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Good Nutritional Care
Are you getting it right?

With over a third of care home residents at risk of malnutrition on admission to a care home, Helen Willis breaks down how providers can ensure good nutritional care for all residents.

Whether as a consequence of illness or disease, or the influence of factors such as depression, anxiety or social exclusion, malnutrition is particularly prevalent in the elderly. Latest figures from BAPEN suggest that as many as 35% of residents are thought to be at risk on admission to a care home. This is why it’s vital to ensure that good nutritional care is prioritised from day one and that all residents are given the support they need to avoid malnutrition and the potentially life-threatening consequences it can have on their health.

What is malnutrition?

The official definition of malnutrition from the National Institute for Health and Care Excellence (NICE) is when an individual has:

  • a BMI of less than 18.5, or
  • unintentional weight loss greater than 10% within the past three to six months, or
  • a BMI of less than 20 and unintentional weight loss greater than 5% within the past three to six months.

However, while these figures are a useful guide, the single most effective way to screen for malnutrition is by using BAPEN’s Malnutrition Universal Screening Tool (MUST). Supported by organisations including the British Dietetic Association (BDA), this is the most widely-used screening tool in the UK and should be used at regular intervals for all residents.

In addition to a formal screening programme, it’s also worthwhile taking the time to train care staff in recognising potential early signs of malnutrition. Weight loss isn’t the only indicator and other signs to look out for include feeling tired all the time and struggling to keep warm.  One idea might be to post simple, visual guides in the home with reminders of these signs.

It can’t be emphasised enough that the earlier the risk of malnutrition is identified, the easier it is to halt its progress.

If your screening process has identified that a resident is at risk of malnutrition, it’s important to inform the person’s GP in case this has been caused by any, as-yet unidentified, underlying illnesses. While treating such illnesses will naturally form an important part of supporting a return to good health, good nutritional care is vital to avoid the progression of malnutrition and the potentially fatal consequences this can have on residents.

What does good nutritional care look like?

Ensuring residents get the nutrition and hydration they need on a daily basis is, of course, a fundamental aspect of quality care. However, what this means in practice is not always clear.

There is a plethora of guidelines on the provision of food and drink in care homes, but the National Association of Care Catering’s (NACC) Nutritional Standards for Adults is a useful place to start. Its aim is to simplify existing standards in line with current best practice.

At a regulatory level, the Care Quality Commission’s (CQC) recently introduced Regulation 14 sets out what is required of homes in meeting the nutritional needs of residents. Reflecting the weight that the regulator places on good nutrition, inspectors now have the power to immediately prosecute homes if a failure to meet these regulations results in avoidable – or significant – risk of harm to a resident.

A personalised approach

In addition to screening for signs of malnutrition, key to providing good nutritional care is to monitor the specific needs of residents, both at the initial assessment stage and on an ongoing basis. Ideally, relatives or close friends should be involved in the initial assessment, which should cover – but not be limited to – the following factors: any special medical and dietary requirements, cultural or religious influences and, most importantly, what they enjoy eating.

This nutritional assessment should form an important part of their overall care plan and all details on their specific needs and preferences should be made clear to all catering staff.

Once their personalised nutritional plan is in place, regularly reviewing this will ensure that any changes in residents’ needs and preferences are accounted for.

At a day-to-day level, the CQC’s Regulation 14 emphasises the importance of choice. This means inspectors will want to be assured that residents are offered a genuine variety of options to choose from at all meal and snack times, including portion sizes to suit different appetites.

This is echoed by the NHS’s 10 Key Characteristics of Good Nutrition and Hydration Care (see table below), which emphasise that choice should be extended to when people eat. In my experience, residents, especially those with dementia, often eat more when given the chance to enjoy food outside of set mealtimes.

Put simply, if a resident wants to eat a small portion of cottage pie at 8pm, for example, they should be free to do just that.

Nutritional care for residents with dementia

As providers will appreciate, caring for residents with dementia can pose particular challenges that can make it much harder to ensure they get the nutritional intake they need.

Among the recommendations within the 10 Key Characteristics of Good Nutrition and Hydration Care is to serve meals in an environment conducive to the enjoyment of food.  This refers to the ‘Protected Mealtimes’ concept, which advocates the avoidance of any visits or appointments during times when food and drinks are being served. For residents with dementia, fostering such an environment is particularly important and should also extend to creating a calm and relaxed setting, removing stimuli such as televisions or loud music to help focus attention.

The emotional and physical changes that can go hand in hand with the progression of dementia can impact on eating habits and it’s common to find that what once was a favourite dish is now regularly refused. This is another reason why it’s so important to regularly review the options you are offering to residents.

Depending on the kind of dementia a resident is experiencing – and the extent to which it has progressed – they may have difficulty recognising cutlery, food and drinks, so tables should be kept uncluttered and contrasting colours should be used for cutlery, crockery and table cloths.

Similarly, some may struggle to recognise what food they are being served, especially if they are also experiencing dysphagia (difficulty swallowing and chewing food) and rely on meals that have been adapted to make them safe to eat. This is where texture-modified meals that closely resemble the ‘normal’ food served to other residents can play a role in encouraging those with dysphagia to eat.

On that note, it cannot be stressed enough that the first step in catering to any resident with dysphagia is for them to be assessed by a speech and language therapist, who can diagnose which stage of the condition they have reached.

Moving forward

Malnutrition has been linked to increased hospitalisation, re-admission and long-term ill health and, if left untreated, even death.

While the range of guidelines and regulations governing nutritional care can be daunting and confusing, what’s most important is to work with residents and their families to create a flexible, nutritional plan that is regularly reviewed and adapted and do all you can to make mealtimes an occasion to look forward to. Together with a formalised nutritional screening programme, which will help identify signs that residents are at risk of malnutrition, your efforts will go a long way to helping avoid its occurrence.

The NHS’s 10 Key Characteristics of Good Nutrition and Hydration Care
  1. Screen all patients and service-users to identify malnourishment or risk of malnourishment and ensure actions are progressed and monitored.
  2. Together with each resident, create a personal care/support plan enabling them to have choice and control over their own nutritional care and fluid needs.
  3. Care providers should include specific guidance on food and beverage services and other nutritional and hydration care in their service delivery and accountability arrangements.
  4. People using care services are involved in the planning and monitoring arrangements for food service and drinks provision.
  5. Food and drinks should be provided alone or with assistance in an environment conducive to patients being able to consume their food (Protected Mealtimes).
  6. All healthcare professionals and volunteers receive regular training to ensure they have the skills, qualifications and competencies needed to meet the nutritional and fluid requirements of people using their services.
  7. Facilities and services providing nutrition and hydration are designed to be flexible and centred on the needs of the people using them, 24-hours a day, every day.
  8. All care providers to have a nutrition and hydration policy centred on the needs of users, and is performance managed in line with local governance, national standards and regulatory frameworks.
  9. Food, drinks and other nutritional care are delivered safely.
  10. Care providers should take a multi-disciplinary approach to nutrition and hydration care, valuing the contribution of all staff, people using the service, carers and volunteers working in partnership.

Helen Willis is a Dietician at apetito. Email: Twitter: @apetitoUK

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