Across the care sector, there are pockets of fantastic practice and award-winning homes. In the changing landscape of inspections, there is more onus on care homes to prove their great results and show awareness of their own status quo and ambition for outstanding ratings.
Perhaps the most recent and informed piece of work in the NHS, which can translate back to care homes, is the Hospital Food Review, chaired by Phil Shelley and published in October 2020. This research highlighted eight areas for improvement required to achieve great nutrition and hydration in hospitals and addresses key subjects, including working together and training. This was a long-awaited study with some very translatable ideas that can be achieved in the care sector.
Henry Dimbleby’s progressive work through the National Food Strategy continues to illustrate how our food system and ill-health are interconnected and, again, whilst not directed specifically at care homes, it will have an influence on food for the nation in time.
Research from 2018 by Bunn, Hooper and Welch is thought-provoking. It suggested that existing knowledge may not translate well into hands-on practice in care homes. Does this mean that all the great research is not landing in practice? Does this mean that toolkits, resources and materials are not suited to practice? It is indeed food for thought when it comes to working with stakeholders, including regulators, commissioners and educators, to help raise awareness and understanding and improve standards.
Screening for malnutrition risk in care settings is essential for enabling early and effective nutritional interventions. The National Institute for Health and Care Excellence (NICE) guidance recommends people in care homes should be screened on admission and when there is clinical concern by staff with appropriate skills and training.1
More than 90% of UK care homes screen for malnutrition at the point of admission and use the Malnutrition Universal Screening Tool (MUST)2. In 2018, further research in this area addressed a gap in the existing screening and embedded another validated tool into MUST (found in the BAPEN subjective MUST section). This uses four simple questions to determine malnutrition risk and assist in the decisions for treatment. This research was a collaboration between Bournemouth University and the Patient Association and can also be used as a stand-alone tool called the Nutrition Checklist. Using this tool may not only help increase the identification of malnutrition but also aid the awareness and successful approaches to help improve and reduce malnutrition.
Anecdotally the downside to MUST is that many care home staff find MUST difficult to use, especially comprehending the concept of unintentional percentage weight loss. Error in screening can result in malnutrition remaining unrecognised and, of even more concern, untreated. The nutrition week survey showed that those identified as ‘malnourished’ were most likely to be underweight on admission to a care home and to lose further weight during their residency; someone at low risk of malnutrition was more likely to gain weight.3
Unfortunately, there is not currently a validated tool for identifying dehydration risk in older adults.4 Dependent older adults are generally considered to be at risk of dehydration, which accounts for most residents living in a care home. Food and fluid record charts can be routinely used by healthcare staff. However, literature indicates that they can be highly inaccurate and should not be standard daily practice.5, 6, 7 Instead when a concern is identified, a three-day food record chart is recommended as it can be useful for identifying patterns and targeting strategies to prevent further deterioration. In specific cases of fluid restriction due to cardiac or renal failure, keeping daily fluid record charts will be essential but this will be for the minority of residents and usually involve medical supervision and oversight.
A project built from sound comprehensive research has also been undertaken in hydration – the NHS England funder project called Good Hydration, which won a patient safety initiative in 2018. This involved 150 residents in care homes and includes training guides and tips to improve hydration. The research piece that influenced this study found that 20% of those in care homes are dehydrated – that’s 1 in 5 residents (Hooper et al 2015) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5018558/
Another study led by Lancashire and South Cumbria NHS foundation Trust used a hydration screening tool called GULP to identify those at risk, in absence of a nationally recognised hydration screening tool.
In a year where sustainability has been propelled into public consciousness, we cannot ignore the relationship between food and environmental impact. Presently, there is a lot of research being undertaken by organisations including the Waste and Resources Action Programme (WRAP) and the Soil Association, with the ambition to help create a more sustainable food system with well-informed research used to advise best practice. This research indicates that carbon emissions are mostly impacting the agricultural production and food processing stages (70-80%), with the remainder found in transport, catering and waste. This can help to focus efforts on quick sustainability wins and in procurement and menu planning. Great initiatives have followed in plant-based menus, or dishes that encourage an increased consumption of plant-based food.
Sustainability in the care catering sector will remain a focus over the coming years, especially with the outcomes of COP26 and the global focus on climate change. There is a lot of support available to care homes – for example, there are some fantastic free resources on WRAP’s Guardians of Grub to tackle food waste. The Soil Association’s Food for Life programme and Love British Food are both accessible programmes to help care homes achieve sustainability goals.
Supply chain challenges
Planning is imperative. It is advisable, where possible, to order further ahead than usual to avoid getting caught out by last-minute changes. Looking at storage capacity for frozen and ambient products and building up additional stock, for example, is sensible. Adaptability is vital should some products not be available, or deliveries disrupted. Having alternative menus ready is recommended as this allows for flexibility and ensures the dietary needs of residents are always met. Collaborating with other care homes in your locality could also be beneficial.
Care sector suppliers have continued to investigate and innovate market products and studies have been undertaken in areas such as protein in drinks and improving food choice for those who may benefit from finger foods.
Catering for dysphagia will also provide innovation over the coming year, as IDDSI implementation continues and the training of care home chefs to create texture-modified foods correctly and safely remains a priority. Innovation is already being seen around the diagnosis of dysphagia itself, with further studies of swallowing assessments via video links taking place. The EDSCF (Eating Drinking Swallowing Competency Framework) will continue to assist improving relevant training.
More work to be done
Whilst available research will continue to be embraced, perhaps we need to focus upon translating messages in practice and ensuring the reach of customers is wide enough to have a meaningful impact.
The NACC will be looking to relaunch its training academy and will continue its regional and virtual training seminars to help improve skills in care homes and share best practice. This will also assist with professional development, which in turn will help recruit new talent to the sector.
Nutrition needs for healthy older people
With regards to guidelines, Dorrington et al. published ‘A Review of Nutritional Requirements of Adults Aged ≥65 Years in the UK’ (Table 1).8 The British Dietetic Association Older People’s Specialist Group is currently designing simple guidance for older adults based on this paper with the aim of supporting them to age well. We aim to focus on six key concepts:
- A nutrient-dense diet.
- Adequate hydration.
- Vitamin D.
- Physical activity.
- Weight and BMI.
- Enjoyment of eating.
Older people in care homes have a range of dietary needs. Thus, a blanket approach should not be adopted to food provision. Individual requirements, preferences and needs must be considered. Not all residents should receive fortified puddings. Similarly, not all residents should receive skimmed milk. Residents who are well and have a good appetite can enjoy a balanced healthy diet whereas residents who are at risk of malnutrition or malnourished can enjoy fortified meals to maximise nutrient density. It is usually combined with a little-and-often strategy i.e., small portions of meals and between-meal snacks. NICE CG32 emphasises that the overall nutrient intake of oral nutrition support should contain a balanced mixture of protein, energy, fibre, electrolytes, vitamins and minerals instead of just calories.1
Therefore, food fortification should use more nutrient-dense ingredients (Table 2) instead of calorie-dense ingredients such as cream and butter. Instead of biscuits and cakes, snacks should include more nutrient-dense choices (Table 3). Nourishing drinks should be encouraged between meals. Each pint of full fat milk can be fortified by adding four heaped tablespoons of dried, skimmed milk powder. For extra nutrition, care homes could also consider fortified drinks rounds during mid-morning and mid-afternoon following the recipes in Figure 1.
A pleasant dining environment and social connections play a key role in supporting residents’ nutritional intake. The sight, smell and associated rituals of eating are an important stage in preparing the body to receive food, and opportunities for pre-meal preparation by residents should be optimised. Care staff should support and assist residents so that they are in a safe and comfortable position for eating and drinking. To encourage choice and autonomy, foods can be displayed in a buffet style or options shown on plates. The food should be presentable, attractive and tasty. This is particularly important for modified texture meals. For example, someone requiring IDDSI Level 4 pureed food could have their meals prepared in food moulds so that they look like their original form and look more appealing.9 The eating environment is also important – distraction such as the TV or the hoover should be avoided during meal service. Appropriate music and lighting can enhance the mealtime experience and create a calming environment for eating. The National Association for Care Catering (NACC) has launched a good practice guide on menu planning and dining.10
Dietitians, catering and care staff should work closely to provide nutrient-dense diets for residents. Person-centred care should be offered, and any intervention offered should improve quality of life.
Sophie Murray is Head of Nutrition and Hydration for Sunrise Senior Living and past Deputy National Chair of the National Association of Care Catering (NACC). Email: email@example.com
Dove Yu is a PR Officer of BDA Older People Specialist Group and Senior Specialist Dietitian (Nutrition Support/ Palliative Care) at South Tees Hospitals NHS Foundation Trust. Email: firstname.lastname@example.org Twitter: @doveyu_RD
- NICE. Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition NICE guideline [CG32] [Internet]. 2006 [cited 29 October 2021]. Available from: nice. org.uk/guidance/cg32
- BAPEN. Malnutrition Universal Screening Tool [Internet]. 2003 [cited 29 October 2021]. Available from: bapen.org.uk/pdfs/must/ must-full.pdf
- Tsutsumimoto K., Doi T., Makizako H., Hotta R., Nakakubo S., Makino K., Suzuki T., Shimada H. Aging-related anorexia and its association with disability and frailty. J. Cachexia Sarcopenia Muscle. 2018; 9:834–843.
- Hooper L., Abdelhamid A., Attreed N.J., Campbell W.W., Channell A.M., Chassagne P., Culp K.R., Fletcher S.J., Fortes M.B., Fuller N., et al. Clinical symptoms, signs and tests for identification of impending and current water-loss dehydration in older people. Cochrane Database Syst. Rev. 2015;30:CD009647.
- Godfrey H et al. An exploration of the hydration care of older people: a qualitative study. International Journal of Nursing Studies. 2012; 49: 10, 1200-1211
- Jimoh OF et al. Assessment of a self-reported drinks diary for the estimation of drinks intake by care home residents: Fluid Intake Study in the Elderly (FISE). The Journal of Nutrition Health and Aging. 2015; 19: 5, 491-496.
- Scherer R et al (2016) Fluid intake and recommendations in older adults: more data are needed. Nutrition Bulletin; 41: 2, 167-174
- Dorrington N, Fallaize R, Hobbs DA, Weech M, Lovegrove JA. A Review of Nutritional Requirements of Adults Aged ≥65 Years in the UK. J Nutr. 2020; 150(9):2245-2256.
- Manabe T, Mizukami K, Akatsu H, Hashizume Y, Ohkubo T, Kudo K et al. Factors Associated with Pneumonia-caused Death in Older Adults with Autopsy-confirmed Dementia. Internal Medicine. 2017;56(8):907-914.
- NACC. Menu planning and dinning in care homes. [Internet]. 2021 [cited 10 Nov 2021]. Available from: https://www.thenacc.co.uk/shop/publications/menu-planning–dining-in-care-care-homes