Dignity in care - Research into eating and nutritional care

• Why does malnutrition persist and what can be done?Open

  Ageism, discrimination, and abuse

  Extracts from the research overview below highlight some of the deep-seated societal issues that influence the way older people are treated:

  • ‘The tendency to view a patient as less than human has been identified with a need to defend oneself against the anxiety which their condition provokes’ (Menzies, 1977).
  • 'Evidence of ageism across all services ‘ranges from patronising and thoughtless treatment from staff to the failure of some mainstream public services [reflecting a] deep-rooted cultural attitude to ageing, where older people are often presented as incapable and dependent…’ (CSCI, 2006)
  • ‘It was an uncomfortable fact, but mainstream services and mainstream society were still seen by the older people in the groups as being both ageist and racist. They said it was impossible to ignore this fact… ’ (Butt, 2004).
  • ‘Cultural differences and needs were not met by mainstream services – including basics such as food.’ (Butt, 2004).
  • 'Threats to dignity in care include: labelling and disrespectful, inadequate communication; target- and/or routine-driven care; unequal power relations, ageism, and racism; staff shortages and poor morale' (Shore and Santy, 2004).

  These issues extend far wider than the health and social care sectors and require a government wide response that reflects this. However it is the responsibility of the health and social care sectors to ensure that they play a significant part in addressing the problems of ageism, racism and abuse. Organisations must strive, through induction, training, good leadership and peer-to-peer learning, to change attitudes and behaviours to ensure that older people are treated with the respect and dignity they deserve. See the Dignity challenge section.

  Attitudes and awareness

  Our failure to address nutrition may reflect a cultural issue in our society – perhaps we do not value the quality of our food as much as we should. I have been particularly struck by the quality of food for patients and staff in hospitals in France, which has much more of a food culture. There, mealtimes are sacrosanct for both patients and staff.

  Baroness Finlay of Llandaff (Hansard, 2008)

  Increased frailty and physical dependence in older people can make them particularly susceptible to malnutrition, but there are clearly wider issues relating to food and nutrition that may compound the problem. Chef Jamie Oliver’s campaign to improve school dinners brought to light a number of worrying trends in terms of general ignorance about food and healthy eating. His campaign highlighted the national problem of schools serving and selling poor-quality food to children, along with the impact on parental and institutional attitudes of increased availability of processed and convenience food. Many parents and catering staff were shown to have accepted an alternative approach to nutrition and food preparation, demonstrating an astonishing lack of knowledge and cooking skills. While ‘consumer awareness of the importance of healthy eating is rising’ (Cabinet Office, 2008) there is still much to be done. With evidence of such widespread ignorance on nutrition, it cannot be assumed that health and social care staff or carers for elderly relatives will have the knowledge to provide, or ensure the provision of, adequate nutritional care. Commissioners and assessors will need to ensure this issue is highlighted, particularly as more people are set to determine their own care through personalisation and individual budgets. It is important that public bodies with food provision responsibilities, either directly or through commissioning services, take the lead in addressing the national deficit in awareness of the importance of food, mealtimes, nutrition and hydration.

  Resources, quality and sustainability

  There are a number of resource issues that may affect the nutritional care of older people. These include low food budgets, inadequate staffing levels (especially around mealtimes) and lack of training. It is important, therefore, that services ensure they are getting the best value by investing in staff and adopting best practice in food procurement.

  Across statutory catering services, there has been an increasing acceptance of the practice of purchasing pre-prepared food that has systematically deskilled and devalued catering staff and impacted on the quality, freshness and nutritional value of the food served. In 2006, the National Audit Office estimated that there were £224 million worth of inefficiencies in public food procurement every year (Cabinet Office, 2008).

  Statutory services and those services commissioned by them are in a key position to influence change. The government has introduced a number of measures to address food standards in schools. The new Care Quality Commission will be developing compliance criteria for health and social care services and is committed to raising awareness about eating for good health, but much more work is needed nationally to change culture and behaviour. 'Food Matters: Towards a Strategy for the 21st Century' recognises the need for culture change and asserts that ‘the public sector in England should be leading by example’ (Cabinet Office, 2008). The government intends to introduce a new ‘Healthier Food Mark’ in public services, linked to standards for nutrition and sustainability.

  Improved education and training for the workforce and the procurement of good-quality food which is, where possible, local, seasonal and sustainable, will have an influence far wider than the improvement of nutrition in older people.

  'Best practice in sustainable public-sector food procurement' (DEFRA) brings together a range of information, recommendations and practice examples on these issues.

  The Food Industry Sustainability Strategy (DEFRA) reflects Government policy objectives on nutrition and health as set out in the Public Health White Paper (DH). It encourages the food industry to work in partnership with Government and other stakeholders to help bring about lasting improvements to the nation’s nutrition and health. It reiterates the challenges set out in the White Paper, stressing the contribution expected of the food industry to help achieve Government policy objectives to increase average consumption of fruit and vegetables to at least five portions a day; increase the average intake of dietary fibre to 18 grams per day; reduce average salt intake to 6 grams per day; reduce average intake of saturated fat to 11 per cent of food energy; maintain the current trends in reducing average intake of total fat to 35 per cent of food energy; and reduce the average intake of added sugar to 11 per cent of food energy."

  Hospitals are already taking these recommendations on board, in ways such as preparing fresh food on the premises (Royal Brompton Hospital) and sourcing locally (Royal Cornwall Hospital Trust).

• Prioritising mealtimesOpen

  Good nutrition, good hydration and enjoyable mealtimes can dramatically improve the health and wellbeing of older people. Mealtimes, therefore, should be considered a priority in terms of importance and dedication of staff time; systems within organisations should support this.

  See the Food Standards Agency's general guidance on healthy diet in the Helpful resources section.

  Protected mealtimes have been introduced in many hospitals: this means that non-emergency clinical activity stops, the ward is tidied and patients are made ready for their meals. It gives patients ‘space’ to eat and enjoy their meals. It also gives housekeepers and nurses time to give assistance to those who need it and raises staff awareness on the importance of good nutrition. See the Council of Europe’s 10 Key Characteristics of good nutritional care in the Helpful resources section.

  In social care, the same model can be applied. Managers should ensure that mealtimes are given a high priority and adequate staff time to give help to those needing support. A pleasant eating environment and opportunities for social interaction will greatly enhance mealtimes. Luncheon clubs in the community, in extra care or in sheltered housing can provide valuable opportunities for people who might otherwise be isolated. Where there is insufficient staff to support people who need help with eating, mealtimes should be staggered so that each individual can receive the attention they need.

  Volunteer schemes can be utilised to provide extra support for people at mealtimes. Managers will need to consider whether it is in the interest of the people using the service to welcome visitors such as relatives and carers at mealtimes; the benefits of social interaction during mealtimes should not be underestimated. However GP’s and district nurses should be encouraged to avoid mealtime visits.

  The Food Standards Agency offer a Body Mass Index calculator.

• AccountabilityOpen

  Who is responsible for ensuring that older people get the food and drink they need? There are a number of answers to this question, depending on where the older person lives and who supports them. In hospitals the nursing staff, and ultimately the ward manager, are responsible for ensuring that the nutritional needs of patients are assessed and met.

  In social care the assessment and care/support plan is key to ensuring that someone is accountable. Good communication of information from these documents between all involved (social workers/assessors, medical professionals, carers, service managers, care workers/frontline staff and catering staff) is essential to ensuring good nutritional care in older people.

  The Commission for Social Care Inspection (CSCI) bulletin 'Highlight of the day?' reports that: ‘Care homes that meet the national minimum standards for meals and mealtimes are more likely to have: staff that consult with the older people in their care on their needs; managers who met the training needs of their staff; and sufficient staff numbers to support older people in enjoying their meals.’ (CSCI, 2006).

  The following table outlines individual responsibilities:

  Responsibility	Action
  Social worker/assessor	Initial identification of nutritional needs and preferences during assessment/review/care planning, ensuring this includes appropriate provision for people receiving Individual Budgets or Direct Payments. Ensure nutritional needs are met through the care plan, making use of local resources such as luncheon clubs and access to mainstream community resources. Consider community meals ('meals on wheels'), but only when all other options have been exhausted or if the individual expresses a preference for them. Referral for financial assessment and income maximisation to ensure good quality food is affordable. Referral for professional assessment (eg speech and language therapy for people with difficulties swallowing, occupational therapy for equipment such as special plates and cutlery, dietician for special dietary needs relating to illness or condition). Communication of the person’s nutritional needs to all relevant professionals, eg. speech and language therapist, Occupational therapist, service managers, care and catering staff. Ensure that assessments of need, including those resulting in Direct Payments and Individual Budgets, take account of social and emotional needs as well as nutritional ones. It is often reported that home care workers are not allocated sufficient time for the preparation of freshly cooked meals and help with eating where required. Company from the home care worker when eating may be of great value to older people who are isolated within the community and at risk of depression.
  Medical professionals (speech therapy, occupational therapy, dietician)	Specialist assessment. Provision of all necessary information on the needs of the older person, in an accessible format, to frontline care and catering staff. Agree protocols with services on action to take if the screening shows someone is at risk of malnutrition and, if there is no improvement over a given time, how to make a referral to the dietician.
  Service provider/Manager	Nutritional screening and monitoring for everyone using the service. This is not yet a requirement but is widely becoming accepted as good practice in line with the prevention agenda. The assessment and recording of all dietary needs and preferences of individuals, along with any assistance needed at mealtimes. These should be referred to by all care and catering staff that work with the person. Ensure the correct information on any conditions is available to front line staff in order to offer appropriate nutritional support. Ensure the provision of appropriate training to all care and catering staff. Introduce best practice in food procurement for residential and day care. Referral for professional assessment (eg speech and language therapy for people with difficulties swallowing, occupational therapy for equipment such as special plates and cutlery, dietician for special dietary needs relating to illness or condition). Allocation of adequate, appropriately trained staff to provide food and assist people with eating. Ensuring a named worker, carer or volunteer is present for each person needing help at each mealtime. For home care and smaller residential providers where care staff are expected to cook meals, ensure staff have sufficient allocated time and the skills to prepare a freshly cooked meal of choice. Ensure time is allocated for help with eating where required and to provide company, which may be of great value to older people who are isolated within the community and at risk of depression. Ensure food is available and accessible 24 hours a day. For people in their own homes who have difficulty with access, this could mean leaving out a flask or jug and some fruit or biscuits. Ensure that fresh water is on offer at all mealtimes and freely available throughout the day. Prevent mealtimes being interrupted by other routine tasks such as medication administration. Where medication needs to be taken with food it should be given to the person (or the person allocated to help them) before the mealtime starts. Provide facilities for people to make drinks and snacks in residential and day settings, where access to industrial kitchens is denied. Carry out regular consultation with people using the service and their carers on the menus offered. Monitor food quality and the provision of help with eating through feedback from people using the service and their carers. Ensure people feel comfortable giving feedback. Monitor the provision of nutritional care and feedback received and take action accordingly.
  Frontline care staff	Consult the person’s assessment and any medical documentation for information regarding their nutritional needs. Provide support and encouragement with eating where necessary. Talk to the person and, if appropriate, their carer, family or friends about about their nutritional care needs and preferences. Avoid making assumptions about people’s preferences on the basis of their cultural background – people should be asked what their preferences are. With the person’s permission, arrange for them to be accurately weighed and use a simple screening tool to measure their body mass index. Consider whether the person has a poor appetite and what can be done to improve their appetite. Encourage people to drink enough fluid and consider what action to take if you are concerned that the person is not properly hydrated. Where necessary complete food/fluid intake charts. Ensure that people living at home can access snacks and drinks between homecare visits. Avoid interruptions to mealtimes by other routine tasks, such as administering medication. Give people time to eat; they should not be rushed. Provide company where it is likely to enhance their eating experience. While socialising during mealtimes should be encouraged, offer privacy to those who have difficulties with eating, to avoid embarrassment or loss of dignity. Where necessary, provide assistance discreetly. Use serviettes, not bibs, to protect clothing. Offer finger food to those who have difficulty using cutlery, and provide adapted crockery and cutlery to enable people to feed themselves where appropriate. For people with communication problems, use visual aids such as pictorial menus and non-verbal communication skills to help people to make choices. In residential and day care settings, inform catering staff of the needs and preferences of individuals. Promote independence wherever possible, involving the older person in meal preparation and planning. Bring concerns to the attention of the service manager. Use whistleblowing procedures if necessary.
  Catering staff	Source local, seasonal, sustainable food where possible. Ensure food is freshly prepared, and where possible avoid ready-made, pre-packaged and processed foods. Ensure meals are nutritionally balanced and appropriate to individual needs using guides such as the ‘eatwell plate’. Offer a range of options to meet different dietary and cultural needs and preferences. Ensure food looks appetising. Where the texture of food needs to be modified seek advice from the speech and language therapist. Not all food for people with swallowing difficulties needs to be puréed. It is important for the quality of the eating experience to keep different foods separate and not mix them all together. Moulds to indicate what the foods are (eg a fish-shaped mould for fish) can be obtained for this purpose. Provide snacks and drinks throughout the day – water should be freely available. Work closely with care staff to ensure that actions identified through screening are reflected in the meals produced – for example someone with a small appetite and identified as at risk of under nourishment could have the calorific content of their meals increased. High calorie foods such as cream or cheese can be added to meals and high calorie snacks can be offered between meals. When high calorie foods are encouraged, care should be taken not to increase cholesterol. Where appetite is a problem it may be better to offer small snacks frequently rather than big meals. Ensure the environment is conducive to eating.
  Commissioners/contracting staff	Ensure contracts include and provide adequate finance for: the provision of sufficient, good quality food food that is well prepared in a safe environment and meets any specific dietary, cultural and religious requirements nutritional screening and monitoring training for catering staff and care/support workers best practice in food procurement the provision of alternatives such as luncheon clubs and access to mainstream community resources. Commissioners should acknowledge the time needed for home care staff to prepare a freshly cooked meal of choice with or for the individual, and provide support with eating and company where needed. Commissioners also need to ensure providers comply with the Council of Europe’s 10 Key Characteristics of good nutritional care  and the good hydration charter.

• ScreeningOpen

  Malnutrition affects over 10 per cent of older people (British Association for Parenteral and Enteral Nutrition, 2006). Nutritional screening on admission to health and social care services, and improving food intake where necessary, is therefore vital and should be a key part of assessment and care planning. Service providers are also responsible for ensuring initial and follow up screening.

  ‘Screening is a process of identifying [people] who are already malnourished or who are at risk of becoming so. Those at high level of risk require referral for a further comprehensive nutritional assessment. (Unqualified staff, students, carers can screen patients if they have received the necessary education and training and have been assessed as competent to undertake the assessment, but accountability remains with the registered practitioner.) (NHS Modernisation Agency, 2003).’

  Preventative, low-level support for older people in the community is an important part of addressing the problem of malnutrition. Health and social care staff in the community have a key role to play in early detection and prevention. It is essential that frontline staff have an awareness of basic nutritional needs, including the symptoms of dehydration, under nutrition and malnutrition and the importance of meals and mealtimes for older people.

  There are many nutritional screening tools available for use by nurses. A study entitled 'Nutritional screening and assessment tools for older adults: literature review' (Green and Watson, 2006) found 21 specific to screening for older people. In the social care sector, however there are fewer.

  Initial screening involves a simple calculation of height and weight to establish a body mass index measurement. Staff expected to carry out screening will require basic training. The screening should alert staff to any problems and they should know how to refer the older person on for professional help. It is vital that screening itself is not seen as a solution. It is the actions that take place once people have undergone screening that make a difference.

  Most health and social care organisations have adopted the Malnutrition Universal Screening Tool (MUST) (328kb PDF file).

  The UK Home Care Association offer a simplified Nutrition Guide screening tool that can be purchased from them.

  The Commission for Social Care Inspection offers a ‘clinical trigger’ tool for the management of nutritional care for older people in care homes (554kb PDF file).

  The Food Standards Agency offer a Body Mass Index calculator.

• TrainingOpen

  Staff should receive training to ensure that they have a nutritional knowledge base appropriate to their role. The training should also equip them with the skills to communicate with people that have dementia and communication difficulties. Visual aids, such as pictorial menus, and non-verbal communication skills may help people to make choices.

  For care staff and managers training should include:

  • screening – awareness of the need to screen older people for malnutrition and training to use a screening tool
  • identification of eating problems
  • dementia
  • communication difficulties
  • dignity issues (including ageism, racism and abuse)
  • creating a conducive environment for mealtimes
  • assisting people to eat
  • choice and dietary/religious/cultural issues.
  • For those handling and preparing food training should include:
  • menu planning/involving older people/providing appropriate levels of choice
  • food hygiene
  • eating for good health
  • cooking skills and food presentation
  • dietary/religious/cultural issues
  • best practice in food procurement.

• Nutritional care: Symptoms, causes and solutionsOpen

  Awareness of nutrition may, for many reasons, be low in older people and their carers. There are a number of conditions and illnesses that may cause additional problems with nutrition in older people. Older people in the community may not be motivated to cook for themselves, and the death of a partner or spouse can lead to people with no experience of cooking having to start in their later years. Further, the tasks associated with cooking, such as shopping and washing up, can be challenging for some older people. All of these related issues should be taken into account during assessment. Local lunch clubs may offer the chance to have a good hot meal regularly as well as providing social opportunities.

  The following table looks at a range of problems along with possible causes and suggested solutions.

  Download the table Range of problems along with possible causes and suggested solutions (PDF file).

  Problem	Possible causes	Possible solutions/resources
  Poor appetite	Illness (eg cancer) Depression (see Guide 03: Assessing the mental health needs of older people) Dementia (see below) Side effects of medication Decrease in sensitivity to taste	Explore all possible medical causes and treatments. Encourage people to eat by involving them in the choice and preparation, and talking about food when eating. Make eating a pleasant, sociable experience rather than a necessary chore.
  Lack of nutritional knowledge or cooking skills	Long-term lack of knowledge could have a greater impact on poor nutrition in old age. Widowers may not have prepared food for themselves before the loss of their spouse.	Raise awareness about the importance of nutrition to health and wellbeing. Try to introduce new skills or rekindle lost ones Offer support to carers.
  Dental problems	Ill-fitting dentures may cause discomfort when eating. Dentures may also cause loss of sensitivity to taste (Health and Age 2008).	Ensure older people have access to good regular dental care. Offer support with cleaning and fitting dentures in preparation for meals. Offer food that is easier to eat, eg softer foods.
  Poor nutrition relating to dementia	Nutritional problems, loss of appetite and weight loss are common problems in dementia, (see NICE/SCIE: Dementia: supporting people with dementia and their carers in health and social care) especially as the severity of illness increases. Swallowing problems become increasingly noticeable as dementia worsens.	The Alzheimer’s Society ‘Food for Thought’ practice guides and advice sheets were produced specifically to help health and social care staff and carers deal with the challenges experienced by people with dementia concerning food, eating and drinking. Manage swallowing disorders (dysphagia) using food thickeners with appropriate posture and feeding techniques. See 'Nutrition support in adults' (NICE) and ‘Eating well for dementia’ (Caroline Walker Trust) in the Helpful resources section. See also Eating well for people with dementia (part of SCIE's Dementia gateway).
  Problems with eating caused by physical difficulties	Difficulty swallowing (dysphagia) could be related to dementia (see above), stroke, abscesses, tumours or degenerative neuromuscular diseases. Physical difficulties which restrict ability to buy, prepare or eat food. Problems with digestion.	Explore all possible medical causes and treatments. Ensure barriers to physical difficulty are removed Provide aids to assist with particular problems
  Toileting concerns	Poor bladder control. Lack of support to go to the toilet. Constipation caused by (from Health and Age 2008): ignoring or over-riding the urge to defecate due to immobility, poor toilet arrangements, pain or confusion poor diet, dehydration gastrointestinal disease (including cancer) drugs hypothyroidism food remaining in the gut for longer (slow transit time) poor digestive system muscle tone.	Explore all possible medical causes and treatments. Ensure people drink enough fluids for good hydration (see Hydration). Ensure people have support to go to the toilet as often as they feel the need to, provide reassurance for people for whom this causes anxiety. Encourage physical activity. Increase fibre intake and encourage good diet.
  Low expectation and fear of complaining	Attitudes to food and eating. Poor levels of support. Poor food provision.	Raise awareness of rights to good nutrition. Encourage feedback and complaints Communicate what people can expect from services. Provide advocacy where needed.
  Lack of access to good nutrition	Lack of appropriate food or help to eat it. Poor levels of identification of nutritional need. Inadequate staffing levels and lack of training. Lack of access to appropriate food for people from black and ethnic minority groups. Lack of meal choice due to communication problems	Raise awareness. Ensure sufficient staff are available at mealtimes. Ensure staff are properly trained. Provide food appropriate for dietary and cultural needs. Provide training and support to carers and volunteers who are willing to provide assistance at mealtimes. Use pictorial menus
  Social issues	Poverty - People who live alone may feel that it is not worth cooking just for one person. People may be embarrassed about eating with others due to physical problems with eating.	Ensure income and benefits are maximised. Encourage social eating through lunch clubs. Provide help with eating Encourage family members to bring food and visit at mealtimes.
  Cultural/religious issues	People that adhere to strict religious diets may be wary of food served in communal or public places, or even in their own home if prepared by someone from outside.	Where specialist food (eg vegan/kosher/halal) cannot be provided, source reputable local providers. Ensure staff have appropriate knowledge and training with regard to special dietary needs. Seek advice from the older person, family members, carers or friends as to what is acceptable. Some religions allow exemptions from strict adherence (eg Muslims that are ill or frail would be exempt from fasting during Ramadan). Where necessary seek advice from specialist religious organisations to provide reassurance.

• Nutritional care – hydrationOpen

  Water is vital to life and there is increasing evidence of the benefits of good hydration in the promotion of health and wellbeing in older people.

  Following a study of four care homes, Anglian Water has launched the Health on Tap campaign (Anglian Water, 2008) to improve hydration for older people in care homes. The study demonstrates that a concerted effort to improve hydration levels in older people can lead to significant benefits for older people and those who support them. For example, both staff and residents may be concerned about increasing the number of trips to the toilet resulting from an increase in fluid intake. However the result can actually lead to fewer toilet visits and better health due to a decrease in urinary tract infections. A reduction in constipation can also improve health and decrease workload with less need for enemas and laxatives.

  There is a huge cost relating to falls both to the older person, in terms of mobility and quality of life, and to the provider, due to a subsequent increase in care needs. A decrease in falls due to good hydration has been attributed to a reduction in dizziness and indicates that encouraging good hydration may be a wise investment for service providers. Anglian Water is promoting a Good Hydration Charter for residential care for older people. It requires three commitments:

  • A drinking water regime is established and matched to the ability of each and every one of those in residential care.
  • Fresh tap water is always available, accessible and presented attractively.
  • The importance of good hydration is part of staff induction, training and is promoted to those who live in or visit the residential setting.

  It is also important that people living in the community receive the support and encouragement they need to maintain good hydration. Day centres and home support workers need to ensure access to fresh tap water and provide encouragement and support with drinking where required.

  Hot drinks

  Many older people prefer drinking tea or coffee to water and it can be difficult to persuade people to drink enough water. Furthermore, older people should not be expected to change their drinking habits just because they are receiving care services. Hot drinks are good for hydration and only likely to act as a diuretic (making the body produce more urine) if they are high in caffeine and consumed in excessive amounts. Decaffeinated teas and coffees and herbal teas should be encouraged if this is a concern. The Food Standards Agency (FSA) advice on tea is that it should be consumed in moderation as part of a balanced diet but should be avoided with meals because it can reduce the absorption of iron within the body. A recent study, however, contradicted this stating that: ‘There was no evidence that iron status could be harmed by tea drinking unless populations were already at risk from anaemia.’ (Gardner et al, 2007) This study also indicated health benefits related to the consumption of black tea (as opposed to green tea), particularly for the heart.

  Based on the available information and the importance of good hydration in older people it would seem appropriate to encourage fluid intake generally, and to offer a selection of hot and cold drinks throughout the day and whenever people request them. There should only be cause for concern if an individual’s overall liquid intake is inadequate, or their intake of caffeinated and or sugary drinks is excessive. Medical advice should be sought if an individual has particular health problems that affect the maintenance of good hydration.

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