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Evaluation article: Nutrition and hydration

Published: Tuesday, 08 September 2015

Martin Hodgson looks at fundamental standards Regulation 14: Nutritional needs, and offers some practical advice.

Summary

  • Services that provide food and drink as part of their offering should encourage service users to have an appropriate and suitable nutritional intake.
  • Nutritional screening and assessment should be carried out and referrals made to specialist assessment where required.
  • Meals should be appropriately spaced out and flexible to meet people’s needs, and people should enjoy their mealtimes and not feel rushed.
  • Service users should be supported to have a balanced diet that promotes healthy eating and be involved in decisions about what they eat and drink.
  • The service should identify risks to people with complex needs in their eating and drinking.

The importance of good nutrition and hydration

Few areas of care are as important as ensuring that service users have enough to eat and drink and have their nutritional and hydration needs met.

Concerns have been raised in recent years about the poor nutritional status of many people using care and healthcare services, particularly that of elderly people entering hospital or care home settings or living alone in the community. Many people receiving or coming into care settings have been identified as suffering from malnutrition and a number of initiatives have been launched to increase the amount of nutritional screening provided to properly assess their status and ensure that they have a plan of care in place and suitable referral to expert advice.

Service providers who provide food and drink as part of their service should encourage service users to have an appropriate and suitable nutritional intake, facilitate appropriate nutritional screening and assessment and facilitate referral for specialist assessment where required. This duty is an important part of the new fundamental standards and the inspection and ratings model based on the Care Quality Commission’s (CQC) five key questions.

KLOEs and rating characteristics

For both residential and community adult social care services, the CQC’s key lines of enquiry (KLOEs), set out in the provider handbooks, prompt inspectors to ask how people are supported to eat and drink enough and maintain a balanced diet. Advice for inspectors includes prompts for them to ask questions about:

  • whether meals are appropriately spaced out and flexible to meet people’s needs
  • how people are supported to have a balanced diet that promotes healthy eating
  • how they are involved in decisions about what they eat and drink
  • how the service identifies risks to people with complex needs in their eating and drinking
  • how people’s nutritional needs are identified, including those relating to culture and religion
  • arrangements for people to have access to dietary and nutritional specialists to help meet their assessed needs
  • whether food is served at the correct temperature
  • whether people enjoy mealtimes and do not feel rushed.


For domiciliary care services, some prompts only apply where the service is responsible for helping service users with their food and drink needs.

Suggested sources of evidence and further question prompts are also set out in the KLOE guidance.

In the rating characteristics, the provider handbooks state that in a residential service rated as ‘good’:

  • staff protect people, especially those with complex needs, from the risk of poor nutrition, dehydration, swallowing problems and other medical conditions that affect their health
  • people’s nutritional and hydration needs are regularly monitored and reviewed
  • relevant professional advice is obtained and people using the service are actively involved in this
  • people say that the food and mealtimes are consistently good and speak positively about the menu and the quality of food provided
  • people feel actively involved in this aspect of the service and able to give feedback on a regular basis.

In domiciliary care services the CQC handbook notes that these characteristics only apply where food is provided as part of the service.

For a good service to be rated ‘outstanding’, the additional characteristics are:

  • a strong emphasis on the importance of eating and drinking well
  • innovative methods and positive staff relationships used to encourage those who are reluctant or have difficulty in eating and drinking
  • people’s dietary and fluid intake significantly improving their well-being, especially those living with dementia or those with a learning disability
  • excellent links with dietetic professionals
  • staff being aware of people’s individual preferences and patterns of eating and drinking
  • people saying that mealtimes and the quality of food and choice are exceptional, their individual needs are met and staff go out of their way to meet their preferences.

Nutritional needs

People do not only need access to adequate amounts of food and drink – they also need access to the right types of decent quality food and drink so that they receive a nutritionally adequate diet. In some cases a person may have access to enough food that they are not hungry, but the diet may be so poor that they remain technically malnourished.

A poor diet is associated with a number of poor health outcomes, including obesity, vitamin deficiencies, constipation and bowel problems and diabetes.

The diet provided in many care homes and hospitals has been criticised in the past both by inspectors and by dieticians and nutritionists. This is changing, just as the national diet is changing. These days a multicultural and varied diet designed to suit a range of people and cultures is a necessary minimum requirement. Religious needs also need to be catered for and festivals, fasts and feast days appropriately supported.

Providers should assess the nutritional needs and preferences of all new users of care homes and domiciliary care and record any malnutrition risks identified at the start of their care. For this purpose many providers use a standardised nutritional screening tool.
Providers should:

  • facilitate or support appropriate nutritional screening and assessment where necessary
  • refer service users for specialist assessment where required.

Where a provider identifies a potential risk, it should take action to minimise this. For example, the service user might be en-couraged to see their GP or may need specialist advice, for example from a dietician, a speech and language therapist (to advise on swallowing problems), or an occupational therapist (to assess daily living skills).
The provider should discuss interventions with the service user and, where appropriate, their family or representatives, and enter these into their plan of care. Providers should review plans regularly.

Menus and food and drink preferences

Many older people in social care settings will not be able to cater for themselves, or may not want to. However, others will still want to do what they can and care homes and domiciliary care settings should support this important aspect of independence wherever possible. The ability to prepare their own snacks and drinks, within a safe environment, will be a key element for some in living with dignity and self-determination.

Settings such as care homes should provide a menu that is changed regularly and offers a choice of meals that meets the preferences of service users. It should be written or produced in a format that is accessible and understandable for all service users. If necessary, it should be explained or read to service users.
Special therapeutic diets and meals should be provided when advised by health care and dietetic professionals. Religious or cultural dietary needs should also be catered for as agreed at admission and recorded in a service user’s care plan. This in-cludes food for special occasions such as feasts and holy days.

Mealtimes

Meals and mealtimes are crucially important in many services, particularly in hospitals or in residential services. For example, in care homes and other residential settings or healthcare settings, many service users regard the food they are given as one of the most important aspects in their care and the availability of food, drinks and snacks are vital elements in maintaining a ‘normal’ life. The quality and standard of food, or of helping those service users who need assistance in eating it, are crucial in ensuring that they receive a nutritious diet.

The social aspects of eating meals, especially in settings such as care homes, are just as important as the quality and nutritious value of them. In a care home, for example, people usually gather to take their meals together and it is part of the running of an effective care home that these times are made to be a pleasant and relaxing experience for service users where they can enjoy each other’s company. Some residents will of course wish to take their meals in their rooms and this should be facilitated wherever possible.

The atmosphere around mealtimes is considered to be particularly important. Mealtimes in both care homes and in domiciliary settings should be unhurried, with staff giving service users enough time to eat.

Staff should be available to offer help and support with eating where necessary. They should do this discreetly, sensitively and individually. Independent eating should be encouraged for as long as possible with service users being helped by the provision of suitable aids and equipment.

Hydration and dehydration

It is important that the hydration needs of service users are not neglected. Hydration means drinking adequate amounts of fluid to keep the body healthy. Water is vital to most bodily functions and if the body does not take in enough water each day the result may be dehydration.

Early signs of dehydration include feeling thirsty and lightheaded, or passing dark-coloured urine. In serious cases the skin will be dry and saggy and the person may experience confusion, lethargy, depression, inactivity and fatigue.

Constipation is common in cases of dehydration, as are blood pressure problems and headaches. For older people the effects may be more pronounced and result in greater vulnerability to infection – especially urinary tract infections, poor skin healing, kidney stones, dizziness, confusion and falls.

Severe dehydration is a medical emergency. It can be made worse as a result of an illness where fluid is lost, such as vomiting and diarrhoea.

Providers should identify any risk of dehydration applying to new users of care homes and new domiciliary care clients at the start of their care. Providers who supply food and drink as part of their service should:
encourage service users to drink so they are adequately hydrated

  • provide drink choices for people to meet their diverse needs
  • provide appropriate, skilled and sensitive help and assistance with drinking where this is required.

For care homes the standards specify the need to ensure that access to drinks is provided throughout the day and night.

The Social Care Institute for Excellence (SCIE) published guidelines on hydration as part of the Dignity in Care campaign.

SCIE states that adult social care providers should:

  • have a drinking water policy to meet the hydration needs of their users
  • promote the importance of good hydration to service users and staff
  • include hydration in staff induction training.

In all settings drinking water should be made accessible to service users throughout the day, either in the care home or in people’s own homes.

Service users in adult social care sometimes have concerns related to drinking fluids, which makes them reluctant to drink water. For example, they may have limited mobility and worry about getting to the toilet. Care staff should reassure service users and ensure that any continence care needs are assessed and addressed.

More information on meeting nutritional needs is in the article ‘Causes of refusal to eat and drink’, which is available online for Premium Plus customers.

Toolkit

Use the following items in the Toolkit to help you to put the ideas in this article into practice:

About the author

Martin Hodgson MSc, PGCEA is a community psychiatric nurse by background, and has had a long career working as a senior manager in various health agencies, including mental health, primary and community care.

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