Nutrition and Hydration in Care Home Settings Training Presentation The presentation is intended as a general introduction and basic awareness tool only. By the end of the presentation the audience will have a general awareness of nutrition and hydration issues affecting adult social care settings. The care service should adapt the presentation to suit its specific policies and procedures.

What is Nutrition and Hydration? Nutrition and hydration means eating the right foods and drinking the right fluids to live well and be healthy Good nutrition and hydration levels are essential for health; inadequate nutrition or hydration can lead to ill health Severe cases of inadequate nutrition or hydration can lead to malnutrition or dehydration Malnutrition has been on the increase in the elderly in recent years Ask the group what they think is meant by nutrition and hydration. Allow several people to give suggestions before revealing the answers.

Types of Nutrient There are six main categories of nutrients that the body needs to acquire from food: protein, carbohydrates, fat, fibres, vitamins and minerals, and water Protein supplies amino acids to build and maintain healthy body tissue Fat supplies energy and transports nutrients Carbohydrates are the body's main source of energy and should be the major part of total daily intake Fibre is essential for digestion and elimination Ask the group what they think are different types of nutrient. Allow some discussion before revealing the points one at a time. For each element, ask them what they think proteins are important for, etc.

Different Diets Service users should have balanced and nutritious diets Some service users may have special dietary needs: a person suffering from constipation may need a high-fibre diet an overweight person may need a low-fat diet a person with heart disease may need a low-cholesterol diet a person with swallowing difficulties may need a puréed diet Ask the group for examples of different diets before displaying the examples. Some people might think of “diet” only in reference to slimming diets. Explain that there are different types of diet and that different people have different needs.

Food and Drink Choices We all have food and drink preferences and it is important that service users also have choices about their diet The care home should provide a varied menu that takes the varied and diverse needs of all of its service users into account Some service users may have cultural or religious dietary needs and these should be supported and respected Providing options and enabling a service user to have autonomy and freedom of choice is a key thread ruining through the Essential Standards and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. In the context of Outcome 5 this includes a real choice of what, when and where to eat and drink. In the Essential Standards the provision of choice in this context is included in Prompts 5C and 5H. Prompt 5C refers to the need for service users to have: accessible information about meals and the arrangements for mealtimes a choice for each meal that takes account of their individual preferences and needs access to snacks and drinks throughout the day and night mealtimes that are reasonably spaced and at appropriate times, 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.

CQC Regulations In order to maintain its registration the home must comply with CQC requirements under: Regulation 14 “Meeting Nutritional Needs” of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 Outcome 5: Meeting Nutritional Needs of the CQC’s Guidance about Compliance: Essential Standards of Quality and Safety Inspectors will check on the home’s standards The care home’s nutritional standards are assessed against their compliance with Regulation 14 “Meeting Nutritional Needs”, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and Outcome 5: Meeting Nutritional Needs of the CQC Guidance about Compliance: Essential Standards of Quality and Safety.

Regulation 14 Residents must be protected from the risks of inadequate nutrition and dehydration by means of: a choice of suitable and nutritious food and drink, in sufficient quantities to meet their needs food and drink that meets any reasonable requirements arising from a person’s religious or cultural background support, where necessary, for the purposes of enabling people to eat and drink sufficient amounts for their needs

CQC Requirements To comply with regulation 14 care home owners and managers must make sure they: reduce the risk of poor nutrition and dehydration by encouraging and supporting people to receive adequate nutrition and hydration 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

Assessing Nutritional Needs All residents of care homes should be screened for the risk of under-nutrition or hydration on admission Where a risk of malnutrition or dehydration is identified the resident should be made subject to a full nutritional assessment The results of the screening and assessment should be entered into the plan of care and regularly reviewed The initial assessment will include a record of the resident’s weight and their food preferences All residents of care homes should be screened for risk of under-nutrition on admission. Inform the delegates of the process by which this is done in the home and of the use of any standardised screening tool. The weight and height of residents should be measured and recorded on admission and at regular intervals thereafter. This will provide an important record to monitor for any changes.

Care Planning Prompt 5A of the Essential Standards specifies that where a resident’s initial nutritional screening indicates that there is nutritional risk, action should be taken to minimise that risk This might include a referral for specialist advice, assessment or support, or support measures to be taken by care home staff All planned care should be fully discussed with the resident and, where appropriate, with their family or representative Care plans should identify exactly how any risk will be managed and should be regularly reviewed and updated, including any reference to nutritional needs. Monitoring may include keeping a regular record of a resident’s weight and nutritional intake. According to Prompt 5B all homes should have, in addition to an initial screening process, effective systems for the ongoing nutritional monitoring of residents and access to appropriate advice, support and referral from relevant specialist healthcare professionals, such as dieticians. Stress the need for any help required or additional monitoring to be included in the plan of care.

Dietary Preferences On admission to the home, as well as a nutritional risk assessment, residents’ individual food preferences should be obtained If they are unable to give the information themselves, their needs and preferences should be obtained from people who know them well Special dietary needs, favourite foods and disliked foods should be recorded and the information used in the establishment of food choices and menu planning Any help needed in eating and drinking should also be assessed, agreed and entered in the care plan Residents’ cultural requirements should be recorded on the care plan and met as appropriate. Care home staff should avoid assuming that a particular resident will like a certain food just because of their ethnic background or religion or age. All residents should be asked for their preferences.

Menu Planning A menu should be produced that provides residents with choice, quality, variety and nutrition It should be based on residents’ needs and preferences All residents should have access to the menu Those that cannot read the menu should have it explained to them so that they can choose what they want to eat

Hydration Many of the prompts included in Outcome 5 of the Essential Standards relate to drink as well as food Prompt 5C specifies the need to ensure that access to drinks is provided throughout the day and night Tap water should always be available The Food Standards Agency recommends an adult daily intake of six to eight glasses of water or other fluids Service users can sometimes be reluctant to drink Good hydration is essential for the health and wellbeing of older people, not only in helping to make people more alert but also helping to prevent confusion, constipation, pressure sores, kidney stones, blood pressure problems and headaches. In addition, evidence suggests that hydration can also promote healing and help to prevent falls, obesity, depression, inactivity and fatigue. Ask the group why they think service users in care home settings can sometimes be reluctant to drink water. This is often because some elderly people worry about possible incontinence, particularly close to bedtime. Where service users do not drink enough water, care homes can consider other ways of increasing their fluid intake, eg through breakfast cereals with milk, or through soup or fruit and vegetables. Where older people worry about incontinence care staff should reassure them that help will be provided with going to the toilet and they should not be encouraged to drink close to bedtime.

Soft Diets A number of conditions may interfere with chewing and swallowing The home can provide softer foods or puréed food to assist residents with these conditions Where puréed foods are used they should be made to look appetising Where necessary seek advice from a speech and language therapist Updated nutritional care guidelines for older people published by the Social Care Institute for Excellence (SCIE) in March 2009 state that where puréed foods are used, they should be made to look appetising. Where the texture of food needs to be modified due to swallowing difficulties the guidelines state that providers should seek advice from a speech and language therapist. The guidelines remind providers that not all food for people with swallowing difficulties needs to be puréed and that it is important for the quality of the eating experience to keep different foods separate and not mix them all together.

Mealtimes and Snacks Mealtimes are a focal point of the day for many and every effort should be made to make these relaxed and enjoyable occasions Mealtimes should be well spaced throughout the day Snacks should be provided or made accessible throughout the day and night

Helping Residents Eat Residents should have the appropriate help if they need assistance with the process of eating or drinking When giving such help it is vitally important to preserve an individual's dignity and independence Any help needed should be agreed with the resident and added to their plan of care Staffing levels should allow help to be given as needed Independence aids are available Privacy may be required An adequate number of staff should be available for the service of meals and to provide assistance in feeding and drinking where required. Residents who require assistance with eating or drinking should have their needs fully assessed and discussed with them. A suitable plan of care should be agreed, with specialist input as required, which clearly identifies any assistance needed. The provision of adequate support and assistance to eat and drink is specified in Regulation 14 as “support, where necessary, for the purposes of enabling service users to eat and drink sufficient amounts for their needs”. This is supported by a number of Prompts (5A) including: the provision of all assistance necessary to ensure service users actually eat and drink where they want to but are unable to do so independently the need for staff to act with sensitivity and respect for service users’ dignity and ability the need for service users to be enabled to eat their food and drink as independently as possible the need to have adequate and appropriate supportive equipment available to enable service users to eat and drink independently, wherever needed the need for staff to help service users into an appropriate position that allows them to eat and drink safely, wherever needed. Staff who assist service users with eating and drinking should be appropriately trained and supervised and there should be adequate numbers of such staff on duty at mealtimes. Privacy may be especially important for a person who has to have direct help with eating. This can be accommodated in a particular part of a dining room, in a separate dining room for those in need of assistance with eating or in the resident’s own room.

Food Handling Food poisoning is any infectious or toxic disease caused by consuming food or drink that has become infected with bacteria, viruses or parasites Food poisoning and infections such as norovirus are easily spread through contaminated food and via infected food handlers Staff preparing food should observe all relevant food hygiene and safety procedures and comply with the home’s food hygiene policies at all times Any storage or handling of food in a home raises a potential risk of food poisoning. It is therefore essential that, wherever food is prepared, handled, stored or served, the highest standards of hygiene are observed by all staff at all times, especially with regard to hand washing.

Staff Health Staff working with food or serving food must advise the care home manager if ill Symptomatic staff, especially food handlers, should be sent home and remain off work until symptom-free for 48 hours Inform the delegates of any relevant staff health policies and procedures.

Monitoring Any resident who has special dietary needs, who needs help with eating or drinking or who is at risk of under-nutrition should be appropriately monitored Concerns should be addressed to the person in charge Where necessary a referral for specialist help and advice should be made

Quality Assurance The quality of the nutritional and catering services provided by the home is very important The home encourages feedback, either verbally or through food questionnaires Where necessary staff should help residents to fill in the food questionnaires The home publishes an annual performance report on its catering services which highlights service user feedback