Project Title:
Food in residential care
Report authors:
Anna Wasielewska, Barbara Drummond & Christine Raiswell
Date of Report:
January 2012
Prepared for:
Public Health Manchester
Prepared by:
Anna Wasielewska, Food Futures Project Officer
Christine Raiswell, Food Futures Programme Manager
Barbara Drummond, Senior Research Officer
Public Health Manchester
Number One First Street,
Manchester
M15 4FN
TABLE OF CONTENTS
Page
INTRODUCTION
1. PROJECT BACKGROUND
2. PROJECT SUMMARY
3
4
5
2.1. AIMS AND OBJECTIVES
2.2. PROJECT CONTENT
2.1.1. Consultation and partnership work with health and social care
colleagues
2.2.2. Literature review
2.2.3. Consultation event with care home managers
2.2.4. In-depth interviews with care home managers
2.2.5. Observational Research
2.2.6. Training for cooks and chefs working in care homes
3. CARE HOMES AND THEIR RESPONSIBILITIES AROUND FOOD PROVISION
5
5
6
3.1. THE HEALTH AND SOCIAL CARE ACT 2008
3.2. CARE QUALITY COMMISSION
3.3. CONTRACTUAL ARRANGEMENTS WITH MANCHESTER CITY COUNCIL
3.4. DISCUSSION
4. FOOD PROVISION AND MEALTIMES IN RESIDENTIAL CARE – CURRENT PICTURE
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9
12
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14
4.1. NATIONAL PICTURE
4.2. LOCAL PICTURE
4.2.1. CQC Reports on residential care homes in Manchester
4.2.2. Anecdotal information
4.2.3. Consultation event - care home managers
4.2.4. In-depth interviews with care home managers
4.2.4.1. All care homes
4.2.4.2. Care homes for older people
4.2.4.3. Care homes for people with learning difficulties and mental
health problems
4.2.5. Observational Research
4.2.6. Training for cooks and chefs working in care homes
5. FURTHER INFORMATION AVAILABLE WITHIN LITERATURE
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17
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23
25
28
29
35
40
5.1. ISSUES AND CHALLENGES LEADING TO POOR NUTRITION IN RESIDENTIAL
CARE
5.1.1. Complexities of the client group
5.1.2. Issues related to staff
5.1.3. Organisational issues
5.2. WAYS OF ENABLING AND ENCOURAGING GOOD NUTRITION AND
MEALTIME EXPERIENCE
5.2.1. Food as stimulus
5.2.2. The Environment as stimulus
5.2.3. Food and food supplementation
5.2.4. Staff training
5.3. IMPLEMENTING CHANGE
5.4. POLICY CONTEXT
5.5. GOOD PRACTICE GUIDANCE
5.5.1. General Principles
5.5.2. Practical Guidance
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6
7
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8
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50
54
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57
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66
68
69
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71
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76
76
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1
5.6. EXAMPLES OF GOOD PRACTICE
5.6.1. National examples
5.6.2. Local examples
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80
6. REFLECTIONS ON THE PROJECT TO DATE
7. PROJECT LIMITATIONS
8. SUMMARY AND RECOMMENDATIONS
LIST OF REFERENCES
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89
2
INTRODUCTION
Manchester Food Futures Partnership is committed to ensuring that every person living in
this city has access to a good diet. Ensuring that vulnerable people are given the support
they need to be able to access good food regardless of their age, disability, medical
condition or living arrangements has been prioritised by the Food Futures Board.
Following discussions with the Directorate for Adults, Valuing Older People and members of
the Food Futures Vulnerable Groups Project, it was agreed to develop a project to improve
food and nutrition in residential care. This was based on the following rationale:
•
Adults in residential care are amongst the most vulnerable as they have little control
over their diet, may be frail and need help with eating.
Food and nutrition is a key aspect of the Dignity in Care.
Anecdotal evidence would suggest that there is a mixed picture of food provision in
homes in Manchester but more information was required.
Food and mealtimes should be recognised as a key part of the day for those in care.
It presented an opportunity to champion food in residential care in Manchester,
promote examples of good practice and provide practical support to other homes to
improve.
•
•
•
•
It was recognised that those receiving home care are equally vulnerable and work to
provide training and support to home care providers would be developed in conjunction
with this work.
The underlying objective of the project is to explore the area of mealtimes and food
provision in residential care and to act on the findings. The report summarises the
knowledge and evidence gathered as a result of the initial work carried out by the Food
Futures Partnership so far, which includes:
-
Consultation and partnership work with health and social care colleagues
Extensive literature review
Consultation event with care home managers
In-depth interviews with care home managers
Observational Research
Training for cooks and chefs working in care homes
This comprehensive information gathering process enabled us to better understand the
current provision of food in residential care, the issues and challenges hindering good
nutrition and enjoyable mealtime experience as well as the complexities of individuals living
in care and their personal experience of the mealtime. Numerous issues, gaps and
challenges have been identified in the process and these need to be addressed and acted
upon. The report includes a list of recommendations for a wide range of stakeholders which
should be considered in order to improve the health and wellbeing of the vulnerable
individuals by improving their nutritional status and mealtime experience.
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1.
PROJECT BACKGROUND
Good nutritional care, adequate hydration and enjoyable mealtimes can dramatically
improve our general health and well-being (DoH & Nutrition Summit Stakeholder group,
2007). Food, nutrition and mealtimes are a high priority for people living in residential care
homes and good experience with food is often perceived as a measure of the quality of
services people receive. Mealtimes affect their quality of life, may be ‘the highlight of the
day’ and are regularly raised as an opportunity to respect residents’ dignity or to undermine
it (CSCI, 2006).
Research evidence, taken alongside complaints data and anecdotal feedback, suggests that
despite an abundance of information and guidance on the subject of food, nutrition and
hydration, there are still concerns about nutrition in the health and social care sectors. The
majority of care homes provide nutritious meals but there are still some that fail to meet
the recommended standards. What seems to be repeatedly highlighted as an issue is that
the people who are being cared for do not always get the right support and encouragement
to eat and drink. Lack of staff and poor training can actually lead to malnutrition and to
mealtimes being equally stressful for both sides. These issues result in mealtimes becoming
a task centred chore rather than a pleasurable experience and an opportunity for the
residents to interact socially with each other and the staff who support them in the home.
Consuming insufficient amounts of nutrients necessary for the body to sustain its basic
functions, for a prolonged period of time, results in malnutrition. Malnutrition is both a
cause and a consequence of ill-health and it is surprisingly common in the UK. Many older
people and those with long-term medical or psycho-social problems are chronically
underweight and so are vulnerable to acute illness. The consequences of malnutrition
include vulnerability to infection, delayed wound healing, impaired function of heart and
lungs, decreased muscle strength and depression. People with malnutrition consult their
general practitioners more frequently, go to hospital more often and stay there longer and
have higher complication and mortality rates. If poor dietary intake or complete inability to
eat persists for weeks, the resulting malnutrition can be life-threatening in itself (NICE,
2006).
In Manchester, some information about food provision in residential care is gathered by
different bodies carrying out assessments in the care homes. Environmental Health Teams
ensure food safety rules are followed, city council contractors ensure the homes comply
with the contractual responsibilities and the Care Quality Commission (CQC) carries out
inspections during which the homes are assessed against a range of expected outcomes.
There is also some anecdotal information about food in care homes coming from care
professionals visiting the homes to support individuals but this information tends to focus
on the extremes and should not be treated as evidence that could be applied to all
establishments in the city.
What is more, the information available is predominantly focused on following the rules and
meeting the requirements rather than the mealtime experience of the residents. There is
very little systematic evidence about the quality of food served, nutritional status of the
residents, level of support people get during the meal, how much input they have in what is
being served or what the actual mealtime experience is like for them on a daily basis.
4
In order to promote any changes in this area, The Food Futures Partnership needs to
understand the current state of food provision in residential care homes across the city. We
need to identify any issues and challenges that the care homes experience and find ways to
support them in overcoming the obstacles. We also need to identify examples of success
and good practice, reward and champion those achieving high standards and share the good
practice. These actions have a potential to raise the profile of good food in care and increase
aspirations of service providers as well as service users.
2. PROJECT SUMMARY
2.1.
AIMS AND OBJECTIVES
The overall aim of the project is to ensure that residents living in care homes across
Manchester enjoy their mealtimes and are provided with nutritious food that satisfies their
expectations and enhances their health and wellbeing.
The specific aims of the project are:
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To ensure dignity in care at mealtimes.
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To ensure that the care home residents have access to healthy and balanced diets.
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To ensure enjoyable dining experience of the residents.
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To raise aspirations around food provision with providers and commissioners.
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To recognise and reward good practice in food provision in care homes in Manchester.
The objectives of the project are:
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To explore the factors that influence food provision in care homes in Manchester as
well as the barriers and challenges that are faced on a daily basis.
-
To carry out observational research of residents to measure levels of ill being and wellbeing during mealtimes (and identify factors that contribute to that).
-
To identify examples of good practice both locally and nationally.
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To identify and support training needs of the staff working in care homes.
-
To develop a package of support, advice and training available to the care homes in
order to facilitate better food provision.
-
To introduce an award scheme that would recognise and reward good practice in food
provision in residential care.
-
To embed learning and available support into future.
2.2.
PROJECT CONTENT
From the outset, the project was designed to have an exploratory character, seeking
understanding of food provision in residential care settings and taking open minded, non5
judgemental and supportive approach to all the information obtained. In order to gather
evidence and knowledge around food provision in residential care, the following actions
have been undertaken:
2.2.1. Consultation and partnership work with health and social care colleagues
The project is supported by a steering group consisting of colleagues from MCC Adults
Directorate, Environmental Health, NHS Colleagues from The Community Nutrition Team
and Medicine Management. The steering group is in place to oversee the work but also to
support us with their knowledge, experience and expertise of working with care homes. The
steering group also highlights some of the areas that need attention and help us focus on
the most important issues that should be considered when working with care homes.
In the course of this initial stage of the project, we have also worked closely with the Speech
and Language Therapists form the 3 trusts in Manchester, made links with specialist nurse
and nurse practitioners who work with care homes on a regular basis and we have also
started building links with Healthy Weight Manchester, Manchester Learning Disability
Partnership and the Fighting Fit team in CMFT.
2.2.2. Literature review
Analysis of the available policy documents, reports, best practice guidance, research
evidence and other available sources has been carried out in order to understand the
complexity of providing meals in residential care homes. A plethora of information on
nutrition in care settings for older people has been identified but very limited information is
available on food in residential care homes for adults with learning disabilities or mental
health problems. This strong focus of literature on mealtimes and nutritional status of older
people makes it very difficult to equally analyse and understand these issues across the
residential care sector catering for all vulnerable adults.
2.2.3. Consultation event with care home managers
In July 2010 Food Futures invited managers from all residential care homes for adults, which
were located in Manchester and contracted by the Manchester City Council, to attend a
consultation event that focused on food provision in their homes. Members of the project
steering group were also part of the session in order to show their support for the work and
participate in the discussions.
The main objectives of the consultation event were:
-
To understand what the care home managers aspired to in regards to food provided to
residents on a daily basis.
-
To identify issues and challenges that hindered achieving these aspirations.
6
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To share the tactics, techniques and ways of dealing with the difficulties.
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To share good practice - things to be proud of.
-
To share the difficulties that still needed to be overcome and thoughts on what would
enable this.
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To identify unmet needs and support that would facilitate better food provision in care
homes across Manchester.
Managers and senior members of staff from 8 homes attended the event. The manageable
size of the group as well as clearly stated objectives of the afternoon enabled open, friendly
and very useful discussions around the complexities of food provision in care homes. Also,
at this point it became clear how challenges differed for those looking after older people
and for those looking after adults with mental health problems and learning difficulties.
These discussions were very helpful in raising further questions and creating a structure of
the one-to-one interviews that followed the event.
2.2.4. In-depth interviews with care home managers
At the end of the consultation event Food Futures agreed with all the attendees that the
project officer would visit each of the homes individually and have more detailed and indepth discussions focusing on food provision in their homes. Another attempt to engage
with more homes was made and an invitation e-mail was sent out to managers of all the
homes that didn’t attend the consultation event. In order to increase managers’ ability to
get involved in our work, we offered to visit the home at any time convenient for them.
Using this approach, we managed to recruit a further 14 homes. As a result of this
recruitment process, Food Futures consulted 22 residential care homes out of 98 across the
city with a good representation of homes in North, Central and South parts of the city. The
consulted homes were an interesting mix in terms of the type of service users and size of
the home. The greatest number of homes was residential settings for older people, some
with nursing and some specialising in dementia but we also managed to speak to managers
of care homes for people with learning difficulties, mental health problems, substance
misuse problems and others, not fitting in with strict criteria but still requiring support
within the residential care setting.
The interviews were designed to be semi structured, with open questions to allow the
managers to share their thoughts on each of the subjects and expand on the areas that they
had more interest in. The interviews consisted of 28 questions but it was not always
appropriate to ask all of them. Our priority was to encourage a friendly and open
conversation hence the flow and positive atmosphere of the interviews was prioritised over
the systematic approach to the conversations. As a result, the data from the interviews may
not be as consistent as it could have been but hopefully gives a better insight, is richer and
more meaningful. This approach enabled Food Futures to build positive relationships with
most of the home managers, many of whom remained supportive all along.
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2.2.5. Observational Research
While reviewing available research evidence as well as the CQC reports, it became clear that
the residents who have lost their ability to communicate and are not able to engage in a
conversation or provide informed consent, are most often excluded from the
information/feedback gathering processes. Also, some residents who have the capacity to
communicate are not comfortable giving negative feedback for numerous reasons such as
fear of falling out of favour or simply upbringing that does not allow complaining. Food
Futures felt really strongly that these people still need to have a voice even if they are
unable or unwilling to explain what they think or feel. In order to be able to gather the
“feedback” from all the care home residents rather than only those who could respond to a
questionnaire or who could be interviewed, we decided to carry out mealtime observations.
With the support we have received from the Sheffield University and colleagues from
Manchester City Council, we designed an observational research study that used an adapted
dementia mapping tool to measure residents’ well being and ill being at the time of
observation without the need for communication.
2.2.6. Training for cooks and chefs working in care homes
In the course of interviewing the care home managers, Food Futures identified an urgent
training need - improving practical skills for chefs and cooks to prepare and present
modified consistency diets. We commissioned a chef consultant to deliver 6 training
sessions in 3 localities in Manchester. We ran 3 half a day sessions in May 2011 and 3 half
day sessions in June 2011. The training consisted of 3 parts:
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Introduction to healthy eating in care homes – delivered by colleagues from the
Community Nutrition Team
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Swallowing difficulties and modified consistency diets – delivered by local speech and
language therapists.
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Practical cooking sessions with the chef consultant
One of the main objectives for all the trainers involved in the sessions was to make the
kitchen staff aware of how much responsibility was put on them when they cater for this
vulnerable client group. They focused on highlighting why the recommendations should be
strictly followed and why the kitchen staff should work more closely with the residents and
the care staff.
3.
CARE HOMES AND THEIR RESPONSIBILITIES AROUND FOOD PROVISION
Food and mealtimes are a very important part of our lives. For people living in care homes
whose lives have often become less active and less purposeful due to their disability or their
social and emotional circumstances, mealtimes have often become even more important
(RSPH, 2009). They are frequently classed as the most important part of the day - something
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that helps people in care to plan and structure their day around. Owners, managers and
staff in care homes are given the responsibility to care for these individuals who may be
experiencing a whole range of physical, emotional and cognitive impairments.
Food and mealtimes are only one of the many areas that care home staff are expected to
deal with in a sensitive and expert manner. However, by paying special attention to this area
of life in care homes, ensuring a healthy, balanced diet, responding to residents’
preferences and making mealtimes relaxed and enjoyable, staff can contribute to an
improvement in residents’ physical and mental health as well as the overall quality of their
lives (RSPH, 2009).
Since October 2010 Care homes in England must register with the Care Quality Commission
(CQC) and as a result, they have to comply with the Health and Social Care Act 2008
(Regulated Activities) Regulations as well as the Care Quality Commission (Registration)
Regulations 2009.
3.1.
THE HEALTH AND SOCIAL CARE ACT 2008
Within The Health and Social Care Act 2008 (Regulated Activities) Regulations, point 14
specifies what is required from the care provider in regards to meeting nutritional needs:
a)
Where food and hydration are provided to service users as a component of the
carrying on of the regulated activity, the registered person must ensure that service
users are protected from the risks of inadequate nutrition and dehydration, by
means of the provision of:
-
a choice of suitable and nutritious food and hydration, in sufficient quantities to
meet service users’ needs
-
food and hydration that meet any reasonable requirements arising from a service
user’s religious or cultural background
-
support, where necessary, for the purposes of enabling service users to eat and drink
sufficient amounts for their needs
b)
For the purposes of this regulation, “food and hydration” includes, where applicable,
parenteral nutrition and the administration of dietary supplements where
prescribed.
3.2.
CARE QUALITY COMMISSION
Since September 2009, The Care Quality Commission has been established as an
independent body responsible for carrying out inspections in all care homes across England.
Before September 2009, it was the Commission for Social Care Inspection that inspected the
homes and awarded quality ratings. The homes were able to obtain following ratings:
1 star – adequate
2 stars – good
3 stars – excellent
9
A new law governing the way health and adult social care is regulated in England came into
force on 1 October 2010. This introduced a new set of essential standards of quality and
safety that all care providers must meet. As a result of this change in legislation, CQC moved
from periodic assessments and quality ratings to a system of continuous monitoring of
compliance with the essential standards. Review of compliance is now produced as
opposed to an Inspection Report. The CQC produced outcomes and prompts that were
designed to support care providers in meeting these regulations.
Outcome 5 focuses on nutrition: “Meeting nutritional needs” - Food and drink should meet
people’s individual dietary needs.
Providers who comply with the regulations will:
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Reduce the risk of poor nutrition and dehydration by encouraging and supporting
people to receive adequate nutrition and hydration.
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Provide choices of food and drink for people to meet their diverse needs, making sure
the food and drink they provide is nutritionally balanced and supports their health.
The prompts for providers advise to ensure:
-
Personalised care in regards to adequate nutrition, hydration and support:
•
•
•
acting on identification of the risks, swallowing difficulties or the impact of any
medicines i.e. referral to appropriate services
giving Service Users’ confidence that their medical dietary and hydration
requirements are identified and reviewed
•
care plans include how any identified risks will be managed
•
relevant staff know what a balanced diet is
•
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identification of risk of poor nutrition, dehydration or swallowing difficulties on
admission and as needs change
staff involved in food preparation produce food to help facilitate a healthy, balanced
diet
Food and drink served:
•
are handled, stored, prepared and delivered in a way that meets the requirements of
the Food Safety Act 1990
•
are presented in an appetising way to encourage enjoyment
•
are provided in an environment that respects dignity
•
meet the requirements of Service Users’ diverse needs
•
take account of any dietary intolerances Service Users may have
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Service Users’ can be confident that staff will support them to meet their eating and
drinking needs with sensitivity and respect for their dignity and ability.
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Service Users are enabled to eat their food and drink as independently as possible.
10
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Assistance is provided to ensure Service Users eat and drink, when they want to but are
unable to do so independently.
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Service Users have supportive equipment available to them that allows them to eat and
drink independently, wherever needed.
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Service Users are helped into an appropriate position that allows them to eat and drink
safely, wherever needed.
-
Service Users are not interrupted during mealtimes unless they wish to be or when an
emergency situation arises.
-
Service Users will have any special diets or dietary supplements that their needs require
arranged on the advice of an appropriately qualified or experienced person.
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Service Users have access to specialist advice and techniques for receiving nutrition
where their needs require it.
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A nutritional screening is carried out to identify if they are at risk of poor nutrition or
dehydration when they first begin to use the service and at regular intervals.
-
Where a full nutritional assessment is necessary because the nutritional screening
identified risk of poor nutrition and dehydration, this is carried out by staff with the
appropriate skills, qualifications and experience.
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Service Users have their food and drink intake monitored when they are at risk of poor
nutrition or dehydration and action is taken as necessary.
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Service Users are not expected to wait for the next meal if their care, treatment and
support means they missed a planned mealtime.
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The person can choose a balanced diet that is relevant to them as an individual, taking
account of their nutritional status and previous wishes.
-
Promote rights and choices by providing the Service Users with:
•
•
choice for each meal that takes account of their individual preferences and needs,
including their religious and cultural requirements
•
access to snacks and drinks throughout the day and night
•
mealtimes that are reasonably spaced and at appropriate times
•
•
•
-
accessible information about meals and the arrangements for mealtimes
taking account of reasonable requests including their religious or cultural
requirements
information on what constitutes a balanced diet to help them make an informed
decision about the type, and amount of food they need to address any risk of poor
nutrition and/or dehydration
service users should be actively supported to plan and prepare their own meals,
where this is safe and they are able to do so
Service User can make choices about:
•
what to eat
•
when to eat
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•
where to eat
•
whether to eat alone or in company
3.3.
CONTRACTUAL ARRANGEMENTS WITH MANCHESTER CITY COUNCIL
In order to ensure that people living in care homes across Manchester are given a
satisfactory level of care, the contract between Manchester City Council and Residential
Care Homes specifies the outcomes that are expected from all the providers of care looking
after Manchester residents. Nutritious food and enjoyable mealtimes that promote Service
Users’ wellbeing are one of the areas covered by the contract in a lot of detail. The contract
details overlap with the CQC prompts to a great extent which indicates and re-enforces the
importance of those prompts. By signing the contract, care homes in Manchester become
legally bound to meet all the specified outcomes. This list includes a summary of the items
covered by the contract:
-
-
-
-
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Service Users to be offered a choice of food and drink that meets their nutritional and
personal requirements and provided with any assistance that they may need to eat and
drink.
Service Users’ nutritional needs and physical ability to eat and drink to be regularly
assessed and reviewed including risks associated with malnutrition and obesity. If
necessary, specialist advice and support to be provided.
Service Users to be encouraged to eat and maintain a healthy, nutritious, varied and
well balanced diet which is hygienically prepared and served at regular times.
Meals to include at least breakfast, lunch and evening meal, one of which is to be a
main meal and at least one of them being a hot meal.
A choice of beverages to be offered and served a minimum of seven times throughout
the day, at and in between meals.
The Service Users to be encouraged to consume sufficient food and fluids to maintain
optimum body weight to height ratio or any medically recommended weight.
Unless the Service User’s dietary requirements state otherwise, meals should contain
foods rich in protein.
The Service User’s diet to include adequate fibre content by including fresh fruit,
vegetables and wholegrain bread and cereals (fluid intake shall be considered in
relation to fibre intake).
The advice of the community dietician to be sought in any cases of uncertainty/doubt.
Special dietary needs to be provided for as agreed between the Service User, Care
Coordinator, GP, dietician and the Establishment (these may be medical, religious,
cultural and personal preferences).
Special diets to be provided, in accordance with Service Users’ medical, religious and
cultural needs (including modified foods).
Foods purchased to be of a suitable quality and condition to meet Service User
requirements.
Food and drink to be served in an acceptable setting, which shall be at the right
temperature and attractively presented.
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-
-
-
The furniture and layout of the dining room should enable ease of movement and allow
for meals to be served safely.
Meals to be served in an attractive and appealing manner, using family style service
where appropriate.
Staff to encourage and enable the Service User to clear away after meals and wash, dry
and store dishes/utensils if appropriate.
Menus to be prepared at least 48 hours in advance to ensure an adequately varied diet.
Menus to be reviewed regularly and consideration given to suitable choices and
alternatives at mealtimes.
Times for all meals and light refreshments to be at the Service User’s choice and to
reflect individual requirements rather than the administrative requirements of the
Establishment, where feasible.
If a meal is missed, alternative food to be offered and/or snacks and drinks shall be
accessed at any time.
Fresh drinking water to be available at all times, except when restrictions are part of the
Service User’s treatment plan.
If eating and/or drinking causes the Service User difficulties, they should receive prompt
assistance, encouragement and appropriate aids or support.
Where his/her ability to swallow food or fluid is compromised, careful attention should
be given to the appropriate consistency of food, e.g. soft diet, pureed diet. This detail
will be recorded in the Support Plan and communicated to all Staff.
Where the Service User has difficulties with taking an appropriate diet of fluids, the
Support Plan to include fluid balance monitoring and regular weights.
Service Users to be referred to State Registered Dieticians and Speech and Language
Therapists as and when appropriate and plans developed to reflect specialist advice.
Service Users shall be encouraged to eat and drink independently. Assistance to be
provided in a manner that preserves dignity and respect.
Aids to enable eating and drinking shall only be provided on specialist advice. Where
provided, Staff must receive appropriate training to use such aids.
Where appropriate, the Service User shall be enabled to menu plan, ensuring an
adequately varied diet.
Service Users shall be supported to undertake shopping activities and eat out at
cafes/restaurants when appropriate.
Service Users will have weights monitored at least monthly.
3.4.
DISCUSSION
These regulations are very detailed and thorough. Both focus on the quality of what is
served and how it is served rather than strictly on the nutritional content of the food.
Nutrition and specific nutrients are addressed but the regulations clearly indicate that there
is more to mealtime than nutrition. This holistic approach to meals and mealtimes identifies
different areas of residents’ needs that have to be met to maximise the likelihood that
people will eat the food provided to them and enjoy the mealtime. The regulations cover all
broad areas:
-
Balanced and nutritious diets
Food quality and presentation
Choice and diversity depending on personal needs and requirements
13
-
Support with eating including positioning and adapted utensils
Engaging the residents with menu planning and mealtime activities
The decor and ambience in the dining room including protected mealtimes and
family style service
Dignity and respect during the mealtime
One missing, but crucial, detail is specifying what knowledge and skills staff are required to
have. While CQC mentions that “relevant staff” should know what a balanced diet is and
that those involved in food preparation produce food “to help to facilitate a healthy and
balanced diet”, neither of the regulations explicitly states that the staff should be trained in
nutritional care. Also, following advice of standard “balanced and healthy diets” is not
always appropriate and is rarely a priority with malnourished people who struggle to eat
anything. Staff need to have sound knowledge and confidence in order to act accurately in
these circumstances.
The contract further talks about providing assistance in a manner that preserves dignity,
providing special diets as recommended by dieticians and speech and language therapist
but again, there is no mention of staff training in this area. It is extremely important for the
managers and all staff members to understand the link between nutrition, food, good dining
experience and health and wellbeing of the residents. Every person working in a care home
should be aware how much this area impacts on the residents, their physical and mental
condition as well as their quality of life. This subject is explored further in the report.
4.
FOOD PROVISION AND MEALTIMES IN RESIDENTIAL CARE – CURRENT PICTURE
4.1.
NATIONAL PICTURE
Considering the amount of guidance and information focusing on improving food provision
in residential care, there is surprisingly little systematic and strong evidence around what
that provision currently is. The inspection reviews produced by the CQC (Reports produced
by CSCI before CQC) are the main large scale, systematic source of information on quality of
food and mealtime in care homes that we have identified. However, there is a lot of
evidence from research and local projects revealing the challenges and difficulties
experienced in care homes during the mealtimes. There is also a lot of information from
organisations such as AGE Concern, The Alzheimer’s Society or Social Care Institute for
Excellence that gather feedback from residents’ families, friends, care workers and carers
and build the evidence base around bad practice, poor outcomes and the need for
improvements across the care sector.
When in 2005 the Commission for Social Care Inspection produced the bulletin “Highlight of
the day? – Improving meals for older people in care homes”, 83% of the homes met or
exceeded the requirements of the meal and mealtime standards. However, 1 in 6 homes
still failed to meet the minimum requirements. The main reasons for complaints addressed
to the commission at the time were about the poor quality, lack of choice and limited
availability of food and drink (CSCI, 2006).
14
In 2011, CQC conducted the Dignity and Nutrition programme, inspecting 100 NHS hospitals
in 96 trusts to assess whether older people were being treated with dignity and respect, and
whether they were getting food and drink that met their needs. In addition to the
inspections of NHS hospitals, CQC monitored other registered providers and services for
compliance with Outcome 5. The results showed that 84% of care homes and 71% of care
homes with nursing were compliant with Outcome 5. In 4% of care homes with nursing and
2% of care homes the inspection raised major concerns around nutritional needs not being
met (CQC, 2011).
The complaints around food in care homes received by the Care Quality Commission
recently focus on the same three issues:
-
poor food quality
-
lack of choice – repetitive options
-
limited food availability
as well as a few additional issues:
-
chef/staff not being aware of person’s likes and dislikes
-
no consideration for ethnic diversity
-
special dietary needs not being catered for
-
lack of skills in terms of providing special diets – diabetic, gluten free, vegetarian etc.
If poor nutrition persists over time, malnutrition and nutritional deficiencies start to occur.
The main symptoms of malnutrition are:
-
Underweight/weight loss
-
Tiredness
-
Disinterest in surroundings
-
Depression
-
Reduced immunity to infections
-
Slow wound healing
-
Slow recovery
-
Dry, scaly skin
(RSPH, 2009)
Reports such as “Hungry to be heard” (Age UK, 2006), “Still hungry to be heard” (Age UK,
2010) or the most recent “Dignity and Nutrition for older people” (CQC, 2011) highlighted
high prevalence of malnutrition among older people admitted to hospitals whose
malnutrition is not only not addressed during the hospital stay but is in fact aggravated by
poor quality of food and lack of necessary assistance. Despite the evidence released in 2006
as well as the ongoing “Hungry to be heard” campaign to improve nutritional care in
hospitals, a recently released CQC report revealed that almost half of the inspected
hospitals were still not providing the expected standard of nutritional care. The main issues
highlighted by the report included:
15
-
lack of necessary assistance to eat the meal
-
patients being interrupted during meals and having to leave their food unfinished
-
special diets not being catered for
-
incomplete and inaccurate records of food and drink intake
Even though there are no similar reports on nutrition in residential care settings or
community, the issue of malnutrition among older people in the UK is well evidenced.
Malnutrition affects over 10% of older people with 60% being at risk of malnutrition. This
risk increases when they go to hospital. The estimated annual cost of malnutrition in the UK
is over £7.3 billion and over half of this cost is spent on people over 65 (BAPEN, 2006).
People who are malnourished are more likely to be admitted to hospital, stay there longer,
are three times more likely to develop complications during surgery and have higher
mortality rate (Age Concern, 2006). Malnutrition is under-recognised and under-treated
however it can be treated effectively if the symptoms are recognised quickly and
appropriate actions are taken before the person deteriorates even further (BAPEN, 2006).
According to the latest Nutrition Screening Survey carried out by BAPEN in 2010, 37% of
residents recently admitted to care homes and screened on admission were ‘malnourished’.
The prevalence of ‘malnutrition’ was greater in residents admitted from hospitals (43%) and
other care homes (42%) than in those admitted from their own homes (30%). The
prevalence was also greater in nursing homes (45%) than in residential homes (30%).
Underweight was 4 to 5 times more common than obesity. Prevalence of ‘malnutrition’
increased with age, hence women had grater prevalence of malnutrition than men (BAPEN,
2011).
These results highlight important facts that we need to bear in mind while we try to
understand nutritional care and interpret the issue of malnutrition in care homes:
-
Malnutrition rarely starts in care homes - people are often already malnourished on
admission and this is more likely if residents are admitted from hospital or another care
setting.
-
By nature of progressive illness and increasing age, the older and more ill people get, the
more likely they are to be malnourished.
-
People who are admitted to residential and nursing care homes are likely to be older,
more ill and have higher needs to those living in the community which means that
prevalence of malnutrition is likely to be higher among care home residents than among
people in the community.
We need to appreciate that a higher proportion of malnourished people in care homes
(both residential and nursing) in comparison to those living in the community is not likely to
be caused by the care that they receive. However, if the standard of care (including
nutritional care) in a care home is high, malnutrition should be identified on admission and
appropriately addressed. Unless the illness is too advanced, malnutrition can be treated and
the health and general wellbeing of the person is likely to improve.
16
4.2.
LOCAL PICTURE
4.2.1. CQC Reports on residential care homes in Manchester
We have carried out a review of publicly available reports and reviews produced by the CSCI
and CQC on all 98 residential care homes in Manchester. We looked at the latest available
information but in some cases that still meant inspections carried out in 2007. CQC produce
an annual review for homes that have not been visited by the inspectors within last 12
months but these reviews do not contain sufficient information about food provision in the
homes.
Since the new regulations were introduced in 2010, the homes have been reviewed based
on the Outcome 5 “Meeting Nutritional Needs”, however all reports from before 2010 look
at Standard 15 “Service users receive a wholesome appealing balanced diet in pleasing
surroundings at times convenient to them”.
Although the CQC reports are structured around the expected outcomes or standards, they
are very different from each other and the content depends on many factors such as the
person inspecting the home, what happens on the day and what draws the inspector’s
attention. The reports often quote what the residents, visitors, staff and managers told the
inspector so the conclusions are based on feeding back that information as well as feeding
back the general impressions that the inspector had during the visit. As a result, we cannot
systematically compare what each of the homes in Manchester does and what it doesn’t do.
However, the CQC reports and reviews are an extremely valuable source of information in
regards to understanding the issues found in some of the homes as well as appreciating a
great number of homes that have been praised by the residents, their families and the
visiting inspectors.
CQC inspectors come to the homes unannounced and they often participate and sometimes
sample one of the meals. This gives them a good opportunity to observe how the residents
behave in the dining room, what the ambience is like, how the residents react to the food
served and how the staff interact with them during the meal. This allows the inspectors to
comment on the overall mealtime experience.
Older people living in residential care homes are usually very frail and they are unable to
participate in meal preparation or shopping activities. Some people with mental health
problems and learning difficulties are capable of taking up these activities with some level of
support from the care staff. However, within each home for this client group, there are also
major differences in the level of needs and the ability to participate in certain activities so
we cannot say that all the residents in care homes for people with mental health problems
or learning difficulty should be making their own meals or doing shopping in the community.
Still, because of the differences between care homes for older people and care homes for
people with learning difficulties and mental health problems, we analysed the CQC reports
separately for these 2 types of homes.
As previously explained, the reports vary in regards to content and the areas commented on
cannot be consistently compared. However, we have put the numbers in brackets that
indicate in how many homes the comment was made to indicate the frequency of the
17
practice. Some of the numbers are very low but unfortunately it is impossible to know if it is
because the good practice does not take place or it is just not mentioned in the report.
Homes for older people (59)
It was encouraging to see that the majority of the inspections made positive comments
about food and mealtimes in care homes across Manchester. The general picture emerging
from the reports is that residents are given food that they enjoy in sufficient amounts, they
are offered choices and alternatives and have some level of input into the menus as well as
opportunity to give feedback on the food they are provided.
Positive comments found in the reports/reviews:
a) Food provided
-
residents usually enjoy the food - positive feedback varied from “the food is excellent”
to “the food is ok here” (38)
sufficient amount of food available, seconds offered to those who eat all their food (16)
diverse dietary requirements well catered for (14)
culturally appropriate food available (10)
meals cooked on site by the staff (7) - none of the reports mentioned outside catering
being used
Snacks, including fruit, available at all times (12)
fresh fruit and vegetables available daily (2)
fresh, locally sourced produce used (2)
appetizing presentation (7) including modified consistency diets (2)
b) Residents’ choices
-
residents always offered choices (39)
alternatives available for those who don’t like any of the menu choices (18)
food discussed regularly during residents’ meetings (6)
menus reviewed to take into account residents’ preferences (7)
chefs speak to the residents personally in order to devise menus (4)
residents asked for their choice of meals on a daily basis (5)
records of residents preferences kept, respected and appropriate foods served (7)
chefs and cooks know the residents very well and they know the preferences, likes and
dislikes as well as dietary needs (5)
chefs alter portion sizes depending on who the plate is for (1)
staff known to go out and buy things for the residents if they fancy something that is
not in stock (1)
staff ask for feedback on food during or after the meal (1)
residents choose where they would like to sit and who they would like to sit with (5)
choice cards (picture menus) used to communicate with people who have no verbal
communication skills (3)
people go out into the community to have a meal, coffee or do a bit of shopping (3)
18
c)
-
The menus
balanced and varied menus (19)
seasonal menus (2)
prominently displayed in the dining room or other suitable areas (8)
d) The assistance
- staff providing necessary assistance during the meal (23) - most of the time the
assistance was described as timely, sensitive and discreet
- adapted cutlery and crockery available (3)
e) Dining room ambience and decor
-
pleasant/suitable dining areas (8)
dining room set with cloths, cutlery, crockery and condiments (4)
mealtimes flexible, pleasant and relaxed (12)
people given as much time as they need to finish their meal (1)
foods from different cultures offered to celebrate religious feast and other occasions (1)
some of the activities link entertainment with food (1)
mealtime is a meaningful social occasion (2)
f)
Nutritional care
-
people weighed at intervals stated in the care plans (5)
food intake monitored (4)
nutritional assessments in place (4)
BMI recorded regularly (1)
issues with weight identified and acted upon (8)
guidance on modified consistency foods displayed in the kitchen (1)
The reports highlighted that some of the arrangements are rather informal i.e. chefs know
to prepare something different for certain residents but there is no record of that in writing.
As a result, the evidence of good practice is missing even though the residents receive good
care.
Unfortunately, the inspectors also found examples of bad and very bad practice. Some of
the issues highlighted are very alarming and show how the dignity, individual needs and
choices are not always respected. However, these comments were usually mentioned in
individual homes and hopefully are an uncommon occurrence/practice.
Negative comments found in the reports/reviews:
a) Food provided:
-
specialized diets not catered for due to lack of skills and knowledge (1)
food is not nice (2)
food does not look appetising – poor presentation (1)
only main course served as the main meal of the day – no starter or pudding (1)
no cooked breakfast available (1)
no supper available – very long break between last meal and breakfast next day (1)
no fruit available (1)
19
b)
-
Residents’ choices
no choice for people on puree diet (1)
no variety i.e. insufficient choice (5)
residents not aware of the choices available (2)
not enough attention paid to what the residents really want (2)
c)
-
Menus
what is on the menus is not served on the day (1)
menus not displayed prominently – even staff unaware what is served (2)
no menus at all (1)
d) Assistance
- residents who don’t eat what is served are not encouraged or offered anything else –
plates just cleared away (2)
- nice hot breakfast is prepared but due to lack of organisation staff take over 30 minutes
to give it to people - cold and unappetizing food served to the residents.
-
assistance with eating not provided in a timely and sensitive way (2)
•
people waiting for the assistance too long and falling asleep at the table
•
staff supporting people with eating not speaking to the person supported
•
•
-
staff leaving in the middle of the meal and not coming back for a long time with
the person sat in front of the food unable to eat
people who need to be observed during the meal according to the care plan left
unattended for prolonged period of time
Staff doing things for people even though they can handle it themselves i.e. adding
sugar and milk to teas and coffees , buttering toast and putting jam on it etc.
e) Dining room ambience and decor
-
-
tables not set with cutlery, crockery or condiments (1)
meals served on plastic trays divided into sections and drinks in plastic cups/glasses (1)
disorganised mealtime (1)
residents brought to the dining room far too early, left waiting for food for too long
because of different reasons: till the cook starts the shift, till the staff get round to it
etc. (3)
people not being provided with serviettes or napkins – wiping hands on their clothes (1)
plastic bibs put on people before they sit for the meal to protect their clothing (1)
TV left on loud during the meal – noisy and disruptive for the residents (particularly bad
for people with dementia) (1)
f)
Nutritional care
-
drinks not offered regularly, difficulties accessing drinks in between the meals (2)
only water offered with the meal – no juices or other alternatives (1)
20
-
no improvements despite complaints (1)
no record of food served (1)
food intake records inaccurate or not completed (1)
weight records not kept up to date (1)
weight loss/gain not followed up by closer monitoring (1)
Homes for people with mental health problems, learning difficulties and other health
issues (38)
The majority of the homes have been praised by the inspectors who made many positive
comments about the food and promoting choice and independence. However some
examples of unacceptable practice have been identified and the homes made accountable.
Positive comments made in the reports:
a) Food provided:
-
residents enjoy the meals (8)
homely meals are served (1)
special diets well catered for (7)
culturally appropriate meals available (2)
healthy diets discussed and principles followed (6)
appetizing presentation (5)
drinks, fruit, and snacks available at all times (12)
b) Residents’ choices:
-
residents plan the meals (11)
meals based on residents’ preferences (11)
residents consulted about the meals during residents’ meetings (4)
residents offered choices (12)
residents involved in shopping for the home (9)
meals planned in advance but can be changed if the residents change their minds (3)
flexible and individualised meals and mealtimes (6)
residents participate in preparing the meals (8)
likes and dislikes recorded and respected (5)
residents can choose what they eat, when, where and who with (2)
c)
Menus
-
nutritionally balanced menus (8)
menus clearly displayed (1)
d) Assistance
-
people provided with support when needed (3)
staff trained in assisting with food (1)
21
-
staff able to communicate and explain meal choices when out in the community (1)
e) Dining room ambience and decor
-
relaxed atmosphere and flexible mealtime arrangements (4)
residents involved in cleaning up after the meal (1)
themed meals (1)
meal is a communal event – chance for people to catch up and socialize (3)
residents go out for meals (7)
f)
Nutritional care
-
nutritional needs assessed (3)
nutritional intake monitored (1)
weight monitored (3)
weight gain or loss addressed (6)
specialist nutritional support sought (4)
Negative comments found in the reports:
a) Food provided
-
lack of choice (2)
poor food quality (1)
puree diet - all components of the meal mixed together (1)
mostly frozen food used in the home (1)
drinks not available at all times (2)
b) Residents’ choices
- rigid mealtimes arranged around staff rotas rather than service users’ choice (1)
- rare opportunities to go out for a meal (1)
c)
-
Menus
food not nutritionally balanced (2)
inaccurate menus – what is on the menu is not served on the day(1)
menus available but difficult to read (1)
d) Assistance
- people not supported to cook their own meals even though it’s in care plans and
residents are willing to do it(2)
e) Dining room ambience and decor
- institutionalised mealtime – people handed out pre plated meals, no opportunity to self
serve, having seconds etc. – functional rather than enjoyable mealtime (1)
- little attempt to encourage service users to sit together and enjoy the company (1)
f)
Nutritional care
22
-
scales inappropriate for residents with mobility problems – inaccurate weights (1)
food intake not recorded (1)
weights not monitored systematically (2)
food charts for those at risk of malnutrition not routinely filled in (2)
Again, a lot of the arrangements are quite informal and not all the information is put on the
menus. This is fine from residents’ perspective but the inspections may pick up on it as lack
of evidence!
One of the issues mentioned within the reports was that people (especially family members)
complain to CQC about the food but fail to give feedback to the staff and managers. This
makes changes and improvements hard to implement in a timely way. Some of the
managers we have spoken to actually encourage people to complain because they want to
improve, however families and the residents are often worried that the person in care will
be punished or “out of favour” for complaining.
The overall positive nature of most of the reports is encouraging and allows us to believe
that in majority of the care homes, the residents are offered enjoyable meals that suit their
likes and dislikes, special requirements and dietary needs. However, certain examples of
good practice are commented on in very few homes which may indicate that they are not as
common as they should be. Also, the rare but extremely important examples of poor
practice expose unacceptable practice. This highlights a lot of scope for improvement in
many of the residential care establishments across the city.
4.2.2. Anecdotal information
While consulting partners from Adults Directorate, Community Nutrition Team, Speech and
Language Therapy Teams (SALT), Medicine Management and Environmental Health and
others, we heard some very positive as well as very negative comments about their
experience of visiting care homes in the city.
Good Practice:
- Environmental health teams that inspect the care homes find that most of them follow
the food safety regulations quite well. There is a feeling that because the service users
are so vulnerable, the staff understand how little it takes for them to get ill so the food
safety standards are high in comparison to other establishments across the city.
- Some of the managers and staff try really hard and give the residents more than
satisfactory care.
- Some of the homes have been described as lovely places with extremely helpful and
committed staff.
- Staff do what they can to encourage the residents to eat sufficient amounts of food.
23
Issues that individuals came across:
- People are sometimes discharged from hospitals to a care home without much guidance
on their needs.
- Staff in hospitals may not understand the difference between residential care home and
nursing home i.e. they don’t realize that there are no qualified nurses in residential care
homes and people who require nursing support are discharged to residential care homes.
- Staff receive guidance on discharge from hospital and they do their best to follow it.
Sometimes they don’t realise that the needs were only temporary and once the resident
fully recovers, the needs have changed.
- SALT often find that the guidance they issue for an individual is not being followed - most
of the time it’s not lack of good will or people not trying - it’s lack of knowledge and
training.
- Chefs sometimes don’t distinguish soft diet from pureed diet and puree everything
without the need for it - as a result, the ability to chew deteriorates, the person loses the
ability to manage soft diet and eventually puree diet becomes necessary.
- Staff sometimes think that if people have no teeth, they need to be on soft diets and
request these consistencies from the kitchen without any recommendation from SALT
team.
- Chefs can be challenging because they don’t like preparing modified consistency diets.
- When the GPs refer to SALT team, they sometimes tell people to thicken fluids till the
person is seen by the therapist. This is bad practice because it can cause damage if it’s
not the right treatment for the person.
- Also, some members of staff who have seen swallowing difficulty in the past, choose to
thicken fluids for people without making a referral to SALT team.
- The staff tend to think that as long as they make the drink thick, it makes it suitable for
person with swallowing difficulties. They rarely distinguish different fluid consistencies
and do not follow the exact recommendations from SALT. As a result, the residents get
very thick drinks that are often unpalatable and can be as dangerous to them as normal
fluids.
- People who were prescribed thickened fluids in the past keep receiving the solution
which is often not used – it is a substantial but unnecessary cost to the NHS.
- Food supplements are prescribed on a regular basis but a lot of people reject them due
to poor palatability. There is a lot of waste resulting from this practice
- People are weighed on a regular basis but the results don’t lead to any further actions.
- The nutritional care of people experiencing weight loss is sometimes insufficient – i.e.
lack of regular monitoring, lack of specialist intervention and support.
- Sometimes the menus displayed differ widely from the food served and the stock
available.
- Food quality issues have been identified in some of the homes.
- Insufficient access to drinks has been reported on few occasions as well as dehydration of
some of the residents.
- The mealtime is regimented and people can only get what they pre-ordered i.e. cannot
change their mind as the exact amounts of food are being ordered and delivered (in case
of homes using outside catering).
These observations have been made by various people visiting care homes, however they
should not be treated as evidence of common practice in homes across the city. As with a
24
lot of information, the comments focus on the most extreme cases that people have
experienced and this is what they are most likely to remember and mention.
4.2.3. Consultation event - care home managers
During the consultation event it was apparent that the managers were very passionate
about looking after their residents and they put a lot of effort into getting things right. They
were all very clear that food and mealtimes were their top priority and getting this area of
residents’ lives in the care home required work, patience, effort, money and commitment
because regardless of the efforts, sometimes things still did not work.
The managers told us that they tried to offer good quality, tasty food, flexible dining
arrangements and respect for individual choices. They tried to strike the balance between
giving the residents what they liked and asked for and providing them with healthy and
balanced diets. The residents were always asked about what they wanted to eat and
alternatives were offered if none of the menu items was acceptable. Offering choices to
people who don’t have much communication skills could be difficult so different techniques
such as picture menus or “show and tell” (show 2 plates with different meals and the person
points or looks at the one that they prefer) were used. However, the managers stressed that
it’s a “trial and error” with every person and what worked with one person did not
necessarily work with another.
The residents were described as being actively involved in creating the menus. One of the
managers told us how tasting sessions allowed obtaining feedback from the residents who
could communicate as well as those who couldnt, simply by observing their reactions to the
different meals served. Using photos and picture menus as a way of communication was
sometimes helpful but according to the managers, this approach worked well with people
who may have lost their communication skills but their brain function remained intact
(stroke, cancer etc.) whereas a lot of people with dementia couldn’t make the connection
between the photo and their meal. Some of the residents with dementia simply didn’t
recognise what was in the photos.
Most of the managers mentioned the importance of good presentation. Unfortunately, their
experience was that some of the chefs/cooks tended to have their own ways and were not
very willing to pay more attention to this detail. Influencing chefs could be difficult but some
of the managers were not willing to challenge them too much because of the fear of losing
them. We were told that it was hard to recruit good chefs to work in care homes because
hotels and restaurants offered better financial conditions and possibly better career options
so it was hard to compete for good catering staff.
We were pleased to hear that a lot of the managers tried to source their produce locally and
some of them already had good relationships with farmers, butchers and other suppliers
who often delivered the items to the homes. We had a discussion about potential savings
that could be made by managing waste and not ordering from major suppliers which were
used by a lot of the care homes across Manchester.
25
Issues and challenges identified during the consultation:
a) Complexities of the client group:
-
Two extremes i.e. people overeating or not wanting to eat at all
•
•
•
-
Specific food choices made by the residents:
•
•
•
-
residents’ likes and dislikes can change dramatically
many residents develop sweet tooth and desserts become the only food they accept
residents get obsessive about one type of food – it can be one colour, one meal or
one specific product which becomes the only thing they accept
Introducing change can be very difficult - residents do not cope well with change.
Implementing improvements can sometimes be resisted by the residents themselves.
Getting feedback or information from residents with no communication skills and no
family or friends is very difficult.
Encouraging healthy diets can be very difficult:
•
•
-
some obese residents ask for food all the time - some don’t remember they’ve
eaten due to their medical condition and some like to eat and feel that there’s no
need to change their behaviour
some people don’t want to eat at all despite the encouragement and prompts from
the staff
within the communal dining area, residents with small appetites give away their food
to the ”big eaters” - those who eat too much have easy access to more food and are
encouraged to eat more by their fellow residents and those who don’t eat enough,
have their plates cleared without eating the food; staff feel like they cannot interfere
people moving into care get used to and enjoy the wide range of food available to
them – they get used to eating cooked breakfast, chips and puddings few times a
day; they wouldn’t cook it all at home but if it’s available and they like it, they eat it;
people moving into care often stop eating healthy foods (like fruit and salads)
because of all the unhealthy options that are available;
Some people don’t complain - staff don’t realise they are not happy.
b) Issues related to staff:
-
staff pass bad habits on to the residents – residents often lack understanding of healthy
eating and easily follow bad example
staff set in their own ways - changing ingrained habits and encouraging new approaches
can be difficult
lack of skills and knowledge :
•
providing and understanding special diets can be difficult for some of the staff
26
•
staff sometimes think that good care is doing everything for the residents – this is
what they think they are paid for; they don’t understand the importance of
independence and preserving skills among the residents
c) Organisational Issues:
-
Within the home/company:
•
•
•
•
-
offering everyone choice if there are many residents in the home – the capacity of
catering staff does not increase proportionately to the number of residents so it
becomes more difficult to cater for numerous individual requests (staff in larger
homes are likely to be more stretched)
providing good quality and varied meals within financial constraints – increasing
costs (including food prices) have not been matched by increased funding from the
city council and the homes feel that they will soon have to start compromising on
quality and choices available to the residents
raising aspirations and expectations in the face of raising costs and unchanged fees.
low occupancy in care homes due to increasing shift towards home care support –
financial impact i.e. less funding, increased cost per person etc.
Within the supporting system:
•
•
difficulties accessing timely support from specialist services such as dieticians,
speech and language therapists or occupational therapists
a lot of the thickeners and food supplements prescribed to the residents goes to
waste because the residents don’t accept the textures or the taste
d) Other:
-
-
Visitors interfere with the nutritional care – they tend to bring sweets and treats which
is not wrong in itself however, if the person is a very poor eater and they eat sweets
before the meal, they very often don’t eat the nutritious meal at all. Also, residents with
diabetes receive sweets as treats which results in problems with their sugar levels.
Families are not aware of the impact of dementia and other kinds of illness on peoples’
eating habits so they are often alarmed and accuse the care staff of neglect when they
see their relative losing weight.
Summary of issues and challenges identified during the consultation event:
a) Complexities of the client group:
- Overeating vs under eating
- Changing eating habits
- Limited/Restricted food choices
b) Issues related to staff:
- Staff passing bad habits on to the residents
27
- Staff set in their own ways – change and new approaches pose a challenge
- Attracting good chefs to work in care homes
- Lack of knowledge and skills
c) Resource and capacity:
- Numerous choices from the residents vs capacity to deliver among the catering staff
- Purchasing good quality food vs financial constraints
- Raising aspirations and expectations vs limited resources
- Financial impact of low occupancy levels
- Accessing timely support from specialist services such as dieticians, speech and language
therapists or occupational therapists
d) Other:
- Changes to eating habits following moving into care
- Families and visitors bringing food disrupting the nutritional care
- Weight loss often perceived as neglect by family and visitors - educational need
4.2.4. In-depth interviews with care home managers
During the consultation event we realised that there were substantial differences between
the challenges faced by the care homes for older people and care homes for people with
learning difficulties and people with mental health problems. They all struggled with
nutritional ill health but while underweight was the more common issue among older
people, overweight and obesity were the more common issues for the other service users.
The managers mentioned that some people with learning difficulties and mental health
problems tended to go out and be more independent in their food choices. Some of them
were also able to participate in preparing their own meals so they had more control over
what they ate and how much food they prepared. Considering the differences between the
service users living in residential care homes it was sometimes more appropriate to split the
information into two separate strands. However, a lot of the themes were common and
could be analysed together.
The interview questions were designed to provide us with a wide range of information on
food provision in residential care homes in the city. The areas we enquired about included:
- brief description of type of home and type of residents
- food provided – priorities, varying needs, special diets, mealtimes, food availability etc.
- residents’ involvement in menu planning and meal preparation
- feedback and waste management
- mealtimes as a social activity - ambience, relationships, staff participation
- food procurement – financial restrictions, priorities, sustainability and local sourcing
- nutritional care – screening, weight monitoring, interventions and treatment
- staff – capacity, skills, training, staff turnover
- main challenges and support required
28
4.2.4.1. All care homes
We interviewed managers of 22 care homes across Manchester, 16 homes for older people
and 8 homes for adults with a range of special needs that required residential care support.
The interviews confirmed what we had heard during the consultation event - food was very
high on the agenda. Mealtimes were what the residents planned their day around and what
most of them looked forward to. Food was always discussed during the residents meetings.
This was a very positive message because it indicated that the residents had a chance to
express their opinions, wishes and preferences and that hopefully they were listened to and
their comments were acted upon.
Residents’ choice
The managers assured us that the residents were always offered choice and there was a lot
of flexibility in terms of preparing different things for different residents. It was positive to
hear that catering staff were willing to prepare alternatives for the residents who didn’t
want anything off the menu. It felt like the fact that the cooks needed to prepare multiple
options was a challenge but most of the time they just “got on with it” and delivered what
the residents asked for. A lot of the managers stressed that the food provided to the
residents was good quality home cooking and there was no place for convenience foods or
ready meals. One of the managers mentioned using outside catering in the past. This had
been deemed unsuccessful, seen as limiting flexibility and responsiveness to residents’
needs and in house catering was brought back in as a result.
Menu planning
Most homes tended to have 4 weeks rolling menus that changed seasonally. Any required
changes identified either by feedback or large amount of waste were actioned straight away
to avoid further waste. Some of the homes had very strict menu planning arrangements
controlled and influenced by company policy. Some of these were done centrally and sent
to the homes to apply locally, whereas the others were compiled internally using software
or systems that ensured the designed menus met the company’s nutritional standards. The
managers often complained about these systems and even though they appreciated their
value in ensuring nutritionally balanced and varied menus, they found them too rigid and
often inappropriate and inflexible for the residents. On the other hand, homes that did not
have these sorts of systems in place put menus together mainly based on their own
knowledge, experience and feedback from residents. The nutritional value of these menus
was not controlled or checked by anyone. Some of the managers felt that they lack the
expertise necessary to ensure good nutritional intake for the residents and they would
welcome some support with creating healthier menus or someone assessing their menus
and providing feedback.
Residents’ feedback
A lot of the times, getting feedback about food is something that happens naturally. There is
no need to ask people or to give them questionnaires, they simply say if they like the food
29
or not. However, there is also a group of people who would not complain in person but they
are likely to write comments down anonymously which shows the value in providing
questionnaires to hear their voice. Also, managers reported that there were some residents
who were not willing to complain or were unable to complain. The first group includes
residents who perceive the support they receive in the care home as a privilege and they are
grateful for what they get, complaining would mean lack of appreciation of this. The second
group is difficult to consult but their feedback is clear from their reaction to food i.e. if they
don’t like it, they will not eat it. Unfortunately they don’t have the ability to tell what
improvements could be made to food.
The set ups of kitchens and dining rooms varies between the homes but a lot of the smaller
homes tend to have kitchens adjacent to the dining room which means that the chef/cook is
physically very close to the residents and can see what is happening in the dining room. This
way kitchen staff know if the residents enjoy the food or if there are any problems. In larger
homes where the central kitchen provides food to numerous dining rooms, the chefs
sometimes visit different units to speak to the residents and gather feedback.
Mealtimes
Making the mealtimes sociable, pleasurable and meaningful occasions is what the managers
try to achieve. This is why people who have very high support needs while eating as well as
those who are challenging and disruptive during the meals tend to eat separately. This is
done to avoid other residents getting upset but also to respect their dignity.
Quite a lot of the homes organise theme days and meals that follow the theme. Anything
from Wimbledon, through Halloween to Bonfire Night gives a good reason to do something
different. Special occasions like Easter or Christmas become a good opportunity to organise
big buffets, baking sessions and other activities focusing around festive food and cooking.
There are more ways in care homes how the staff try to make mealtime a bit more
meaningful. The residents are invited to taster sessions when they sample foods, pick meals
that will go on the menu or sample different brands and select those that they want to be
used in the home (brands of tea, bread, butter etc.).
Inviting family members, volunteers and people from the community to join in the meals
also improves the atmosphere in the dining room. That is particularly popular on special
occasions and makes people feel that something special is happening.
Some of the managers occasionally eat the meals with the residents and they encourage the
staff to do the same to understand what the experience is like. One of the managers told us
how much difference that seemed to be making for some of the usually very withdrawn
residents in her home. She told us that people who would not speak to the other residents,
were much more willing to engage with the members of staff and they became much more
sociable during the meal.
Food provision for staff
Food provision for staff differs between the homes:
-
staff bring their own food and eat during their breaks (most homes)
30
-
staff are able to purchase the same food the residents eat at low cost and eat once the
residents finish their meals
-
staff eat the same food the residents eat at no cost once the residents finish their meals
-
staff share the food and the dining room with the residents (very rare)
Staff sharing food and the dining room with the residents is a known factor that can
contribute to improved nutritional intake among care home residents. It is known to
improve the mealtime ambience and communication between staff and the residents.
Unfortunately only very few homes currently have that arrangement in place. More
evidence confirming the benefits of this approach is presented further in the report.
Catering staff
Chefs and cooks vary across the city and some of them like experimenting and encourage
the residents to taste new things and different cuisines while others stick to the traditional
meals that always go down well. Also, looking for information on special diets and different
ethnic food is something that some of the chefs are much better at than the others. As a
result, catering staff in some homes tend to order ready meals if someone requires a more
specific diet. However, there are also homes where ready meals are not allowed as part of
company policy which means the staff have to prepare the food themselves even if they lack
confidence or skills.
Some of the homes (particularly smaller ones) don’t have chefs - care staff either support
the residents to cook their own meal or prepare meals for the residents. All catering staff
and care staff who get involved with food have food hygiene training but very few members
of staff have nutrition training, menu planning or actual cooking training. Even the qualified
chefs working in care homes have very little training around catering for vulnerable groups,
special dietary requirements, nutrition in illness, food fortification or modified consistency
diets. This area has been highlighted by many managers as requiring improvements and
substantial support.
Staff turnover
In most of the homes, the managers felt that the staff turnover was not very high and that
the staff knew the residents very well (especially in smaller homes).This is a very interesting
finding because literature and front line staff always stress how high staff turnover in this
sector is. One of the arguments against providing training for staff working in care sector is
that as soon as people are trained, they leave the system. The question is, if the managers
are used to high staff turnover and their perception of high staff turnover is very different to
what other people would class as high turnover, or has the retention of staff in care homes
improved over the last few years in Manchester?
Food sourcing and purchasing
Sustainability and local food sourcing are popular themes and a lot of the managers would
like to source their food in that way. The main concerns around purchasing food on local
markets seem to be food hygiene, food traceability and obtaining suitable receipts.
31
However, a lot of the homes can only purchase food (and other produce) from “approved
providers” and don’t have much say about where the food comes from. The main reasons
for using those providers are food traceability and lower cost. However, those managers
who source food from local providers praise the quality of the produce and flexibility of the
arrangements and claim that costs don’t need to be higher as long as a good relationship
with the provider is built.
Different types of care arrangements
There are major differences between the homes depending on the size, ownership, type of
service users and their level of dependence. The homes that are part of large groups tend to
have much more structured policies around budgetary arrangements, food procurement,
menu planning, staff training, nutritional care and other areas of care. This does not mean
that any specific types of homes provide better care than others; it simply means that they
work in very different ways. Some of the comments we heard from the managers in regards
to the ownership type included both pros and cons on each side.
The pros of being part of a group are:
- access to training and support packages provided by the company – we saw menu
planning tools and software, guidance on preparing and presenting modified consistency
foods, guidance around special diets such as diabetic or gluten free diets, ideas for food
related activities etc.
- best practice guidance around food and nutritional care are part of the policy - the
homes have clarity on what they are expected to provide
- purchasing power – because all the products are purchased in bulk from a group of
approved providers, the prices are very competitive and food cost is likely to be lower;
however, some chefs contradict this opinion and say that the items could be purchased
cheaper in local shops
- food can be traced “from farm to fork” which gives the home confidence in case of food
poisoning outbreaks
The cons of being part of a group:
- some of the rules and policies hinder flexibility and contribute to a lot of waste:
•
•
•
only “approved items” can be purchased from the “approved suppliers” - if residents
want something that is not on the list, staff cannot purchase it
no freezing policy – food moulds for puree diets cannot be used unless the kitchen is
equipped with a blast chiller, food that only one person eats (often an issue with
people from ethnic minorities) cannot be prepared in bulk, portioned and frozen but
has to be prepared each time from scratch – discouraging for chefs and not efficient,
resulting in ordering ready meals
food needs to be disposed of as soon as the meal is finished – people who missed
the meal will need to have something else prepared for them as the cooked food
cannot be stored
32
•
if the order comes incomplete, the chefs have no flexibility to go out to a shop and
buy the missing items
- Menu planning seems problematic – there are few issues across different groups:
•
•
•
•
•
menus are done centrally - not appropriate culturally for a lot of the residents (it’s
not about ethnic background but regional differences between people from
Yorkshire and people from London who are used to different food)
residents have little influence on the menus
residents do not understand the sophisticated wording on the menu and don’t want
the fancy dishes – they usually want simple, traditional food
the menus focus on nutritional balance too much – the residents often want
completely different kind of foods which may not be as healthy or nutritious but will
be more enjoyable and more likely to be eaten
certain items are not allowed on the menu - if the residents ask for one of these
items, the managers have a dilemma if they should comply with the policy or if they
should give the residents what they ask for
Some of these issues may to some extent explain why the displayed menus and what the
residents get on the day don’t correspond with each other. The managers and cooks want to
give people what they want and what they will eat but they also need to put on the menu
what the system tells them to.
Despite some of the issues mentioned, we were interested to hear that the managers and
staff often found their ways around the restrictions and regulations in order to provide the
residents what they asked for. Managers and staff are known to go out shopping for items
that are not approved by the company, the menus are changed to be more appropriate to
the residents and strict food budgets are exceeded to make sure that the residents are
happy. This highlights the issue and the conflict between providing person centred care and
following regulations and policies.
The pros of being an independent provider are:
- flexibility and freedom in terms of budgeting and purchasing
- shopping can be part of the activity for the residents
- person responsible for supplies can shop around and look for good providers and
competitive prices
- staff get involved in shopping – buy what the residents ask for or purchase foods when
they find a good offer; this approach makes the staff feel more involved and more
empowered to make decisions relating to running of the home/kitchen
- local sourcing and good relationships with local providers – good prices for loyal and
regular customers can be negotiated
- potentially more flexibility in terms of offering residents choice
- menu planning based on resident’s choice, likes and dislikes rather than on nutritional
guidance
Cons of being an independent provider are:
33
- lack of centralized support – finding best practice, creating policies and procedures and
all other arrangements are up to the manager and the staff
- some of the managers feel lost in the system when they need support or the required
support is not available to them
- feeling of isolation – there are few networking opportunities so the managers have no
peers that they can consult, they have few opportunities to share their problems and
challenges
- tight budgets and financial restrictions are a major issue for some of the homes
- staff training needs to be sourced from independent providers which has cost
implications
Financial issues
One of the areas of concern emerging from the interviews was the financial situation in
residential care homes. We were told by the managers that the fees paid by MCC had not
been increased for the last few years which was having a substantial impact on the
budgetary restrictions. There is a feeling of frustration among the managers who struggle to
meet the increasing requirements and expectations while coping on what is effectively a
smaller budget due to increase in cost of running the home.
The interviews with managers revealed very wide range of financial circumstances between
the homes. The impression we had was that some of the homes had substantially larger
budgets than the others. Within the interviews we asked about budget for food in the home
and the responses showed that while some homes could quite comfortably afford anything
the residents asked for, other homes needed to compromise on food quality to stay within
the budget. The amount of money that was spent on food in care homes we have spoken to
varied from £1.75 per person per day to practically no budgetary restrictions.
The funding arrangements between City Council and Care Homes are complex and depend
on a range of factors such as level of needs, type of bed within the home (i.e. dementia,
nursing etc.) or home performance rating. However, the amount of money spent on the
resident often depends on the arrangements within the home or company. There are three
main types of care home providers across Manchester:
- charitable organisations – not for profit
- private individual providers – for profit
- group care providers – for profit
The picture emerging from our interviews seems to indicate that the not for profit homes
are in a better position than the other two types, however that applies to larger homes. The
small homes, despite not having profit margins, tend to be stretched as well. Homes that
are part of large groups have very tight budgets but because of the buying power of the
group and usually large size of the homes, cost per person tends to be smaller than in
individually ran homes. Small, privately owned establishments and set up for profit tend to
be in most difficult financial situation. These results are not well evidenced and are only
based on informal conversations with the managers however they do highlight the question
34
of what proportion of the fee coming from MCC is spent on the residents in care homes
depending on the type of organisation?
4.2.4.2. Care homes for older people
Food Provided
The type of residents, their ethnic, cultural and social background, determine the character
of the place as well as the type of food that is provided. Most of the homes we visited had
predominantly White British residents and the food offered was traditional simple British
cooking. However, we have also been to a Jewish care home, Polish care home and another
home which had a mix of English and Irish residents and the menus and food served in those
homes were specifically tailored towards the cultural expectations of the residents. The
managers recognise the importance of food in each culture and if a person from an ethnic
minority comes to live in a predominantly White British home, the staff try to accommodate
them. Unfortunately, people from ethnic minorities are more likely to be provided with
ready meals, takeaways or be unhappy with what the cooks prepare in an attempt to
provide culturally appropriate food. The main reasons are lack of confidence and skills to
prepare food from different cultures. Considering that food, nutrition and mealtimes are top
priority for older people from Black and Ethnic Minority Groups (CSCI, 2006), this is a major
issue that needs to be addressed.
Most of the homes gather information about food preferences during the initial assessment
as soon as the new resident moves in to the home. Some homes collect that information
prior to admission and share the information with staff before the new person is admitted.
The information on likes, dislikes, special dietary requirements, food allergies etc. is
collected from the service user, family members or staff from care home that the person
may have previously lived in. However, this information is usually verified in due course as
sometimes turns out to be inaccurate or no longer valid due to changes occurring in person
in question. Some of the homes have a policy which specifies that the chef needs to see
each new resident within 24hrs of admission and discuss food preferences, likes, dislikes
and any special requirements. That is followed up after 2 weeks to ensure if the person is
happy with the food provided or if changes are required. This is a very good policy that
should be encouraged in all the homes. Also, if someone has very specific likes and dislikes
or dietary requirements, special menus are devised to meet these.
Resident’s involvement
In most of the homes, the residents are somehow involved in planning the menus. They are
consulted during the residents’ meetings on what they would like to see on the menus, any
additional feedback and comments from conversations with the chefs are taken into
consideration and the menus reflect what the residents say. Very often, the residents forget
what they said or no longer want what they asked for but the managers feel that it is very
important for them to have input in what happens in the home including what food is
served on a daily basis. However, we were also told that some residents didn’t want to be
involved in menu planning and making choices because, as they said, they had done it all
35
their lives and they were happy for someone else to do it for them. Some of the men, never
had any input in menu planning because that was the wife’s responsibility, so they were not
interested in contributing to it as long as they enjoyed what was served.
Involving the residents in some of the tasks around mealtimes is seen as good practice and
staff in most of the homes try to engage the residents in some of these - folding napkins,
setting tables or tidying up but usually only one or two residents show some interest. One of
the managers highlighted how much depended on the individuals living in the home at any
time. She told us that the residents who had lived in the home few years earlier were much
more proactive and willing to engage in all sorts of “domestic activities” like menu planning,
preparation of the dining room and even some of the cooking, whereas the group that
currently lived in the home was not really interested and simply accepted that things were
done for them.
Another manager highlighted that people came from very different backgrounds and that
determined if certain things were acceptable for them or not. People from very affluent
backgrounds who may even had servants in their homes expect hotel/restaurant type of
service because this is what they class as normal, whereas for other people, who were used
to doing chores themselves, participating in these activities makes them feel more normal
and needed. This shows that following good practice guidance always needs to be
supported by understanding who the residents are and what is culturally appropriate for
them.
Nutritional care
A lot of the managers feel that their home has a clear nutritional care plan for people who
are at risk of malnutrition or already malnourished. All the homes we consulted weigh the
residents on a monthly basis and any unexpected yet substantial changes to weight are
being addressed. Some of the residents have very poor appetites but as long as they are
willing to eat at least one thing, even if it’s sweets, the staff will try to capitalise on it. We
heard about people who lived for years on ice cream and custard or bread and stock but
they ate something which even if not particularly nutritious was better than no food at all.
Despite best efforts, some people still don’t eat which is a major concern for the managers,
staff and the family members but it is accepted that no one can be forced to eat. You can
try, encourage, tempt and make sure that food is always available in case the person
decides to eat, but you need to respect their wish if they choose not to.
Most of the managers feel that the staff know the residents well which means that they
notice changes in mealtime behaviours or habits. Anyone who stops eating or is not their
usual self starts being closely monitored and if the situation prevails, specialist support is
sought. We were told that some of the residents have small appetites and are very slim but
they eat regularly and eat well. When they are assessed by MUST screening tool they
appear to be malnourished or at risk of malnutrition and they are usually prescribed
supplements which they tend to reject anyway. Some of the managers feel that they are in a
better position than unfamiliar GPs or other visiting practitioners to make the judgement if
the person needs nutritional support or not. A good relationship with a GP is seen as very
important because if the GP knows the residents well, they know what is an issue and what
isn’t. Some GPs visit the homes regularly or even put on weekly clinics in the home but
these are very individual arrangements between the homes and the GPs.
36
Staff training
Generally, regardless of the options available to staff, hands on and peer to peer training
remain the main training methods within the homes. In this area, theoretically, being part of
a large group puts the staff in a better position. Different companies have different range of
support available but most provide internal training as well as resources that staff can learn
from or use in case of doubts. One of the managers told us about access to internal training
courses on nutrition, special diets, food preparation for the elderly and menu planning as
well as impressive resources that staff refer to on a regular basis while planning the menus
or cooking for residents with special dietary requirements. The same manager told us that if
they needed support, the company had dieticians who could be consulted and provided
guidance when problems occurred. Some of the group providers have access to regional and
national chefs’ forums and networks where they have opportunity to share experience,
ideas and good practice.
Availability of these support mechanisms and resources does not mean that they are used
by every home that is part of the company. Also, we don’t know what the quality and
content of the training is. However, if the manager and staff are interested in accessing
training or support, they can do that relatively easily and free of charge whereas if an
independent provider wants staff to receive training, they have to source and usually
commission that training themselves.
Issues and challenges identified during the interviews:
a) Complexities of the client group:
-
-
-
level of dependence among service users has substantially increased – this has not been
matched by higher staffing levels or better staff training
most of the residents are unable to get involved in food preparation or “domestic
activities”
people are not interested in planning the menus, they are happy for someone else to
take over this responsibility - if they don’t like the food they will provide feedback and if
they want something specific, they will ask for it but they don’t want to contribute to
menus on a regular basis
residents make suggestions, ask for something and once it’s provided, they no longer
want it
very high mortality in nursing homes - people come from hospital very poorly and don’t
live very long; little time to get to know the person, their likes and dislikes
some people are unable to communicate and have no families who would help with
likes and dislikes
some people become very aggressive during the meal – it may be because they don’t
want to eat, don’t like the food, don’t want someone else to support them with eating
but it is difficult to understand what the issue is because they don’t have
communication skills and aggressive behaviour is their way of communicating that
something is not right
catering for people who no longer want to eat
catering for people from ethnic minorities
37
-
mealtime experience for people on special diets (modified consistency in particular), is
much worse than it is for other residents - limited choices, unappetising and not tasty
most residents dislike the supplements and reject them so it’s not very effective yet
expensive way of improving their nutritional status
b) Staff
-
-
some of the homes have no qualified or even designated chef/cook - the care staff
prepare the meals and devise the menus; most of the time staff don’t have any
nutrition training just food hygiene
lack of skills, knowledge and confidence in preparing special diets is a major concern:
•
even though the chefs know special dietary requirements i.e. high calorie, puree,
they are not proficient in executing this - menu planning and presentation are major
issues
•
providing snacks for people on soft/puree diets
•
offering choice to people on modified consistencies
•
offering desserts to people with diabetes
-
staff sometimes puree meat for people who cannot chew it even though they are not
on a puree diet; they should prepare tender meat (slow cooked or braised) for these
residents rather than puree the same meat everybody else has
-
staff habits - lack of understanding how much could be improved if some of the practice
is changed
c)
Resource and Capacity
-
increasing costs and needs have not been matched by the increased funding
time during the meal - providing support with eating is difficult with the number of staff
and number of people requiring assistance
using volunteers to improve capacity during the meals didn’t work in the home that
tried it – the volunteers lacked the skills and understanding of swallowing difficulties,
modified consistencies and the people they were dealing with; also being able to rely on
them on a daily basis was an issue
residents from ethnic minority groups are more likely to be given ready meals or take
away food; there are a few different reasons for this:
-
-
•
•
•
lack of confidence that the chef can cook what is expected
lack of confidence about complying with religious or cultural requirements - if the
ready meal says halal the home is reassured they offer halal and in case of any
issues, these go to the manufacturer
it is not cost effective to cook something different and labour intensive for one
person - some homes overcome this issues by cooking more and freezing few
portions for future use but those who have “no freezing” policy are unable to do that
38
-
very few homes use food moulds for puree diets - perceived as time consuming and
expensive, plus require blast chiller or freezer which means that they would not be
allowed by homes that are not allowed to freeze foods;
d) Other
-
Organisational issues:
•
menus designed centrally - residents don’t have much input as a result
•
restrictions on what can be purchased and served - giving people what they want or
what is approved is a dilemma
•
poor communication within the home - cooks/chefs not updated on needs of new
residents or changed needs of the “old resident”, not involved in food
supplementation/fortification, staff see it as dietician’s or GPs role
-
Ethical issues in regards to nutritional care that care homes struggle with:
•
•
•
-
if the staff are concerned about an underweight person, they fortify the food and try
to increase calorie intake as much as possible but if the staff are concerned about an
obese person, they cannot cook “light versions” of meals unless the person
specifically agrees to being served food different to anyone else
some of the diabetic residents want to eat “normal desserts” or even develop very
sweet tooth as part of their dementia – the staff struggle to make the choice
between giving the person what they ask for and looking after their health; the staff
find these situations very distressing and hard to handle
disguising foods – this happens when staff want to improve nutritional value of foods
and add certain “disliked items” into stews, curries etc.; some people think that as
long as the residents enjoy the meal, it’s ok whereas others say that disguising
something what they classed as “dislike” in a meal is not ethical
Support from specialist services:
•
•
•
•
•
the dieticians are seen as people who only get involved with peg fed residents
one of the managers believed that as soon as someone has a MUST score of 2, they
have to be referred to a dietician who “automatically” puts them on supplements;
this is perceived unnecessary with some of the residents who are very slim but their
food intake is stable and regular even though small
accessing specialist services when they are needed is a challenge – waiting times are
perceived as much too long
different specialists provide different guidance that are sometimes contradicting and
confusing
on discharge from hospital staff say that people don’t eat and don’t drink and that’s
why they are malnourished but actually when they come to the home and the food
and support are provided they eat well
Summary of issues and challenges identified during the interviews:
39
a)
-
Complexities of the client group:
increasing levels of dependency
illness affecting food intake – poor, limited or changing food choices
challenging behaviours during mealtimes
communication difficulties
gathering information about people who have no communication skills and no family
members who could help
residents unable or unwilling to participate in domestic activities
people on special diets, food supplements rejecting the food and drinks provided
b) Staff:
- lack of knowledge around nutrition, swallowing difficulties, special diets, ethnic foods
etc.
- lack of practical skills to deliver good quality special diets
- staff set in their own ways – change and new approaches pose a challenge
- lack of initiative and ability to look for solutions
- lack of understanding how things could be improved
c)
-
Resource and capacity:
increasing costs not matched by increasing fees
providing support during the meals with existing staffing levels
volunteers are not reliable and trained enough to support vulnerable people
providing different foods for people from ethnic minorities
using moulds for puree diets perceived as too expensive and time consuming
d) Other:
- menu planning and procurement determined centrally – company policy rather than
residents’ choice is the priority
- poor communication within the home
- stopping obese and diabetic residents from eating too much or inappropriate foods
- accessing timely support from specialist services
- following contradicting guidance coming from specialist services
4.2.4.3 Care homes for people with learning difficulties and mental health problems
These homes are very different from homes for older people as well as from each other due
to the level of support service users require. Some of the residents live in “supported
housing” arrangements where they plan their own menu, do the shopping and prepare the
food with a bit of support from the care staff. Other service users may have communal
meals that are prepared by the care staff (the main meal of the day) but help themselves
with anything they want for breakfast, supper and when they need a snack. They are still
consulted on what they would like to see on the menu and often involved in the shopping
and food preparation to some extent. In some of the homes, the residents help with
40
preparing the dining room, clean up after the meal and help washing the dishes. In homes
where level of needs is higher and the residents are not able to have as much involvement
in the meal preparation, it is a common practice for the staff to discuss meals with the
residents. All managers we have spoken to said that the residents were very vocal about
what they liked and what they disliked and had no problems giving feedback on what they
had been served.
Characteristics of the homes
These homes tend to be much smaller than homes for older people and the residents tend
to live there for many years if they settle well. As a result, the care staff and the catering
staff know the residents very well and they know each person’s likes and dislikes, special
dietary requirements or weight issues. People responsible for cooking meals in most of the
homes we consulted were not qualified chefs. Most of the time it’s care staff who cook the
meals or support the residents with cooking their own food. They all have food hygiene
training but very few have nutrition training or any training around special diets. In most of
these homes the residents have free access to either kitchens or kitchenettes where snacks
and drinks are available and the residents are free to help themselves. The staff are usually
around to make sure that the residents use the equipment safely.
Mealtimes
The mealtime atmosphere varies between and within the homes. Some managers expressed
concerns that the meal could be quite a “lonely experience” because it was part of the
mental health problem that people were very isolated and not willing to engage in social
activities. Quite often, people chose to eat in their own room or later, after most of the
residents left the dining room. In other homes though, the residents enjoy sharing the meal
with other residents, it becomes a social occasion and an opportunity to catch up with
them. Again, a lot depends on type of residents and how they interact with other people.
One very interesting observation made by a manager was how much the residents seemed
to change their behaviour when the members of staff shared the meal with them in the
dining room. This arrangement seemed to encourage the “isolated” individuals to open up
and talk to the staff while they wouldn’t normally talk to the other residents. This finding is
supported by research evidence and highlights the impact small changes can have on
residents’ mealtime experience.
Nutritional care
The residents in this type of care homes tend to be on the 2 opposite sides of the extreme –
most of the residents are either overweight/obese or underweight. There are very few
people with healthy weight. One of the main issues for the managers was that the residents
not only eat too much but they also eat a lot of unhealthy foods. This results in high
prevalence of overweight and obesity. The staff struggle to provide the residents with what
they ask for while providing a healthy and balanced diets at the same time.
The residents are weighed every month and any unexpected changes are addressed. The
food intake is also monitored especially among those who have some problem with either
41
food intake or weight, although as mentioned before, monitoring can be difficult with
residents going out into the community. Weight can be a sensitive issue for some people
because it is often linked to mental health and as soon as the condition deteriorates, the
weight is affected. Some of the residents are supported by the community nutrition service,
their GPs or Fighting Fit team in order to manage their weights better but a lot of people
don’t have any additional support despite their weight issues.
One of the managers made a thought provoking statement summarising how they tried to
ensure that the residents had a healthy, balanced diet: “making healthy food enjoyable
rather than talking about healthy food is the key; as long as they like the food, they eat it
but they do not and will not understand healthy eating messages if somebody tries to talk
about it”.
Issues and challenges identified during the interviews:
a) Complexity of the client group:
-
lack of motivation and self worth mentioned by most of the managers
lack of interest in being healthy
lack of capacity to understand healthy messages
lack of physical activity
service users lose interest quite quickly - start to eat fruit but they will get bored very
quickly and fall back into eating crisps and sweets instead
tendency to comfort eat when the mood goes down – weight increases while person is
unwell mentally which becomes an issue on top of the poor mental state they are in
medication and drugs impact on the appetite and weights of the residents
there is a general feeling that a lot of the service users have given up on themselves and
even though some are able to understand what healthy food is, they are aware that
they are obese but they are not interested in losing weight because they cannot see the
point
b) Skills, knowledge and staff training
-
-
staff is sometimes too eager to “care for the residents”, they do too much for them –
service users should always be encouraged and pushed to do as much as they can
themselves; staff don’t always understand that by doing things for the residents they
de-skill them and make them more dependent
some of the cooks provide very large portions so the residents get used to eating too
much
some of the cooks lack skills and imagination in regards to “healthy options”
c)
Organisational issues
-
unable to prepare home meals for the residents due to budgetary constraints as well as
staff capacity issues – tinned and frozen meals served to the residents (1 home only)
despite residents’ capacity to prepare some of their own food, the staffing levels and
kitchen arrangements would not allow the assisted cooking to take place (the same
home)
-
-
42
-
despite high prevalence of overweight and obesity, very few people seek support from
community nutrition service
d) Other:
-
-
monitoring food intake is a challenge – residents have their own money and are free to
go out and purchase any food they want; they very often buy crisps, chocolates and
other unhealthy snacks or even meals despite having eaten the meal at home; this
cannot be controlled or monitored but it is believed to substantially contribute to the
problem;
people who have lived in care for a long time tend to have a problem with making their
own decisions; they have often been institutionalised and it is hard to reintroduce them
to taking on more responsibilities
Summary of issues and challenges identified during the interviews:
a)
-
Complexities of the client group:
no capacity to understand healthy eating messages
high levels of nutritional ill health (obesity vs underweight)
lack of motivation
lack of interest in being healthier
impact of the mood on food intake
impact of medication on food intake and weight
b) Skills, knowledge and staff training:
- staff set in their own ways – “caring for the residents” rather than encouraging
independence
- lack of imagination, skill and knowledge around “healthy options”
c)
-
Organisational issues:
low staffing levels hinder exercising independence and up skilling the Service Users
budgetary constraints impact on food quality
d) Other:
- residents purchasing unhealthy food in the community
- residents are institutionalised – used to people making decisions and taking the
responsibility for them
Questions emerging:
43
- How much do residents living in the home determine the arrangements and how much
do the arrangements within the home determine what the residents are like? Do the
residents “make the home” or does the home “make the residents”?
- Managers seem to think that staff turnover in their homes is either “healthy” or very low
– this contradicts literature and general view across frontline services working with care
homes that claim staff turnover is very high in this sector. Is managers’ perception of
high staff turnover very different to what other people class as high, or has the retention
of staff in care homes improved over the last few years in Manchester?
- What should be prioritised while planning the menu – resident’s choice or nutritional
balance?
- How often the menus do not match the stock and food served on a day for a good reason
– i.e. staff providing the residents with what they asked for rather than what the
headquarters chose?
- What proportion of the fee coming from MCC is spent on the residents in care homes
depending on the type of organisation?
- Who should be responsible for ensuring that staff working in care sector have training and
knowledge essential to provide good care?
4.2.5. Observational Research
In order to assess how far residents enjoy or demonstrate well-being during mealtimes an
observational research study was carried out. This enabled us to give a voice to residents
who lacked the capacity to communicate their views or to those who didn’t want to
complain.
The methodology for the research was devised with support from expert academic
colleagues from the School of Health and Related Research (ScHARR) at the University of
Sheffield to ensure the research was rigorous and appropriate. The research was approved
as part of Adults Directorate research governance framework.
Due to the vulnerability of the service user and the fact that some of the observed
individuals had no capacity to give informed consent, the research needed to obtain
additional ethics approval from the Social Care Research Ethics Committee. Following on
securing that approval, Food Futures were able to carry out the observations. Apart from
the smallest homes that had been consulted, most consulted managers provisionally agreed
to be involved in the research. Observations in homes that have very few residents were
perceived as too intrusive by the managers as well as the research team.
To carry out the observations (2 mealtime observations on 2 pre-arranged days) we needed
consent from the manager, consent from all the residents who would be present in the
dining room on the day of the observation, consent from care staff on duty in the dining
44
room and for those residents who were unable to give informed consent, declarations from
consultees (i.e. a relative, friend or social worker who knows the person well).
Unfortunately, a lot of the managers who had initially expressed interest in participating in
the research, were unable to allow us to observe the residents in their care home. There
were 4 main reasons for their withdrawal:
-
obtaining consent from staff and residents was perceived as too much additional work
for the staff
inability to find a consultee for the residents with no friends or family
residents not wanting to be observed and not wanting the researchers in the dining
room
family members objecting to the observations
However, despite these difficulties, we observed residents in seven dining rooms and gained
valuable insight into what the meals felt like for residents in those settings. All the observed
dining rooms were in care homes for older people but the level of need varied between the
settings. We observed four dining rooms where residents were still quite independent and
they required only a little assistance and 3 dining rooms where the residents were more
frail, less mobile and needed a bit more time and support with the meal. In all seven dining
rooms we observed lunchtime service which consisted of 2 or 3 courses.
Our observations were carried out using an adapted dementia mapping tool that allowed a
systematic and structured observation of selected individuals during the meal. Using this
approach we were able to describe the mealtime experience from a resident perspective
regardless of their ability to communicate verbally. We allocated a wellbeing score to each
of the dining rooms which described the % of time when the residents engaged in positive
behaviours.
Despite our best efforts to be unobtrusive and have a low profile during the observations,
we need to appreciate that the residents and staff saw us as outsiders, which is likely to
have had some impact on their behaviour and possibly experience of the meal. However,
most of the residents didn’t seem particularly interested in our presence and got on with
their meal.
There were a lot of positive points to our observations and we were pleased to see that the
homes followed some of the good practice guidance. Generally, all the dining rooms we
observed were pleasant, clean and inviting, the food served was a wholesome hot meal
followed by a dessert and accompanied or followed by a hot drink. The staff were available
in the dining room to support the residents at all times. However, there were some major
differences in the way the mealtimes were arranged and we believe that these
arrangements were likely to have a major impact on how the residents experienced the
mealtime but also how well the residents appeared to be.
Good practice found during the observations:
a) Food provided
- nutritious and appetising hot meals provided on the day
- tasty food served - clearly satisfied residents praised the food and most residents
cleared their plates
45
-
impressive selection of desserts on offer
what was on the menus was served on the day but we also saw that some residents
received alternatives that they requested earlier
special diets were catered for – staff had information about different diets for some of
the residents and handed out different types of food to different people
b) Residents’ choices
- two types of family style dining:
•
food in serving dishes placed on each table and residents helping themselves or staff
supporting those who cannot or chose not to self serve
•
chef present in the dining room with the choices available, plating for each person
individually, based on what’s requested
- tea served in individual teapots – encouraged activity and interaction at the table
- staff asking if the resident want any more food before they clear the plates
- staff consulting on portion sizes with the residents while plating the food
- selection of desserts brought into the dining room on a trolley – residents making
choice on the spot
- residents chose their places - people tend to sit with the same person/people
- residents asked if they wanted music and what music they wanted
c)
-
d)
-
Assistance
staff appeared responsive to residents’ requests
carers slicing meat discreetly on the side for residents who require a bit of help
carers supporting the residents with eating and patiently encouraging them to eat more
staff offering only necessary support to the residents while encouraging them to
manage most things themselves
carers had a warm and friendly, informal manner dealing with the residents
staff skilfully handled challenging residents
staff clearly knew the residents, their abilities and habits
box of tissues in front of each resident to allow them to wipe their hands or face if
needed (residents seemed to reach out for them quite a lot indicating that they were
conscious of spills and drips and may have felt embarrassed)
people were given drinks in suitable/adapted types of cups
Ambience/ decor
staff cheering and singing
staff showing affection and care towards the residents
staff addressing the residents by names
staff checking on the residents, asking for feedback on food
kitchen staff coming bringing the food into the dining room - they seemed to have a
very friendly relationship with the residents
relaxed atmosphere in the dining room, people were in no rush to start the meal,
neither were they rushed during the meal
visitors having a meal with the residents
the residents seem comfortable asking for seconds or additional items
unobtrusive music playing in the background
46
-
tables set nicely with cloths, cutlery, crockery, napkins and condiments
Areas that could be improved found during the observations:
a) Food provided
- the food was already plated in 3 out of 7 settings – this may be more efficient and
practical arrangement in some homes but has a negative impact on residents’
experience
- kitchen staff prepare puree food in individual serving dishes arranged on plates to
improve presentation but the care staff who was serving the food poured it all on one
plate and then gave it to the resident (looking far less attractive than when it left the
kitchen) – the same member of staff later made comment to the researcher that puree
food looks unappetising which means that the person did not understand what the
kitchen was trying to achieve by putting puree meat into a separate dish
- dessert offered in small unsteady goblets – difficult to eat for people with dexterity
problems
b) Residents’ choices
- plates cleared away without people being asked if they wanted any more food
- pre plated service doesn’t encourage making choice
c)
-
-
Assistance
one of the carers started needlessly feeding one of the residents who was a bit slow
and still eating while the others had finished; what made it worse, she was standing up
while doing it and then made the decision that the lady had enough, cleared the
unfinished main and replaced it with a dessert; it looked like the carer wanted to finish
off the service and clear up and that’s why she was rushing the lady;
one of the carers walked around the dining room and mixed the food on all plates with
modified consistencies
task centred behaviour during the meal – one of the carers simply passing the plates
without paying too much attention to the residents
in most settings carers prepare teas and coffees for the residents, including adding milk
and sugar - a large group would be able to do it themselves;
d) Ambience/ decor
- there was little or no communication between the residents (some communication
between the residents and the staff)
- one resident dominated the dining room with disruptive behaviour – other residents
seemed very tense as a result of that
- staff felt under pressure to finish the meal before certain time in order to be ready for
afternoon activities
- plastic bibs were used in one of the settings – it was done to protect the clothing of
some of the residents – linen napkins or some sort of protective clothing are more
dignified
- the dining rooms in some of the homes were only partially set up with a lot of items
missing
47
-
-
the TV was on in the lounge - it can be potentially very distracting for people with
dementia
member of staff was tidying up the dining room and the lounge during the meal (taking
decorations off) - this can be quite distracting for the residents and doesn’t feel like an
appropriate time to be doing it
mealtime seemed a bit institutionalised in 3 out of 7 settings i.e. those that didn’t offer
family style dining
staff use sweetheart, love and other forms to address the residents but they also use
the names; it feels more friendly than patronising - is it acceptable?
staff talk about the residents as if they are not there or cannot understand what is
being said
Important findings
The most striking difference we experienced whilst observing different dining rooms was
how much more “lively” the dining rooms offering family style of service were than those
offering pre plated meals. Residents who dined family style seemed to communicate and
interact much more with each other. They seemed to have formed good relationships and
they supported each other and helped each other during the meal. Some of the residents
(visibly more able) tended to take on “normal” activities at the table like pouring a drink for
the person next to them, putting plates together after a finished meal etc. The
conversations happened naturally around food that was offered, people needed to say how
much and what they wanted and they either plated the food themselves or someone else
did it for them. We witnessed people communicating using their own version of sign
language, people encouraging poor eaters to have some food and people raising concerns
with the staff about one of them not being well. The family style dining seemed to create a
community feel in the home and made the mealtime feel like a meaningful social occasion.
The homes using pre plated service also provided the residents with a good wholesome
meal but the atmosphere in the dining rooms seemed institutionalised and task centred.
The staff handed out the meal, people ate it in silence and scarcely communicated. People
seemed very withdrawn and disengaged but often as soon as one of the staff members said
something, residents responded, which meant that at least some of them still had the ability
to communicate.
The environment is likely be the factor preventing people or simply not stimulating the
interaction. What we also noticed was that staff were more relaxed during the family style
service. Because of the arrangements, the residents were doing more things themselves and
the staff could focus on overseeing the dining room and responding to requests. Even the
dining room with people who needed support with eating, staff and the residents appeared
relaxed, taking their time to talk and joke with the residents while they were supporting
them.
The residents in the dining rooms may have had different level of needs but it was striking
how much better and happier people looked in those places offering family style service. It
may sound like a farfetched conclusion, but the research evidence discussed in the next
chapter actually confirms that family style dining has the potential to improve peoples’
health and wellbeing not only due to improved food intake but also because of the
48
improved social interaction. What we experienced seems to support already existing
evidence.
Despite the importance of the environmental factors, individual experience of mealtime
differed between the residents. Within one setting, individuals who had a different
experience than the majority, were usually identified. Sometimes, it was the individuals with
the highest needs who seemed to experience the mealtime better than the others due to
the attention of the staff and the one to one interaction with the person supporting them.
One the other hand, within a lively and chatty environment of some of the dining rooms,
there were few individuals who appeared withdrawn and not interested in the interactions
taking place around them. This indicates that sometimes, regardless of the environmental
factors, the mealtime experience is determined by the individuals - their state of health,
their mental health, mood on the day or even personality.
Important questions/observations/conclusions :
-
-
-
People who need help with eating tend to be the ones who have more interaction with
the care staff and as a result have some sort of communication with another person.
Those who don’t need support tend to be left to themselves. Does it mean that those
who need assistance experience the mealtime better? Is it possible that some of the
residents become troublesome just to get the attention?
In 3 out of the 7 settings there was no communication between the residents at all.
However, when the staff asked questions, most people responded. This indicates that
people are able to communicate but don’t do it. The question is why? Are they not
encouraged or do they not want to speak to the other residents?
Within the settings offering family style dining, the residents seem to communicate and
interact much more. They seem to have formed good relationships and they support
each other and help each other during the meal. They also seem much more engaged
with the surroundings. Some of the residents (visibly more able) tend to take on
“normal” activities at the table like pouring a drink for the person next to them, putting
plates together after a finished meal etc. Is exercising independence in the dining room
and family style dining having such a positive impact on people that they stay well for
longer or is this type of dining only possible with the residents who are still quite well?
THINGS WE OBSERVED THAT SHOULD BE ENCOURAGE IN ALL HOMES:
•
•
Family style dining
Small tables – max 4 people together; having small groups of people sat at the table
makes it more personal and intimate;
Serving dishes on each table – residents can help themselves or someone can plate
the food for them while asking what they want and how much; people at the table
tend to take on the roles and those stronger and more able help others with their
meals; this encourages communication at the table and helps building relationships
49
•
•
-
Individual teapots on the table for the residents to make their own drink – very simple
thing using in the home where chef plates the food in front of the residents; tea pots
play the same role as serving dishes in the other home i.e. people help each other and
tend to automatically engage in a conversation
Chef in the dining room during service engaging with the residents, asking for
feedback, talking about the food served seemed to be a focal point of the meal; good
light hearted banter between the chef, care staff and the residents made the
mealtime very relaxed and pleasant
Protected mealtimes – making the mealtime all about enjoying the food and the
company made a big difference to what the residents and staff behaved like; handing
out medication, tidying up the lounge and the activities should never interfere with
residents taking as much time as they want and need to finish their meal
4.2.6. Training for cooks and chefs working in care homes
The consultation event as well as the interviews with care home managers highlighted an
area that most people were concerned about – mealtime experience of people who
required modified consistency diets. The reasons for concern have already been mentioned
and mainly focused on:
-
lack of choice
-
poor presentation
-
unpleasant taste
The managers felt that some catering staff lacked skills, knowledge and imagination in this
area and as a result the residents were presented with food that dies not encourage eating.
The training was an output of the exploratory work we had done, however it provided so
much additional information that it turned out to be a very important part of that
exploration process. It was an unintended but a great benefit to our information gathering
process and this is why the training is described and summarised in this part of the report.
There was a lot of discussion during the training around the difficulties and pressures that
the care home staff experienced and there was even quite a bit of anger and frustration
coming from the chefs who were talking about the ways things were ran in the homes they
worked in. The issues highlighted by the catering staff indicated that even though the
managers may believe the nutritional care was clearly planned and actioned within their
homes, in practice, things were much more complex. These discussions gave us a very good
understanding of where a lot of the issues lay and where the improvements needed to be
made.
Communication
Communication between care staff, management and kitchen staff is a big issue.
Information about new residents or changing needs of “old residents” is often not passed on
to the kitchen, it comes too late or it is inaccurate. The chefs are not seen (and often don’t
see themselves) as being part of the care system. Even though everybody highlights how
50
important food is for peoples’ health and wellbeing, the nutritional care is very disjointed
and is not followed through the system.
The kitchen staff don’t tend to be updated on residents’ state of health which means that
they are not aware if someone has pressure sores, any kind of infections or has just got back
from hospital and is healing after a surgery. This sort of information should trigger changes
to nutrition but that can only happen if the care staff understand the importance of
nutrition and the kitchen staff know and understand nutrition in illness. Very often kitchen
staff are simply asked to prepare x number of option 1 and x number of option 2 plus any
alternatives or puree meals. If the numbers change, they don’t tend to know the reason.
Kitchen staff are not involved with the assessments done by the speech and language
therapists or the dieticians. By the time the information reaches the kitchen, it often gets
diluted, misinterpreted, changed or sometimes it actually never gets there. This is a major
issue because staff often do not understand subtle differences within the recommendations
and unless they pass the message accurately, the catering staff will continuously prepare
wrong things. Also, not being part of the assessment means that the kitchen staff have no
opportunity to clarify any doubts or ask for more guidance around providing appropriate
diets.
Knowledge
Catering staff seem frustrated by the care staff having no understanding of swallowing
difficulties and they feel that they jeopardise the effort kitchen puts into preparing
appropriate consistencies. The chefs mentioned that care staff:
-
give the resident wrong foods just because the residents enjoy it more than the pureed
food - they don’t realise the consequences and think that they are doing the right thing
-
as soon as the care staff start serving the meals to people, they tend to mix it all into one
as it is perceived “easier to eat for the resident” – kitchen staff put all the effort into
improving presentation of puree meals – using small dishes, moulds or scoops to plate
the food nicely but that is all destroyed by the carer who mixes it all before it even gets
to the person - we have witnessed this practice during one of our observations which
indicates that it may not be uncommon;
It was clear during the training that most of the cooks and chefs didn’t understand
swallowing difficulties and how pureed food improved the safety of the resident. Even if
they knew how to prepare pureed food, they didn’t seem convinced why they were doing it.
A lot of the cooks had no knowledge or understanding of how to prepare nice and
attractively looking puree food, always trying to serve the residents exactly what the others
were having regardless of the fact that maybe some of the items served to the others were
not appropriate for blending.
The issue of unused thickeners and food supplements came out very clearly during the
training – none of the chefs used thickeners for preparing pureed foods or supplements to
fortify the foods for underweight residents. The thickeners and the supplements are used
only by the care staff and never get to the kitchen. This is a major issue of waste per se as
51
well as wasted opportunities to improve nutritional status of the residents due to lack of
skills and understanding among staff.
Resource and capacity
Some of the chefs feel that they cannot provide everything that is expected of them within
the financial and capacity constraints that they are under. The chefs feel that achieving the
expected standards in regards to choice, quality and preparing special diets to numerous
residents with the number of people working in the kitchen is not possible. Also, the
budgets were discussed and some of the chefs felt that they could no longer provide good
quality food within unchanged food budgets.
Another issue was lack of adequate stock in some of the kitchens - usually in places where
someone other than chef was responsible for purchasing. This made the kitchen staff feel
like they cannot cater for the residents in a satisfactory manner.
Organisational culture
Some of the chefs feet involved in deciding what is served to the residents, they also feet
that they consult the residents on a regular basis so that what they prepare or put on the
menu is based on the feedback received. However, there are quite a few chefs who feel
clearly disempowered and disillusioned. Some of it is caused by the manager taking the
control over the menu planning and purchasing which leaves the cooks simply preparing
what they are told to prepare.
Summary of needs identified in the process of consulting care home managers and
catering staff – consultation event, interviews and training event:
-
Care homes staff should be able to have better access to support from community
nutrition service and speech and language therapists – instantaneous contact with the
service in case of an emergency, shorter waiting times and direct referrals would
reassure staff and give them more confidence that they will receive the support when
they need it.
-
Raising awareness among all members of staff around good nutritional care and the
importance of enjoyable mealtimes for the residents’ physical and mental health.
-
Raising awareness of malnutrition – training on how to prevent, recognise and treat
malnutrition is necessary for all care and catering staff.
-
Improving understanding of the conditions that the residents suffer from and how they
may affect their behaviour, appetite and what difficulties they may experience –
training in dementia awareness and other relevant conditions
-
Chefs and cooks need specialist training that would cover cooking for people with high
and complex nutritional needs – catering staff need to understand nutritional needs of
people with different types of illness and how the food they prepare can potentially
52
enhance their wellbeing or hamper it; the training should cover areas such as modified
consistency diets, food fortification, using supplements in cooking, finger foods,
diabetic and gluten free diets etc.
-
Raising awareness among all members of staff why consistencies need to be modified
and teaching ways of making these things taste better (serve cold drinks, add to juices
rather than water etc) and look better.
-
Balanced diets and menu planning training for all care homes.
-
Healthy eating workshops and cooking sessions for care staff and the residents from
homes for people with mental health problems and learning difficulties – people may
not understand the information given to them but if they learn that healthy food can
also be tasty, they will not have a problem eating it.
-
More support is needed for care homes for people with learning difficulties and mental
health problems around weight management.
-
Recognition of good practice and good chefs is necessary to inspire, motivate and
encourage others.
THINGS TO ENCOURAGE IN ALL HOMES:
-
-
-
-
-
Kitchen staff should hear the recommendations directly from the teams (SALT and
Community Nutrition) to be able to understand the recommendations, ask questions
and take responsibility for ensuring that they prepare suitable food.
Chefs should feel free to contact community nutrition team or SLT team for advice.
All kitchens and staff rooms should have boards with names of residents and their
special requirements so that all staff know who needs what!
A book with names and pictures of the residents, their special dietary requirements,
likes and dislikes and support required should be created and updated on a regular
basis.
Kitchen staff should be aware of any changes to residents’ health - they need to know if
someone was in hospital, had a fall or has an injury, pressure sore or anything of this
sort. This needs to trigger changes to person’s diet and kitchen staff need to know what
conditions require what dietary changes.
The chefs need to feel involved in decision making about what and how should be
prepared for the residents. They should feel responsible but also empowered.
The chefs/cooks should become more visible and approachable for the residents by
coming into the dining room on a regular basis, talking to the residents, asking for
feedback, being opened to suggestions and particularly speaking to those who don’t eat
enough in order to find ways of “tempting them” to eat a bit more. They cannot rely
solely on care staff for all this information, they need to be proactive.
Techniques of supporting people with eating and drinking need to be improved among
the care staff.
Care home staff as a whole (care staff, catering staff, management) need to appreciate that
they need to work together to improve resident’s care as well as the overall experience.
Communication and good knowledge of each resident are key!
53
5.
FURTHER INFORMATION AVAILABLE WITHIN LITERATURE
Literature clearly proves that meal provision in residential care setting is a complex issue. It
covers nutritional care, a patient centred, co-ordinated, multidisciplinary approach to
meeting individual needs for food and fluids (Savage and Scott, 2005), but also encompasses
meals as an integral part of well-being and quality of life going far beyond satisfying hunger
and providing nourishment (Nijs et al., 2009). The complexity of the subject is reflected by
the range of information and resources available. The literature review that we carried out
included:
-
already mentioned reports of the Care Quality Commission and the legislation care
homes are subject to
-
a wide range of policy and strategy documents
-
reports of various charities raising awareness of issues and necessary improvements
-
reports of professional organisations raising concerns, recommending changes and
improvements
-
project reports evaluating and summarising the outcomes of interventions tried in
residential care settings
-
recommendations and good practice guidance
-
manuals and training resources
-
a range of academic research evidence (local, national and international) analysing
nutrition and mealtimes in residential care from multiple perspectives
-
media reports highlighting good and bad practice identified nationally
This chapter is as a summary of the information available and more detailed literature
review can be obtained from the Food Futures Team.
The main findings of our literature review are:
-
There is a lot of information available regarding:
•
the importance of mealtimes for people in care
•
the impact of age and illness on eating habits and ability to eat
•
prevalence of malnutrition among older people
•
examples of poor practice in care homes for older people
•
examples of good practice in care homes for older people
•
strategies to improve the nutritional care of people living in care
•
ways of improving food intake and/or mealtime experience
•
issues relating to staff - staffing levels, lack of skills, communication problems
54
•
•
-
insufficient support from health practitioners, dieticians, Speech and Language
Therapists, Occupational Therapists and other professionals
Issues identified by our work that we haven’t come across within the literature - areas
for further research:
•
•
•
•
•
-
organisational issues - poor communication and cooperation between members of
staff, lack of joint working
high levels of waste of the food supplements and the soaking solution; even though
the subject of poor compliance among the residents prescribed food supplements is
mentioned in the literature, the fact that some of these products could be used in
recipes and become much more acceptable if the staff had the skills and knowledge
to try these approaches, has not been explored
information about organisational and financial differences between care homes and
how that impacts on the daily arrangements and residents’ experience
our observational research was an attempt to gather information about how the
residents experience the mealtimes; one of the important findings was that
regardless of the environmental aspects of the mealtime, the experience of
individual person may be determined to a great extent by their state of health
(mental health predominantly); information in this area, together with information
about what the residents, carers and nurses think about the meals and how they
perceive the mealtimes is very scarce and needs further research (Manthorpe &
Watson, 2003)
information about residents’ input into what is served and what the mealtimes look
like, food sourcing practices or the challenges that the care home staff face on a day
to day basis while catering for the residents
information about mealtimes in residential care settings for people with learning
difficulties or people with mental health problems; the evidence base for good
practice is solely based on research carried out in care homes for older people and
while some of the evidence is likely to be transferable, considering the differences
between the service users, not all the information applies; this appears as a very
under researched area especially considering extremely high prevalence of ill health
within these groups; adults with learning difficulties and mental health problems
living in residential care tend to spend many years in one establishment which in
theory gives staff a lot of time and opportunity to change and shape the eating
habits and dining experience within the home. Unfortunately, there seems to be no
research and (as a result) no evidence into improving nutritional care and the dining
experience of this group.
There is limited information or no information about:
•
Reasons the recommendations and good practice guidance not being implemented are they not accessed, do they not work in practice or maybe the staff have no skill
or capacity to implement it?
55
•
•
•
•
•
Mealtimes in residential care for adults who don’t fall under the older people
category i.e. people with mental health problems, substance misuse, learning
difficulties or those on the autistic spectrum who also require residential care
support.
How much of how the home operates depends on the management and the staff
and how much depends on the residents and their level of needs/engagement?
What impacts on the culture of care within the residential care setting and how can
that be influenced?
Strong, quantified evidence of the impact of various changes and interventions on
food intake, health outcomes and perceived quality of life among the residents - the
studies are often small and the loss to follow up very high due to high mortality measuring impact is very difficult.
People with more advanced illness are often excluded from the studies either
because they are not able to provide consent or the probability of death is too high
to include them in the study. This means that the evidence available is likely to be
applicable only to those individuals who live in residential care but their health is still
relatively good.
The summary is divided into sections that draw on available research (issues and challenges
leading to poor nutrition in residential care, ways of enabling and encouraging good
nutrition and mealtime experience), policy and strategy documents, good practice guidance
and examples of good practice we came across while exploring the subject.
5.1.
ISSUES AND CHALLENGES LEADING TO POOR NUTRITION IN RESIDENTIAL CARE
There are many factors that can contribute to poor nutrition among people living in
residential care and these are neither exclusive nor definite (RSPH, 2009):
-
Loneliness
Depression
Mental health problems
Physical disability
Side effects of some drugs/medication
Lack of nutritional knowledge
Increased nutritional requirements
High alcohol intake
Poor dentition
Loss of taste and/or smell
Further aspects of the mealtimes have also been highlighted as having a major impact on
residents’ experience and their food intake (Wylie and Nebauer, 2010).
-
Psychological, physical, social and environmental dynamics of dining
Respect for a person’s food choices
Awareness of possible changing patterns in food consumption
56
-
Adequate staffing levels
Appropriate staff education
Service skills
Provision of varied tasty meals
Within our local findings as well as the evidence base, we can distinguish three main areas
that contribute to poor nutritional care and poor dining experience within the care setting.
These areas are not exclusive and frequently overlap with the reason for one being a
consequence of the other:
a) Complexity of the client group
b) Issues related to staff
c) Organisational issues (culture of care, work arrangements, policies, funding etc.)
5.1.1. Complexities of the client group
Older people
Prevalence of underweight among older people is much higher than prevalence of obesity in
this group (BAPEN, 2011). The reasons why older people start having problems are
physiological, psychological as well as environmental. A lot of the behaviours around food
and mealtimes we heard of from the care home staff have been explained by the ongoing
research in this area.
-
Loss of appetite and changing eating habits due to:
•
•
•
-
The process of ageing including impaired senses and changes to taste – food served
is experienced as bland and tasteless (Tamura et al. 2008);
Medication altering taste or smell (Wylie & Neubauer, 2010)
Physical and physiological difficulties/changes that can lead to malnutrition
•
•
•
-
Low levels of physical activity (www.scie.org.uk).
Impaired food intake due to pain, inability to chew (Dunne A.,2009).
Swallowing difficulties (dysphagia) - research show that 55% of nursing home
residents have some degree of dysphagia and only 22% had been referred to a
speech and language therapist. Unrecognised and unmanaged dysphasia may lead to
malnutrition, dehydration, aspiration pneumonia and asphyxiation (Welch, 2008).
Altered nutritional requirements – altered or increased nutritional requirements due
to disease, infection or injury (RSPH, 2009).
Impact of dementia on eating and dinking
People with dementia can develop severe eating difficulties which progress as the dementia
becomes more advanced. Low body weight of people with dementia is a major issue but the
57
cause of this situation is subject to discussions, debates and poor understanding (Shepherd
A., 2010).
•
Weight loss and poor appetite
•
Overeating and weight gain - don’t remember they’ve eaten and they keep eating
•
Forgetting to eat or when they last ate
•
Slowness in eating or eating too quickly
•
Difficulties swallowing
•
Over chewing food or holding food in the mouth
•
Eating inedible items
•
Changes in food preferences
•
Unusual eating habits
•
Loss of eating skills - forgetting how to eat, difficulties with using knife and fork,
unwrapping packets or peeling fruit
•
Hoarding food or throwing it away
•
Difficulties recognising as well as locating cutlery, crockery and food
•
Visual changes
•
Difficulty making menu choices and reading
•
•
•
Poor concentration at mealtimes (frequently leaving the table, not paying attention
to the food etc.)
Challenging eating behaviours i.e. rejecting food, spitting out food, not accepting
assistance
Anxieties or delusional ideas about food safety (poisoned food etc.)
In the face of the complexity of this issue, it is necessary to appreciate the fact that each
person is an individual and their reasons for weight loss may be varied. The cause of weight
loss is highly likely to be a combination of physiological and psychological factors that need
to be identified in order to support each person is an individualised way (Shepherd A.,
2010).
People with learning difficulties and mental health problems:
Mental health and learning difficulties are two separate diagnoses but the issues the
individuals and staff face, often overlap. Also, because people with learning disability often
cannot express themselves, their mental health needs are very often misdiagnosed or
unrecognised. Evidence indicates that between 10% and 39% of adults with learning
disability have mental health needs. Due to lack of awareness and communication skills
among staff these needs are often perceived as challenging behaviour or part of the
learning disability itself (Crawley, 2007).
Mental ill health can in itself be a risk factor in becoming obese or for under eating:
58
-
Drugs such as tranquilisers, anti-psychotics or anti-depressants influence appetite and
food intake and may have very negative side effects.
-
People on the autistic spectrum often exhibit obsessive, restrictive and repetitive
behaviours that seriously impacts on their food choices and mealtime behaviour.
-
Prevalence of both, underweight and obesity is higher in this group than among the
general population (Crawley, 2007).
The impact of learning disabilities on eating and drinking (Crawley, 2007):
-
-
Higher prevalence of eating disorders than in the general population.
Lack of understanding about the need for a balanced diet - poor food choices.
Physical and dental health problems and difficulties with eating, chewing or swallowing
– impact on the ability to eat independently.
High prevalence of digestive problems – potential to deter people from eating.
Structural brain damage or dysfunction such as epilepsy (common among people with
LDs), have been linked to appetite, metabolic and weight changes, hyperphagia
(abnormally increased or excessive appetite) and episodes of binge eating.
Some medication has side effects that result in:
•
•
•
•
•
-
Abnormal eating behaviours, appetite changes, cravings or eating disorders
Adverse reactions to food i.e. nausea, dry mouth, loss of taste
Altered bowel function – constipation or diarrhoea
Weight gain
Raised blood cholesterol and increased incidence of diabetes
Sensory impairments, need for assistance and loss of independence with eating may
reduce the enjoyment of mealtime
Difficulties and frustration during the meal - lack of experienced skilled staff, specialist
eating and drinking equipment or insufficient support at mealtimes.
Poor communication – lack of skills may result in overlooked food choices, wrong
temperatures, wrong portion sizes etc.
Overfeeding to compensate for boredom, social isolation and behavioural problems
All people living in residential care
Older people, people with learning difficulties and people with mental health problems are
very different but some of the issues affecting them and posing a challenge in regards to
mealtimes and nutrition are common to all of them. The two very important areas that
require more detail are the social aspect of mealtimes and swallowing difficulties. Whilst the
social aspect of mealtimes was mentioned and highlighted by the managers we spoke to in
all types of residential settings, swallowing difficulties were only mentioned in the context
of older people.
SOCIAL ASPECT OF MEALTIMES
59
Residential care homes look after people with very different health problems and varying
levels of dependency. Even though the research focused on older people, a great majority of
these findings can be applied to all people living in residential care.
-
Some residents prefer to eat on their own and some eat better on their own because
other residents and the staff cause distraction to them (Timmins, 2009).
-
Reluctance to share the dining space and tables may be a result of behaviours that are
found unacceptable. The loss of manners (their own or others’ that they see in the
dining room) can be distressing and fearsome. As a result, mealtimes can become
occasions of greatest tension, frustration and disappointment for many residents
(Manthorpe & Watson, 2003).
-
Mealtimes are not always a good opportunity for conversations among the residents people often feels that they have nothing to talk about or that there’s no point in trying
to make a conversation because everybody at the table is hard of hearing (Philipin,
2010).
-
Some people who move into care homes had been living on their own, often isolated,
for many years and had lost their social skills – they are no longer able or interested in
fitting in with the rest.
-
Some tensions between the staff and residents have been found i.e. staff feel that the
residents try to make their lives difficult and they expect the staff to do everything for
them regardless of their abilities simply because that’s what they are paid for (Timmins,
2009).
-
People in care use strategies to maintain their “self”. These strategies include:
•
•
denying that they “belong” to the group - this may explain why some of the
residents are very isolated i.e. they do not identify with the rest and do not want to
be part of the group
fighting “against the regime” - people can choose not to co-operate with the staff or
other residents, because they want to challenge their physical disempowerment by
showing that they can control their activities
(Tulle & Mooney, 2002)
Our interviews and observations highlighted that in some care homes, people who require a
lot of support as well as those who can be challenging during the meal, tend to eat
separately. These arrangements aim to protect others from distress and to respect the
dignity of the person who may have no control or awareness of their behaviour. One of the
managers stated during the interview that dining room is the place where residents lose
their temper most often which is supported by the findings of Manthorpe and Watson that
mealtime may be an occasion of greatest tension and frustration for the residents and trying
to minimise that is a good practice.
The findings around maintaining “self” can also explain some of the challenging behaviours
we have been told about. The residents being isolated and not wanting to get involved in
any of the activities or rejecting the food, support with eating or any opportunities that are
offered to them may be their attempt to regain control over their lives.
60
The findings by Philipin (2011) about residents having nothing to talk about or being unable
to talk are obviously valid and we have witnessed similar behaviours. However, some of our
observations seem to indicate that if the meal service and the environment encourage
communication simply by how they are organised, people start communicating even if it is
communication focused only around what is happening at the table. We have observed a
table with hard of hearing residents who engaged in a sort of conversation using their own
version of sign language. This indicates that as long as people are encouraged to
communicate and the environment promotes communication, they can find a way round
the disability.
SWALLOWING DIFFICULTIES
Difficulties with swallowing are mentioned in literature as an issue for older people as well
as people with learning difficulties. This is an important factor contributing to malnutrition,
increased morbidity and mortality in both groups, which has been highlighted as a major
problem area by our consultation process. Swallowing difficulties (dysphagia) is any
difficulty swallowing saliva, food or drink which occurs at any point of the swallowing
process. It can be temporary or long term and it can deteriorate or improve over time. The
main causes of swallowing difficulties among older adults are medical conditions such as:
-
Stroke
-
Parkinson’s disease
-
Multiple Sclerosis
-
Motor Neurone Disease
-
Dementia
-
Head Injury
-
Brain Tumour
-
Head and Neck Cancer
-
Surgeries to Head and Neck
Among adults with learning disability is more common among those who also have a
physical disability such as:
-
Cerebral palsy
-
Physical disability of the palate, teeth or tongue
-
General higher level of need
Aspirating food or drink is not an issue when it occurs occasionally in a healthy person.
However, if it occurs repeatedly, it can be very serious and result in obstruction of the
airway, chest infection and potentially death. Respiratory disease is one of the major causes
of death among people with learning disability (Crawley, 2007).
61
It is not uncommon for people to develop temporary swallowing difficulties when they are
unwell. At the time of infection, people are likely to be confused and their muscles weaker.
Because the muscles don’t work as well as usually, the swallow becomes problematic. Once
the infection is treated, the swallowing goes back to normal (RSPH, 2009).
Speech and language therapists need to be involved as soon as swallowing difficulties are
recognised or suspected. The therapists assess each individual to understand which stage of
the swallow is affected and advise on methods and tactics that can be used to prevent
aspiration. If swallowing difficulties cannot be managed this way, the Speech and language
therapist recommends modified consistency diets. The therapists involved in our project
were adamant that the decision to recommend modified consistency diet is a last resort and
it is not taken lightly because the impact on person’s quality of life and nutritional status are
very serious. People on modified consistency diets are more likely to be malnourished due
to (BAPEN, 2010):
-
A health condition that requires modified consistency - people are likely to be weaker,
less independent, less active and struggle with eating physically
-
thickened fluids and modified consistency diets are perceived as much less palatable
and often unacceptable for people
-
unskilfully prepared modified consistency diets are likely to look unappetising, have
unpleasant taste and be poor in nutrients
5.1.2. Issues related to staff
This issue has been subject to numerous projects, reports, policy documents and strategies
over many years but the fact that it prevails indicates how complex the problems are. Our
consultation and research revealed many of the issues supported by literature especially in
regards to lack of certain skills among care staff as well as the catering staff but there are
also other issue that we identified in literature that have not been mentioned by managers
or the catering staff we have spoken to.
A lot of the family members and carers believe that the staff are the basis for a good home
and good care. The Alzheimer’s Society (2007) has a lot of good feedback about extremely
hard working and caring staff however, there are also numerous issues relating to staff that
keep coming up as hindering good care. Lack of staff, poor training and lack of
understanding can lead to malnutrition among care home residents. The same issues result
in mealtimes being stressful for both sides - the residents and the staff. Meal and assisted
eating become a task centred rather than a pleasurable and sociable experience (Castle,
2008).
An American study showed that care staff experience very high levels of stress and an extremely
high (1 in 3) level of burnout which resulted in treating the residents more impersonally or by being
hardened emotionally. The causes of stress and burnout were lack of time to complete basic tasks,
staff shortages, lack of training in how to deal with challenges and lack of good supervision. The
same study showed that the nurses were not perceived as active participants during mealtimes
(Crogan , 2001).
62
STAFF TRAINING, KNOWLEDGE AND SKILLS
The better the knowledge and skills of the workforce, the better the quality of life of those
who they care for. However, due to multiple changes that had taken place over the years,
there had been a gradual decline in the perception of skills required to provide good quality
residential care. This has resulted in an assumption that to provide care, staff do not require
high level professional training (Timmins, 2009). The extensive workforce review carried out
for the social care sector found that even in the most skill intensive sectors i.e. nursing
homes, learning and physical disability settings and children’s homes, nurses were only a
minority among the staff providing care (Gospel, 2008).
Majority of the care jobs are classed as “low skilled” even though the range of skills the staff
are supposed to have include:
-
technical skills - lifting, bathing, feeding, administration of medicine
-
interpersonal or social skills - interacting with old, disabled, and challenging people and
their relatives
-
administrative skills in terms of record keeping and administration
The majority of the care staff consist of untrained labour with low skills, few qualifications,
who have also been found to have substantial problems in terms of literacy, language, and
numeracy (Gospel, 2008).
Concerns around lack of and inadequate training for health care assistants in the UK have
been raised on numerous occasions (Fitzpatrick, 2005). Working with people who have high
support needs requires a broad range of skills, which include understanding dementia,
mental health or learning difficulty, working with very diverse people and communicating
with them despite their cognitive or/and sensory impairment (Manthorpe, 2010). Current
regulations mean that staff in residential care homes (especially in homes for older people),
are not equipped with the necessary tools to deal with these complex customers (Timmins,
2009).
Most of the managers we have consulted stated that the level of dependence among
residents has substantially increased over the last 5 – 10 years. This is supported by the
Dementia Strategy (DoH, 2009) that highlights the increasing numbers of people with
dementia going into care and Timmins (2009) who believes that the increase in dependency
level has been happening due to changes in eligibility criteria to enter residential care. The
Dementia Strategy (DoH, 2009) states that at least two thirds of all people currently living in
care homes have a form of dementia (only 60% are in dementia registered beds). There is a
concern these changes have not been matched by increased access to specialist training, so
that staff are better able to support residents with dementia (SCIE, 2010).
The three main training areas mentioned by literature as substantial gaps are that have
impact on nutritional status as well as general wellbeing of people living in care homes are:
-
dementia awareness
communication skills
nutrition
63
All these areas overlap in regards to delivering good care, including good nutritional care.
Care staff must have an understanding of the illness their residents have, how that affects
their physical and mental health as well as their behaviour in order to understand where the
issues come from, how to communicate with the service users and how to address these
issues in a sensitive and effective way. This means that people working with individuals with
mental health problems or learning disability also require “awareness” training which would
be relevant to the client group they work with.
DEMENTIA AWARENESS
Two thirds of care home residents have dementia and 40% of them are not in dementia
registered beds. Caring for people with dementia requires a high level of skills and if people
with dementia are to be cared for by general care home sector, training in dementia care
must be mandatory for all care home staff. A well supported, fulfilled workforce who are
confident in their skills and motivated in their work are less likely to leave and more satisfied
with their job and people with dementia are likely to receive better care (Alzheimer’s
Society, 2007)
COMMUNICATION SKILLS
Quality of staff communication with people in care homes has a major impact on the
residents. The consequences of denying them access to positive social interactions are
serious as they impact negatively on residents’ quality of life but they are also contribute to
an increased agitation and distress (SCIE, 2010). Care staff perceive communication
problems as one of the biggest challenges in providing dementia care (The Alzheimer’s
Society, 2007).
NUTRITION TRAINING
Even though the importance of nutrition in care settings is widely recognised and accepted,
there is no mandatory training or qualification in nutrition or nutritional care for care home
staff (care staff or catering staff). Existing training provision in this area is patchy and
organisations are not clear about what training they should commission or from where
(DoH, 2007).
Numerous issues have been identified by research as poor practice resulting from lack of
awareness and understanding of nutritional care among care staff and these issues identify
only some of the areas that should be covered by training:
-
Despite the staff feeling that they were effectively identifying and addressing
malnutrition, the nutritional care was fragmented and incomplete, hindered by lack of
clear action plan, poor communication and attitudes toward malnutrition (Brown &
Copeman, 2008).
-
Despite using a screening tool, the staff relied on their own judgement to identify
residents who they thought were malnourished (Crawley, 2007, Timmins, 2009).
64
-
Care home staff at all levels considered “small appetite” to be a normal part of ageing
process and some felt that if the residents suffer from certain conditions such as
Parkinson’s or dementia, they lose weight regardless of the support (Brown &
Copeman, 2008).
-
A lot of the times, people who assist with eating are unaware of the person’s medical
diagnosis. This knowledge could assist them in understanding the problems residents
have with eating and potential solutions. Also, the staff often have very limited
knowledge and understanding of residents’ eating skills and they do not realise that
they could use this opportunity to improve those skills (Timmins, 2009).
Staff sometimes provide support with eating which is unnecessary. As a consequence,
the person is labelled as “requiring assistance” which leads to de-skilling and is
potentially damaging for the person’s dignity (Manthorpe & Watson, 2003).
Residents are routinely served minced meals or soft diets without the need for it - they
can manage normal diet as long as some level of support is provided (Ruigrok &
Sheridan, 2006).
Staff often draw on their family experience for knowledge of cooking and tend to rely
on their own instincts to decide what constitutes a good diet – this indicates a training
need to ensure that all staff involved in preparing food have a good understanding of
nutrition and the special nutritional needs that the residents may have (Philipin, 2010).
-
-
-
Workforce review done in 2008 found that staff working in care homes are interested in
improving their skills and taking on more responsible roles within the homes (Gospel, 2008).
This confirms the findings from Alzheimer’s society survey (2007) where staff responding to
the survey said that they enjoyed their work and would like more training opportunities and
support to improve their skills.
The need for training is widely recognised however, there are some issues that prevent staff
from accessing training, and commissioners and support services from funding/delivering it:
-
There are many training courses available but because there are no agreed standards
and no consistency, these courses are not seen as priority considering capacity and
resource constraints (Ullman, 2009).
-
Facilitating time off work for nursing staff to undertake study and covering replacement
staff costs - increased costs to individual care homes (Fitzpatrick, 2005).
-
Insufficient capacity to release staff for study (Fitzpatrick, 2005).
-
There is no incentive to develop staff skills above certain level because they may leave
to progress with their training (Timmins, 2009).
-
Providing training is perceived as having marginal impact due to high staff turnover in
this sector (Timmins,2009)
STAFF TURNOVER/STAFF WAGES
A lot of the literature as well as the front line staff we have consulted mention high staff
turnover in this sector as one of the big challenges in ensuring skilful and qualified staff
support people in care. However, most of the care home managers we interviewed thought
65
they didn’t have high staff turnover and great majority of the staff had been there for many
years. One of the managers mentioned 70% as long term, core staff and 30% as people who
come and go.
A national research into workforce in social care sector highlighted (Gospel, 2008):
-
high staff turnover
-
higher than average percentage of care establishments reporting staff with skills needs
-
wages for social care assistants among the lowest in the country - little difference in pay
depending on qualifications within the homes
-
around 40% of staff work part-time – people work long hours to make up for the low
hourly rate
-
influx of foreign workers into the sector (from within the EU or from outside)
-
limited scope for career development
5.1.3. Organisational issues
Homes found to experience difficulties in meeting minimum standards for meals and
mealtimes tend to (CSCI, 2006):
-
be care homes with nursing
-
have insufficient staffing levels
-
be run by the private sector
Care Homes that meet the national minimum standards for meals and mealtimes are more
likely to have:
-
staff who consult with people on their needs
managers who meet the training needs of their staff
sufficient staff numbers to support people in enjoying their meals
The manager is responsible for improving performance and leading the quality assurance
process. Well qualified and experienced managers are more likely to ensure good standards,
clear management systems and sufficient staffing levels which are critical for improving the
quality of meals (CSCI, 2006).
The top three challenges to providing good care from a care home manager’s point of view
relate to developing a staff team with the right attributes and skills and keeping them
motivated (The Alzheimer’s Society, 2007). However, staff often feel disempowered
because of the organisational and hierarchical policies within the homes, that sometimes
contradict their aesthetic knowledge and person centred approach (Timmins, 2009). What is
more, research indicate that management’s failure to make care staff feel valued and
respected is a potential reason for high levels of stress and burnout in this group (Crogan,
2001).
Nutritional care
66
The BAPEN survey carried out in 2010 showed that a great majority of the care homes
reported having a screening policy – the residents were weighed on admission and regularly
throughout their stay. MUST screening tool was used by 85% of the homes and 90% the
staff received some form of training on nutritional screening (BAPEN, 2011). Despite high
screening uptake, there is little information on actions taken once people have been
identified as being malnourished or at risk of malnutrition. There are no clear pathways on
sharing the information with staff, referring to specialist services or carrying out more
detailed nutritional assessments (DoH, 2007). There is no systematic line of response to the
problems. Some evidence indicates that residents’ weights are only translated to a
nutritional score on admission and even though residents are weighed regularly, the score is
not recalculated (Timmins, 2009).
Mealtimes
Staff attitudes and organisational culture of the home affect levels of attention to residents’
nutrition in care homes. Peer pressure and difficulties in staffing (staff shortages or high
turnover) can create an environment in which completing practical tasks as swiftly as
possible becomes more important than spending time communicating with residents (SCIE,
2010). Staff tend to get into behavioural patterns, systems and procedures and this results
in mealtimes being task centred, repetitive, mundane routine and as a result they become
institutionalised and lack glamour (Welch, 2008). Working with complex service users
requires time, patience and empathy and these are difficult to apply in a busy and pressured
environment (Watson et al. 2002). Also, mealtimes are perceived by many healthcare staff
as a basic non-skilled care and as a result non-qualified staff, who often lack nutritional
knowledge, are left to supervise mealtimes while the qualified staff perform other tasks.
This results in over-stretched and undertrained staff, failing to provide appropriate care
regardless of how kind and caring they might be (Wylie & Nebauer, 2010). Within the
pressured environment where staff lack knowledge and understanding of nutritional care,
standard practice when somebody starts losing weight is to start providing them with oral
supplementation (Wylie & Nebauer, 2010).
Choice
The CQC outcomes and contract details stress the importance of choice within all aspects of
care. All managers we have spoken to assured us that the residents always have choice. A
great number of the CQC reports we reviewed confirmed what the mangers said. What the
research highlights and what we need to bear in mind is that when the environment is not
structured to promote choice or when people have not been made aware that they have
the choice, they are in fact not given the opportunity to make choices or what we’d call
“meaningful choices”. In this type of environment, service users are not stimulated to think
about their options and as a result, they become increasingly passive and dependent
(Goodman & Keeton, 2005).
Specialist support
Despite government policy statements that care homes should receive good support from
specialist services, through advice, support and training, the Alzheimer’s Society (2007)
67
found that a quarter of care home managers named accessing advice from external services
as one of the top three challenges in providing good dementia care. These results support
the concerns expressed by the managers in Manchester who saw the inability to obtain
timely support for the residents as an area of great concern.
Another issue with the support provided to people living in care homes is the fragmentation
of this support. GPs, dieticians, nutritionists, speech and language therapists, occupational
therapists and others, all work as independent entities using different systems, protocols
having different care priorities and different focus. This often results in delayed response to
the residents’ needs as well as inconsistent or contradictory recommendations being given
to staff (Timmins, 2009).
5.2.
WAYS OF ENABLING AND ENCOURAGING GOOD NUTRITION AND MEALTIME
EXPERIENCE
Improving meals alone is not enough to improve quality of life in care homes (Nijs et al.,
2009). However, changing the culture of care, empowering the staff and improving their
skills and knowledge can potentially have a major impact on life as a whole in these homes.
Using nutrition and mealtimes as facilitators of the change is a good starting point because
of how strongly people (residents, families, staff and managers) feel about this part of life in
residential care.
We can distinguish 4 dimensions of quality of life. These dimensions are interactive and
interconnected and can be applied to all areas of life in residential care (including mealtimes
and nutrition):
-
Personal resources (skills, knowledge, health status, social contacts etc)
-
Control of environment (the ability to influence our reality) – the more older people feel
that they control their life and the less dependent they feel, the more they enjoy good
quality of life
-
Values (what we consider important, worthwhile and valuable) – older people value
independence, privacy and companionship, dignity, involvement, security
-
Actual living conditions
The expectations in regards to these dimensions will vary between people depending on
their lifestyle and experience prior to moving into care, however each individual should be
empowered and supported to achieve the outcomes desired (Hoffmann, 2008). When we
look at a lot of good practice guidance, despite the difference in detail, the main messages
focus on encouraging independence, offering choice, respecting the person and their dignity
and providing suitable environment, we can clearly see how this fits into the 4 dimensions
of quality of life.
There is a lot of evidence available to support the link between improving outcomes within
these 4 dimensions of quality of life and the impact it has on individuals:
-
Involving residents in all the activities of daily living as far as their physical, mental and
emotional conditions allowed, resulted in life becoming more normal and lively, the
residents eating better and loneliness, helplessness and monotony of their lives
68
reducing. The residents also needed less medication and they slept better (Hoffman,
2008).
-
In institutional care people who are more assertive in defining their own needs and
interests survive longer (Tobin, 1991)
-
Having a say or even the impression that one has the say about their daily activities
made the residents feel better emotionally and cognitively (Langer et al., 1988).
This evidence highlights how good quality of life in care homes can positively impact on
emotional and cognitive health of the residents. Mealtimes as one of the most important
part of the day in care homes have a great potential to improve the quality of life by
addressing all the 4 dimensions listed by Hoffman. Most of the research around food
provision in residential care focuses on much narrower and more defined elements of
nutritional care but to a large extent, these elements fit into these 4 dimensions.
A lot of research is being carried out to provide evidence around what factors impact on
food intake in residential care and the results show how many areas can be potentially
modified in order to achieve better outcomes for the residents. Poor nutritional intake is
usually a multifactorial problem and as such, requires a multi – stimulus intervention. The
stimulus can be related to food (texture, flavour enhancements, palatability), the
environment (assistance during the meal, ambience in the dining room, verbal and social
cues) and food supplements (Welch, 2008). The factors having impact on food intake often
result in improved socialisation and quality of life.
5.2.1. Food as stimulus
-
Attractive presentation and good quality of food (Welch, 2008)
-
Increased variety of food available (Nijs et al., 2009)
-
Culturally appropriate meals (Jina, 2009)
-
Linking food with memories of family mealtime experiences (Philipin, 2011)
-
Enhancing flavour can potentially stimulate the appetites of people with a cognitive
impairment (Mathey et al, 2001). However, research into flavour enhancement is
ongoing in the UK as well as in other countries and has not yet been conclusive. In
England, celebrity chef Heston Blumenthal has been working with scientists at the
University of Reading on using umami flavour in order to make the meals in Royal
Berkshire Hospital more palatable and enjoyable for older patients (BBC, 2010).
-
Alcoholic beverage given 30 minutes before a meal (Wylie & Nebauer, 2010).
5.2.2. The Environment as stimulus
There has been a lot of research looking into this area. The results are consistently showing
the benefits of promoting independence and positive social atmosphere during the meals
on the state of health of the residents.
69
Dining arrangements
Even though the value of social aspect of mealtimes is often mentioned, there is little British
literature focusing on the social context on nutritional care. Numerous Scandinavian and
Dutch studies have shown how spatial arrangements and dining style can positively impact
on nutritional intake but these were recently supported by a Welsh study that had similar
findings (Philipin, 2011). Family style mealtimes vs individual pre-plated service showed a
significant positive impact on overall quality of life, gross and fine motor function and body
weight among nursing home residents (Nijs et al, 2006, Nijs et al., 2009).
-
People eat more when they eat with others - more social atmosphere, companionship
and enjoyment result in mealtimes taking longer and people eating more (Nijs et al.,
2009, Ruigrok & Sheridan, 2006). Factors that have been found to contribute to
increased sociability and enjoyment:
•
smaller tables shared with the same people on a daily basis (Philipin, 2011)
•
self serving from dishes placed on the tables (Ruigrok & Sheridan, 2006)
•
buffet style dining allowing the residents to make choices (Philipin, 2011)
•
•
restaurant style service, family style or cooking on the wards and involving the
residents – all 3 interventions positively affected the mealtime ambience; suitability
depends on the residents and the set up of the home (Nijs et al., 2009)
personal choice, discreet support and longer time allocated for the meals (Ruigrok &
Sheridan, 2006)
-
Changes to the food and drink provision i.e. improved dining atmosphere, food choice,
extended restaurant hours, readily available snacks and drinks resulted in better
physical and mental state for some of the residents who previously struggled to eat,
increased interest in food, more sociable mealtimes and more relatives eating meals
with the residents. Improved nutritional care had a noticeable impact on reducing
number of falls among care home residents however this result was not statistically
significant (Norfolk County Council, 2009)
-
Involving people in mealtime activities can help maintaining their interest in food or to
be engaged in a pleasurable and meaningful activity that may stimulate the appetite –
people in care, especially women, who were used to preparing food for the family, find
the lack of engagement in meal preparation difficult and potentially disempowering
(Manthrope & Watson, 2003).
Staff and family involvement
Protecting mealtimes from any unnecessary distractions, involving all staff and encouraging
family and friends to participate in the meal have been found to improve the atmosphere in
the dining room by making it more relaxed and unrushed for the residents.
-
Friends, relatives or members of staff joining the residents at the table can make the
mealtime feel more sociable and encourage more interaction at the table (Phillipin,
2011).
70
-
Staff having a meal with the residents resulted in more relaxed atmosphere - residents
felt that they had more time to eat because no one seemed to be in a rush (Nijs et al.
2009).
-
Protected mealtimes affected the way nurses and carers interacted with the residents
during mealtimes as there were fewer distractions and they could focus on the
individuals requiring support. Staff dedicated their time to ensure that the mealtime
was a pleasurable and therapeutic experience for the residents. Staff breaks were not
taken during mealtimes to allow more staff members to be involved in the service
(Ulrich et al., 2011).
-
Improved targeting and quality of assistance provided during the meal resulted in a
significant increase in food and drink intake of 50% of the residents. The residents with
the greatest cognitive impairment benefitted most from the improvements (Schnelle
and Simmons,2004).
-
Forming Nutrition Group – they ensure protected mealtimes are being respected, have the
potential to enhance mealtime socialisation among the residents; Nurses present during the
meals have the opportunity to supervise and educate the care staff about effective eating
assistance techniques and the catering staff gathers information on uneaten food (Ulrich et al.,
2010);
5.2.3. Food and food supplementation
Food supplementation is frequently prescribed to people in residential care homes who
experience weight loss and have problem consuming sufficient amount of food to satisfy
their nutritional needs. However, the results of our local consultation indicate that a lot of
the supplements prescribed to people in care homes goes to waste. Evidence around
efficacy of food supplements and the cost effectiveness of this type of intervention seems to
suggest that if taken as prescribed, the supplements can bring benefits, however
considering that a lot of people reject them, it is more effective to use natural food
fortification and availability of calorie dense foods and snacks for malnourished residents.
-
The Cochrane review looking at the effectiveness of supplements in elderly at risk of
malnutrition (2009) concluded that supplements, if taken, produce small but consistent
weight gain. However, the results show no significant improvement in health outcomes
or do not indicate cost effectiveness of a long term use. The review suggests that
there’s insufficient evidence looking into alternative ways of food supplementation to
conclude if sip feeds are the best option for older people.
-
Simmons et al. (2010) looked at cost effectiveness of oral supplementation in relation
to offering residents encouragement and snacks between the meals. Whilst both
interventions significantly increased caloric intake between the meals, the snack
intervention was slightly less expensive and more effective (refusal rates, declined meal
intake, staff time required and caloric gain) than the supplement intervention i.e. it
would be recommended to improve availability and choice of snacks and drinks rather
than use oral liquid nutrition supplementation.
-
The cost effectiveness summary produced by BAPEN highlighted that supplementation
in the community adds costs to the health care budget while reducing the costs in
71
hospital. We can assume the same result is valid for care homes where food cost is
covered by the home whereas the prescribed supplement is free of charge.
5.2.4. Staff training
Lack of training has been highlighted as a major factor contributing to poor care within the
residential care setting which makes it even more important to gather evidence around the
effectiveness and impact of this approach. Evidence shows that the better the skills of
people providing care, the better the outcomes for those they look after.
-
-
-
Hospital outreach team provided a series of seminars to key care staff working in
selected care homes in South Manchester. The homes also received the weekly visits
from a psychiatric nurse to assist in developing care planning skills. As a result of the
intervention the prevalence of depression and severe impairment (physical and
behavioural) decreased significantly, psychological distress among staff in the control
group increased significantly but not among the intervention group who received the
training. Also, there was a significant increase in the proportion of time staff spent in
positive interaction with residents, both in terms of direct care and social contact
following the training staff received. This research provided evidence that elderly
residents can benefit from improvements in the quality of care as a result of care staff
training and that there are important implications for the role of hospital outreach
teams in nursing and residential homes (Proctor et al, 1998).
Piloted in 10 care homes PEARL project (Positively Enriching Residents’ Lives) involves
training for staff that aims to improve their awareness and understanding of dementia.
Final results are not yet available but the initial evaluation showed a number of positive
outcomes including 52% decline in the use of antipsychotic medication (Valios, 2010).
Communication training for staff resulted in:
Staff adopting more effective communication strategies i.e. giving clearer and more
detailed explanations and encouraging independence by using verbal and visual
prompts when undertaking care tasks
•
Staff showing greater signs of empathy, indicated by increased use of touch and eye
contact
•
Staff rated to be warmer, less authoritarian and more concerned with increasing
choices for residents.
•
Increased frequency of positive interactions and reductions in negative interactions.
•
The outcomes for the residents are difficult to assess but studies indicate that improved
verbal communication, positive improvements in wellbeing and mood as well as some
reductions in behaviours such as anxiety and agitation have been found as a result of
training delivered to staff. These improvements however are only likely to occur if training is
sustained and reinforced by individualised supervision and feedback (Moriarty et al., 2010).
-
Teaching staff how to build decision making into the daily routine of the residents and
seeing it as an opportunity to give them more independence can improve the outcomes
72
-
for the service users and the therapeutic relationship with the staff (Goodman &
Keeton, 2005).
A review of weight loss interventions for people with LDs reported that moderate
weight loss can be achieved by teaching behavioural techniques such as managing
meals, portion sizes and eating patterns, the involvement of support staff, increased
physical activity and sharing of information around healthy lifestyle. Adults with LDs
often work together with their carers on making decisions around their daily activities
including food choices. This is why motivated, skilled and well trained staff supporting
the individual can have a big impact on their food choices and weight management as a
result. Evidence shows that health knowledge and skills of adults with LDs can be
improved and raising awareness of obesity and its’ consequences is necessary in long
term behavioural change (Crawley, 2007).
Formal training doesn’t always need to be delivered. Evidence shows that as long as staff
are given an opportunity to witness or participate in improved practice, they are likely to
embrace the opportunity and the residents are likely to benefit as a result.
- Staff involved in a project witnessed the developing potential of some of the individuals
and started to appreciate the value and need to preserve and foster eating skills as well
as the importance of social and aesthetic aspects of the mealtime. They learnt to
understand the importance of dignified and acceptable ways of supporting the
residents with eating whilst the residents enjoyed the “sense of occasion” the
mealtimes became. The evaluation showed that the staff was very supportive of the
changes and felt that positive changes among the residents were worth the extra effort
(Ruigrok & Sheridan, 2006).
- The chefs appreciate the opportunity to try out new ideas and deviate from rigid and
standardized food “production” (Jina, 2009).
- Participants appreciated the experience of mixed groups i.e. managers, cooks and chefs
which helped to recognise communication issues within the homes; developing
relationships and understanding each others’ points of view, working closer together
enabled more comfortable and free discussions around mealtimes and nutritional care.
(Ulrich et al., 2010, The Care Commission, 2009).
Most of the research that provides evidence for good practice tends to follow the same pattern i.e.
issues within the setting or settings are identified, intervention is planned, changes are made and
the results are measured. Good practice guidance follows based on the findings. Great majority of
the research involves active support (usually action research approach) provided to the homes – this
may include highlighting the areas of concern, providing training, providing professional support,
help with shaping the environment and implementing changes etc. Good practice guidance is made
available to everybody (often at national level) but this is no longer supported by the additional
capacity that was available during the research. There is very little research looking into care home
staff’s ability to implement this guidance (Philipin, 2011).
5.3.
IMPLEMENTING CHANGE
Changes to the system and culture within the organisation need to happen through good
leadership, defining the main values and vision for the service. The vision needs to be
communicated effectively and people delivering the vision need to be valued, trusted and
73
enabled to develop (Rutheford, 2005). The range of health and care needs emphasises the
need for effective interdisciplinary working within and between sectors and with the
involvement of multidisciplinary specialists (Fitzpatrick, 2005).
To achieve long term sustainable changes all initiatives need:
-
Good management and strong leadership (Manthorpe, 2010).
-
Partnership work (Care Commission, 2009; Manthorpe, 2010).
-
Include those mostly involved – dieticians, nurses, chefs and service users themselves
(Dewar & Sharp, 2006).
-
Group decision making and ownership by those who implement the changes (Carr and
Kemiss, 2008)
-
Improving and developing practice needs to be matched by the capacity and skills of
staff working in care homes (CSCI, 2006).
5.4.
POLICY CONTEXT
In December 2007, Department of Health published 'Putting People First’. This document is
the concordat with the Local Government Association (LGA), the Association of Directors of
Adult Social Services (ADASS), the NHS and others. It was a shared vision and commitment
to the transformation of adult social care over a period of three years.
Expected outcomes of this concordat include ensuring older people, people with chronic
conditions, disabled people and people with mental health problems retain maximum
dignity and respect and they have the best possible quality of life, irrespective of their illness
or disability.
‘Putting People First’ placed responsibility on local authority adult social care departments
for championing the rights and needs of vulnerable people and carers within the local
authority, across public services and in the wider community as well as developing local
workforce strategies focussed on raising skill levels and providing career development
opportunities across all sectors (HM Government, 2007).
Following on to ‘Putting People First’, Department of Health issued ‘Valuing People Now: A
New Three-Year Strategy for people with learning disabilities’ (2008), as well as ‘Carers at
the heart of 21st‑century families and communities’ (2008) which were followed by ‘Living
well with Dementia: A National Dementia Strategy’ (2009). All these documents highlight
the need to improve the quality of life for vulnerable people and their carers. They focus on
treating everyone as an individual who has a right to make choices and decisions about their
own life and be treated with dignity and respect. Also, all the strategies recognise that
workforce across services need to be given the appropriate support and training to equip
them with the values, skills and knowledge necessary to deliver expected quality of care.
The importance of improving skills and knowledge of people supporting vulnerable adults
highlighted frequently in this report is reinforced by a separate strategy issued in 2009 by
the Department of Health. ‘Working to Put People First: The Strategy for the Adult Social
Care Workforce in England’ outlines that workforce development should aim to create a
more confident, empowered and diverse workforce with increasingly sophisticated skills in
74
order to secure the dignity, quality of services and quality of life of those people receiving
social care. The strategy also highlights that social care leaders and employers must work
together to deliver effective initial, professional, vocational and post-qualifying learning and
development and agree the best ways to achieve improvements in capacity, skills, and
competence, while smaller employers and people who directly employ services should
receive support in understanding the needs of their staff and how they can find appropriate
development and training. There is also recognition that recruitment, retention and career
pathways need to be strengthened (DoH, 2009).
More specifically to our food and nutrition focus, in 2007 Department of Health together
with a wide range of stakeholders committed to improving nutritional care in the NHS and
social care, came up with a Joint Action Plan of on Improving Nutritional Care. The Nutrition
Summit stakeholders agreed 5 priorities for action:
-
To raise awareness of the link between nutrition and good health and that malnutrition
can be prevented,
-
To ensure that accessible guidance is available across all sectors and guidance is
appropriate and user friendly,
-
To encourage nutritional screening for all people using health and social care services,
paying particular attention to those groups known to be vulnerable,
-
To encourage provision and access to relevant training for front line staff and managers
on the importance of nutrition for good health and nutritional care,
-
To clarify standards and strengthen inspection and regulation
In August 2009 The Nutrition Plan Delivery Board issued the final report in which it
expressed concern that despite some progress and achievements the work failed to connect
with relevant people: managers, service providers and board members. The Delivery Board
strongly advocates for commitment from the Department of Health to provide leadership
and co-ordination of work on nutrition. The response issued by the Department of Health in
February 2010 stated that it would:
-
Identify ways of improving how they engage with local communities, carers, health and
social care and third sector organisations, and professional and other staff delivering
services to improve access to information on maintaining healthy weight and the risks of
malnutrition, particularly for vulnerable people, such as older people living alone and
others with specific nutritional needs.
-
Examine how they make better use of communication channels to ensure that all those
providing health and social care services include good nutritional care as an integral part
of delivering effective care and are aware of the risks of malnutrition where people have
specific health needs, including people cared for at home and their carers.
-
Work with stakeholders to ensure health and social care staff have access to good
practice guidance and other tools.
-
Take forward action to improve how we use and present information, as part of a strong
evidence base to support policy development and how we assess progress on
implementation.
75
-
Support and enable action to deliver high quality nutritional care by skilled staff working
in an integrated way across health and social care.
-
Continue to track the Nutrition Action Plan’s 5 key priorities through information on
delivery of the programmes outlined in our response, including the Care Quality
Commission registration requirements.
5.5.
GOOD PRACTICE GUIDANCE
A plethora of guidance, tools and information exists around nutrition and mealtimes in
health and social care settings. The volume and complexity of these resources contribute to
the confusion of managers and care home staff who struggle to choose what is most
appropriate for their service users (DoH, 2007). The guidance differs depending on who the
intended audience is but it can be used by everyone to inform good practice.
The available guidance can be split into two main categories:
-
General principles of ensuring good nutritional care in care setting.
-
Practical guidance on implementing improvements and overcoming challenges in order
to achieve the desired outcomes.
5.5.1. General Principles
We can say that the CQC prompts that facilitate achieving compliance with Outcome 5 that
are mentioned in chapter 2 of this report are the first of many good practice guidance
available. Some of the guidance is very detailed and some of it just states few main
principles. Most of the guidance is applicable to care homes but only some of it is
specifically tailored towards them. The three sets of good practice guidance we chose to
mention start with the most strategic one applicable to the whole care sector, followed by
one applicable to hospitals, care homes and community finishing with one specific to care
homes:
ESSENCE OF CARE – BENCHMARKS ON FOOD AND DRINK (DoH, 2010)
The Essence of care is predominantly addressed to high level audience within the NHS, PCTs,
Local Authorities, Academia and other professional bodies. It is unlikely to be used by
managers of residential care homes or other frontline staff. Benchmarks on food and drink
are built around the best practice general indicators and all factors that need to be
considered with relation to these indicators.
THE TEN KEY CHARACTERISTICS OF GOOD NUTRITIONAL CARE - The 10 key characteristics of
good nutritional care in hospitals developed by The Council of Europe Alliance in order to
improve understanding of good nutritional care in hospitals. The document was adapted for
care homes and community settings following the recommendations of the Joint Action Plan
– Improving Nutritional Care (DoH, 2007).
CSCI GUIDANCE - “HIGHLIGHT OF THE DAY? IMPROVING MEALS FOR OLDER PEOPLE IN CARE
HOMES”. This guidance is specifically designed for care homes and is much more person
centred and less generic than the other two. Even though it was released in 2006, this
76
guidance is still suitable and practical enough to be used by the managers and care home
staff.
5.5.2. Practical Guidance
The resources available are very detailed and comprehensive and cover advice on how to
deal with a lot of the complexities of the client group that we discussed earlier, as well as
some of the environmental factors that impact on their food intake and general experience
of the mealtime. There is a lot of resources available but some of the latest and most up to
date are:
- Caroline Walker Trust:
• Eating well: supporting older people and older people with dementia. Practical guide
(2011).
• Eating well: children and adults with learning disabilities (2007)
- Royal Society of Public Health – Eating for Health in Care Homes. A practical nutrition
handbook (2009)
- Alzheimer’s society guide to catering for people with dementia (2009)
- Dignity in Care - Eating and Nutritional Care (available on Social Care Institute for
Excellence website)
- National Association of Care Catering: Menu Planning and Special Diets in Care Homes
The resources from Caroline Walker Trust and Social Care Institute for Excellence can be
accessed on-line free of charge, whereas the other resources are publications that need to
be purchased.
As highlighted by The Care Commission (2009), changes to culture and practice rather than
more legislation and guidance is necessary to make improvements. The challenge is to get
people to use them to influence how they work on a daily basis. However, there is very little
research into the extent to which care home staff are able to incorporate these initiatives
into practice (Philipin, 2011). Considering the issues we discussed earlier, i.e. complexity of
client group, staffing levels, lack of training etc., it is unlikely that a lot of the care homes are
able to implement the guidance without additional support.
5.6.
EXAMPLES OF GOOD PRACTICE
There are many issues that have been identified locally as well as nationally and
internationally that hinder good nutrition and enjoyable mealtimes in residential care
settings. Poor practice and challenges need to be identified so that changes and
improvements can be implemented. However, despite the negative focus of media coverage
and a lot of the reports, there are numerous examples of good work done across the
country. Recognising good practice is equally important to identifying bad practice in order
to share the success and support the evidence around improving nutrition and mealtime
experience within residential care settings. Championing and rewarding good practice can
be used to set an example, show the others how improvements can work in practice, share
the experience and lessons learnt from implementing the changes and finally and most
77
importantly raise aspirations of other people working in the sector as well as raising
expectations among service users themselves.
5.6.1. National examples:
CARE COMMISSION – PROMOTING NUTRITION IN CARE HOMES FOR OLDER PEOPLE (2009)
The aim of the project was to improve nutrition, food and eating practices within care home
sector through education and opportunities to learn from experts and from each other. The
programme was led by Care Commission’s Nurse consultant for Care Homes for Older
People who invited staff from all care homes across Scotland to become nutrition
champions in their own homes.
The programme gave the participants:
-
Good grounding in nutrition (3 day course)
-
Support network from other nutrition champions
-
Knowledge, new skills and confidence including managing change, providing support
and feedback and project planning
-
Chance to challenge and change current care practice in their homes
-
The opportunity to raise the profile of nutrition and residents’ needs
The programme came across many obstacles and challenges and only some of the homes
chose to participate. However, this is one of few examples when an initiative/project or
programme around nutrition was made available to all care homes in the area i.e. Scotland.
Too often, these types of initiatives are limited to a specified (usually very small) number of
settings and the benefits are not shared by other homes. One of the homes participating in
the project, Woodlands Nursing Home reported increased Body Mass Indexes of almost 90%
of the residents!
CARE SECTOR ALLIANCE CUMBRIA – CARE SCHOOL MOVE AND FOOD
This project is part of a wider initiative delivered by Age Concern North West Cumbria and it
aims to help managers and staff delivering social care in Cumbria to increase their
knowledge, skills and confidence so that they are able to deliver high quality personal
care/support which enhances individuals’ wellbeing.
The Care School includes work on:
-
the importance of ensuring every service user’s dignity is maintained
-
understanding nutrition and the impact good/bad nutrition can have on other aspects
of life e.g. energy, self esteem, medication, falls, continence, dignity
-
practical ways to enhance good nutrition in a range of settings
-
encouraging activities amongst older people
-
promoting the independence of individuals whenever possible
As a result of the project hundreds of care staff and volunteers attended a range of courses
and workshops, enhanced induction packs were updated with new modules and made
78
available to managers and large number of older people are already experiencing improved
health and wellbeing. The modules now available to all staff are:
-
person centred care & dignity
-
nutrition, malnutrition and dehydration
-
dementia
-
falls prevention
The project is still ongoing and the evaluation has not been carried out. However, what is
very positive about this work is the holistic approach to improving care and open access to
care providers across Cumbria. The 4 modules available as induction to all new staff as well
as refresher to existing staff, cover the 4 areas that substantially overlap and understanding
them all constitutes good care (including good nutritional care).
COMMUNITY FOOD AND HEALTH (SCOTLAND) – FOOD AND HEALTH TRAINING PROJECT FOR
SUPPORT WORKERS
In 2008 Community Food and Health (Scotland)provided funding to the Scottish Learning
and Clinical Disability Dietetic Network to register as Elementary Food and Health course
tutors and deliver courses to support workers working in the learning disability sector.
Additional funding was made available to deliver practical courses on cooking and menu
planning.
Courses were free of charge for the participants who were mainly support workers, care
home managers and care home chefs. The feedback indicated that the participants would
welcome more information tailored to the specific health and nutrition issues commonly
experienced by adults with learning difficulties. As a result, a tailored course accredited by
The Royal Environmental Health Institute of Scotland “The Food and Health Course for
Carers of Adults with a Learning Disability” was developed in 2011.
BARCHESTER HEALTHCARE – looks after over 10,000 residents in 200 homes across the UK;
The company has a very strong focus on good nutritional care and staff training.
-
prior to admission, the home collates information about dietary needs, likes and dislikes
and favourite dishes.
chefs go into the dining room at mealtimes and ask for feedback
chefs are encouraged to speak regularly to carers, nursing staff and residents to get the
understanding of what is wanted and needed
all chefs working for the company receive ongoing professional development with the
Barchester Chef Academy providing training on specialist dietary requirements
the Barchester Healthcare has its’ own system of recognising excellence in nutrition
called "five-star dining experience"; Only 12 homes have been accredited this status.
one of the 12, Queen’s Court in Wimbledon, has recently become (Sept 2011) an
academy of nutrition; one senior care assistant (a nutritional champion) and a head
chef work together to ensure that the health and well being of the residents is
improved through good nutrition; the results show weight gain among the residents
and decline in prescribed food supplements;
79
(Community Care, 2011)
5.6.2. Local examples:
A lot of the examples of good practice in care homes across Manchester have already been
mentioned in earlier sections covering what we have heard from the managers during the
consultation event, one to one interviews, training event and what we saw during the
observations. There are few more local initiatives that we would like to mention is this part
of the report.
WREA BANK CARE HOME
According to CQC report, the manager allocates a specified amount of money each month
towards purchasing additional food to be prepared for residents as part of social activities.
This food is purchased from various culturally appropriate stores and an activity is then held
where the food is sampled and residents can discuss their likes/dislikes. Visitors are
encouraged to participate in these occasions. Some of the activities mentioned by CQC
included cheese and wine party, concerts with Oysters and Sushi, beer or chocolate tasting
sessions.
Comments from the residents praised the food provided and the inspector was told that
even though the main choice is between two dishes, kitchen staff always accommodate if a
resident asks for something different.
SHINE CARE HOME COLLABORATIVE
Improving nutritional status of the residents was only one part of the project but the staff in
involved care homes prioritised this area alongside the end of life care. The staff was
explained the importance of monitoring nutritional status, trained how to use MUST
screening tool and made aware of appropriate practice following on any changes occurring.
Additional training included dementia awareness and how it can impact on nutrition and
mealtime behaviour.
The homes identified changes and improvements that would be practical and realistic in
their environment which resulted in improved nutritional status of the under nourished
residents.
Improved knowledge and working with other members of staff as well as the support team
empowered the staff to make changes and improve practice. The culture within the homes
changed and instead of working in isolation, staff view themselves as part of a wider multidisciplinary team.
THE DEPARTMENT OF SPEECH, VOICE AND SWALLOWING - UHSM, WYTHENSHAWE
HOSPITAL, SOUTH MANCHESTER
The team identified providing training on swallowing difficulties to nursing home staff as an
urgent need. They now provide a rolling programme of training twice a year (April and
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October). All staff are encouraged to attend including carers, chefs and volunteers. The
sessions cover identification of swallowing problems and give lots of tips about how to
encourage eating for patients with dementia, stroke, progressive neurological disease etc.
The training looks at the nutritional experience from preparation (chef) through service and
support with eating (nurse/carer/volunteer) up until the swallowing stage (the resident).
Since the training event organised by Food Futures, which facilitated the face to face
meeting with some of the chefs working in care homes within the South Manchester area,
the team involve the chefs more directly in the assessment and recommendation process.
The chefs are also provided with texture advice sheets for each patient whose diet/drinks
we modify. Initial feedback from the team is very positive as the chefs appear to be taking
on board the importance of their role in both the safety of the patient and in encouraging
patients to eat by improving presentation etc.
The team have also begun to provide the homes with advice sheets on thickening fluids for
particular residents. These sheets are to be kept on the tea trolley so that the carers who
prepare drinks have an easy access to information specifying which thickness is safe for each
of the residents.
6.
REFLECTIONS ON THE PROJECT TO DATE
The main objectives of the project were exploratory which means that we aimed to gain
understanding of food provision in residential care settings and the issues that hinder good
nutrition and enjoyable mealtimes. By engaging with a range of stakeholders we have
gathered sufficient amount of information to identify the areas that are modifiable and can
be influenced.
Obtaining Social Research Ethics Approval for our observational research as well as number
of observations we carried out means that we have gathered some information about
mealtime experience of individuals who otherwise would not be consulted. This may be a
small scale research but in face of very little evidence around how people who lack capacity
(most often people with advanced dementia) or are unwilling to complain experience their
mealtimes in residential care settings, our findings are still very important piece of
information.
Having input from managers in care homes for people with learning difficulties and mental
health problems is also an important element filling in gaps within the evidence base.
Considering how little information is available around nutritional care for these vulnerable
adults in face of their poor health outcomes, we felt that anything we found locally was
extremely important. Making links with the Healthy Weight Manchester has already
resulted in some progress towards dietetic support for adults with learning difficulties and
further developments in this area are being discussed.
One of the most prominent achievements so far was the training for cooks and chefs that
we commissioned. This was our response to a very concerning and urgent gap in skills
highlighted by the managers and the Speech and Language Therapists.
The uptake of the training was very good and even homes from outside of Manchester
contacted us showing interest in attending. We trained 40 members of staff working across
North, Central and South Manchester. The training was rated very highly with 35 people
81
rating it as excellent and 5 people rating it as good. Only suggestions around improvements
to the training asked for more training of this kind and training on different areas such as
cooking for people with diabetes and other medical conditions. It was clear from the verbal
and written feedback that most of the staff would welcome more initiatives of this kind to
improve their skills and residents’ experience in effect.
This type of training was completely new to the staff, who were taken by surprise by the
form as well as the content. The opening discussions about the issues within their homes
and necessary changes proved very useful for us, colleagues from the SALT Team, colleagues
from the Community Nutrition Team, as well as the chefs. Exchanging views, experiences
and challenges, discussions about the various problems and tensions occurring on a day to
day basis was an invaluable source of information for all the participants. Introducing the
health practitioners to the chefs resulted in opened dialogues and appreciation on both
sides that involving kitchen staff in patient care much more is necessary to achieve better
outcomes.
The practical cooking sessions enthused most of the participants by showing everyone that
puree meals can look good and taste great if that extra effort is put into preparing these
meals. The cooks realised that they can still be proud of the food they offer to the residents
and the residents are still likely to enjoy their meals even though the texture has been
changed for them. What was also extremely important the chefs learnt exactly what
consistencies can be recommended and why it is crucial for residents’ safety to provide
appropriate consistency food and drink at all times.
The training was welcomed and appreciated by the cooks and chefs working in care homes
as well as a wide range of stakeholders who have been involved in this project. However,
the teams who have been most affected and appreciative of it were the Speech and
Language Therapists across the city. Thanks to the discussions and the content of the
training, the teams have changed their practice when they go to care homes. The chefs are
now included in the discussions around recommendations for an individual making them
feel more responsible for the health of that person but also making sure that they get the
exact recommendation rather than changed or partial information passed on by another
member of staff. Two of the practitioners also told us that because of the practical training
in preparing the foods, they feel much more confident to speak to the chefs and advise
them on how to prepare those foods. Another practitioner also told us how much difference
the training made to the food served in one of the homes where a “trained cook” now
prepares appetising puree meals. Meeting the dietician, nutritionist and the speech and
language therapists in person, gave the chefs and cooks confidence in dealing with these
health professionals. Building and improving these relationships is very important for both
sides and the residents will benefit from it as a result.
7.
PROJECT LIMITATIONS
There were 98 residential care homes registered with MCC at the time we started working
on this project but only 22 of the homes got involved. This means that we have engaged
with just over 22% of the homes in the city. Homes that have responded to the invitation
are likely to already see food as an important factor contributing to residents’ quality of life
and are more likely to be those already putting a lot of work into making dining experience
good and pleasurable for their residents - this may potentially cause bias as we may have
consulted only the “better homes”.
82
What we have learnt interviewing the managers is what they decide to tell us - it is their
subjective opinion or what they want us to hear or believe. We cannot verify what we have
heard. The training event and discussions with the catering staff highlighted some of the
issues that mangers may not be aware of or may not want to share.
We tried to engage with a wide range of stakeholders who support care homes as part of
their service. However, specifying all the teams that visit care homes and have potential
input into nutritional care of the residents proved to be very complicated. Also, the timing
of the project i.e. transformation of community service, structural changes within the NHS,
MCC and the trusts due to the NHS reform, made things much more complex with people
moving locations, employers, teams being disestablished etc. As a result, so far we have not
managed to map all the services supporting residential care homes in Manchester.
Our observational research was a very important part of the project but due to the
complexity of the client group and difficulties in obtaining the ethical approval from all
required parties, numerous limitations apply:
-
we observed only seven dining rooms
-
we only observed residents in homes for older people
-
in order to obtain consent from the residents we needed to rely on the managers’ or
staff’s opinion about each resident - they made the decision who could provide
informed consent and who was not able to do that and needed an appointed consultee;
this means that we relied on their subjective judgement of each person’s capacity
-
most of the homes that we were able to observe had over ten residents - observing
residents in very small establishments was felt to be overly intrusive and not feasible;
these homes are more like family homes where any outsider is clearly noticeable and
can cause distress for the residents
-
in larger homes which tend to have more than one dining areas the managers or care
staff will make a decision which areas are appropriate for the observation; some of the
residents can present challenging behaviours and presence of the researcher in the
dining room could be potentially distressing for the residents as well as the researchers;
this means that some of the residents with most complex needs may have not been
observed; safety of the residents as well as the researchers need to take the priority
-
the observations were announced i.e. the dates were agreed with the managers; this
meant that the staff as well as the residents were aware that researchers were present
on premises on that day, observing the meal time; as a result the staff and the residents
may not have presented their “usual” behaviour; also the kitchen staff was likely to be
aware that the mealtime was observed which may have resulted in better quality meals
-
we did not know the residents and did not know their usual behaviour which means
that our understanding of the “context” was limited and was likely to affect the
perception and wellbeing score
8.
SUMMARY AND RECOMMENDATIONS
Providing good nutritional care is only one of many responsibilities of staff working in
residential care homes. Good nutritional care goes far beyond providing safe and nutritious
83
food throughout the day. It includes providing people with what they want, when they want
it and where they want it whilst maintaining individual’s safety. Moreover, it includes
supporting and encouraging those who may not want to eat or may not be able to eat in an
acceptable and sensitive manner, respecting individual choices, promoting independence,
maintaining dignity and simply ensuring that people enjoy the mealtime as much as their
state of health allows.
Improving nutrition in isolation is unlikely to improve care standards and health outcomes in
residential care homes. However, improving mealtimes as a way of initiating wider change
in care homes – as a catalyst for wider changes to the culture of care - could potentially
have a big impact on health and wellbeing of the residents. A lot of the issues hindering
good nutritional care have impact on other aspects of care and this is why they should not
be separated.
Providing good care (including nutritional care) to vulnerable individuals with varied and
often very complex health needs is extremely difficult. Understanding the illness, the needs,
the symptoms and the context to certain behaviours is necessary in order to respond
skilfully and appropriately. This means quite specialist knowledge and a broad range of
skills, yet people working in residential care are predominantly unskilled and low paid
workforce with little access to training opportunities. There is a common feeling that the
level of complexity and general needs have been increasing over the years but these have
not been matched by increasing staffing levels or increasing numbers of skilled workforce
within the care sector.
Evidence shows very high levels of stress and burnout as well as very poor staff retention in
care sector. However, evidence also shows that improved knowledge and ability to deal
with complex issues improves outcomes for the residents and decreases stress levels among
the staff. The conclusion is that currently, staff are asked to deliver care to vulnerable
people with complex needs without being given the tools to do it, which results in poor
outcomes for both sides i.e. the residents and the staff.
In order to provide good care, staff working in care homes need to:
-
-
have a good understanding of the conditions prevalent among the residents and
how they impact on physical and mental health as well as residents’ behaviours
have a good understanding of how to address difficulties and handle challenging
behaviours
have the ability to recognise symptoms and signs of deterioration as well as the
knowledge of how to respond to these
have an understanding of what is meant by “good care” and how it should be
delivered
have an understanding how their role fits in with the other roles as part of a holistic
care and how important it is to work together towards the same goal i.e. good care
for the residents
have enough time and support/have manageable workload in order to implement
the knowledge and provide truly person centred care
have access to specialist training appropriate to their role
have access to specialist and timely support whenever the complexity of needs
exceeds their level of knowledge
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There is a plethora of guidelines on the nutritional care of older people in residential care
settings, which are not always implemented. This indicates that rather than provide more
guidance, toolkits and recommendations, we should actively support the care homes in
identifying the barriers to implementing the changes and improving the care provided to the
residents and finding ways to overcome these.
As previously mentioned, to address this complex issue, a holistic approach needs to be
taken by all those involved directly or indirectly in providing care to adults living in
residential care settings. We have produced lists of recommendations for a range of
stakeholders.
Recommendations for the commissioners:
1.
2.
3.
4.
5.
6.
All those who regulate care homes’ activity should ensure that inspection reports
include specific and detailed comments on food service and the management of
nutritional issues in that setting.
If any issues are identified, the regulator should support the care home to make
changes and improvements. This can mean advice, information on resources and
training available, information on supporting services available.
The issues identified need to be followed up to ensure that the advice has been acted
upon.
A possibility of specifying minimum spend per resident within the contractual
arrangements between MCC and care homes should be investigated.
Manchester currently has no specialist dietetic support for people with learning
difficulties or mental health issues. Considering the complexity of these client groups
and the high prevalence of nutritional ill health, this is a major gap within the system
that should be filled in as soon as possible.
Commissioners need to ensure that residents in care homes are cared for by staff who
have the right training, skills and knowledge. Training needs identified as essential:
- Everyone involved in supporting people in residential care needs:
• a good understanding of what it means to eat well in practice (diverse needs
and diverse guidance)
• a good understanding of residents’ health and medical conditions found in care
homes, how they affect individuals and how to manage the complex issues
• training in recognising and managing swallowing difficulties
• training in effective communication with complex service users
- Everyone who supports people with eating has to be trained to provide this support
in a sensitive and efficient way. Helping someone with eating can be complex and
stressful and it is essential that staff are given sufficient support from colleagues
when it’s challenging.
- Everyone who prepares meals and snacks for people on special diets including
modified consistency diets, fortified diets, diabetic diet etc. should receive
specialised training in this area.
85
Some of the training needs to be mandatory for all members of staff and some of it needs to
be mandatory for relevant members of staff. This should be specified within the contract
and the managers should be responsible for allocating time for the staff to attend the
training.
To ensure that the quality and content of training is satisfactory and that the training is
accessible to all the homes, the commissioners should take on the responsibility of choosing
the training provider and make it either free of charge to the care homes or make it
mandatory part of the contract reflected in the payment.
7.
Considering the difficulties in recruiting catering staff to work in care homes, this could
potentially be linked with the jobs and skills agenda.
8. Courses and training on healthy cooking should be accessible for people with learning
disabilities and mental health problems as well as their carers.
9. Some of the training could be delivered using existing capacity in the city. However, as
mentioned earlier in the report, the teams are already stretched and unlikely to be able
to commit to providing ongoing training for the staff working in care homes. This
indicates a need to increase the capacity of specialist services in the city. There are two
options available i.e. a) increasing the capacity of existing teams or b) creating an
additional “Care homes support team” which would focus on delivering a holistic
support to all care homes across Manchester.
10. Recognise good practice in nutritional care – Truly Good Food in Care award scheme to
be implemented.
Recommendations for the specialist services (teams supporting individuals in residential
care i.e. Speech and Language Therapists, Dieticians, Occupational Therapists, specialist
nurses and others):
1. The services should be more visible and accessible to all care homes. A resource pack or
communication exercise raising awareness of the support available seems necessary.
The care home staff should have clear information about all the services available
across the city. The information should cover:
- Remit of the service (geographical and contextual)
- Extent of the support provided
- Referral process
- Contact details
The homes should be able to contact the teams directly for advice before the referral is made in
order to avoid inappropriate referrals and deal with simple issues instantaneously.
2.
Some of the teams accept direct referrals but most still require GP or nurse to refer
people to the service. A lot of the residential care homes don’t have a nursing staff who
could make the referral so they need to make an appointment with a GP in order for
the resident to be referred. This system results in delayed specialist support that the
person requires and waits for and the GP is unable to offer. The referral process should
be simplified and all managers should be able to refer the residents straight to the
service. This may need to be backed up with training to prevent inappropriate referrals.
86
3.
The teams should actively identify training needs in care homes and either respond to
them within their own capacity (if feasible) or address them with a relevant
commissioner.
4.
When working with an individual in a care home, the practitioners/assessors should
involve staff members involved in all aspects of care to participate in the assessment
and/or recommendations provided.
5.
The teams providing support in care homes should use every opportunity to raise
awareness among the care home staff how they all play part in residents’ care and how
they all contribute to their well being or ill being.
6.
The teams supporting care homes in each locality should work closely together to avoid
duplication or giving contradictory advice, and to improve patient care. Setting up
processes to work together on complex cases can be initially difficult and labour
intensive but is likely to result in better case management, better outcomes for the
individual and fewer referrals to each of the services in the long run.
7.
Residents living and staff working in care homes across Manchester (North, Central and
South) should all have access to the same kind of support. Structural differences may
exist but the services and support provided should be the same. Heads of the services
should work together on making their offer consistent.
Recommendations for care homes:
The overarching, long term aim for the care homes should be to achieve the culture of care
that ensures dignity and good quality of life for all the residents.
General recommendations:
1. Managers should continue to foster a positive culture of care in their homes – they need
to ensure that all staff work together to provide good, holistic care for the residents.
This can be enhanced by:
•
improving staff’s understanding and better knowledge about the residents and their
illness
•
promoting training among staff – the better the skills the better the ability to deal
with complex issues i.e. the residents receive better care and the staff are under
less pressure
•
empowering, valuing and appreciating staff
2. Managers should ensure that the home follows best practice guidance in regards to food
and mealtimes. Using the contract details with Manchester City Council and prompts to
achieve Outcome 5 produced by the Care Quality Commission as an initial framework
would be one of the ways forward.
Practical recommendations:
87
1. Managers need to raise the profile of good food and enjoyable mealtime experience in
the home.
2. Groups of food champions should be formed in each home including staff members
from all the departments. These groups would ensure that:
•
All members of staff understand the importance of good food and nutrition for the
health of an individual.
•
All members of staff understand different factors that impact on food intake of the
residents (dementia, dental health, depression, environment, physical activity).
•
All members of staff are aware of the signs of malnutrition and swallowing
difficulties
•
All members of staff understand how their role impacts on the residents’ health and
wellbeing – directly or indirectly
•
All members of staff understand that working closely with other departments and
sharing information about the residents is crucial for effective communication and
good resident care
•
Any communication breakdown or conflicting messages between the departments
are identified and addressed.
•
Food intake is monitored, the residents screened regularly and any issues
highlighted are followed up and acted upon.
•
All residents receive appropriate support to consume a diet that is enjoyable,
reflects their needs and choices and enhances their wellbeing.
3. Managers, food champions or nursing staff should take turns in participating in the
mealtime with the residents. They should sit down with them and eat the same food to
experience the meals first hand - the way the residents experience it.
4. Care staff should take the meals with the residents on a regular basis.
5. Practical examples of making the mealtime more enjoyable identified in our
observations could be tried and implemented by other homes:
•
•
•
Family style dining :
Small tables – max 4 people together
Serving dishes on each table
Individual teapots on the table
Chef in the dining room
Protected mealtimes
88
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