Nutrition for older people in care homes: Dignity in care videos

What is the video about?

This film highlights the role of good nutritional care and hydration for older people living in residential care homes. The film promotes the use of the Malnutrition Universal Screening Tool (MUST) in identifying those at risk of malnutrition through a simple body mass index calculation. Where height and weight are difficult to measure, the tool suggests alternatives. Food and meal times can be very important to older people. By listening to what older people want to eat and preparing fresh food, the meal time experience can be enhanced. The benefits of good hydration are also highlighted.

• Video transcript Open

  Philip Hurst

  Although older people are not immune from the rising tide of obesity, the biggest problem is actually under nutrition.

  Elaine Cass

  Up to 10% of older people are at risk of malnutrition in this country.

  Philip Hurst

  Around 30% of older people are admitted to hospital as suffering from malnutrition.

  Elaine Cass

  It’s shocking that in such an affluent country, the numbers of older people at risk of malnutrition are so high, and it’s really unnecessary because the solutions to the problem are so simple.

  Narrator

  In this programme, we’ll see how malnutrition can pose a risk for older people both in the community and in residential care. We’ll look at steps being implemented to counter the problem, and we’ll take a glimpse at the simple screening technique being rolled out across the country that promises to safeguard against weight loss

  Philip Hurst

  There does seem to be quite a wide variation in the extent to which care homes prioritise nutrition and hydration and deal with it effectively. There are some fantastic examples of care homes who have actually grappled with this issue and made it a real priority. There’s a real opportunity to learn from the best and bring everyone up to a really high standard.

  Residential care

  Narrator

  In the Dorset town of Sherborne, the fifty residents of the Hayes Care Home live in cottages of ten bedrooms each. In 2008 the Hayes was named Care Home of the year by the National Association of Care Caterers.

  Jennifer Jones

  There really isn’t a secret in doing well; it’s training. I think that you have to learn from the bottom, you know, how to make rule, knowing how to do home traditional cooking. It’s not opening a bag. I think that in a residential home it should be all home made food and not convenience food, and that’s what I was trained to do.

  Ann Aylott

  Meal times are extremely important; it’s the highlight of a lot of people’s days.

  Jennifer Jones

  The pork is in there, and your vegetables and all under there.

  Carer

  Bless you. Oh I need some large spoons.

  Jennifer Jones

  I’ll go and get you some.

  Ann Aylott

  And it’s an opportunity for people to meet together, especially for those residents who prefer to spend time on their own in their bedrooms, we do try and encourage them to join in with at least one meal a day.

  Resident

  That’s quite hard.

  Carer

  I think it is stuck here.

  Sue Hawkins

  Meal times are not just the food that we eat, it’s who you ate it with, where you were seated, was it comfortable …

  Carer

  Oh this is very nice.

  Ann Aylott

  We put the effort in to make sure that the cutlery, the crockery will match, the tables are decorated, residents are assisted to eat in a dignified respectful manner.

  Jennifer Jones

  Every morning, I go round and ask if the residents are up, what they’d like for breakfast. I always keep on one to one with my residents, even though there’s fifty.

  Resident

  ... fine, I eat everything – lovely food.

  Carer

  Good.

  Jennifer Jones

  Cheese salad and the ham sandwich are the two visitors.

  Carer

  Okay.

  Ann Aylott

  We encourage relatives and friends to come as well to eat meals with the residents. We think it gives them reassurance that we are providing good nutritional diets.

  Carer

  Are those vegetables. Do you want some carrots and some cabbage?

  Resident

  I’ve always said the food is excellent, yes, and it is, and plenty of it.

  Resident:

  The food in here is very good. You wouldn’t get a better place than this, to have your meals in.

  Carer

  Right, afternoon everybody.

  Residents

  Good afternoon.

  Carer

  Hope you’ve all enjoyed your lunch? Good, good, good.

  Ann Aylott

  As part of ensuring that residents feel that they have choice and control in their lives, we have a resident’s forum every month. We always try and make sure that the catering manager, Jenny, attends the forum meetings because food is always a hot topic.

  Jennifer Jones

  A couple of the residents always ask for things like faggots, the old traditional food like rice pudding, oh why don’t we have it done in the oven so it’s got skin on, syrup on their bread and butter, and that’s what we’re here to please, you know. Here to please them.

  Carer

  I’m going to hand over to Jenny now.

  Jenny

  Anybody who has any suggestions they would like on the new menus or there’s something wrong with them, I’m here today to take your complaints.

  Resident

  Well I know I’m going to get shouted down – tripe. Tripe and onions.

  Jenny

  Tripe – anyone else agree with Bill, tripe and onions? Oh, we’ve had some yeses.

  You know, if you would like that on, that’s what, you know, I can put on the menu.

  Resident

  I appreciate that, I thought I was going to get shouted down.

  Ann Aylott

  They will often ask for things that we can’t always provide. They wanted roast leg of lamb once a week, but the budget won’t run to that. As long as we tell them why we can’t provide, generally they seem to accept that. And what is important is making sure that they have an opportunity to discuss their ideas and their views about the home.

  Jenny

  Are you happy when you have your birthday teas?

  Resident

  I think I’d like to mention, Jenny and that, is that in some of the homes, every cottage comes out on the birthday …

  Ann Aylott

  One or two can be more vocal than others, so we also undertake monthly quality assurance exercises’, and that’s where we have a fairly simple form and one of the questions is that, do you enjoy the food, and would you like to see any changes, so in that way, we try and reach as many residents as possible.

  Resident

  People say, what’s it like there, and I just say well, it’s the best hotel in Sherbourne. I think I’ll have the management from the hotels after me saying that, they’re losing customers.

  Narrator

  Soon, all residents of the Hayes will be nutritionally screened by a technique called the Malnutrition Universal Screening Tool, otherwise known as MUST

  Elaine Cass

  It’s important that when people come into Health and Social Care Services, we screen them to make sure they are not at risk of malnutrition. There’s a screening tool called the MUST tool that’s been primarily used in Healthcare Services, but it requires minimal training for front line workers to use it.

  Sue Hawkins

  So Sue, what we’ll do is we’ll run through the new nutritional screening policy, and we’re going to use Maria here as our resident as an example.

  I must admit I always thought MUST was quite a complicated tool, but when you understand that it is just a matter of talking to people and finding out about their weight and height, you realise that it’s a very simple tool.

  So the first thing you do is you calculate the resident’s BMI score. Do you know what your weight is?

  Marie

  61.8 kilos.

  Sue Hawkins

  And your height?

  Marie

  170 centimetres.

  Sue Hawkins

  So we’ll come up to 61 kilos and then you take the lines up to there and across there and it would join there, and have a BMI score of 21.

  Then what you’re also doing is talking to your resident about whether or not they’ve recently had any unplanned losing of weight. So Maria, have you recently lost any weight?

  Marie

  Yes I have, 5kg.

  Sue Hawkins

  Okay, so on the opposite side of the sheet, that gives her a score of 1.

  Narrator

  While her BMI is spot on, Maria’s recent weight loss means she scores 1 on the MUST scale.

  Sue Hawkins

  She’s at medium risk of malnutrition, so what you’re wanting to do is encourage and observe. Encouraging more of the cakes and crumpets, the high calorific type foods that perhaps you wouldn’t normally be eating. If somebody has a score of zero, you just need to observe and really take no action. If they are looking towards the slightly heavy side, you might be trying to encourage healthier eating. If someone has a 2 or higher, then you’re trying to add extra creams, or probably offering Complan or Build-Up as a midmorning and mid-afternoon drink. If you’re feeling like you’ve really not had much success, they would then get referred via the GP to a dietician.

  Within really 48 hours of a new resident coming into the care home, we complete a nutritional care needs chart. And you’re talking about really, likes and dislikes. Maria, what sort of likes and dislikes do you have around food.

  Maria

  I like a lot of fresh salads, feta cheese and fresh tomatoes, basil, mozzarella …

  Sue Hawkins

  So that’s a real growing document, because as you get to know your residents more, you can add to it, so that for instance, when they’re not feeling particularly well and you’re trying to encourage them to eat, you can say, well actually, we’ve bought some mozzarella cheese and we’ve done this for you. Wouldn’t you like it, and it might be just enough to turn it around so that Maria goes, yeah, okay, I’ll eat that, and she’ll start to feel better.

  Narrator

  It’s hoped that the MUST tool will ensure we know when older people aren’t having enough to eat. But eating is only half the issue.

  Elaine Cass

  Hydration is also a really important part of nutrition. You may find that older people will reduce their fluid intake because they’re frightened about incontinence issues and that they have to ask to be helped to go to the toilet and that’s embarrassing, so they try and reduce their intake, and the result of that will be that they end up with a urinary tract infection and actually have to go to the toilet more often and possibly have medication.

  Narrator

  In the fight against dehydration, one care manager in Suffolk evangelises one of the cheapest and most plentiful ingredients around.

  Wendy Harvey

  Things started really, because I have a passion. I’ve been a nurse for over thirty years, and one other thing having worked in community and different care settings is that people don’t drink enough, and I realised that the home I was working in, people were having accidents, falls, a lot of constipation, a lot of medication for constipation, people really getting urinary tract infections, and I thought unnecessarily. I introduced a drinking regime, so the residents were encouraged by staff at all times to drink, and we got some water coolers in and instigated people having jugs in their room. Very, very simple, not expensive …

  Wendy Harvey

  Have you always drunk water, or do you find it difficult?

  Resident

  I don’t have to think about that. In the morning for breakfast I don’t have fruit juice, I have water. And I have water in the night because I do wake and feel a little parched, and so I have a sip or two of water, and that puts me okay

  Wendy Harvey

  I don’t think anybody realised by drinking water what a positive affect it has on people’s lives. They’ve participated more in life, they were more alert, they stopped taking [unclear] for constipation.

  Resident

  And I’m glad that all the staff introduced water as a main drink.

  Resident

  I’ve had a urine infection, a quite severe one, and water is the thing to help clear it up.

  Wendy Harvey

  In Alice Grange, I started six months ago, and I brought everything with me. Everybody, even the maintenance man, knows about drinking water. It’s 1p a litre, that’s what we get down to, and really there’s no excuse not to do it.

  Narrator

  While hydration and meal times are major challenges for those working in residential care, the group most at risk of becoming malnourished is older people living at home. And it’s domiciliary care workers who are uniquely placed to make sure this isn’t so.

  Home Care

  Renuka Saparamadu

  My job is a home care assistant looking after elderly people.

  Hello. You okay? Would you like to have porridge or toast or …

  Lady

  Porridge dear

  Renuka Saparamadu

  You want to have porridge. With a cup of tea?

  Lady

  Oh no thanks, no. Just porridge.

  Renuka Saparamadu

  No cup of tea?

  Lady

  Just the porridge.

  Renuka Saparamadu

  All right, okay.

  Lady

  With a drop of sugar on it.

  Renuka Saparamadu:

  Yes, I’ll do that, I’ll do that for you

  Philip Hurst

  The problems of malnutrition of older people, the people living in their own homes, it’s often quite a hidden problem, so it may be for example, following a bereavement, someone living on their own doesn’t have either the skills to shop and cook, because their partner used to do it, and in around 25% of older people living in the community have symptoms of depression, and that can really impact on motivation to do things like shopping and cooking.

  Renuka Saparamadu

  She doesn’t need a big breakfast you know, but she does eat lunch, a good lunch, and the supper also, you know, kind of diet somethings. She always says, she doesn’t want to get fat.

  Renuka Saparamadu

  Oh you are ready. Here is your porridge. Tiny little, okay, I didn’t make lot. I am sure you can eat this, yeah.

  Lady

  Oh, this is lovely.

  Renuka Saparamadu

  Sometimes some of my clients, they don’t want to eat because they have a lonely life, they’re living in their home alone, and sometimes they are sad, depressed, so that time I have to encourage them to eat well, drink well. Sometimes they ask me, please, I don’t want to eat anything … I am not hungry. If I been to the plan for long time, yes of course, I know their interest and then I can change their mind. I cannot force them to do things. I just encourage them to eat and drink and take their medication.

  Renuka Saparamadu

  This is your medication.

  Lady

  Thank you dear.

  Renuka Saparamadu

  You're welcome.

  Elaine Cass

  Problems might arise in older people who live at home and receive domiciliary care services, because invariably the care workers who are coming into support the older person won’t have sufficient time to cook them a meal from fresh ingredients, so it’s important that commissioners and service providers take into account that care workers need to be given sufficient time to both cook a decent meal and to ensure that the person gets the help and support that they need to eat it, and that might even involve someone spending time talking to the person whilst they encouraging them to eat.

  Renuka Saparamadu

  How was your weekend?

  Lady

  Lovely. Anne came, then Samantha phoned me and said she was coming in October to see me for three weeks.

  Renuka Saparamadu

  Well that’s good. Fantastic.

  Lady

  Yes, good isn’t it. I know

  Renuka Saparamadu

  The key to get someone to eat is respect and choice. Sometimes they’ve been fed up with eating the same thing every day.

  I’ll be seeing you tomorrow morning, and have a chat again.

  Lady

  Ooh you are a darling.

  Renuka Saparamudu

  Okay, god bless you, bye.

  Lady

  Bless you dear.

  Renuka Saparamadu

  They have a choice. We cannot force anybody to do anything in their life, even my children, I cannot force them.

  Narrator

  In the case of thousands of older people, professional care workers stand between them and malnutrition. In the case of many more older people, unpaid carers shoulder the responsibility for the wellbeing of their loved ones.

  Family Care

  Debbie Scholes

  Do you feel like Fanny Craddock ma?

  Pauline Masters

  Eh?

  Debbie Scholes

  Do you feel like Fanny Craddock?

  Pauline Masters

  Erm, yeah, I probably look like her as well.

  Debbie Scholes

  My mother and step father were married previously, therefore I have a step brother and step sister quite a long time after the three of us had left home. It was my mother’s idea to go and live in France; quite extraordinary because they’d never even been on holiday to France before.

  Pauline Masters

  The French people were absolutely charming in our village and we had beautiful parties and things like that.

  Debbie Scholes

  They lived there for about eighteen years, very, very happily, until life became a little bit difficult for them. I had to make the decision for them to come and live with us and rescue them essentially.

  Do you remember where I keep the oil ma?

  Pauline Masters

  Somewhere down there or there, I’m not quite sure.

  Debbie Scholes

  That one, well done

  My step father’s health had deteriorated a lot. He’s got vascular dementia, kidney problems, he’s since been registered blind and Parkinson’s and my mother was unable to cope.

  Pauline Masters

  He’s in hospital at the moment, and then he’s got to go to another hospital for rehabilitation, and then hopefully at some point he can come home here, which will be lovely.

  There’s my shopping list up there.

  Debbie Scholes

  Well let’s do it before we forget.

  Pauline Masters

  Lest we forget.

  Debbie Scholes

  I didn’t know until we got them back into this country that she had Alzheimer’s.

  Pauline Masters

  I’ll put dried apricots sort of about half way down.

  Debbie Scholes

  She’s now not confident writing, she doesn’t read. She was a brilliant cook, and now she has to have a very strict menu plan for every day of the week. Each Friday we prepare a dish involving gammon steaks and dried apricots. I think I’ve made it with my mother about 8 or 9 times now; she’s still not confident about doing it.

  Debbie Scholes

  Do you think that you’re going to be able to remember how to do this sometime? Or follow the recipe at least.

  Pauline Masters

  I hope so.

  You know, once I’ve got the ingredients in front of me, I can manage. I’m trying to think of some things that we’ve done lately, Debbie and I … erm … no I can’t remember.

  Debbie Scholes

  It’s a difficult situation because I need to look not only at the nutritional benefits of what they’re having to eat, their personal tastes, my mother’s ability to prepare the elements and my step father being able to manage to swallow them. Meal plans are pretty difficult.

  Debbie Scholes

  Do you know what you’ll need to chop them with?

  Pauline Masters

  One of these.

  Debbie Schole

  Yeah.

  We could use meals on wheels, however I think for her mental state, I think she needs to be pushed.

  There’s that. Put some wine in.

  Pauline Masters

  Ooh, yes.

  Debbie Scholes

  I think she needs to have the responsibility of caring for herself and for him. The difficulty is that there’s a balance between causing them stress and making the person exercise their mind.

  Pauline Masters

  She only gets cross with me when I do silly things, and if I don’t do silly things then she’s wonderful.

  Debbie Scholes

  Certainly my step father, it would be appropriate for him to go to go to a care home, it wouldn’t be appropriate for my mother, they shouldn’t be separated … really, we’re just living each day as it comes.

  Pauline Masters

  Of course I don’t think he likes broad beans but we’ll find out when he gets back.

  Debbie Scholes

  Oh there’s hardly any vegetables that either of you eat.

  Pauline Masters

  I eat all my vegetables.

  Debbie Scholes

  It’s not like you choose to put carrot or broccoli on your plate is it?

  Pauline Masters

  I do put carrot and broccoli on my plate because you make me!

  Debbie Scholes

  Well precisely.

  Narrator

  While Debbie strives to facilitate nutritious meals and engaging in social mealtimes outside the care system, social care professionals need to understand the simple but necessary steps that can ensure that older people eat well.

  People need to be offered dignity and respect as well as good nutritional food. Staff need to be trained to the highest standard, and all users of health and social services need to be screened on admission.

  Philip Hurst

  Everyone needs to take action to make sure that we address malnutrition so that all older people get the food they need and any help to eat it.

  Elaine Cass

  They just want what everybody else wants. You know, a nice enjoyable meal in a nice environment with friends and family, and we need to try and provide that for people.

  [End of recording]

Who will find this useful?

Commissioners, managers of home care services, frontline care workers and unpaid carers.