all people in the UK will experience a communication difficulty at some point in their lives

Up to 10 %

of all children and young people have some form of long-term communication need

Up to 90 %

of people with a learning disability have a communication need

1 in 3

of stroke survivors will develop a communication difficulty

Stories

Stories

Astra is the receptionist at the Royal College of Speech and Language Therapists, one of the country's first Communication Accessible organisations.

In this video, she talks about the value of communication access training.

This video was filmed before the COVID-19 pandemic.

See more videos like this in our stories page.

Keep Communication Access UK free

Award Winning

Communication Access UK is a multi-award winning initiative with thousands of people accessing and using our resources.

Please help to keep Communication Access UK free by donating here.

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Communication Access UK - Inclusive communication for all

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Millions of people across the UK experience communication difficulties every day. The Communication Access Symbol and training will support inclusive communication for all. Communication Access means supporting people with communication difficulties more effectively. Once an organisation commits to our free training and standards to become Communication Accessible, we will include them in our national directory.

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'Dysphagia' (swallowing difficulties) in adults is associated with a number of different conditions, including:

Stroke

Progressive neurological disorders, including dementia, Parkinson’s disease, motor neurone disease, multiple sclerosis, and muscular dystrophy

Cancer, including head and neck, lung, and oesophageal

Respiratory conditions, including chronic obstructive pulmonary disease, emphysema, and asthma

Learning disability, developmental and acquired disorders

Disorders of the immune system

Traumatic brain injury

Acutely ill patients in critical care beds, including those with cervical spinal injuries and those with community-acquired pneumonia, Guillain-Barré and influenza can also have dysphagia.

Any illness can lead to 'decompensation' of the swallow. The swallow deteriorates because the person is unwell, eg UTI

Acid reflux can also result in swallowing difficulties

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RCSLT - managing dysphagia in care homes

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RCSLT - managing dysphagia in care homes

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RCSLT advice: managing dysphagia in care homes.

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Signs & Symptoms of Swallowing Difficulties

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Signs & Symptoms of Swallowing Difficulties

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If a resident if having difficulties like the ones in this advice sheet, they may benefit from a swallowing assessment.

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There is loads of useful information about food and fluid modification here

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DRAFT Medication and thickened liquids LINK NOT FOUND

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DRAFT Medication and thickened liquids LINK NOT FOUND

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Often people ask about using thickeners with medications. There is some helpful information here, but we would always suggesting linking with your GP or pharmacy around specific medications and thickness levels.

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General advice

Introduction

It is important that thickening agents are mixed appropriately in order to produce the required IDDSI Level for the patient.

Thickening agents are typically available as tubs (with scoops) or sachets of powder to be mixed with the liquid that needs thickening.

Directions for mixing are product specific and are provided on the product packaging, with instructions on the amount of powder (number of 'scoops') to be added to a specified volume of fluid (typically 200ml) to achieve IDDSI Levels 1, 2, 3 or 4.

Scoop size differs between products. Always use the correct scoop for the product.

The directions on the packaging will say whether to add powder to liquid or liquid to powder; this differs between products.

The directions will also say if the product has to stand to reach the desired consistency.

Choosing between starch-based and gum-based thickeners

There are two main types of thickening agent: starch-based (typically modified maize starch) and gum-based.

Gums

Gums include xanthan, guar, locust bean (aka carob) and carrageenan. Not all gum-based thickening agents have the same properties. In the UK, gum-based thickening agents are mostly xanthan gum-based. Different brands may also contain additional ingredients such as maltodextrin.

Starch

Starch-based thickening agents were widely used in the 1990s but gum-based thickening agents have gained popularity more recently.

Palatability

Patients may have a preference for one type of thickener over another. Starch-based products might give a starch flavour and grainy texture while gum-based thickeners might give a 'slicker' result. The flavour of food and drink has been shown to deteriorate with increasing fluid thickness, regardless of the thickener used.

Drug-thickener interactions

If thickeners are used to thicken medicines, there is the potential for a drug-thickener interaction. Information on interactions between medicines and thickeners is limited.

Macrogol (PEG) laxatives and starch-based thickeners

Starch-based thickeners must NOT be used to thicken Macrogol (PEG) laxatives (e.g. Movicol, Laxido, Cosmocol, Klean Preg, Vista prep), and macrogol (PEG) powder must NOT be dissolved in a fluid thickened with a starch-based thickener as the resulting mixture is thin and watery.

The MHRA has asked manufacturers of UK macrogol (PEG) laxative products add information about this potential interaction to the Summary of Product Characteristics and the Patient Information Leaflet.

Xanthan gum-based thickeners can be used to thicken macrogol (PEG) laxatives. Some brands of thickener (e.g. Swalloweze Clear and Thick & Easy Clear) are promoted as being suitable for mixing with macrogol (PEG) laxatives, and provide information on how they should be mixed.

Not all gum-based thickeners are the same. Thickeners based on carob gum (locust bean gum) might not be suitable for thickening macrogol (PEG) laxatives.

Other specific areas

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Using thickeners of different types for patients with swallowing difficulties

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Gum and starch based thickeners are available; drug-thickener interactions are possible and should be avoided.

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Click on this document to find out dates of our upcoming Swallowing Awareness Training (East region) and to book a place

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Keeping a record chart is useful for observing patterns of difficulties. This chart can be used for a period of time then forms part of your nursing / care record. It also helps inform the formal swallow assessment if needed.

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IDDSI for food workers, Nursing Assistants and Carers

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IDDSI for food workers, Nursing Assistants and Carers

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IDDSI 101 for Food Service Workers, Certified Nursing Assistants and Caregivers

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Gwên am Byth Dental Education – Mouth Care

Gwên am Byth is an oral health improvement programme aimed at helping to improve the oral health and hygiene of older people living in care homes.

The purpose of Gwên am Byth is to promote better oral hygiene within the care home environment with a view to preventing tooth decay and gum disease as well as serious health conditions such as acquired pneumonias. The programme will help care home staff to tailor oral hygiene routines for the people in their care as well as risk assess to identify dental treatment need

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Everyone should clean their teeth and mouth twice a day, but a person with dementia may need your support with this. It may be helpful to sit with them while they clean their teeth so you can watch what they're doing and prompt or help them.

Use a pea-sized amount of toothpaste containing no less than 1450ppm fluoride - this will be marked on the tube.

Make sure you give them clear, short instructions, demonstrating what to do and gently guiding them to clean their mouth and teeth in stages.

Encourage them to spit out the toothpaste rather than rinsing, as the fluoride in the toothpaste will continue to protect their teeth.

It's important to replace their toothbrush every three months, or sooner if it shows wear.

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Dementia UK is a charity that provides Admiral Nurses for families affected by dementia. Call our Dementia Helpline to find out how we can support you.

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BCUHB typically recommends Resource Thicken-Up Clear as the product of choice is a person needs their drinks / fluids thickened.

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You can contact the oral health promotion team for training on:

BCU.NWCDSGaBCareHomesAdvice@wales.nhs.uk

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Images of IDDSI Level 6 - Soft & Bite-Sized

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Images of IDDSI Level 6 - Soft & Bite-Sized

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Images of IDDSI Level 5 - Minced & Moist

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Images of IDDSI Level 5 - Minced & Moist

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Using food moulds really helps Pureed foods look appealing and appetising

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What do I do if....?

Poor oral hygiene - Mouth Care

Poor positioning for eating and drinking

Drowsiness / fatigue during eating and drinking

Excessive drooling

Person is pocketing / storing food in mouth

Person is overfilling their mouth or eating too quickly

Food refusal

Fluid refusal

Person spits out foods

Persons has difficulties taking medication only

Person is coughing, spluttering, eye watering with food

Person is coughing, spluttering, eye-watering with fluids

Person has a gurgly, wet voice after swallowing

Person is reporting food / drink sticking in throat

Managing acid reflux

Reducing the risk of aspiration pneumonia

Mealtime environment (POSTER coming soon!)

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Oral hygiene difficulties can exacerbate eating and drinking problems and can lead to pneumonia even if someone is Nil By Mouth. These leaflets explain more...

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Being as upright and comfortable as possible when eating or drinking is best. This leaflet tells you more...

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These things can help:

Only feed someone when they are awake and alert enough to eat and drink safely.

Adopt a 'little and often' approach.

Be flexible with mealtimes so they can eat when they are most awake.

Offer regular snacks and drinks in case they have been too drowsy to have enough oral intake.

Monitor their intake with food / fluid charts.

Problem solve why are they drowsy?

Medication changes?

Acute illness?

Time of day?

Poor sleep?

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This usually occurs because the person is not swallowing as often as needed. These tips may help:

Frequent reminders / prompts to swallow or 'suck your spit and then swallow'.

Regular sips of fluids through the day if the person is able to drink.

If severe, liaise with the GP regarding saliva medication to help dry secretions. Be aware that medication can also make the mouth too dry and there may be other side effects to look out for.

Check the person's mouth for infection / pain which can cause drooling.

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'Oral holding' and encouraging a swallow

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'Oral holding' and encouraging a swallow

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Oral holding

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This is a common feature in dementia for example.

Ways to help:

Check their dentition / mouth in case of pain or infection. Regular oral hygiene is crucial, even if someone is not eating and drinking often.

Environment: eating in the company of other residents or staff, such as in a dining room or kitchen, has been found to increase the amount of food someone eats and also reduces agitation.

Offer preferred foods: Some people may prefer sweet foods - balance eating enough with 'healthy' eating and contact the dietitian if you are concerned about someone's nutritional intake.

Offer small meals or snacks more often, sometimes called a 'little and often' approach.

Consider the time of day. Some residents may eat more at particular times of the day. The Swallowing Difficulties diary in column 1 may help you to recognise when is best.

Use familiar cutlery and plates etc. The person may have one they feel more comfortable or more independent with.

Routine is key.

If you can, involve the person in mealtime prep by setting the table, pushing the trolley, handing out napkins, pouring drinks, preparing foods.

Finger foods can help people to snack and nibble foods gradually. They also help independence.

Leave snacks within reach in places that your resident wanders to, as long as this is not putting anyone else at risk.

Maintain a calm environment. Some residents will like calming music.

Keep a food chart and contact the dietitians if you are concerned about nutritional intake.

Remember that someone declining food and not feeling hungry, can be a normal part of the dying process.

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This can be a common feature of dementia for example.

Offer someone's favourite / preferred drinks.

If thickened drinks are needed, make sure the drink is smooth. Thickened drinks can be more palatable if they are chilled or have added flavour, such as cordial, hot chocolate, etc.

Support independence from a normal cup with no lid unless they have been advised to have one.

Offer foods with high liquid content such as soups and sauces.

Offer drinks at the person's best time of day, when they are most alert and receptive. Fluid intake charts and swallowing difficulties diaries can help to recognise when this is.

Monitor for signs of UTIs, AKI and contact the GP if concerns arise.

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Offering food and fluid as a 'medication' can increase oral intake. Offer food at regular medication times.

Keep food and fluid charts.

If you are concerned about someone's food and fluid intake, contact the community dietitian for advice on food fortification and/or supplements.

Use the Swallowing Difficulties diary in the first column to help work out any patterns.

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Many people with dementia spit out food or will not tolerate small 'bits'

Check whether the food is particularly 'bitty', 'gristly' or difficult to chew in case it is due to the food and not the person.

Check food preferences

Try diet modification by stepping down by one level (eg from IDDSI Level 6 to IDDSI Level 5). (There is more help and advice in columns 4 and 5.)

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This can include

coughing

pocketing tablets in the mouth

chewing non-chewable tablets

leaving them on their tongue

Try the following:

**A full review of medication by the GP may be needed to make sure the person is getting any essential medications. Some may no longer be needed.

**Give the tablets in a teaspoon of pureed texture food such as custard or smooth yoghurt.

**Check if it is a particular tablet they are struggling with, eg the tiny ones or the large ones.

**Make sure it is not related to dry mouth. Encourage the person to have a sip of their usual fluids before taking tablets or consider an oral saliva substitute such as Oralieve / BioXtra. Ensure and support with regular oral hygiene.

** If the person has thickened fluids, give tablets with the correct consistency, smooth fluid.

**If a person has Level 4 pureed diet, they should not be given medication in tablet form unless this has been agreed with GP / pharmacy.

**Request medication in liquid or dispersible forms.

** Some tablets may be safely crushed or opened and mixed with a teaspoon of pureed food.

**Covert medications may be appropriate.

You can find out more information by clicking the link above to the BCUHB 'Care Homes Medicines Optimisation Toolkit'.

Always check with GP / pharmacy about any changes to medication and covert medications.

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All Wales Therapeutics and Toxicology Centre

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Care home medicines optimisation toolkit

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Care homes have a legal responsibility to ensure that all aspects of medicines management are covered within written policies and procedures. The aim of the Care Home Medicines Optimisation Toolkit is to bring together a suite of guidance documents, tools and useful resources for care home staff and pharmacy teams who provide advice and support to care homes.

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If someone is coughing and spluttering during drinking try the following:

Let them cough as much as they need to.

Remove any distractions and discourage talking while drinking. If you are having a conversation, only ask them questions when their mouth is empty.

Support independence and self-feeding from an open cup. Use hand-over-hand feeding if necessary.

If you are assisting the person, the amount of fluid they take can be difficult to control from a spout or straw, but can be managed more easily from an open cup.

Encourage the person to take small sips, one at a time.

Make sure the person is upright, alert and focused on drinking.

They should be sitting upright with their head flexed slightly forward. If the head is tilted back, the person's airway is open and this increases the risk of fluids 'going down the wrong way'.

If the person has been advised to have thickened fluids, make sure the drink has been made correctly and is smooth.

Thickened fluids aren't suitable for everyone. RCSLT have produced a useful leaflet - in column 5 - about the pros and cons of thickened fluids.

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Resident says food or fluid is 'sticking' in their throat

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Resident says food or fluid is 'sticking' in their throat

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If someone feels like food is 'getting stuck' this could be a sign of swallowing difficulties. It could also be a sign of reflux or oesophageal difficulties so we suggest seeking advice from the person's GP.

You can also try:

Use the swallowing difficulties diary in column one to help keep track of any patterns.

Encourage the person to swallow again after every few mouthfuls.

Sipping fluids between mouthfuls may help someone to swallow foods down if they are dry or sticky.

If there is a pattern to food texture, try stepping down by one texture, eg If IDDSI Level 6 feels like it is sticking, try IDDSI Level 5. Have a look at the resources in column 4 & 5 to help you with this.

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There are lots of items of specialist equipment available to make eating and drinking safer or easier. Click the image above to see a few of them and speak to your Speech and Language Therapist for more information if you have a particular person in mind.

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A bit of fun while supporting your Eating, Drinking and Swallowing learning....

(This was developed by Nutricia with NHS England, Royal College of Speech & Language Therapists ad British Dietetics Association.) Information from the site says:

"The game is very easy to set-up and all that’s needed is a space large enough for the board and the players. It works best with between 2-12 players divided into 2 teams. Games usually last 45-60 minutes, but you can make it shorter or longer depending on the time you have available.

Games can be run as an informal activity in the workplace, or as part of more structured training and workshops. The game does not require a facilitator with an expert knowledge of dysphagia, and a facilitator’s role can be very ‘hands off’.

The game encourages players to discuss a series of questions, allowing them to acquire new knowledge, share experiences and learn from each other. These discussions are what make the game effective and help players to learn."

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Developed in collaboration with:

The Dysphagia Game is an educational board game that helps frontline staff to recognise and manage dysphagia more effectively. The game now includes a set of questions and picture cards devoted to the IDDSI (International Dysphagia Diet Standardisation Initiative) framework. The game can help you implement IDDSI in your organisation and train your staff more effectively.

The game is very easy to set-up and all that's needed is a space large enough for the board and the players. It works best with between 2-12 players divided into 2 teams. Games usually last 45-60 minutes, but you can make it shorter or longer depending on the time you have available.

Games can be run as an informal activity in the workplace, or as part of more structured training and workshops. The game does not require a facilitator with an expert knowledge of dysphagia, and a facilitator's role can be very 'hands off'.

The game encourages players to discuss a series of questions, allowing them to acquire new knowledge, share experiences and learn from each other. These discussions are what make the game effective and help players to learn.

Face-to-face and online versions available

Board game for face-to-face learning.
Traditional tabletop game for groups working face-to-face. Encourages collaborative team discussions.

Generates fun and enthusiasm with a serious purpose and clear outcomes.

Online for socially distanced learning.
Digital board game replicates the intensity of face-to-face on Zoom, Skype & Teams.

Can be used for remote learning or socially distanced face-to-face sessions. Just share your screen with the group, wherever they are.

What does the Dysphagia game teach?

Helps staff and students to learn about:

Prevalence, causes and impact of dysphagia

Recognising dysphagia

Reducing risks and improving management

IDDSI framework

The Dysphagia Game contains 3 packs of cards:

1. General questions- 40 cards that address a wide range of dysphagia-related issues.

2. IDDSI questions - 22 question cards plus related pictures that address the IDDSI framework

3. Activity cards - 8 activities that involve eating, drinking and mixing. These are optional.

There are more cards in the box than would be played in 45-minute game and the organiser can choose a selection of cards that meet the specific training needs of the people playing.

What's in the box?

A BETTER WAY TO LEARN

Games make face-to-face training more engaging and effective.

Games encourage people to talk and learn from each other.

Games can be used anywhere, by anyone with no external support.
Games = a workshop in a box.

PLAY THE DIGITAL DYSPHAGIA GAME

We have created a simplified digital version of the board game. You can play this game on any device through any web browser, no visits to an app store. It's 100% free to use. Just click and play:

Visit our shop to purchase The Dysphagia Game and to see our other games.

We also sell a German and Spanish language versions of The Dysphagia Game. These versions do not yet include the IDDSI Framework. Visit the shop to learn more.

Price of game:
£80.00 EXC Vat

More from Focus Games

Ready to buy the the Dysphagia Game?Or perhaps you'd like to get in touch?

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Developed in collaboration with: The Dysphagia Game is an educational board game that helps frontline staff to recognise and manage dysphagia more effectively. The game now includes a set of questions and picture cards devoted to the IDDSI (International Dysphagia Diet Standardisation Initiative) framework.

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How to refer to Speech & Language Therapy

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How to refer to Speech & Language Therapy

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You can seek support for people with swallowing and/or communication difficulties through Speech and Language Therapy in East, West and Central areas of Betsi Cadwaldr Health Board. Click the link above to find out how.

Our Speech and Language Therapy teams operate Monday to Friday 8.30am to 4.30pm and do not cover weekends or bank holidays. Speech and Language Therapy does not offer a rapid response service. If you are concerned about someone's swallow and are unable to access an assessment, please contact the person's GP for advice.

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How to access Speech and Language Therapy

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We have an ‘open referral’ policy and accept referrals from parents/carers and professionals. Referrals are triaged by qualified speech and language therapists who may contact referrers for more information. In line with BCUHB policy parents and carers will be asked to contact us to agree an appointment. Please see below for how to refer in your area.

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Your resident may not need a specialist swallow assessment. Before you refer, make sure you have a looked at the information (pane 2), which will help you support your residents with a range of presentations. If you decide you do need to refer, please use the list of signs and symptoms (pane 1) to provide the most helpful information for our clinical team.

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Community SALT referral form Adult Centre

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Symptoms of acid reflux can be similar to symptoms of swallowing difficulties, eg coughing and throat-clearing. If you think a resident could be having reflux, this advice sheet will be helpful.

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When to involve other health and care professionals:

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When to involve other health and care professionals:

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Other members of the person's care team can help manage eating, drinking and swallowing difficulties. Click the image to see how.

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Aspiration Pneumonia - risk factors and protective factors

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Aspiration Pneumonia - risk factors and protective factors

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This advice sheet provides information about aspiration pneumonia and the things that can increase the risk of aspiration pneumonia or help prevent it.

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Padlet_Risk factors for aspiration pneumonia

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Supporting people with a vision impairment to eat and drink.

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Supporting people with a vision impairment to eat and drink.

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POSTER COMING SOON!!