SCIE Practice guide 09: Dignity in care

Mealtimes and nutritional care

This section was updated in August 2007

Key points from research and policy
Practice points
Ideas from practice
Other resources

Food, nutrition and mealtimes are a consistent feature in the research and 'have been raised repeatedly... as an opportunity to respect residents’ dignity, or undermine it’ (Research overview). 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) people 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.

Despite a raft of guidance, and improvements in the quality of hospital food (DH, 2005c), there are still serious concerns about mealtimes in the health and social care sectors. A recent 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, 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 have published a compelling report ‘Hungry to be heard’ (511kb PDF file) (Age Concern, 2006) into the scandal of malnourished older people in hospital which strongly argues that it is a change in culture and practice that is required.

Good nutrition and hydration and enjoyable mealtimes can dramatically improve the health and well-being 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. 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.

The Commission for Social Care Inspection (CSCI) bulletin 'Highlight of the day?' (747kb PDF file) 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.’ (Commission for Social Care Inspection, 2006).

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 care planning. This issue also highlights the importance of preventative, low-level support for older people. Health and social care staff in the community have a key role to play in early detection and prevention of malnutrition. It is essential that frontline staff have an awareness of basic nutritional needs, including the symptoms of dehydration and malnutrition, and the importance of meals and mealtimes in care services for older people. Commissioners and home care agencies should ensure that staff are given sufficient time to prepare freshly cooked meals with, or for, the older person and to provide a degree of company through 'time for a chat’ - this can improve the mealtime experience and can be a lifeline for people who rarely leave the house and are socially isolated.

Older people in the community are not always able or 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. Local lunch clubs may offer the chance to have a good hot meal regularly as well as providing social opportunities.

Some conditions that affect people in later life, such as stroke, Parkinson’s and Alzheimer’s disease, can seriously affect a person’s ability to feed themselves and to swallow. In addition to medical assessment of nutritional needs, consideration should be given to the impact of eating difficulties on the social aspect of mealtimes. A Swedish study (Sidenvall, 1999) noted that older people strive to retain their independence and dignity when eating when they have been affected by debilitating physical or mental conditions, 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 highlight the person’s difficulties.

Key points from research and policy

Food, nutrition and mealtimes are a high priority for older people and a top priority for older people from black and ethnic minority groups.(PRIAE/Help the Aged, 2001).
Malnutrition affects over 10 per cent of older people. (British Association for Parenteral and Enteral Nutrition, 2006).
Malnutrition is estimated to cost the UK over £7.3 billion a year. (BBC, 2006).

Malnourished patients stay in hospital for much 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 ethnic minority 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’ (DH, 2004e).
National minimum standards for care homes (340kb PDF file) require that 'service users receive a wholesome appealing balanced diet in pleasing surroundings at a time convenient to them.’ (DH, 2003a). Nearly 2,000 care homes in England do not meet this standard (Commission for Social Care Inspection, 2006).

National minimum standards for domiciliary care (249kb PDF file) require that 'personal care and support is provided in a way which maintains and respects the privacy, dignity and lifestyle of the person receiving care at all times’; this includes eating and meals. (DH, 2003b).
The NHS Essence of Care benchmarks (384kb PDF file) for food and nutrition include attention to nutritional assessment, the environment, presentation of food and appropriate assistance (DH, 2003c).
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 (40kb PDF file).

Practice points

Routine nutritional screening should be carried out on admission to hospital or residential care. The dietary needs and preferences of service users, and any assistance needed at mealtimes, should be assessed, recorded and referred to by all frontline staff.
A speech and language therapist should assess anyone exhibiting swallowing difficulties, to ensure the correct textures of foods and liquids are provided.
Where necessary, record food and fluid intake daily.
Food should be made available and accessible between mealtimes.
Give people time to eat; they should not be rushed.
Avoid interruptions to mealtimes by other routine tasks, such as administering medication.
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.
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.
Managers should ensure that mealtimes are sufficiently staffed to provide assistance to those who need it.
Don’t make assumptions about people’s preferences on the basis of their cultural background - people should be asked what their preferences are.
Staff should receive training to equip them with the skills to communicate with people with dementia and communication difficulties. Visual aids (such as pictorial menus) and non-verbal communication skills may help people to make choices. Gather information on people’s needs and preferences from people who know the person well.
All care staff, including caterers, should have access to quality training to raise awareness of the risk of malnutrition and the importance of providing good nutritional care for all service users.
Commissioners and providers should ensure that home care staff have sufficient allocated time and the skills to prepare a meal of choice for the service user, including freshly cooked meals.
Food should be made to look appetising. Where food needs to be puréed, use moulds to keep foods separate and indicate what they are - for instance a fish-shaped mould for fish.
Carry out regular consultation with service users on menus.
Wherever possible, involve service users 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.

Ideas from practice

Practice examples are self-reported and have not been evaluated.

Other resources

The Hospital Caterers Association have suggested a framework for a protected mealtime policy. Many hospital trusts have used this as a template to develop their own local policies.

Link: Protected mealtime policy

Foundation of Nursing Studies project 'Improving the health choices for older people: implementing patient-focused mealtime practice' through addressing the culture within a hospital unit.

Link: Improving the health choices for older people

The Alzheimer’s Society training pack, Yesterday, Today, Tomorrow, includes a 90-minute video/DVD and 130-page training manual providing eight training sessions. The pack has been designed to help deliver training at a time that is convenient to the home/ward/department. Session five of the pack particularly focuses on personal care, including eating and drinking. The session aims to develop participants’ understanding of appropriate choices of food and drink.The Alzheimer's Society also provides nutrition training events, called Food for Thought.

Link: Yesterday, Today, Tomorrow

Link: Food for Thought

The Commission for Social Care Inspection’s bulletin 'Highlight of the day?' is 'designed to assist care home managers and staff to improve the delivery of meals to older people, and in particular to improve their experiences of mealtimes in care homes’.

Link: Highlight of the day?' (PDF file)

Hungry to be heard (Age Concern, 2006) gives seven steps to end malnutrition in hospital.

Link: Hungry to be heard (511kb PDF file)

The National Association of Care Catering offers guidance and a checklist for care caterers and has produced a series of guidance manuals. Key publications are:

Menu Planning and Special Diets in Care Homes (2006/7)
National Minimum Care Standards for Care Catering (Care Homes for Older People, 2005)
A Recommended Standard for Community Meals (2005)

These can be purchased in hard copy, CD ROM or PDF format from NACC

Link: National Association of Care Catering

Skills for Care have produced a Knowledge set for nutrition and well-being. It sets out the competencies expected of care workers in terms of the preparation and presentation of food, understanding the importance of food and drink, and helping people to eat.

Link: Knowledge set for nutrition and well-being (100kb PDF file)

The Food Standards Agency have produced nutrient and food based guidance for care homes, including 'Food served to older people in residential care', 'Nutrient and Food Based Guidelines for UK Institutions' and 'Menus for Care Homes'. The advice for care homes includes guidance on appropriate nutrient intakes, healthy eating, allergy and food hygiene tips. There is also an example menu plan to help caterers for care homes follow the guidance, with a technical report showing how the menus follow Food Standards Agency advice.

Link: Food Standards Agency

Water UK has published Water for Healthy Ageing: Hydration Best Practice Toolkit for Care Homes to help care managers, caterers and other service providers to develop best practice on keeping older people well hydrated.

Link: Water for Healthy Ageing

The British Dietetic Association has produced a report, Delivering Nutritional Care through Food and Beverage Services, which is endorsed by the Hospital Caterers Association and provides useful information on the nutritional content of food in a hospital setting.

Link: British Dietetic Association

The Caroline Walker Trust has issued two reports containing nutritional guidance specifically for older people. The first, entitled Eating well for older people (CWT, 2004), offers practical guidance on catering for older people in care homes, nursing homes, at lunch clubs or community meals. The second, Eating well for older people with dementia gives specific advice on how dementia affects the ability to eat and the role that good nutrition can play in patient care.

Link: Caroline Walker Trust

The Royal Institute of Public Health's 'Eating for Health in Care Homes' is a practical nutrition handbook is designed for owners, managers, chefs and other care home staff responsible for the nutritional health of older people. Call 0207 2918353 to purchase a copy, or order from RIPH.

Link: Royal Institute of Public Health

The British Association for Parenteral and Enteral Nutrition (BAPEN) provides a wealth of information on how to screen people for nutritional health in the form of the Malnutrition Universal Screening Tool (MUST).

Link: Malnutrition Universal Screening Tool (MUST) (328kb PDF file).

The National Patient Safety Agency produce a range of good practice on nutrition and hydration.

Link: National Patient Safety Agency

The Department of Health have published a Nutrition Action Plan that aims to ensure that health and social care staff are well informed, equipped and supported to provide effective nutritional care.

Link: Department of Health's Nutrition Action Plan

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