Eating well in care homes for older people

scottish commission for the regulation of care

eating well in care homes for older peolple

Eating well in care homes for older people

Acknowledgements Photography by Ally Stuart and PA photos © PA photos and the Care Commission Thanks to Janet Brougham House and to Andrew Cosgrove, Williamina Gordon, Catherine Inglis and Clara Simpson.

About this publication Author

The Care Commission

eating well in care homes for older peolple

Publication date August 2009 Audience

People who use care services Carers Service providers and commissioners Scottish Government Local authorities and health boards Universities and colleges of further education Other regulators Advocacy organisations The general public Care Commission Board, committees and groups Care Commission officers and staff

Reference

IHD/007/0709

Copyright

© Care Commission 2009. All or part of this publication may be reproduced, free of charge, in any format or medium provided it is not for commercial gain. The text may not be changed and must be acknowledged as Care Commission copyright with the document’s date and title specified.

This publication is available in other formats and languages on request. www.carecommission.com Helpline 0845 603 0890

Foreword

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Terms we use in this report

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Summary, findings, conclusions and recommendations

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Part 1 – The background to this report

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Part 2 – What did we find at our inspections?

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Part 3 – What did we find when we investigated complaints?

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Part 4 – What enforcement action did we take?

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Part 5 – Promoting nutrition in care homes for older people

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References

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Appendix

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eating well in care homes for older peolple

Contents

eating well in care homes for older peolple

Foreword Eating and drinking is an important part of everyone’s daily life. Meals are social occasions and should be enjoyable. Good nutrition is a fundamental part of good care. People in care homes are among the most vulnerable in our community. They depend on the care home and its staff to provide balanced meals and ready access to as much water and other liquids as they need. So it’s important that care services aren’t just aware of what they ought to be doing – of the policies and procedures they should have in place. They should also be skilled in assessing each person’s unique eating, drinking and dietary needs and make sure all staff know how to meet those needs. Everyone who cares for people in a care home must know what the National Care Standards for Eating Well mean to them and to each individual in their care. We found examples of good quality nutritional care in Scotland’s care homes for older people. We also found there is plenty of room to improve. We are concerned about the high numbers of complaints we receive and the enforcement action we have had to take to ensure the safety and welfare of people living in care homes. As a result of our findings we’ve made clear recommendations in this report about what all care homes should do. We’re also going to build on the excellent work of the Nutrition Champions Programme that we tell you about in Part 5. This will include encouraging Scottish Government to help fund and support the programme across Scotland.

Susan Brimelow Director of Healthcare Regulation Care Commission

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eating well in care homes for older peolple

We’re confident the findings and recommendations in this report will contribute towards improving standards of nutritional care in care homes for older people across Scotland.

Terms we use in this report This report uses many specialist terms and, where possible, we explain these in the report. In this section we define terms that occur several times throughout the report. Best practice In this report, best practice describes ways of caring, which have been shown to work well in care homes for older people and in other social care services. Personal plan A care home should agree a personal plan for each person. The plan sets out in writing how the home will provide for the person’s health and well-being. Hydration In this report hydration is the act of giving a person enough fluid, so that they do not become dehydrated (see ‘dehydration’ below). An average person’s weight is made up of two-thirds water. Dehydration This is loss of fluid from the body, for example through illness or from not drinking enough fluids. Dehydration can have serious consequences for the health and well-being of older people. It can contribute to problems such as increased confusion, constipation, pressure ulcers, urine infections and falling. Food and fluid charts These charts help care home staff to monitor how much food and drink that individual people are taking in every 24 hours.

eating well in care homes for older peolple

Nutrition Nutrition is the food and drink people take to sustain them. Under-nutrition This is when a person does not get enough calories in their diet. It can cause problems such as unplanned weight loss. Nutritional Screening Tool This is an aid to assess and identify people at risk of under-nutrition. Malnutrition This can refer to both under-nutrition and over-nutrition. In this report it is used to refer to under-nutrition.

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Dietitian A person who is specially trained in the nutritional needs of people. A dietitian will assess a person in order that the food and fluid given to the person is nutritionally balanced and meets their needs. They will advise about how best to ensure that people have the right nutrition. Food textured diets This is when food is mashed, pureed or liquidised to make it easier to eat and swallow safely without choking.

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Fortified diets This is when meals and snacks are made more nourishing and have far more calories by adding ingredients such as extra butter, double cream, cheese or sugar.

Summary, findings, conclusions and recommendations About this report This report details what we, the Care Commission, found when we: • looked in detail at five areas of food and nutrition in a sample of 303 care homes for older people in Scotland during our inspections in 2006 to 2007 • investigated 91 complaints about eating, drinking and nutrition in 2006 to 2007 • looked at the improvement notices we served on care homes in 2008 to 2009 • worked with staff called nutrition champions to make improvements in eating, drinking and nutritional care in the care homes where they were working. Our findings We found that just over half (51%) of the 303 care homes met the National Care Standards in all the five areas we looked at. We found most of the 303 care homes (85%) had a written food and nutrition policy, which is good practice. Indeed, we found that most of the care homes that had such a policy took care to assess their residents for the risk of under-nutrition and had their menus nutritionally assessed by a dietitian. We found that almost three quarters (71%) of the 303 care homes screened people for the risk of under-nutrition. The majority of care homes (94%) reported that their residents could be seen by a NHS dietitian if they needed to. 66% of care homes screened people for the risk of dehydration when they first came to the care home and 85% of services had personal plans which identified care for every person ‘at risk’ of dehydration. These positive findings at inspection differed from our complaint investigation findings.

eating well in care homes for older peolple

What did we find from complaints? We investigated 91 complaints about eating, drinking and nutrition in care homes. We upheld or partially upheld 76 of the 91 complaints. This means we agreed that the complaints, or parts of them, were valid. Some of the 76 complaints raised more than one concern about food and nutrition. In total, we investigated 164 concerns. By far the largest number of complaints were about people’s dietary needs not being met, in particular not providing enough fluids. 52 of the 164 concerns investigated were about dehydration. Our biggest concern was that people were not being offered drinks, and/or

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encouraged to drink regularly. The other most frequent issues which we received complaints about were: • unplanned weight loss • not having enough fresh fruit and vegetables • not being provided with special diets when needed: for example, high calorie diets for people who are underweight or pureed food if they have eating and drinking difficulties • lack of choice of meals and drinks • not getting enough help to eat and drink • failing to assess people’s nutritional needs and then not taking the correct action. What enforcement action did we take? We served improvement notices on 10 care homes for older people from 1 April 2008 to 31 March 2009 to enforce improvements in nutrition and hydration. An improvement notice is a legal notice that requires services to make improvements within a set timescale. We took enforcement action to improve important areas of nutritional care, including: • meeting people’s dietary needs – for example, for unplanned weight loss or pureed food • using recognised nutritional screening tools, to assess under-nutrition • providing more staff training in planning menus and meeting the nutritional needs of older people • making more staff available to help people to eat and drink • doing more to make sure people have access to enough to drink and to encourage them to drink fluids regularly. Our conclusions

Most care homes had written food and nutrition policies and, in the vast majority, people using the service had access to dietitians. Most care homes screened for the risk of under-nutrition and for the risk of dehydration when people come to stay in the service. The exception to this mainly positive picture was that slightly over half of care homes did not have menus nutritionally assessed by a dietitian. However, we were concerned that the positive findings from our inspections were in contrast to what we learned from our complaints investigations. Almost half of these were about people’s dietary needs not being met, both in appropriateness of food and in getting enough to drink. We have therefore come to the conclusion that policies and procedures are not

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In the five areas we specifically looked at in our inspections our findings were generally positive.

nearly enough. All staff in care homes need to be far more aware of best practice to ensure people eat and drink well. We received 91 complaints between 1 April 2006 and 31 March 2007 about eating, drinking and nutrition and we are concerned about the high number of complaints we continue to receive. Taken together, this report’s findings from inspections, complaints and enforcement action highlight areas in which everyone involved with care services for older people in Scotland can take action to improve standards of nutritional care. Our recommendations

eating well in care homes for older peolple

People who live in care homes, their families and carers should: • be aware that there are National Care Standards for eating well in care homes • expect to be able to discuss with the people who provide services what they have in place to make sure people’s eating, drinking and nutritional care needs are met • ask questions about how their loved ones nutritional needs are being met. Care homes should: • ensure that nutrition and hydration is specifically set out in all personal plans • read this report and use the information in it to continue to improve their practices • make sure they have a relevant and up-to-date eating, drinking and nutrition policy and procedures that reflect best practice • provide education and training for staff so that they can understand, assess and meet people’s needs in eating, drinking and nutrition • assess people’s risk of dehydration and put in place best practice to help prevent dehydration • measure and monitor people’s fluid intake on individual charts • have a reliable nutritional screening tool • regularly weigh and record people’s weight with well-maintained scales • assess the risk of under-nutrition, as detailed in the National Care Standards • make sure that menus are planned to meet dietary needs of older people • involve people in developing and planning menus • ensure there are sufficient staff to help people to eat and drink • ensure good communication between care home staff and the person living in the care home and their relatives • go to the Care Commission website and the new nutrition website for information on best practice at www.carecommission.com and www.nutritioncare.scot.nhs.uk

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Local authorities should: • ensure that care managers take account of the eating, drinking and nutritional care needs of people in their assessment and review process • ensure that they take account of the eating, drinking and nutrition needs when commissioning care home places • make clear in their contracts with care home providers the standards of food and nutrition they expect care homes to provide. NHS Boards should: • make training available to care home staff in eating, drinking and nutritional care • make sure that people who require a special dietary assessment and advice can see a dietitian when they need to. The Scottish Government should: • use the findings of this report to inform future development work in the area of food, drink and nutrition.

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eating well in care homes for older peolple

We will: • continue to promote the National Care Standards and best practice in eating well in care homes for older people • work with other organisations, such as Scottish Care, to encourage widespread use of the National Care Standards for Eating Well • ensure that care homes act on all the requirements and recommendations we make about eating, drinking and nutrition • actively encourage Scottish Government to fund and support the nutrition champions programme across all care homes in Scotland • work with dietitians across Scotland towards making sure that standards of nutrition in care homes are of a consistently high standard.

Part 1: The background to this report This part of the report sets out: 1. 2. 3. 4.

Who we are and what we do What the national care standards say Why we have published this report The information we looked at

1. Who we are and what we do The Care Commission was set up in 2002 to help improve care services in Scotland. We register and inspect just over 14,500 services that care for more than 320,000 people in all parts of Scotland. These services include childminders, foster care and adoption services, nurseries, daycare services, care homes and private hospitals. As Scotland’s national care regulator, we register and inspect services, investigate complaints and, where necessary, take legal action to make sure a service is meeting the standard of care it should be. After we inspect each service we send out an inspection report. This describes what we found and may include one or more recommendations or requirements: • Recommendations are improvements we consider a service needs to make to meet the National Care Standards. • Requirements are statements we make if a service is not complying with legislation. They set out what the service must do within a timescale agreed with us.

eating well in care homes for older peolple

We also have a legal power of enforcement which means we can use the law to: • vary or impose new conditions that services must meet to be registered with us • serve a legal notice that requires services to make improvements within a set timescale • cancel a service’s registration. All inspection reports are available on our website at www.carecommission.com or by contacting our lo-call helpline on 0845 603 0890. We also publish reports that give a national picture of how available care services are and what we have found about the quality of care services.

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2. What the National Care Standards say National Care Standards set out the standards of care that people can expect from any care service they use. The National Care Standards for care homes for older people1 describe the standards that older people can expect for eating well in care homes. These are available on our website at www.carecommission.com Standard 13 “Your meals are varied and nutritious. They reflect your food preferences and any special dietary needs. They are well prepared and cooked and attractively presented.” Standard 14 “You can be confident that the provider is aware of your nutritional state and will, with your agreement, arrange for this to be regularly assessed and reviewed. This assessment will take account of any changes in your health.”

3. Why we have published this report People in care homes are among the most vulnerable in our community and depend on others for their eating, drinking and nutritional care. Eating and drinking should be an enjoyable part of their daily life. Making sure older people have nutritious food and drinks is fundamental to good care.

Previous work in the area of food and nutrition for older people, A Diet Action Plan for Scotland2, and Eating for Health - Meeting the Challenge3, has shown that there are specific areas of concern. For example, a national study published by the Scottish Executive in 20004 showed that, from 1997 to 2000, older people in long-term care were at increased risk of not having their nutritional needs met and were not being screened for the risk of under-nutrition. We published this report to make people more aware of the standards of good practice we expect all care homes to follow and to report that a lot more work needs to be done to improve people’s eating, drinking and nutritional care across care homes in Scotland. 1 The National Care Standards: Care homes for Older People, (Scottish Government 2007) 2 A Diet Action Plan for Scotland (Scottish Executive 1996) 3 Eating for Health – Meeting the Challenge (Scottish Executive 2004) 4 The Nutrition of Elderly People and Nutritional Aspects of Their Care in Long-term Care Settings Final Audit Report 1997-2000 (Clinical Resource and Audit Group (CRAG) August 2000 Scottish Executive)

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Care homes should be promoting good nutrition to maintain people’s health and prevent problems such as constipation and dehydration. They should also provide good care to manage swallowing difficulties and weight loss.

4. The information we looked at During our inspections in 2006/07 we looked in detail at five main areas in a sample of 303 care homes for older people in Scotland. We wanted to know: • Do care homes have food and nutrition policies that help make sure people are eating well? • Do care homes assess people for the risk of under-nutrition and regularly check for signs of under-nutrition? • Do care homes: – assess people for the risk of dehydration when they first come to the care home – have personal plans that set out the care for each person ‘at risk’ of dehydration – make sure people drink enough? • Can people see a dietitian if they need to? • Do care homes have their menus nutritionally assessed by a dietitian? In addition to our inspections, we looked at all the complaints we received in the same year about eating, drinking and nutrition and then examined our enforcement activity in 2008/09 in this area. We received a total of 91 complaints in 2006/07 about eating, drinking and nutrition and we continue to be concerned about the high number of complaints we receive.

eating well in care homes for older peolple

We served improvement notices on 10 care homes for older people to enforce improvements in nutrition and hydration from 1 April 2008 to 31 March 2009.

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Part 2: What did we find at our inspections? This section sets out what we found in 2006/07 when we looked closely at five areas of eating, drinking and nutritional care in a sample of 303 care homes across Scotland and the actions we took to address any concerns. It also highlights the best practice we would expect all care homes to follow.

1. Do care homes have food and nutrition policies that help make sure people eat well? Food and nutrition policies and procedures help to show that the people who manage a care home understand best practice in eating and drinking. They set out how staff can best meet people’s eating, drinking and nutritional care needs. They are also used for staff training. Of course, it is possible to have good food and nutritional care without having a food and nutrition policy. But nutritional care is often not as good as it could be because: • it is not clear who is responsible for doing what • there is no clear plan for meeting people’s eating and drinking needs • there is no clear advice on how to deal with nutritional problems. We found that the majority of these care homes, 258 (85%) had a written food and nutrition policy. We also found that the care homes with a food and nutrition policy were more likely to assess people for the risk of under-nutrition and have their menus assessed by a dietitian. However, many services with a policy did not have clear enough written procedures for staff to follow on how eating, drinking and nutritional care should be provided. We would expect all care homes to have a clear written policy and procedures based on best practice. This will help ensure people’s meals are varied and nutritious, that meal times are enjoyable and help staff with training to understand people’s special dietary needs including food textured diets and fortified diets.

• We made requirements about food and nutrition policy in 26 care homes. • We made recommendations about food and nutrition policy in 105 care homes.

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What action did we take?

2. Do care homes assess people for the risk of under-nutrition and regularly check for signs of under-nutrition? Under-nutrition is often unrecognised and untreated in care homes5. Under-nutrition is when a person does not get enough calories in their diet. It can cause problems such as unplanned weight loss. In September 2007, the British Association for Parenteral and Enteral Nutrition (BAPEN)6 carried out the UK’s first national survey of nutrition screening among people admitted to hospitals and care homes. It found that the overall risk of under-nutrition in general hospitals and care homes was 28%. Nutritional screening is a quick and good way for care staff to detect significant risk of undernutrition. There are over 50 published nutritional screening procedures, or tools, but many have not been tested for reliability and accuracy for people in care homes. In 2003, following a research project5 the Malnutrition Universal Screening Tool (MUST) was developed to help identify adults who are underweight and at risk of under-nutrition. MUST works by assessing: • body mass index (BMI), which measures people’s weight against their height, and • how much weight a person loses over time. It also takes account of any illness that may affect how much a person eats and drinks. Body mass index highlights the risk of under-nutrition and is much more useful than measuring weight alone. We expect all care homes to undertake nutritional screening when people first come to stay in a care home and people’s nutrition and weight should be assessed at regular intervals with their consent.

eating well in care homes for older peolple

We expect all care homes to be using a reliable nutritional screening tool such as MUST and to have well maintained and calibrated scales. If people are found to be at risk of under-nutrition, we expect care homes to have a personal plan in place to deal with unplanned weight loss.

5 The “MUST” Report – Nutritional screening of adults: a multidisciplinary responsibility (British Association of Parenteral and Enteral Nutrition 2003) 6 BAPEN Nutrition Screening Week 2007 data: information is provided courtesy of BAPEN www.bapen.org.uk

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What did we find? In the 303 care homes we looked at we found that 216 (71%) screened people for the risk of under-nutrition. Eighty-seven care homes (29%) did not screen people for the risk of under-nutrition. Mistakenly, some staff thought that they could tell just by looking at a person if they were at risk of under-nutrition. What action did we take? • We made requirements in 27 care homes about screening for the risk of under-nutrition. • We made recommendations in 23 care homes about screening for the risk of undernutrition. • We made a further 38 recommendations because care homes could not show us that they were using a nutritional screening tool that is nationally recognised as being best practice.

Ways to improve people’s experience In one care home we looked at, the manager had reviewed the processes that were being used to assess all residents for the risk of under-nutrition. The manager was concerned about the accuracy of service users’ weight. The care home purchased new scales and reassessed all service users.

3. Do care homes:

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• assess people for the risk of dehydration when they first come to the care home • have personal plans that set out the care for each person ‘at risk’ of dehydration • make sure people drink enough?

Dehydration is a loss of fluid from the body caused by illness or not drinking enough fluids. Water is essential to health and not having enough to drink can cause dehydration. Dehydration can have serious consequences for the health and well-being of older people. It can contribute to problems such as increased confusion, constipation, pressure ulcers, urine infections and falling. We expect services to: • assess if people are at risk of becoming dehydrated • have systems in place to make sure people are drinking enough fluids, such as water and other liquids • adopt best practice on fluids which has been shown to work well, for example the 7 Water for Healthy Ageing toolkit published by Water UK in 2005 . What did we find? A total of 201 care homes (66%) screened people for the risk of dehydration. 257 care homes (85%) had set out, in the personal plans in place, a plan of care for those identified as being at risk of dehydration. However we found 102 care homes (34%) did not screen people for dehydration when they came to live in the care home. In 46 services (15%), the care home had not set out in people’s personal plans how they would make sure a person was drinking enough fluid to stop them becoming dehydrated. Whilst many care homes did make sure people were drinking enough, we found that not all had drinks easily available or accessible, for example in the sitting room, at mealtimes and in bedrooms. Further, in some care homes where people were at risk of dehydration we found that staff were not making sure that they were drinking enough fluids and were not always aware of the minimum level of fluids people should be drinking.

eating well in care homes for older peolple

What action did we take? • We made requirements about improving practice to avoid dehydration in 9 care homes. • We made recommendations about avoiding dehydration and having drinks available in 21 care homes.

7 To access this online link, go to our website and click through ‘Care services’, then ‘healthcare advice’, then ‘nutrition information’, then ‘Water for Healthy Ageing Toolkit’.

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Ways to improve people’s experience Staff can agree on an accurate method of measuring and monitoring what people drink to ensure all staff are using the same measurements when updating fluid charts. Posters and cards with the measurements can be displayed in the kitchen.

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Can people see a dietitian if they need to?

A dietitian is a person who is specially trained in the nutritional needs of people. A dietitian will assess a person in order that the food/fluid given to the person is nutritionally balanced and meets their needs. Sometimes people will need a dietitian to assess their eating, drinking and nutrition needs or give them advice. This should happen if, for example, a person: • is fed through a tube, rather than taking food by mouth • is continuing to lose weight, even though the service has been trying to help them gain weight • needs food mashed or pureed to make it easier to eat and swallow safely • has diabetes which is not well controlled. A care home must make sure people have access to any healthcare professional they need. This is set out in the Regulation of Care (Scotland) Act 2001. What did we find? We found that most care homes 285 (94%) said they had access to an NHS dietitian.

We also found that some services: • could only get help from a dietitian if the person was being fed through a tube, or • could, and did, request the help of a dietitian but were not making best use of the advice they were given. What action did we take? • We made recommendations to four care homes about improving their access to a dietitian.

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However, 18 services (6%) reported that they had difficulties in arranging for an NHS dietitian to visit people.

5. Are menus nutritionally assessed by a dietitian? A national audit in Scotland8 of people in care, including care homes, recommended that all menus should be assessed by a dietitian before they were introduced to make sure they met people’s nutritional needs. Dietitians can help care home staff, cooks and chefs assess the nutritional value of their menus. What did we find? We found that only 40% of the 303 care homes had their menus nutritionally assessed by a dietitian. We found some menus had not been planned to meet the individual needs or preferences of older people in care homes. For example: • Not enough food choices were high enough in energy to help older people with small appetites to stop losing weight. • Not enough soft, easily chewed food was available at meals and as snacks. • Menus had not been designed to be nutritionally balanced to ensure the quality of the food rather than the quantity. Eating five portions of fruit and vegetables a day is now widely considered as best practice for adults and we would expect care homes to have more than five portions of fruit and vegetables on the menu every day to allow for people’s varied appetites and preferences. What people said:

“I get three courses at

eating well in care homes for older peolple

lunch time and two courses at tea time – it’s all very nice food”

“The food is grand – I clear my plate”

“I a m well fed with “I like the meals – just like a hotel”

good food and I get breakfast in my room”

8 The Nutrition of Elderly People and Nutritional Aspects of Their Care in Long-term Care Settings Final Audit Report 1997-2000 (Clinical Resource and Audit Group (CRAG) August 2000 Scottish Executive)

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What action did we take? • We made recommendations in 26 care homes to assess and improve their menus. • We made requirements and recommendations about including more fruit and vegetables for people in 35 care homes.

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Ways to improve people’s experience Chop fruit up and serve it attractively. Offer it every day at snack and meal times.

Part 3: What did we find when we investigated complaints? We received a total of 91 complaints in 88 care homes about eating, drinking and nutrition in 2006/07 and investigated them all. We upheld or partially upheld 76 complaints in 73 care homes (this means we agreed that the complaints, or parts of them, were valid). We did not uphold 15 complaints. In some of the 76 complaints we upheld or partially upheld, complainants had raised more than one concern about eating, drinking and nutrition. In total we investigated 164 separate concerns. What were the complaints about? We considered each complaint against the National Care Standards for care homes for older people, in particular, standard 13, which is about eating well, and standard 14.6 which is about nutrition and health.

eating well in care homes for older peolple

During our complaints investigations we may observe meal times, and sometimes our inspectors have a meal with service users. We can ask people whether they are being given the help they need with eating and drinking and we ask them about the quality of the food.

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Standard 13 Eating well: “Your meals are varied and nutritious. They reflect your food preferences and any special dietary needs. They are Number of well prepared and cooked and attractively presented.” concerns 13.1 Catering and care staff get to know your food choices and preferences, 2 including ethnic, cultural and faith ones. Any special diet (for example, vegetarian, low fat or high protein) is recorded in your personal plan. 13.2 You are offered a daily menu that reflects your preferences. The menu 9 varies regularly according to your comments and will always contain fresh fruit and vegetables. 13.3 You have a choice of cooked breakfast and choices in courses in your 18 midday and evening meals. 13.4 Meals are nutritionally balanced for your dietary needs, for example, if 81 you are diabetic or have poor kidney function. 13.5 You can have snacks and hot and cold drinks whenever you like. 0 13.6 If you are unable to say if you are getting enough to eat or drink, staff will keep an eye on this for you. If there are concerns, staff will explain them 25 to you or your representative. With your agreement, staff will take any action needed, such as seeking advice from a dietitian or your GP. 13.7 Your meals are well prepared and presented. All food handling follows 13 good food hygiene practices. 13.8 You are free to eat your meals wherever you like, for example in your 0 own room or in the dining room. You can eat them in your own time. 13.9 You must be able to eat and enjoy your food. If you need any help to 9 do so (for example, a liquidised diet, adapted cutlery or crockery, or help from a staff member), staff will arrange this for you. 13.10 Staff will regularly review anything that may affect your ability to 4 eat or drink, such as your dental health. They will arrange for you to get advice. Standard 14 Keeping well – healthcare: “You can be confident that the provider knows your healthcare needs and arranges to meet them in a way that suits you best.” 14.6 You can be confident that the provider is aware of your nutritional state and will, with your agreement, arrange for this to be regularly assessed and reviewed. This assessment will take account of any changes in your health. Total

3 164

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Table 1: Shows the number of complaints we received and how they link to the National Care Standards 13 and 14.

What did we find in our complaints investigations? The most common concerns in the complaints we received were about people not receiving balanced meals to meet their individual needs: standard 13.4. These included: • 27 concerns about people not having access to enough water and other liquids to drink. • 17 concerns about weight loss or under-nutrition. • 13 concerns about the general quality of food. • 13 concerns about special dietary needs not being met, for example pureed or diabetic diets. • 11 concerns were about a lack of fruit and vegetables and general dietary needs not being met. Dehydration Dehydration is when there is loss of fluid from the body, for example through illness or from not drinking enough fluids. Dehydration can have serious consequences for the health and well-being of older people. It can contribute to problems such as increased confusion, constipation, pressure ulcers, urine infections and falling.

eating well in care homes for older peolple

Overall dehydration was the biggest issue with a total of 52 complaints. We found that: • people were not being offered and encouraged to drink regularly • drinks were out of people’s reach • there was confusion about who was responsible for offering cold drinks to people • personal plans were not in place to make sure people at risk of dehydration were given enough to drink • care home staff were slow in starting fluid charts and were not keeping them up to date and acting on the results. We expect all care staff to understand about dehydration and how to treat it. Staff should regularly check that people are drinking plenty and people who are at risk of dehydration should have fluid charts set up. These charts help staff to monitor the drinks that individual people are taking.

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Getting help to eat and drink We upheld nine complaints about people who were not getting help to eat and drink. When we investigated these complaints we found: • there were not enough staff to help people at meal times • there was no personal plan setting out what assistance to give at meal times to people who needed help to eat and drink • there was poor communication between staff about people’s need for help to eat and drink. Assessing people’s food preferences and dietary needs Some homes were not ensuring that, when people move into and live in a care home, the information about what they liked to eat and drink was detailed enough to allow staff to: • help people eat healthily • identify the best food to offer people when they are unwell • help people choose the food they like if they needed to boost the number of calories they are eating • plan menus.

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Menus and catering for special diets Some homes did not plan menus to meet people’s needs. We found that care homes needed to: • develop catering arrangements to manage special diets, for example, for people with weight loss, or diabetes, or who need pureed food • properly consult people about menus as they are being developed, to make sure they cater for people’s preferences • offer enough choice on their menus for meals, snacks and drinks • provide choices reflecting religious beliefs, or special diets such as vegetarian diets • provide a suitable alternative if the person did not like the dish on the menu • improve cooking quality, as we found evidence of tough, over cooked and dried-up food • take steps to ensure food is served hot, especially for people who need a long time to eat their meal.

What action did we take? To address the poor practice we found in our complaints investigations, we made 101 requirements for improvement in 52 care homes and 38 recommendations for improvement in 25 care homes. The Care Commission officers follow up on all the requirements and recommendations we make to ensure services improve.

Ways to improve people’s experience In some care homes mealtimes are protected periods of time when staff stop all other activities and help serve meals, give assistance to people who need it and allow them to eat their meals undisturbed.

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Ways to improve people’s experience Staff can ensure that people’s nutritional likes and dislikes, cultural and religious needs for food and drink are identified and recorded in their personal plan.

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Part 4: What enforcement action did we take? In addition to our inspections and the complaints we received about eating, drinking and nutrition, we reviewed our enforcement activity in this area in 2008/09 to examine what issues still remain, after 2006/07. Enforcement is an essential part of the Care Commission’s role under the Regulation of Care (Scotland) Act 2001 and is central to our aim of protecting people and bringing about an improvement in the quality of care services. What did we find from enforcement? We served improvement notices on 10 care homes for older people from 1 April 2008 to 31 March 2009 to enforce improvements in nutrition and hydration. A list of the care homes is in the appendix. An improvement notice is a legal notice that requires services to make improvements within a set timescale. Failure to comply with a notice may result in the Care Commission proposing to cancel the registration of the service. We know that delivering good quality care to meet Scotland’s ambitious National Care Standards is both demanding and challenging and we work closely with care services to help improve the quality of care. When standards of care fall short and are not improving, we move quickly to make sure the service does improve and to ensure the safety of people who live in care homes. Improvement notices were made in the following important areas of nutritional care.

Six enforcement notices were served because menus were not planned to meet the dietary needs and preferences of older people and the care homes were not catering for special diets, for example, pureed foods or diets to increase weight. In six care homes, we served improvement notices because there were not enough staff to help people with eating and drinking. In one care home, improvement was required to balance the timing of meals and snacks. Balancing the times of meals across the day is important to encourage appetite and ensure people eat and drink enough.

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eating well in care homes for older peolple

There was no regular assessment in place to screen for under-nutrition using a nutritional screening tool in four care homes. Improvement notices were served on eight care homes to improve personal plans to ensure that people’s eating, drinking and nutritional needs are met. We found that five of the eight care homes were not managing people’s unplanned weight loss.

In four care homes we served improvement notices because we found people were not being offered and encouraged to drink regularly, drinks were out of reach and staff were not using fluid charts, or if they were in place, they were not keeping them up to date or checking them regularly. In four care homes, there were improvement notices in place to ensure new and existing staff were given appropriate training about how to meet the eating, drinking and nutritional needs of older people and menu planning.

eating well in care homes for older peolple

We worked closely with all the care homes to bring about improvement to the quality of care for people, and all the care homes, except one which has now closed, met the improvements and the legal enforcement notices have been lifted.

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Part 5: Promoting nutrition in care homes for older people Our findings from complaints investigations inspired our Nurse Consultant for Older People to develop a proposal to improve nutritional care in care homes. In 2007 the Scottish Government funded an education programme to help improve nutrition in care homes throughout Scotland. Our Nurse Consultant for Older People worked with key partners from the NHS, universities and care homes to improve standards of nutritional care. Fifty people who worked in care homes across Scotland became nutrition champions and took part in the six month programme to: • help them learn more about nutrition for older people • give them expert and practical advice from dietitians • develop individual projects to improve aspects of nutrition in the care homes that each worked in • give them skills they need to make changes in their own care home • learn from each other and share their experiences in meetings and online. The programme allowed the nutrition champions to make improvements in eating, drinking and nutritional care in their care home. We published a report on this very successful education programme9 and details of all the excellent projects the nutrition champions took forward in their care homes is available on the Care Home Learning Network at www.carecommission.com

9 Promoting Nutrition in Care Homes for Older People (Care Commission 2008)

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eating well in care homes for older peolple

We will actively encourage Scottish Government to consider funding and support to extend the nutrition champions programme across all care homes in Scotland.

References 1. The National Care Standards: Care Homes for Older People (Scottish Government 2007) 2. A Diet Action Plan for Scotland (Scottish Executive 1996) 3. Eating for Health – Meeting the Challenge (Scottish Executive 2004) 4. The Nutrition of Elderly People and Nutritional Aspects of Their Care in Long-term Care Settings, Final Audit Report 1997-2000 (Clinical Resource and Audit Group (CRAG) August 2000, Scottish Executive) 5. The “MUST” Report – Nutritional screening of adults: a multidisciplinary responsibility (British Association of Parenteral and Enteral Nutrition 2003) www.bapen.org.uk 6. BAPEN Nutrition Screening Week 2007 data: information is provided courtesy of BAPEN www.bapen.org.uk 7. Water for Healthy Ageing Toolkit (Water UK 2005) 8. The Nutrition of Elderly People and Nutritional Aspects of Their Care in Long-term Care Settings, Final Audit Report 1997-2000 (Clinical Resource and Audit Group (CRAG) August 2000, Scottish Executive)

eating well in care homes for older peolple

9. Promoting Nutrition in Care Homes for Older People (Care Commission 2008)

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Appendix

Care homes

Address

Moor Cottage

Strathpeffer

Renfield Care Home

Dunoon

Kingsmead Nursing Home

Aberdeen

Burlington Court Care Centre

Glasgow

Broxburn Nursing Home

Broxburn

Rowan House

Kirriemuir

Kerrvale Care Home

Glasgow

Craigielea Residential Home

Brodick, Isle of Arran

St. Raphael’s Care Home

Edinburgh

Tranent Care Home

East Lothian

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Care homes with enforcement notices to improve nutrition and dehydration – 1 April 2008–31 March 2009

C HEADQUARTERS

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eating well in care homes for older peolple

Helpline: 0845 603 0890 Website: www.carecommission.com

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