Older people’s nutrition: cooking in care homes – best practice

Malnutrition is a significant problem in older people’s care homes. But, as Jamie Oliver asked in relation to school dinners, is it just a question of more cash? Natalie Valios investigates

Headlines about weight fluctuate between alarm at the rise in obesity and the fashion industry’s use of size zero models. Malnutrition is rarely mentioned and is generally associated with poorer countries than the UK.

It may come as a shock, then, to learn that malnutrition is estimated to cost the UK economy £7.3bn per year.

The causes of malnutrition include underlying disease, decreased mobility, limited transport to local shops, social isolation, and poverty. So it is not surprising that more than 10% of over-65s are at a medium or high risk of malnutrition. For older people in hospitals or care homes, this figure rises to between 10% and 40%.

The reasons don’t always lie with the care homes themselves. Nowadays, people are entering care homes when they are much older and frailer. Consequently, a higher percentage are suffering from problems relating to nutrition because of general ill-health.

Sue Hawkins, chair of the National Association of Care Catering (NACC), says: “Malnutrition isn’t simply that people aren’t eating enough. People who go into care homes are already likely to be suffering from malnutrition, related to the reasons they have gone in – for example, if they’ve lost a partner, have difficulty looking after themselves, are ill, or are on medication. This results in them not being able, or wanting, to eat properly.”

Nevertheless, many care homes need to improve practice to tackle this issue. High staff turnover, poor recording of what residents have eaten, and a lack of staff at mealtimes to help or encourage residents to eat, can all contribute to malnutrition.

Additionally, new residents may not feel comfortable in their surroundings, particularly if they have gone from living in their own home to being cared for they might not like the food, or it might not be culturally appropriate.

Under the national minimum standards for care homes for older people, two standards concern nutrition. Standard 8 requires users’ health care needs to be fully met. Within this, nutritional screening should be undertaken on admission and subsequently on a periodic basis. Standard 15 requires users to receive a “wholesome, appealing, balanced diet in pleasing surroundings at times convenient to them”.

The Commission for Social Care Inspection monitors care home methods for assessing and reviewing older people’s nutrition, weight and dietary requirements as part of the inspection process. But inspectors do not assess for malnutrition – and aren’t qualified to do so.

According to the CSCI, on 31 March 2005, 83% of care homes met or exceeded the requirements of the meals and mealtime standard. This means that one in six homes, providing about 70,000 places, needed to improve their performance against the national minimum standard.

Between April 2004 and October 2005, there were 453 complaints upheld by the CSCI about food across all regulated care services. The most common were about the quality (28%), choice (16%), and limited availability of food (27%).

As with the school dinners campaign, spearheaded by celebrity chef Jamie Oliver, some blame has been attributed to the amount of money spent on food per head. In 2004, the Joseph Rowntree Foundation estimated that care homes spent just £2.43 on food per person per day.

Some fear that the amount of money available means that corners are cut, resulting in convenience foods with little nutritional value being used instead of cooking from scratch. Others, like Hawkins, don’t believe it is down to penny-pinching. “It’s more likely that they are buying the wrong food, have unqualified staff who don’t understand their residents’ nutritional needs, or are not making sure that residents are eating.”

As if to prove this, entrants to the NACC’s care cook of the year competition are asked to create a nutritious meal and pudding for four people within a budget of just £1.10 each. Chef Garry Maundrill, who works at not-for-profit HICA Care Homes’ Wilton Lodge in Hull, was crowned care cook of the year 2006 for cooking his residents’ favourite meal with a twist, from scratch, in one and a half hours and within budget.

At the time, he was working at The Hollies, near Hull, another HICA care home. “The residents said they liked fish, chips and mushy peas so I did a healthier option of fishcakes with tomato salsa, carrots, parsnips and snap peas,” says Maundrill. “Pudding was an exotic fruit smoothie.”

Maundrill is a firm believer in cooking all meals from scratch and residents are offered a choice of two main meals and puddings every day. A woman also comes in to the kitchen every day to bake fresh buns for teatime and other treats including flapjacks and jam tarts.

“When I was a kid, my mum did all the home baking, things like steak pie and bread and butter pudding. This is the food the residents know and like. If they don’t know the name, they won’t eat it,” he says. Encouraging residents to eat more nutritious meals isn’t always easy, so Maundrill has devised some alternative ways of ensuring a healthy diet. “For those who don’t like carrots I put them in carrot cake and they love it. The same for bananas – I put them in a smoothie. You can put loads of different fruit in smoothies and they love them.”

Some residents have trouble chewing so their food has to be blended. This can look fairly unappetising on a plate, so Maundrill blends the potatoes and vegetables separately from the meat or fish and puts them into apt moulds, such as a fish one, or a cabbage one to make it look more appealing on the plate.

Maundrill has spent 20 years in catering, all bar the last seven years in the restaurant business. HICA sent him on nutrition and diabetes courses to learn about the right way to feed his new clientele. HICA also sends its care staff on the same training. Maundrill’s tips for other care chefs are: “Get to know your clientele, find out their likes and dislikes. If there’s anything they really like, put it on the menu.

“Get good suppliers on board. We have dedicated suppliers so everything is fresh. If you want to introduce something new to the menu, check with the residents first. Pop in and see the residents, build up a rapport with them.”

Chefs who aren’t sure about what to do can turn to the Food Standards Agency’s nutrient guidance for care homes. But if the problem is lack of knowledge, qualifications or money, guidance won’t do much on its own. Staff need to bear in mind that, at home, you can eat what you want, when you like. In a care home, residents largely rely on staff to make food and drink available, and what’s on the menu isn’t necessarily what you feel like eating.

Despite its lack of publicity, the issue of malnutrition is not a new one. Dietician Sue Thomas has been the tutor for the Royal Institute of Public Health’s Eating for Health in Care Homes courses for 20 years, and has recently co-edited a book of the same name. “I’ve been banging on about malnutrition for a long time. I’ve seen it my entire career,” she says.

For Thomas the problem rests with ignorance and lack of training. For example, pureed food needs to be diluted, but butter, cream or milk should be used rather than water, which reduces the nutritional value. Malnutrition is more than not having enough to eat. It means not getting enough vitamins and minerals into your body.

Calcium and vitamin D reduce the risk of osteoporosis, fractures and disability, for example. Simply ensuring that residents have access to sunlight can help prevent vitamin D deficiency, adds Thomas.

“We run eight courses a year, but when you think of the overall number of care homes, we are only scraping the surface,” she says, adding that generally those who come on the courses are already interested in the subject, and it’s the ones who aren’t who most need the help. “It’s hard to reach the people you want to train,” she says.

But whatever training is on offer is undermined by the absence of any requirement for mandatory accredited training on nutrition or special diets for care or kitchen staff in care homes.

Change could be on the way after Hawkins wrote to care services minister Ivan Lewis urging him to improve the situation. He held a nutrition summit in March, attended by charities, clinicians, nutrition experts and care home representatives. As a result, an action plan is due to be published in the summer.

Hawkins wants training and nutritional screening to be top of the list. “All staff should have care and nutrition qualifications commensurate with their job. Everyone who is involved in providing services to older people in the community should be trained: domiciliary care workers, social workers, GPs, and informal carers,” she says.

“If you can reduce the instances of malnutrition in the community, you might reduce the numbers needing to go into care because malnutrition can cause confusion and frailty.”

Meanwhile, the British Association for Parenteral and Enteral Nutrition is calling for a government tsar on malnutrition. It also wants an awareness campaign to dispel the myth that becoming thinner is a natural part of the ageing process.

Malnutrition can result in hospitalisation, even death. Without the right training, care and kitchen staff will not be sufficiently qualified to recognise the symptoms. What greater reason can the government need to ensure its action plan makes nutrition training mandatory for all care home staff?

● Significant weight loss (over half a stone in the last three to six months).
● A recent loss of appetite.
● Loose fitting clothes or jewellery.
● Ill-fitting dentures.
● Recurrent infections.
● Inability to keep warm.
● Difficulty recovering from illness.
● Constipation or diarrhoea.
● Dizziness (prone to falls).
● Pressure sores.
● Swollen or bleeding gums.
● Sore mouth or tongue.
● Difficulties chewing or swallowing.
● Tooth decay.

● Make food accessible between mealtimes so that older people don’t feel uncomfortable about asking, for example, by providing kitchenettes or fridges in rooms.
● Involve residents in planning meals.
● Supply culturally appropriate food.
● Ensure staff are aware of the nutritional needs of older people.
● Adhere to standard 15.
● Provide good quality food.
● Provide good staff training on nutrition.
● Encourage residents to eat with appropriate portion sizes and appetising presentation.
● Balance the timing of meals.
● Have a relaxed atmosphere at mealtimes.

The Chartered Institute of Environmental Health is running a conference in London on 27 June called Managing Care Homes for the Elderly: An essential legal, policy and practice update.
National Minimum Standards on Care Homes for Older People
Food Standards Agency’s nutrient guidance for care homes
● National Institute for Health and Clinical Excellence, Nutrition Support In Adults
Information on the malnutrition universal screening tool
Malnutrition among Older People in the Community
● CCSI report: Highlight of the day? Improving Meals for Older People in Care Homes

Contact the author
Natalie Valios

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