Dignity factors - Eating and nutritional care

Providing a choice of nutritious, appetising meals, that meet the needs and choices of individuals, and support with eating where needed.

Mealtimes aren't just about the food we eat. It's about who you eat it with, where you sit, is it comfortable?

Eating and nutritional care in practice

• Carry out routine nutritional screening when admitting people to hospital or residential care. Record the dietary needs and preferences of individuals and any assistance they need at mealtimes and ensure staff act on this
• Refer the person for professional assessment if screening raises particular concerns (eg speech and language therapy for people with swallowing difficulties, occupational therapy for equipment such as special plates and cutlery, dietician for special dietary needs relating to illness or condition, physiotherapist to assess physical needs and posture).
• Make food look appetising. If 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. Keep different foods separate to enhance the quality of the eating experience.
• If necessary, record food and fluid intake daily and act on the findings.
• Make sure food is available and accessible between mealtimes.
• Give people time to eat; they should not be rushed.
• Provide assistance discreetly to people who have difficulty eating. 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.
• While socialising during mealtimes should be encouraged, offer privacy to those who have difficulties with eating, if they wish, to avoid embarrassment or loss of dignity.
• Ensure that mealtimes are sufficiently staffed to provide assistance to those who need it.
• If there are insufficient staff to support those who need it, introduce a system of staggered mealtimes.
• Develop or make use of existing volunteer schemes to help give support to people at mealtimes.
• Encourage carers, family and friends to visit and offer support at mealtimes.
• Don’t make assumptions about people’s preferences on the basis of their cultural background – people should be asked what their preferences are.
• Ensure all care staff, including caterers, have access to training.
• Raise awareness of the risk of malnutrition and the importance of providing good nutritional care.
• Ensure staff have the skills to communicate with people who have dementia and communication difficulties. Visual aids, such as pictorial menus, and non-verbal communication skills may help people to make choices.
• Gather information on the older person’s needs and preferences from people who know them well.
• Ensure that home care staff have sufficient allocated time and the skills to prepare a meal of choice for the person, including freshly cooked meals.
• For residential and day care, implement best practice in food procurement ensuring food is of good quality and is, where possible, local, seasonal and sustainable.
• Carry out regular consultation on menus with people using the service.
• Wherever possible, involve people using the service in meal preparation.
• In residential settings, where access to industrial kitchens is denied, provide facilities for people to make drinks and snacks.
• Ensure that fresh water is on offer at all mealtimes and freely available throughout the day.

Hydration

• Encourage people to drink regularly throughout the day. The Food Standards Agency recommends a daily intake of six to eight glasses of water or other fluids.
• Provide education, training and information about the benefits of good hydration to staff, carers and people who use services, and encourage peer-to-peer learning.
• Provide promotional materials to remind people who use services, staff and carers of the importance of hydration (available free from Anglian Water).
• Ensure there is access to clean drinking water 24 hours a day.
• If people are reluctant to drink water, think of other ways of increasing their fluid intake, for example with alternative drinks and foods that have a higher fluid content, (eg breakfast cereals with milk, soup, and fruit and vegetables).
• If people show reluctance to drink because they are worried about incontinence, reassure them that help will be provided with going to the toilet. It may help some people to avoid drinking before bedtime.
• Be aware of urine colour as an indication of hydration level (Water UK, 2005); odourless, pale urine indicates good hydration. Dark, strong-smelling urine could be an indicator of poor hydration – but there may be other causes that should be investigated.

What others are doing – Ideas you could use

• Use a ‘secret signal’ for people who need assistance with meals
• Use the ‘knife and fork’ symbol
• Introduce a range of measures to improve nutritional care
• Use a survey to get feedback about the food – and other aspects of care
• Improve the mealtime experience
• Produce your own Best Practice Guidelines
• Ask people how their mealtimes could be improved
• Recruit volunteers to improve mealtimes
• Make sure the food you provide is delicious as well as nutritious: join the Cooking with Care campaign
• Have a ‘nutritional awareness week’
• Make nutritional screening part of your assessment process
• Develop a ‘nutrition support’ information pack
• Improve nutritional care
• Take a person centred approach to mealtimes
• Become a model of good practice in care catering
• Source food locally to improve quality and nutritional value
• Use pictorial menus to help communicate food choices
• Motivate and encourage people to cook
• Find alternatives to ‘meals on wheels’
• Encourage kitchen staff to listen to people’s individual preferences
• Listen to and support carers
• Aid communication for hearing impaired people through text
• Use the single assessment process to deliver person-centred care
• Improve you practice using the essence of care benchmarking tool
• Train key staff to improve nutritional care
• Encourage kitchen staff to listen to people’s individual preferences

These practice examples are self-reported and have not been evaluated.

Care Quality Commission - what the regulator says

The CQC is the independent regulator for health and social care services. They have set out Essential Standards of Quality and Safety (CQC, 2010) for all those registered to provide health and social care services. There are 28 outcomes relating to the different aspects of care provision.

• What CQC outcomes say about Eating and nutritional careOpen

  The outcome that relates to eating and nutritional care is:

  Outcome 5: Meeting nutritional needs - Requires services that provide food to ensure:

  • a choice of suitable and nutritious food and hydration, in sufficient quantities to meet people’s needs
  • food and hydration provision meets any reasonable requirements arising from a person’s religious or cultural background
  • support, where necessary, for the purposes of enabling people to eat and drink sufficient amounts for their needs.

  See all outcomes in the Care Quality Commission Essential Standards of Quality and Safety (PDF file)

Eating and nutritional care and dignity - key points from policy and research

• Food, nutrition and mealtimes are a high priority for older people and a top priority for older people from black and minority ethnic groups (PRIAE/Help the Aged, 2001).
• Malnutrition affects over 10 per cent of older people (British Association for Parenteral and Enteral Nutrition, 2006).
• Between 19 and 30 per cent of all people admitted to hospitals, care homes or mental health units are at risk of malnutrition (British Association for Parenteral and Enteral Nutrition 2007).
• The UK Home Care Association estimates that up to 90,000 people who receive home care services could be at risk of malnutrition (Grove, 2008).
• Public expenditure on disease-related malnutrition in the UK in 2007 has been estimated at in excess of £13 billion per annum (Elia.M, Russell, C.A. Combating Malnutrition – Recommendations for Action BAPEN 2009)
• Malnourished patients stay in hospital longer, are three times as likely to develop complications during surgery, and have a higher mortality rate (Age Concern, 2006; BBC, 2006).
• The needs of people from black and minority ethnic groups, including ‘basics such as food’ are not always met by mainstream services (PRIAE/Help the Aged, 2001; Afshar et al, 2002).
• Key points in bringing about a culture change in food, nutrition and mealtimes are: good leadership, staff induction and training and adequate staffing levels (Commission for Social Care Inspection, 2006).
• The NHS Standards for Better Health requires healthcare organisations to ensure that patients have a choice of food that is prepared safely and provides a balanced diet; and that ‘individual nutritional, personal and clinical dietary requirements are met, including any necessary help with feeding and access to food 24 hours a day’ (Department of Health, 2004e).
• In February 2006 the National Institute for Health and Clinical Excellence (NICE) and the National Collaborating Centre for Acute Care launched clinical guidance to help the NHS identify patients who are malnourished or at risk of malnutrition.
• The NHS Essence of Care benchmarks for food and nutrition include attention to nutritional assessment, the environment, presentation of food and appropriate assistance (Department of Health, 2003c). These can be used by care homes, as well as healthcare providers, to benchmark services.

Hydration

• The evidence suggests that good hydration can help prevent falls, constipation, pressure sores, kidney stones, blood pressure problems and headaches (Ellins, 2006).
• Poor hydration has been shown to contribute to obesity, depression, inactivity and fatigue and to prolong healing and recovery (Ellins, 2006).
• There is some evidence to suggest that dehydration can increase mortality in stroke patients and prolong hospital stays for patients with community-acquired pneumonia (Water UK, 2005).
• For some older people the sensation of feeling thirsty may be impaired and may not be an accurate indicator for good hydration (Kenney et al, 2001; Caroline Walker Trust Expert Working Group on Nutritional Guidelines for Food Prepared for Older People, 2004) particularly for people who have had a stroke and those with dementia (Albert et al, 1994; Water UK, 2005).
• 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 key findings of the study were:
  • Availability, visibility and reminders were some of the key factors to drinking more water.
  • After a regime was introduced and a water cooler installed, anecdotal evidence from one home reported: a 50 per cent reduction in falls; a greater than 50 per cent reduction in the number of residents taking laxatives; and a decrease in GP call-outs and urinary infections.
  • There were language barriers for some staff, with 50 per cent not having English as a first language.
  • Hydration does not feature as a specific training topic in its own right.
  • Residents’ fear of increased toilet trips was the main barrier to drinking more water (the report states: ‘Once the bladder had adjusted and was able to hold more volume, toilet trips soon settled down to pre-trial levels.’)
  • Peer-to-peer learning, rather than formal training, plays a large role in the knowledge and working habits of staff.
  • Knowledgeable and committed managers generate positive results.
  • Visual and mental impairments were a problem for many residents, with a high dependency on care staff to instigate water intake.
  • Staff said they would like promotional materials for themselves, residents and their families, to remind them of the importance of hydration.
  • The ability to spread and share good practice was seen as very important (Anglian Water, 2008).

• Eating and nutritional care and dignity - policy and research in more detailOpen

  Nutritional care is a consistent feature in the research on dignity and there is a profusion of information and guidance on the subjects of food, mealtimes, nutrition and hydration. Despite this there are still serious concerns about nutrition in the health and social care sectors. The Department of Health is taking these issues very seriously; in October 2007 it published a joint action plan, ‘Improving nutritional care’, and set up a delivery board to ensure implementation. The Council of Europe’s 10 Key Characteristics of good nutritional care offers a concise summary of the meaning of good nutritional careSome of the guidance available gives conflicting advice and information, particularly with regard to specific nutritional matters. Good nutrition depends on the needs of the individual. People may be over or under eating and may have health conditions that affect their needs. Obesity is increasingly a problem and obese people can also be malnourished through eating the wrong sort of diet. Messages about ‘healthy eating’ need to be understood in the context of individual needs. ‘Healthy eating’ usually refers to the consumption of foods that are low in fat, salt and sugar but, for an older person who is at risk of malnutrition, healthy eating could mean increasing their calorie intake. It is very important to assess each person to ascertain their needs and preferences and to tailor their diet accordingly.

  See the Food Standards Agency's general guidance on healthy diet and Nutrient and food-based guidelines for UK institutions and also the Council of Europe’s 10 Key Characteristics of good nutritional care in the Helpful resources section.

  For social care staff, only a basic knowledge of nutrition is necessary in order to tackle malnutrition in older people. The fundamental point is that older people should undergo routine screening and have access to food that:

  • is adequate in amount and of good quality
  • is well prepared in a safe environment
  • meets any specific dietary, cultural and religious requirements
  • is provided in an environment conducive to eating.

  Most important of all, older people should receive the time, help and encouragement they need in order to eat the food provided.

  Much of the media attention and campaign focus to improve nutrition has been on hospitals. A report by the Patient and Public Involvement Forums entitled ‘Hospital food, could you stomach it?’ (Commission for Patient and Public Involvement in Health, 2006) found that more than a third of hospital patients have left their food uneaten, and issues were raised about choice, the temperature and presentation of food and people not receiving the help they need to eat their meals. Age Concern also published a compelling report ‘Hungry to be heard’ into the scandal of malnourished older people in hospital which strongly argues that it is a change in culture and practice that is required. It is clear, however, that the problem also exists for many older people who access social services, including residential, day care, extra care and domiciliary care.

  Older people, for a number of reasons, are more likely to suffer from malnutrition and this increases for those using health and social care services. The largest nutritional screening survey, Nutrition Screening Survey in the UK 2007 was carried out by BAPEN, the British Association for Parenteral and Enteral Nutrition. The survey found that between 19 and 30 per cent of all people admitted to hospitals, care homes or mental health units were at risk of malnutrition. The 2008 survey is available on the BAPEN website (PDF file). The UK Home Care Association estimates that up to 90,000 people who receive home care services could be at risk of malnutrition (Grove, 2008).

  Some conditions that affect people in later life, such as stroke, Parkinson’s and Alzheimer’s disease, can affect a person’s ability to feed themselves and to swallow. Even where there is no particular health condition other age related issues, such as ill-fitting dentures or loss of appetite, can affect the older person’s nutritional intake. Consideration should also be given to the impact of eating difficulties on the social aspect of mealtimes. A Swedish study (Sidenvall, 1999) noted that older people affected by debilitating physical or mental conditions strive to retain their independence and dignity when eating, and that such loss of skill can be painful and can cause embarrassment. It is important that support is provided in a discreet, sensitive and respectful manner that does not draw attention to the person’s difficulties.

  Mealtimes and nutrition are important to older people in relation to their quality of life and as a measure of the quality of service they receive. Evidence for this comes from a range of studies into different types of health and social care provision. Mealtimes and nutrition ‘have been raised repeatedly... as an opportunity to respect residents’ dignity, or undermine it’.

  Meals and mealtimes affect the quality of life for older people and are indeed the ‘Highlight of the day’ for many people in residential care (Commission for Social Care Inspection, 2006). A small study into care homes found that, for residents, food is a definer of the quality of a home (PG Professional and the English Community Care Association, 2006). In the Department of Health (DH) online survey (DH, 2006d) respondents complained that not enough help is available to those who need assistance with eating. The analysis of British data from the Dignity and Older Europeans study supports this: ‘participants said patients were often not fed by nurses and this was often a problem for older people who could not feed themselves’ (Calnan et al, 2003). As the research overview found, not having appropriate help with eating and drinking can have more serious consequences for people with dementia or depression.

  View further Background research on Eating and nutritional care.

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