Malnutrition in Later Life: Prevention and Early I ntervention

Malnutrition in Later Life: Prevention and Early I ntervention Best Practice Principles & I mplementation Guide Food and Beverage Providers Visit our website for more information: www.malnutritiontaskforce.org.uk

2013 This document may also be downloaded from http://www.malnutritiontaskforce.org.uk Malnutrition Task Force Tavis House, 1 6 Tavistock Square London WC1H 9NA 020 3033 1469 This document was graphically designed by a volunteer using open source software

Reader Box Health, social care, voluntary organisations, food and beverage providers Document purpose Title Author Publication date Target audience Description Contact details The Malnutrition Task Force (MTF) members Partnership working Implementation guidance Malnutrition in Later Life: Prevention and Early Intervention. Best Practice Principles and Implementation Guide: Food and Beverage Providers The Malnutrition Task Force May 2013 Domiciliary Care Providers, Luncheon Clubs Organisers, Meals on Wheels Providers, Residential and Nursing Home Managers, Health and Social Care Contract Caterers, Local Authorities, Health and Social Care Procurement, Professional Bodies, Specialist Associations and Regulators This document is part of a series of guides that defines the principles of best practice, the moral, legal, quality and financial case for change and practical advice to counter malnutrition in a wide range of health and social care settings enquiries@malnutritiontaskforce.org.uk Association of Directors of Adult Social Services (ADASS) Anchor Trust British Association of Parenteral and Enteral Nutrition (BAPEN) British Dietetic Association (BDA) British Geriatrics Society (BGS) Carers UK Elior English Community Care Association (ECCA) Gateshead Primary Care Trust Hertfordshire Community Meals Service International Longevity Centre UK (ILC UK) National Association of Care Catering (NACC) NHS Commissioning Board (Patient Safety) Royal College of General Practitioners (RCGP) Royal College of Nursing (RCN) Royal Pharmaceutical Society (RPS) West Leicestershire Clinical Commissioning Group Wrightington, Wigan and Leigh NHS Foundation Trust 3 June 2013

Contents I ntroduction 5 Foreword 6 About malnutrition 7 The case for change 8 Best practice principles 1 1 An introduction 1 2 Principle 1 : Raising awareness to prevent and treat malnutrition 1 3 Principle 2: Working together 1 7 Principle 3: I dentifying malnutrition 1 9 Principle 4: Personalising care, support and treatment 20 Principle 5: Monitoring and evaluating 22 Making the changes 23 Preparing to make the change 25 Knowing where you are and where you want to be 26 Making it happen 28 Measuring, monitoring and embedding your changes 29 Appendices 30 References 32 Resources 34 4 June 2013

I ntroduction

Foreword Malnutrition is a major cause and consequence of poor health and older people are particularly vulnerable. It is estimated that in the UK around one million people over 65 years old are malnourished or at risk of malnutrition. 1 The human cost of malnutrition and dehydration are harrowing to both the individual and those that care for them. Food and water left out of reach, lack of support to eat and drink and supplements not given are frequent occurrences. One family s experience of their mother s care was just that. Despite desperate pleas with staff, she died. 2 In another case, an 81 year old widow was left at home without food and water, no contact and no support. She died a tragic death that could have been avoided. 3 Malnutrition and dehydration are not recognised as problems in our society. Most people (older people, carers, professionals, commissioners and senior managers in health and social care) do not realise how common malnutrition is or how serious the consequences can be and so malnutrition and dehydration continue to go unrecognised and untreated. The costs of malnutrition run into billions of pounds 1 in spite of proven interventions that can help prevent, identify and promptly manage the problem and risks, thereby reducing the human suffering and the astronomical associated costs. There has never been a more urgent need to act. The Care Quality Commission Dignity and Nutrition inspections 4 and Adult Social Care Survey 5 demonstrate that organisations are still repeatedly failing to provide older people with the basic right to food, drink and support when they need it. The Malnutrition Task Force is an independent group of experts from health, social care and local government united to address preventable malnutrition and dehydration in hospitals, care homes and in the community. We believe that prevention and treatment of malnutrition should be at the heart of everything we do to ensure older people can live more independent, fulfilling lives. Together, with a wide range of stakeholders, we have identified many excellent examples of practice and existing guides, tools and resources that are readily available. We have drawn from these the principles of best practice and developed a framework to support those in a position to make changes for older people wherever they are. Food and beverage providers have a vital role to play and many have contributed to the development of this guide. We urge you to act now and play your part to put an end to this needless suffering and neglect of basic human rights so that older people receive the dignified and personalised care, support and treatment required to combat malnutrition. We hope this guide will help you. Dianne Jeffrey, CBE DL, Chairman, Malnutrition Task Force Karen Oliver, National Chair, National Association of Care Catering 6 June 2013

About malnutrition What is malnutrition? According to NICE (National Institute for Health and Care Excellence) guidance in Nutrition support in adults (CG32), 6 malnutrition is defined as: a body mass index (BMI) of less than 18.5 kg/m 2 unintentional weight loss greater than 10% within the last 3 6 months a BMI of less than 20 kg/m 2 and unintentional weight loss greater than 5% within the last 3 6 months Those who have eaten little or nothing for more than five days and/ or are likely to eat little or nothing for five days or longer are at risk and should also be considered for nutrition support. The contributing factors Malnutrition is both a cause and consequence of disease and illness and there can be many contributing factors. Whilst some causes of malnutrition might be the result of underlying ill health, disease or the body's inability to absorb nutrients, malnutrition can also be linked to other experiences or factors in a person's life. These include (see fig. 1) depression or anxiety, social isolation, poor access to transport, mobility difficulties, poverty, difficulties with shopping, dental problems or the influence of medication on appetite. This list is not meant to be exhaustive but highlights many of the contributing factors. Malnutrition can be a result of one or a combination of factors. Factors that contribute to malnutrition: Social Access, affordability and attitude Difficulties in shopping or access to food due to transport or physical mobility Low income; many have to choose between eating and heating in winter Myths, e.g. 'It's normal to lose weight as you age'; attitudes of professional staff to providing basic care Barriers to eating or getting support Lack of nutritional understanding, poor appetite, lack of interest in food Not enough help and support to eat and drink Social isolation and loneliness Capability Difficulty in preparing and cooking food due to physical mobility or ability Physiological Physiological changes Illness and disease Decreased sensation of thirst, Illness and disease can put an older person decreased at increased taste and risk decreased of malnutrition appetite due to less energy expenditure Physiological changes Illness and disease Such as: Stroke, cancer, respiratory and gastrointestinal illness, dementia and depression Eating problems such as difficulties with chewing and swallowing Surgery Lack of cooking skills Figure 1 7 June 2013

The case for change Scale of the challenge At any given time, more than three million people in the UK are either malnourished or at risk of malnutrition 1 The vast majority of these (approximately 93%) are living in the community, with a further 5% in care homes and 2% in hospitals 1 It is estimated that 1 in 10 people over 65 are malnourished or at risk 7 The population of people over 75 is at highest risk of malnutrition and is projected to double in the next 30 years 8 As many as 37% of older people who have recently moved into care homes are at risk 9 It is imperative to identify and treat people as quickly as possible. If we do not put mechanisms in place now to address malnutrition, the numbers of malnourished people and the associated human and financial costs could spiral in the future. Consequences of malnutrition Research has found that individuals who are malnourished will experience: increased ill health, increased hospital admissions, increased risk of infection and greater antibiotic use, longer recovery time from surgery and illness and increased risk of mortality10 11 12 When compared with well nourished people, malnourished individuals in the community saw their GP twice as often, had 3 times the number of hospital admissions and stayed in hospital more than 3 days longer 13 Malnutrition in care homes has been linked to increased hospitalisation, re admission and long term ill health10 14 Figure 2 8 June 2013

Cost of malnutrition Malnutrition leads to increased use of health and care services and the national estimated costs run into billions of pounds. 1 Addressing it could lead to really significant savings Severely malnourished patients identified in general practice incur additional health care costs of 1,449 per patient in the year following diagnosis 13 The financial case for change There are interventions that can demonstrate benefit and cost effectiveness. Fully implementing NICE guidance (see below) will result in better nourished patients, fewer hospital admissions, reduced length of stay for admitted patients and reduced demand for GPs NICE identified malnutrition as the sixth largest source for NHS savings 15 Early identification and treatment of malnutrition in adults could save the NHS 13 million a year even after costs of training and screening 16 EXAMPLE "A Social Return on Investment analysis was conducted on Hertfordshire's community meals service. Service users reported improved health and increased independence. The analysis calculated that, for every pound invested, the likely social value created was approx. 5. 28. " Note: these interventions and benefits are not solely specific to older people and cover all ages. The levers for change Health and Social Care Act 2008 Extract from Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010: 17 "Meeting nutritional needs: 14 (1) Where food and hydration are provided to service users as a component of the carrying on of the regulated activity, the registered person must ensure that service users are protected from the risks of inadequate nutrition and dehydration, by means of the provision of: (a) a choice of suitable and nutritious food and hydration, in sufficient quantities to meet service users needs; (b) food and hydration that meet any reasonable requirements arising from a service user s religious or cultural background; (c) support, where necessary, for the purposes of enabling service users to eat and drink sufficient amounts for their needs. (2) For the purposes of this regulation, food and hydration includes, where applicable, parenteral nutrition and the administration of dietary supplements where prescribed. 9 June 2013

Clinical guidance Whilst this guide is aimed at food and beverage providers, it is important to note that there is clinical guidance available to support people with malnutrition. This includes: NICE's Nutrition support in adults (CG32) 6 NICE's Patient experience in adult NHS services (QS15) 18 NICE's Nutrition support in adults (QS24) 19 (appendix 1) Managing Adult Malnutrition in the Community pathway 20 Need for action There is evidence of good practice already but we know that some organisations need to improve nutritional care. Food and beverage providers play a critical role in this. The Adult Social Care Survey shows that only two thirds (64%) of older people who are receiving social care either in care homes or in their own homes say they get all the food and drink they like when they want it 5 The Care Quality Commission's (CQC) Dignity and Nutrition Inspection Programme in 2012, which inspected 500 care homes and 50 hospitals for the quality of nutritional care, found that care for older people in 17% of care homes and 12% of hospitals did not meet the required standard 4 Malnutrition affects the families and carers of older people too. Research by Carers UK has found that 60% of carers worry about the nutrition of the person they care for. One in six carers are looking after someone at real risk of malnutrition but do not have nutritional support of any kind 21 "Organisations have to deal with so many competing priorities and may ask, 'why should we prioritise nutrition and hydration care?' The answer is simple. Without food and water, people will die." Janine Roberts, Programme Director Malnutrition Task Force 1 0 June 2013

Best practice principles 1 1 June 2013

An introduction This guide......is dedicated entirely to the provision of food and beverage services for older people. These services include: Delivery to an individual s home Provision of food by carers in individual homes Meals within the community (e.g. luncheon clubs and community cafes) Meals within residential care and nursing homes (including those that provide respite care) Best practice principles We believe there are five key principles to help prevent and provide early intervention to treat malnutrition and dehydration. These principles have been adapted for those that provide food and beverage services. It is important to include them all. Figure 3 1 2 June 2013

Principle 1 Raising awareness to prevent and treat malnutrition At a glance Information for older people Staff training and education Older people, their families and carers should be made aware and kept informed about being properly nourished and hydrated. This must be done in a dignified way at all times. Information for older people It is important to have the following: Easy to read information on the importance of good nutrition and hydration for the older person. This needs to include the benefits they should feel and the personal health costs if this is neglected ('why is good nutrition important?') Easy to read information which explains what users can expect from the service they receive ('what will I get from this service?'), including, as a minimum: EXAMPLE The Dairy Council have produced a range of leaflets about the importance of eating well and what to do if someone is undernourished. See www. milk. co. uk Choice of what they want to eat and drink, where and when they want it ('what are my choices?') Types of foods available, e.g. soft, texture modified or pureed foods ('is the food suitable for me?') A flexible service that meets the needs of the individual ('How flexible is the service?') Guidance on how to provide feedback on the service including general comments, praise or complaints ('how can I give feedback?') EXAMPLE A private meals provider holds regular tasting sessions with older people and those with specific dietary requirements to evaluate the taste and quality of their foods. 1 3 June 2013

Figure 4 demonstrates a range of options where older people can raise any concerns they have with eating or drinking or where they can be signposted to access the right support. Figure 4 Staff training and education Everyone involved in providing food, drink, support and care for an older person must have a clear understanding of good nutritional care. They need to know the causes, consequences and signs of malnutrition and dehydration ('what do I need to know?'). They should also have a detailed understanding of the organisation s food and beverage policy. Staff who support people with eating and drinking need to be trained and must understand how to help those with specialist needs such as swallowing diffiulties or memory problems, e.g. dementia. EXAMPLE A contract catering company included experience-based training for their staff. Staff experienced what it felt like to be old and this led to providing greater personal care. 1 4 June 2013

Figure 5 shows staff groups likely to meet and be in contact with older people and should therefore receive training. Figure 5 More specifically, members of staff involved in the following activities require appropriate training: Screening Menu planning Taking menu order choices Preparing meals Serving meals and beverages Assisting people to eat or drink Clearing away food and beverages Monitoring and reviewing 1 5 June 2013

See the table (figure 6) below for a breakdown of essential skills per role. Figure 6 Top Tips for Early Success Do not re invent the wheel. There are plenty of resources already out there to raise awareness. See our resources section for a few examples. 1 6 June 2013

Principle 2 Working together At a glance Role of senior management Involving the older person Communication between and across all teams Working together and communicating user needs clearly within and across all teams and organisations is the foundation for delivering best practice. Everyone involved in delivering food, drink and support needs to understand their own role, responsibilities and which responsibilities they share. Senior management Those in senior management roles need to enable and support others to provide high quality services. This should include: Creating an enjoyable and social environment for dining where relevant Planning staff breaks to ensure adequate staff are on duty to assist with serving meals and providing support to help people eat and drink Making sure there is sufficient time to produce and serve high quality meals Using funding to access high quality suppliers to provide good quality, well presented food Creating a home or restaurant environment as appropriate Protecting meal times by limiting non related distractions, e.g. GP visits, hairdressers and medication rounds Involving the older person It is important to: Work in partnership with the older person in receipt of the service (and/ or their family) in order to meet their needs Communicate with their family, friends and carers about their progress Involve carers working with particular residents Involve staff who enable service users to prepare for meal times, e.g. washing hands and discussing menu choices EXAMPLE A private meal provider's tasting sessions are well evaluated and involve staff from the front line making the meals. Invite cooks and chefs to service user forums to hear what their customers have to say about their food and service Provide tasting sessions for service users and their families and use the information gained to support menu planning and provision of choices 1 7 June 2013

Communication between and across all teams It is important to communicate between teams such as care, catering, housekeepers, delivery drivers and members of clinical teams. Consider: Common agreement on food and beverage standards and the overarching nutritional care policy Clearly described job descriptions clarifying the roles and responsibilities of all staff involved in the delivery of food and beverages. Everyone must be aware of their role and the channels of communication between each other Ensuring everyone is aware of how to highlight or report poor service Involve and clarify the important role of domestic and night staff EXAMPLE Dorset LINk and Dorset County Council Health Scrutiny Committee ran a free informal session called 'Let them eat cake' to encourage networking and shared learning across different care homes. 50 care home managers attended. Cooks and chefs should be involved when GPs, dietitians and speech and language therapists (SALT) plan specific care for an older person Activity staff should work together with care and catering staff to ensure meal times are fun and a highlight of the day Establish clear channels of communication between staff to ensure comprehensive handover of information about residents / customers All forms and records shared appropriately to ensure all care and catering staff have up to date knowledge on nutritional status and personal preferences Appropriate monitoring of what is and what is not eaten and appropriate actions taken in response Top Tips for Success Value all staff involved in the process. 1 8 June 2013

Principle 3 I dentifying malnutrition At a glance Identifying malnutrition Identifying malnutrition Staff involved in the provision of food and beverage services or supporting someone to eat and drink are in a very good position to notice whether someone is becoming underweight or at risk of malnutrition. As a minimum, staff should know what signs suggest whether someone is underweight. Derbyshire County Council's 'How to spot if someone is underweight' leaflet 23 is a great example of what to look out for. Using MUST (Malnutrition Universal Screening Tool) 24 Staff can also be trained to use the MUST screening tool. It is available from BAPEN and is recommended by NICE. Derbyshire County Council leaflet Referring and Managing Once someone is identified as being malnourished or at risk, it is important to establish the cause. If the cause relates to support required to eat and drink, then teams can discuss this directly. If there are health concerns, then refer to the appropriate support (see personalising care and support section). EXAMPLE Derbyshire County Council have produced a range of materials enabling staff to identify the common signs of someone who might be underweight. Top Tips for Success Make sure all of your staff can identify the signs of malnutrition and dehydration. 1 9 June 2013

Principle 4 Personalising care, support and treatment At a glance Minimum standards Personalised services Recommendations A personalised plan of care and support is required and must be developed with each older person and their family or carer. As a minimum, it is essential to: Ensure older people have 24 hour access to food and beverages, enabling them to eat throughout the day and night if they choose Provide the right type of food, particularly for those with swallowing difficulties e.g. soft and pureed foods or fortified foods Provide service users with enough time to eat Provide dignified assistance with eating and drinking, and ensure staff are trained to do this in a compassionate and caring manner EXAMPLE The Leeds Older People Matter Food Group sent out over 1000 A4-size fridge magnets with a dry wipe style pen. These have helped older people monitor their own intake by ticking off drinks taken in a day and serving as a visual reminder to drink for dementia sufferers. Personalised services Providers should aim for the most dignified, personal service and care possible, including: Provide a family style service Give residents the chance to choose from a menu at the time of the meal Consider using picture menus/ visual menu selectors Invite family and friends to join users or residents for dinner Ensure that people know they can change their mind about their food choice be flexible Enable residents to help themselves and be independent, e.g. being involved with preparing food, laying the table and serving others EXAMPLE Age UK County Durham have a come dine with me programme of activities including 'Dining with interest' where they take their lunch club members to local places of interest such as museums. Use food smells to encourage those with poor appetites Encourage staff to eat alongside service users Have conversations at meal times with service users, not at or over them Make meal times interesting Available Tools Should an individual have specialist dietary and clinical needs, there are a range of tools and guides developed to assist with providing the right type of foods and clinical treatment if required. This may include (but is not limited to): 20 June 2013

Natural food fortification or pureed food Supplements Other clinical interventions This guide does not intend to cover these specifically. There are many excellent guides and resources readily available to help with both the decision making process and food support such as: Clinical guidance NICE's Nutrition support in adults (CG32) 6 NICE's Nutrition support in adults (QS24) 19 (see appendix 1) Managing Adult Malnutrition in the Community pathway 20 Food and beverage guidance The Nutrition and Hydration Digest: Improving Outcomes through Food and Beverage Services 24 The National Association of Care Catering (NACC) good practice guides 25 The Hospital Caterers Association (HCA) guides 26 However, a combination of clinical, food and social solutions may be required and some running in parallel, dependent upon the severity of malnutrition or the individual s condition, can be helpful too. Food providers with doubts over what they should provide for their users should consult with the clinical team involved or the individual s GP. Recommendations National Association of Care Catering (NACC) The implementation packs within NACC s How to comply with CQC s Outcome 5: Meeting nutritional needs, Residential and Community Social Care 25 highlights all the aspects of food and beverage services that need to be personalised. They include: Providing specialist support depending upon the person s condition and needs Personal aids and special equipment Special diets and screening dietary requirements Food and fluid consistency Likes, dislikes and special occasion preferences How to help older people make choices Meal time preferences such as seating and table arrangements What meal time assistance is required How to support someone with dementia More specific examples include: A desire or need for their handbag, zimmer frame or other personal items Doors or windows being shut or opened Using their own mug or china cup and saucer Preferring cold or warm milk on cereal Preferring hot or cold toast A preference between meat portions e.g. chicken breast and leg Top Tips for Success Consider personalised catering think of what you do not like about hotel food and what food you look forward to when you get home after a holiday! 21 June 2013

Principle 5 Monitoring and evaluating At a glance Monitoring: The individual Processes in place Regularly monitor and review the older person s food and drink habits and intake and report any changes. Evaluate the processes in place and their success. The individual Food and beverage providers can and must play a vital role in this. This can involve: Monitor the weight of the people they serve on a regular basis and report any changes to their clinical carers, the GP or encourage the older person to keep a diary of their weight and share this with their GP on a regular basis Investigate any unintentional weight loss ask the person if they are getting enough access to food and drink and, if not, what are the reasons and can they be signposted to getting the right support? EXAMPLE The Dairy Council have produced small compact mini diaries available for download free. See www. milk. co. uk. Monitor nutrition and fluid intake using any one of the many tools available Review the impact of the food and drink support provided Obtain feedback from the individual (and their family/ carers) and act on recommendations and negative experiences Processes in place When reviewing your organisation s processes, consider monitoring: Number and % of people with weight recorded and monitored Number of people losing weight when it could have been prevented (unintentional weight loss) Number and % of people screened (if relevant for the care setting) Number and % of staff trained in good nutrition and hydration care Number of complaints or incidents related to poor nutritional care or food provided Number of people on a personalised plan of care and care pathway Top Tips for Success Do not forget to ask older people for their opinion. The best services reflect these opinions and personal testimony is more important than just numbers. 22 June 2013

Making the changes 23 June 2013

Making the changes We now know what best practice and its underpinning principles look like: Figure 7 But the question most organisations and teams face is how do we actually make this happen? This section is dedicated entirely to the implementation process of reducing preventable malnutrition and dehydration and /or treating it when it occurs. It draws upon evidence, practical experience and examples from a wide range of teams, individuals and implementation models where successful and sustainable changes have been achieved. This has been translated into key steps to help you achieve good nutrition and hydration care, regardless of where you are starting from. There are plenty of excellent resources freely available to support change in the public sector and many, but not all, are listed in our resources section. 24 June 2013

Preparing to make the change At a glance Form a powerful team Project meetings Communication Form a powerful team The provision of food and beverages requires excellent team work and good communication. If you are making changes to the service, everyone involved in the service provision must be represented. A team providing food and beverages services will require these people as a minimum: A senior manager that influences local policy and standards for nutrition and hydration, e.g. home manager, luncheon club organiser, domiciliary care manager or a meals supplier manager EXAMPLE In Swindon s Community Nutrition Support Project, dietitians provide 'MUST' sessions for community teams, carers, sheltered housing staff, Age UK Befrienders and Health Ambassadors. Nutrition champion, e.g. day to day lead to manage and coordinate the changes required to raise standards Those who serve meals and beverages, e.g. care staff, housekeeping staff, delivery drivers or volunteers Those who prepare the meals and beverages, e.g. cook manager or chef Service user or someone who receives the service Health professionals involved as required, e.g. dietitians, speech and language therapists, occupational therapists and pharmacists Activity leads Project meetings It is important to establish regular meetings with the team that are going to work on making the changes. Communication It is important to communicate to everyone (including users and residents) what you are trying to do and how they can get involved. Top Tips for Success Meeting for less time but more often can be more productive and a better use of everyone s time. 25 June 2013

Knowing where you are and where you want to be At a glance Understand your current position Decide where you want to be Your team will need to establish and agree where your services are now and develop and agree a vision of how the service should operate in the future. Your current position This is your opportunity to build your local case for change by understanding any problems and issues in your services. As a team, ask yourselves about the following: Quality Business What choices are available what to eat, when, where and with whom? Do you comply with CQC's Outcome 5: Meeting nutritional needs (appendix 2)? Do you provide person centred and dignified services? Do you meet all of the personal needs highlighted within the NACC Food Facts Sheet? 25 This is part of the implementation packs (appendices 3 and 4) within 'How to comply with CQC's Outcome 5: Meeting nutritional needs' Are your staff appropriately trained in the nutritional care needs of your service users/ residents? Do you meet the NACC s Nutritional Standards? 25 Do you have a reducing customer base? Do you have high food costs with high wastage? Do you need to improve staff retention? Try and find some or all of the following: Levels of malnutrition within your customers or residents Care plans what do they say about a person s personal choices and nutritional requirements and are you meeting them? Average expenditure on food and beverages Customer or resident feedback Best practice examples from similar organisations Menus: are there appropriate choices for all meals? Are they non repetitive? Are service users involved and aware of their choices? Records of staff trained in nutrition and hydration care 26 June 2013

Once you know where you are, agree as a team where you want to be Have a vision and strategy for the provision of food and beverages including: 24 hour service food and beverages easily accessible (1)* Menus offering choice good menu planning (1) Service users know and understand what they can choose, when and how (1) All staff being appropriately and well trained (2) Appropriate monitoring of meals and beverages and assistance provided to those who need it (1) All individual personal needs met see Food Facts sheet (1) Enjoyable meal times (2) involving activity staff Meet CQC Outcome 5 requirements (3) A close working relationship with GPs, dietitians, speech and language therapists (SALTS) and other professionals (1) Close liaison with carers (1) Good service user feedback and appropriate actions taken (1) Excellent team work between those who assist with menu choices, cook, serve and clear away food and beverages (1) Nutrition champions, preferably one from care staff and one from catering (1) An environment conducive to people enjoying their meal times (protected meal times) (1) Ensure comfortable eating environment with restaurant style service (4) Family style service (1) Choices made at the time of the meal (4) * The numbers in brackets relate to the correct location on the graph in 'Making it happen'. Top Tips for Success Consider an organisational raid: look at the good work other organisations do and adopt it yourself (with adaptation where required). 27 June 2013

Making it happen At a glance Implementing in the right order Implementation Prioritise and implement actions in your plan. Have a clear action plan with timescales and a named lead to ensure it happens. Implement the easiest and most effective options first. Try implementing the options from the above list in order of number. 1 Quick wins 2 Important but requires time and resources 3 Testing (in small pilots) 4 Set aside and consider for later in the program No For testing in small pilots (3) Set aside (4) Quick wins (1) Important but requires time and resources (2) Yes Easy Hard Figure 8 Top Tips for Success Implementing quick wins will encourage and galvanise your team. 28 June 2013

Measuring, monitoring and embedding your changes At a glance Measure changes Communicate and celebrate Measure changes It is important to measure the changes you have made and monitor them over time so you can be assured the changes you are making are being embedded and sustained. Consider doing the following: Measure levels of malnutrition and how long it takes an individual to recover or show progress in the right direction Compile service user feedback evaluations when you make changes to see how they have been received Monitor the number of complaints and praise before and after your changes EXAMPLE The Lunch Club Service in Leicestershire has been popular with locals. Emma, aged 90, said, I always come here - it s a bit of company. I live on my own you see and it saves me getting dinner. ' Measure your service against CQC s Outcome 5: Meeting nutritional needs (appendix 2) on a regular basis Communicate and celebrate Do not forget to share your team s progress with all stakeholders. Keep everyone in touch and create an atmosphere where everyone can continue to improve the food and beverage services they offer and be proud of the service they deliver. Top Tips for Success Always remember to ask receivers of care for their opinion in measuring your success. 29 June 2013

Appendices 30 June 2013

Appendices Appendix 1: NICE's Quality Standard for Nutrition support in adults (QS24) Statement 1. People in care settings are screened for the risk of malnutrition using a validated screening tool. Statement 2. People who are malnourished or at risk of malnutrition have a management care plan that aims to meet their nutritional requirements. Statement 3. All people who are screened for the risk of malnutrition have their screening results and nutrition support goals (if applicable) documented and communicated in writing within and between settings. Statement 4. People managing their own artificial nutrition support and/or their carers are trained to manage their nutrition delivery system and monitor their wellbeing. Statement 5. People receiving nutrition support are offered a review of the indications, route, risks, benefits and goals of nutrition support at planned intervals. For more information, please see: http://www.nice.org.uk/guidance/qs24 A supporting document, QS24 Nutrition support in adults: NICE support for commissioners and others is also available from this site. Appendix 2: Care Quality Commission (CQC)'s Outcome 5: Meeting nutritional needs 14 (1) Where food and hydration are provided to service users as a component of the carrying on of the regulated activity, the registered person must ensure that service users are protected from the risks of inadequate nutrition and dehydration, by means of the provision of: (a) a choice of suitable and nutritious food and hydration, in sufficient quantities to meet service users needs; (b) food and hydration that meet any reasonable requirements arising from a service user s religious or cultural background; (c) support, where necessary, for the purposes of enabling service users to eat and drink sufficient amounts for their needs. (2) For the purposes of this regulation, food and hydration includes, where applicable, parenteral nutrition and the administration of dietary supplements where prescribed. Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 http://www.cqc.org.uk/sites/default/files/media/documents/guidance_about_compliance_s ummary.pdf For more information, see Essential Standards of Quality and Safety http://www.cqc.org.uk/organisations we regulate/registered services/guidance meetingstandards 31 June 2013

References

References 1 M. Elia, R. M. Smith, Improving Nutritional Care and Treatment: Pespectives and Recommendations from Population Groups, Patients and Carers, BAPEN, 2009 2 Robert Francis (chair), The Mid Staffordshire NHS Foundation Trust Public Inquiry, 2013 3 Available at: http://www.telegraph.co.uk/health/healthnews/9850323/starved pensioner leftwithout care dies.html 4 Available at: http://www.cqc.org.uk/public/reportssurveysandreviews/themed inspections/dignityandnutritionolderpeople 5 Personal Social Services Adult Social Care Survey, England 2011 12, The NHS Information Centre, 2012 6 Nutrition Support in Adults (CG32), NICE, 2006 7 Malnutrition in Older People in the Community: Policy Recommendations for Change, European Nutrition for Health Alliance, BAPEN and ILC UK, 2006 8 National Population Projections, 2010 Based Projections, Office for National Statistics, 2011 9 Calculation based on BAPEN Screening weeks 2007 11 10 R. J. Stratton et al, 'Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the 'malnutrition universal screening tool' ('MUST') for adults', British Journal of Nutrition, 2004, 92 11 M. Elia et al, The cost of disease related malnutrition in the in the UK and economic considerations for the use of oral nutritional supplements (ONS) in adults, BAPEN, 2005 12 M. Heismayr et al, 'Decreased food intake is a risk factor for mortality in hospitalised patients: The NutritionDay survey 2006', Clinical Nutrition, 2009, 28 13 J. F. Guest et al, 'Health economic impact of managing patients following a communitybased diagnosis of malnutrition in the UK', Clinical Nutrition, 2011, 30, 4 14 J. M. M. Meijers et al, 'Estimating the costs associated with malnutrition in Dutch nursing homes', Clinical Nutrition, 2012, 31, 1 15 Benefits of Implementation: Cost saving guidance, NICE, (updated) 2013 16 National cost impact report to accompany CG32, NICE, 2006 17 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 18 Patient Experience in Adult NHS Services (QS15), NICE, 2012 19 Nutrition Support in Adults (QS24), NICE, 2012 20 Available at: http://malnutritionpathway.co.uk 21 Malnutrition and Caring: The Hidden Cost for Families, Carers UK, 2012 22 Available at: http://malnutritiontaskforce.org.uk/downloads/integrated_working/derbyshire_eat_well_leafl ets_1.pdf 23 Available at: http://www.bapen.org.uk/screening for malnutrition/must/must toolkit/the mustitself 24 The Nutrition and Hydration Digest: Improving Outcomes through Food and Beverage Services, The British Dietetic Association, 2012 25 Available at: http://www.thenacc.co.uk/shop/goodpracticeguides 26 Available at: http://www.hospitalcaterers.org/publications 33 June 2013

Resources

Resources Age UK www.ageuk.org.uk Alzheimer s Society www.alzheimers.org.uk Association for Nutrition www.associationfornutrition.org BAPEN 1) Organising food and nutritional support in hospitals: an interactive diagram to demonstrate how nutritional services might link within a hospital www.bapen.org.uk/ofnsh/index.html 2) Education and training: interactive e learning modules on nutritional screening using MUST for hospitals and community www.bapen.org.uk/screening formalnutrition/must/must toolkit/e learningresources on nutritional screening forhospitals and the community 3) Malnutrition Matters: Meeting Quality Standards in Nutritional Care, A Toolkit for Commissioners and Providers in England www.bapen.org.uk/pdfs/toolkit forcommissioners.pdf 4) MUST toolkit www.bapen.org.uk/screening formalnutrition/must/must toolkit/the mustitself British Dietetic Association (BDA) Mind the Hunger Gap resources www.mindthehungergap.com British Dietetic Association (BDA) Nutrition and Hydration Digest www.bda.uk.com/publications/nutritionhyd rationdigest.pdf Carers UK www.carersuk.org Caroline Walker Trust www.cwt.org.uk Care Quality Commission Domain 5 Standard www.cqc.org.uk CQC Dignity and Nutrition Inspections 2011: http://www.cqc.org.uk/sites/default/files/me dia/documents/20111007_dignity_and_nut rition_inspection_report_final_update.pdf CQC Dignity and Nutrition Inspections 2012: http://www.cqc.org.uk/public/reportssurveys and reviews/themedinspections/dignity and nutrition olderpeople The Dairy Council www.milk.co.uk Hospital Caterers Association (HCA) www.hospitalcaterers.org Managing Adult Malnutrition in the Community pathway www.malnutritionpathway.co.uk My Home Life www.myhomelife.org.uk National Association of Care Catering (NACC) www.thenacc.co.uk National patient safety agency www.npsa.nhs.uk 10 key characteristics of good nutritional care http://www.nrls.npsa.nhs.uk/resources/?ent ryid45=59865 NHS resource to help make changes www.changemodel.nhs.uk/pg/dashboard NHS resource of improvement tools www.institute.nhs.uk/quality_and_service_i mprovement_tools/ NICE Nutrition support in adults (CG32) www.nice.org.uk/cg32 NICE Nutrition support in adults (QS24) www.publications.nice.org.uk/qualitystandard for nutrition support in adultsqs24 NICE Patient experience in adult NHS services (QS15) www.guidance.nice.org.uk/qs15 'Ready to Go?' discharge guide, Department of Health http://ow.ly/khxl7 Royal College of Nursing www.rcn.org.uk Royal Society of Public Health: Eating for health in residential care homes www.rsph.org.uk/en/trainingsolutions/index.cfm Salvation Army www.salvationarmy.org.uk/ SCIE Dignity in Care http://www.scie.org.uk/ Women s institute http://www.thewi.org.uk/ WRVS http://www.wrvs.org.uk/ Please see the Malnutrition Task Force resources page for full details of the examples featured in this guide. 35 June 2013

Visit our website for more information: www.malnutritiontaskforce.org.uk