Improving meals and mealtimes for older people in residential care

Research into achieving dignity in care for older people in the UK has consistently found that meals and mealtimes are a major priority for people staying in residential settings. People have cited meals as the “highlight of the day” and often define the quality of a home based on their experience at mealtimes.

Unfortunately, the same research has found that the quality of food and service is still a major concern for many.

In a recent Department of Health online survey, people complained that too little help is available to those who need assistance with eating.

The analysis of UK data from the Dignity and Older Europeans study supports this: “Participants said patients were often not fed by nurses and this was often a problem for older people who could not feed themselves.”

Age Concern has also published information about problems with malnourished older people in hospital and a recent report by the Patient and Public Involvement Forums found that more than one-third of hospital patients left their food because of a lack of choice, correct temperature, presentation and help.

Evidence

Malnutrition affects more than one in 10 older people, according to findings last year by the British Association for Parenteral and Enteral Nutrition. It is therefore vitally important that older people are nutritionally screened when they enter health and social care services and receive adequate support. A lack of support when eating and drinking can have more serious consequences for people with dementia or depression.

Good nutrition and hydration and enjoyable mealtimes can dramatically improve the health and well-being of older people. Mealtimes, therefore, should be considered a priority in terms of importance and dedication of staff time systems within organisations should support this.

Protected mealtimes have been introduced in many hospitals: this means that non-emergency clinical activity stops, the ward is tidied and patients are made ready for their meals. It gives patients “space” to eat and enjoy their meals. It also gives housekeepers and nurses time to give assistance to those who need it.

The Commission for Social Care Inspection bulletin, Highlight of the Day?, reports: “Care homes that meet the national minimum standards for meals and mealtimes are more likely to have: staff who consult with the older people in their care on their needs managers who meet the training needs of their staff and sufficient staff numbers to support older people in enjoying their meals.”

Evidence for raising standards

● Food, nutrition and mealtimes are a high priority for older people and a top priority for older people from ethnic minorities (PRIAE/Help the Aged, 2001).
● Malnutrition affects more than one in 10 older people (British Association for Parenteral and Enteral Nutrition, 2006).
● Malnutrition is estimated to cost the UK more than £7.3bn a year (BBC, 2006).
● Malnourished patients stay in hospital for much longer, are three times as likely to develop complications during surgery, and have a higher mortality rate (Age Concern, 2006 BBC, 2006).
● The needs of people from black and ethnic minority groups, including “basics such as food” are not always met by mainstream services (PRIAE/Help the Aged, 2001, Afshar et al, 2002).
● To bring about a culture change in food, nutrition and mealtimes good leadership, staff induction and training and adequate staffing levels are needed (Commission for Social Care Inspection, 2006).
● The NHS Standards for Better Health requires health care organisations to ensure that patients have a choice of food that is prepared safely and provides a balanced diet and that “individual nutritional, personal and clinical dietary requirements are met, including help with feeding and access to food 24 hours a day” (Department of Health (DH), 2004).
● National minimum standards for care homes require that “service users receive a wholesome appealing balanced diet in pleasing surroundings at a time convenient to them” (DH, 2003a). Nearly 2,000 care homes in England do not meet this standard (Commission for Social Care Inspection, 2006).
● National minimum standards for domiciliary care require that “personal care and support is provided in a way that maintains and respects the privacy, dignity and lifestyle of the person receiving care at all times” this includes eating and meals. (DH, 2003).
● The NHS Essence of Care benchmarks for food and nutrition include attention to nutritional assessment, the environment, presentation of food and appropriate assistance (DH, 2003).
● In February 2006 the National Institute for Health and Clinical Excellence and the National Collaborating Centre for Acute Care launched guidance to help the NHS identify patients who are malnourished or at risk of malnutrition.

Practitioners’ messages

● Routine nutritional screening should be carried out on admission to hospital or residential care. The dietary needs and preferences of service users, and any assistance needed at mealtimes, should be assessed, recorded and referred to by all front-line staff.
● A speech and language therapist should assess anyone exhibiting swallowing difficulties to ensure the correct textures of foods and liquids are provided.
● Food should be available between mealtimes.
● Give people time to eat.
● Avoid interruptions to mealtimes by other routine tasks, such as administering medication.
● Provide assistance discreetly. Use serviettes, not bibs, to protect clothing. Offer finger food to those who have difficulty using cutlery, and provide adapted crockery and cutlery to enable people to feed themselves.
● While socialising during mealtimes should be encouraged, offer privacy to those who have difficulties with eating.
● Managers should ensure that mealtimes are sufficiently staffed to provide assistance.
● Don’t make assumptions about people’s preferences on the basis of their cultural background – people should be asked what their preferences are.
● Staff should receive training to equip them with the skills to communicate with people with dementia and communication difficulties. Visual aids (such as pictorial menus) and non-verbal communication skills may help people make choices. Gather information on preferences from people who know the person well.
● Record food and fluid intake daily, where needed.
● All care staff, including caterers, should have access to quality training to raise awareness of the risk of malnutrition and the importance of providing good nutritional care.
● Commissioners and providers should ensure that care home staff have enough allocated time and skills to prepare a meal of choice for the service user, including freshly cooked meals.
● Where food needs to be puréed, use moulds to keep foods separate and indicate what they are – for instance, a fish-shaped mould for fish.
● Carry out regular consultation with service users on menus.
● Involve service users in meal preparation.
● In residential settings, where access to industrial kitchens is denied, provide facilities for people to make drinks and snacks.
● Ensure that fresh water is on offer at all mealtimes and available throughout the day.

➔ For more on good food for older people

Further information
● Practice guide 09: Dignity in care
● The Patient and Public Involvement (PPI) Forums
● Age Concern, Hungry to be heard
● National Minimum Standards – care homes for older people 
● Commission for Social Care Inspection
● Alzheimer’s Society, Food for Thought – diet, nutrition and care of people with dementia
● National Association of Care Catering
● Department of Health (2003) National minimum standards for adult placements 
● DH (2001) Valuing People: a new strategy for learning disability for the 21st century, 

Related article
Research abstracts: Feeding older people in care

This article appeared in the 26 July issue under the headline “Meals in residential care”