Dorset Soundbites patient and user experiences of mealtimes in Dorset hospital and care settings Report Prepared by Annie Dimmick ( Development Officer) For Further Information contact: T: - 0300 111 0102 E: - contact@makesachange.org.uk November 2011 1
Acknowledgements would like to thank all those who provided the information used in this report, including Dorset County Council, NHS Dorset and staff/volunteers at POPP (Partnership for Older People Programme) Our particular thanks go to the volunteers who were involved in visiting hospitals and care homes and to service users, carers and interested members of the public who took the time to participate in the project and provide their feedback. We would especially like to acknowledge the input of the following people: Sue Hawkins, Dorset County Council Care Catering Services Manager who provided our volunteers with invaluable and interesting training on MUST (Malnutrition Universal Screening Tool) Jo Mitchard from POPP who undertook to gather feedback from lunch club service users Fiona Gibson, Therapy Services & Dietetic Manager Dorset County Hospital for taking the time to discuss MUST training and nutritional care in the hospital setting 2
Contents: Executive Summary 1. Introduction 2. Aims & Objectives of the report 3. Methodology 4. Consultation 5. Findings 6. Conclusions 7. Recommendations 8. Summary Appendix Glossary of Terms 3
Executive Summary Every person receiving care in the acute hospital, community hospital or care home setting should receive the appropriate nutrition to aid recovery from illness or to remain well. People who may require support and help to eat should receive that support from nursing and care staff who are trained appropriately and who ensure that the patient/service user experience of mealtimes in those settings is a good experience and maintains people s dignity and wellbeing. This report details the work undertaken by Dorset Local Involvement Network to review standards of nutritional care and support in the elderly care wards at Dorset County Hospital, in all of Dorset s community hospitals and in the care homes managed by Dorset County Council. Included in the report is a detailed methodology, findings from the visits to wards and units, conclusions and a list of recommendations in Section 7. The recommendations have been assigned to specific service commissioners and or providers for their consideration and review. Where more than one commissioner and/or provider has been assigned an action believes all have a part to play in bringing about change either within their own areas of responsibility or working together across organisational boundaries. Overall findings were generally positive with a number of minor issues and concerns arising. Much work is currently being undertaken both within the local NHS and local authority regarding nutrition and nutritional support and it is hoped that the conclusions and recommendations arising from the review will be incorporated into this work. will be following up the recommendations with the commissioners/providers 6 months from the date of this report. A copy will also be sent to the Care Quality Commission. 4
1. Introduction 1.1 Background to the report During 2010 worked with the Dorset County Council Health Scrutiny Committee on a review of dementia services in Dorset. During this work it became evident that awareness of the importance of nutrition for people with dementia (and for older people in general) was often quite poor in health and social care staff, patients, carers and relatives. Of the 100 carers, patients and relatives interviewed for the project, 70% were unaware of nutritional importance. Good nutrition is not just vital for older people but for those who are more vulnerable due to illness, people in hospital or those with mental health problems. has received feedback from people concerned about malnutrition of relatives in care homes and hospital settings as well as those concerned for vulnerable people in the community who may not be in the system i.e. who are not accessing health and social care services and who often fall through the gap due to isolation and other factors. 1.2 Campaigns and Research Age UK have been running a campaign called Hungry to be Heard and through their work and research it has been estimated that malnutrition costs the NHS at least 7.3 billion per year (although more recent research suggests the figure could be at least double that). Malnutrition leads to longer hospital stays, more medication and a higher risk of infection and it is estimated 180,000 people a year leave hospital malnourished. The Alzheimer s Society research Counting the Cost: Caring for People with Dementia on Hospital Wards (Nov 2009) surveyed 1000 carers of patients with dementia admitted to hospital. Only 23% were satisfied with the help given to their cared for to eat and drink. The national inpatient survey asks patients if they feel they are given enough help by NHS staff when eating meals. For 6 years now the results suggest around 1 in 5 patients have said No. 5
Using the BAPEN (British Association for Parenteral and Enteral Nutrition) toolkit and population data taken from POPPI/PANSA database (Sept 2010) the following information was compiled by Dorset County Hospital: 2015 Projected number of people at risk of malnutrition in Dorset Aged 65 and over (general population) Aged 65 and over (sheltered housing) Aged 65 and over (care at home) Aged 65 and over (care homes) Prevalence of malnutrition Numbers at risk in Dorset 119,900 (14% prevalence) Approx. 16,786 2,491 (12% prevalence) Approx. 299 15,810 (25% prevalence) Approx. 3,593 4,097 (30% -42% prevalence) Approx. 1,229-1,721 Therefore the total estimated number of people at risk of malnutrition is 22,267 22,759 NOT including residents of Mental Health Units or Hospital Admissions 1.3 The Project agreed to develop a project to assess patient and user experiences of mealtimes in hospital and care settings across Dorset (outside of Poole and Bournemouth). The focus of the review was to establish where best practice guidance on nutrition and malnutrition is being implemented and identify gaps. Key lines of enquiry included: How nutritional awareness training for health and social care staff is commissioned, funded and provided How carers, relatives, patients and those working with vulnerable people in our communities are provided with appropriate information and support to raise awareness of nutritional needs and to identify those people at risk or potentially at risk from malnutrition To assess the patient/service user experience of mealtimes in hospital and care settings 6
2. Aims & Objectives of the report The review sought to achieve the following outcomes: To raise awareness of the importance of good nutritional care in hospital and social care settings To ensure local health and social care providers can evidence that their staff are given effective training in order that people with malnutrition, or at risk from malnutrition, are identified, assessed and treated appropriately To highlight good practice in nutrition care ensuring that it is disseminated across the county To raise awareness of malnutrition in the voluntary and private sector To ensure the nutritional needs of vulnerable people are recognised as integral to well-being and quality of life To be a catalyst for improvement and changes where it is needed To show real and effective partnership working 3. Methodology 3.1 Background Research Contact was made with various NHS and Local Authority representatives/staff with an interest in, or holding a role responsible for, aspects of nutritional care in the primary and social care setting. The information gathered helped to establish an understanding of the current policies and practices in nutritional care, to find out about proposed developments and projects, to gain an awareness of how malnutrition is identified and assessed and to alert interested people to the project in general. Through meetings with statutory sector colleagues and general research the following documents were used to build up an understanding of malnutrition issues, to provide relevant statistics, to develop an enter & view template and to support volunteer training: Department of Health Best Practice Guidance Essence of Care 2010 Benchmarks for Food and Drink (2010) NICE Nutrition support in adults, Understanding NICE guidance information for people who need nutrition support, their families and carers and the public (2006) NICE Implementation Advice Suggested actions for implementing the NICE clinical guideline on nutrition support in adults (2006) Care Quality Commission Observation prompts and guidance for monitoring compliance, Guidance for CQC inspectors Outcome 5: Meeting nutritional needs (2010) 7
BAPEN (British Association for Parenteral and Enteral Nutrition) Malnutrition Matters, Meeting Quality Standards in Nutritional Care A Toolkit for Commissioners and Providers in England (2010) Age Concern/Age UK Still Hungry to Be Heard The scandal of people in later life becoming malnourished in hospital Social Care Institute for Excellence The Dignity factors: Eating and nutritional care taken from www.scie.org.uk/publications/guides Dorset County Council Catering Services Adult and Community Services An information guide on how to build yourself up and reduce the risks of malnutrition 3.2 Training for Volunteers An open meeting was advertised and held in autumn 2010 for interested potential volunteers to learn more about the project and to discuss the role of LINk enter & view authorised representatives. This was followed by a series of training days covering use of MUST (Malnutrition Universal Screening Tool), LINk enter & view protocols and procedures, how to undertake observation visits, safeguarding, privacy, dignity and confidentiality, codes of conduct and resolution of conflict. Training was provided by the Host, Help & Care and by Sue Hawkins, Care Catering Services Manager at Dorset County Council. Safeguarding training was provided through Adult Learning. All authorised enter& view volunteer representatives were Criminal Records Bureau checked. 3.3 Signposting Throughout the project and during the visits endeavoured to signpost members of the public, patients, carers and relatives to useful information about nutrition, including that provided by Age UK, Dorset County Council and Help The Aged (in association with the British Dietetic Association). 3.4 Visits to Premises Visits were conducted to elderly care wards at Dorset County Hospital, to all Dorset County Council managed elderly care homes (except those supporting people with learning disabilities) and to all community hospitals in Dorset. Visits were carried out at breakfast or lunch time and on different days of the week. Providers were not given actual dates for the visits but were advised that visits would take place at some time week beginning xxxx. These advices were sent out the week before the planned visits by the Host. Enter & View teams were made up of two volunteers who were provided with badges and letters of authority and all relevant provider information and question/prompt templates. All volunteers were also aware of procedures relating to identifying and reporting safeguarding issues. 8
3.5 Learning Points The following learning points for future projects have been identified as follows: Enter & View authorised representatives needed CRB checks to undertake visits. This was a lengthy process thus making the project timing slip somewhat. It was hoped that visits could be made to services to observe evening mealtimes and at weekends. However, due to volunteer capacity and availability this was not possible but it is hoped this could be undertaken in the future Visits were not made to care homes supporting people with learning disabilities at this time. It was felt that volunteers needed to gain experience of undertaking visits to other premises before taking on this potentially more demanding area. This decision was taken both in order to support volunteers but also to ensure service users were not put under any undue stress. It is hoped that some volunteers will wish to undertake observations at these premises in the future (possibly part of Phase 2) as it is acknowledged that these service users are potentially the most vulnerable Although volunteers were given a comprehensive question/prompt template it was difficult to provide something that covered all scenarios/type of premises. Volunteers needed to use their initiative when making observations and taking notes. Although this was not a problem, overall it did make it more difficult to compare and contrast findings 3.6 Reporting the findings The full findings from each visit are documented in the Appendix. A summary is provided in Section 5. All visits have been documented using an agreed template that records the actual observations made, what the setting did well and what could be improved. 4. Consultation 4.1 Comments provided to the LINk through POPP lunch clubs The LINk received a number of comments from people attending POPP lunch clubs. These are detailed in the Appendix. would like to thank POPP staff for taking the time to document these findings. 9
5. Findings Findings are documented for each setting (acute care, care homes and community hospitals) under what they did well and what could be improved. 5.1 Acute care Dorset County Hospital Barnes Ward Ward has made big improvements recently Patients were observed being treated with dignity and respect during the meal and staff supporting more vulnerable patients were caring and sensitive Abbotsbury Ward Staff observed were treating patients with respect Barnes Ward Communication with relatives about the nutritional needs of patient Communication with care homes etc re patient preferences/must scores (this is an improvement that needs to happen in the care homes etc as well) Staff awareness of MUST could be improved Abbotsbury Ward Staff awareness of MUST could be improved 10
5.2 Dorset County Council managed care homes Anglebury Court Staff are advised to record anything useful in service user care plans e.g. someone may suddenly tell them a favourite drink or food or something about themselves that may be useful to know to make their experience/life better Care needs charts are available. Staff know about fortified foods and who should have them Birthday cakes/teas are provided for service users. Families can come in and eat for a small fee they are also encouraged to come in for Xmas dinner etc Home is working to the Gold Standards Framework Staff would like more help to support people to eat. This would give them more one-toone time especially for those with dementias Agency staff may not have as robust training as permanent staff e.g. in MUST If service users have been into acute care sometimes the home has had to get them back to a good level of nutrition/balance. (Needs to be an improvement in acute care areas) Communication between services is sometimes not good there is a lack of common practice across acute care, community hospitals and care homes Some areas did not use table cloths or have any fresh flowers or condiments on the tables although the team realise this may be different at other mealtimes Castleman House Social environment and interaction played an important part in encouraging residents to eat Very cheerful, light and airy atmosphere No negative smells! Nothing to add at this time 11
Avon View Staff interacted with residents with dignity and respect Health Care Assistants addressed everyone by name and knew individual preferences Even though the home is quite large it retains an intimate and friendly feel Good to see menus with photos Nothing to add at this time Sidney Gale House Menus seemed appropriate but also imaginative Staff interaction and support was excellent Good care taken to make the dining area settings pleasant and attractive with restaurant like table settings Individual needs, likes and dislikes accommodated staff even went to the trouble of making a special steak and kidney pie for a resident who needed extra encouragement to eat Nothing to add at this time The Lawns Did not see a Food Hygiene Policy on display in the dining area but all Inspection Reports and Policies were out in the Front Foyer for all to read Very good ambiance and atmosphere throughout the mealtime Nice to see activities involving residents and food Nothing to add at this time 12
Streets Meadow Did not see a Food Hygiene Policy on display in the dining area but Inspection Reports and Policies were out in the Front Foyer for all to read A Residents Questionnaire was also available in the foyer with specific areas dedicated to the food elements Picture menus would be a great advantage to residents with or without communication difficulties Using a person s name and naming food is an advantage when supporting and prompting someone to eat and staff could do more of this The Hayes Nice to see vegetables being served separately on each table with residents taking the amount they want Monthly forum where residents are consulted on menu design and encouraged to try new dishes Nothing to add at this time 13
5.3 Community Hospitals Portland Community Hospital Sending patients home with emergency food parcels where necessary Meals need to be ordered two days in advance. Not many people know what they wish to eat two days in advance and a patient may not wish to eat the food they have previously requested (for whatever reason) Although food appeared good there is a lack of flexibility when food is not prepared on site Swanage Community Hospital Staff celebrate things like the Royal wedding lay on something nice and they do birthday cakes as well for patients Children from the school send in vegetables they have grown. The children give the kitchen feedback on the food as well which is a great piece of community partnership work Kitchen staff actively encourage patients to express their likes and dislikes All staff, but especially kitchen staff, appear very passionate about providing good quality food and a good quality eating experience Staff would like to set up a Community Kitchen this seems like a worthwhile initiative that should be supported both here and at other hospitals where feasible Finding it hard to get usable light lipped crockery for people who have for example, Parkinson s 14
Wareham Community Hospital Atmosphere in the dining room was very open and pleasant No unpleasant smells Food is cooked on site and there is a project being discussed to grow own vegetables next year via an allotment project with the local school Social interaction is encouraged but patients can eat in their rooms if they wish One lady who was struggling with appetite was encouraged to try different foods Nothing to add at this time Westhaven Hospital Excellent dining room facility with good support from staff for those needing help with meals Staff at all levels appeared to have good knowledge of MUST Staff encourage relatives and carers to help with mealtimes where possible Staff actively helping people with dignity and respect Little flexibility for patients because no onsite kitchens. Staff spoken to all agreed they would prefer on site facilities given a choice Use of post-it notes attached to meal covers means there is a possibility of them becoming detached. This was observed on the visit with the consequence that one patient received the wrong meal Use of green plastic aprons for patients is not very dignified More staff in the bays would be helpful to avoid the sense of patients being rushed and getting meals later than those in the dining room 15
Blandford Community Hospital Hopefully by Xmas ward will be transformed to look like a cafe - new curtains Blackboard - Bistro feel Good awareness of MUST and food fortification requirements The smell of urine on the ward at mealtime was not good It is a shame that the Productive Community Hospital initiative was not being followed through The Yeatman Community Hospital Good to see patients can choose portion size of meal Nothing to add at this time Westminster Memorial Hospital Use of the red tray system Although not specifically relevant to this project it is worth raising that staff read daily newspapers to patients in the mornings where they can not do so for themselves On site kitchen means less waste and more flexibility Choice of de-caffeinated tea and coffee should be provided (would help with any caffeine intolerances and also with sleeping at nights) It was noted that staff have a better quality coffee available than patients All staff need to be aware of aids such as the picture menu which would help patients making choices A more pro-active approach to using the Comment book should be encouraged If the table was laid it may encourage patients to use it rather than bedside chairs 16
St. Leonard s Community Hospital Staff appeared friendly Overall this ward was not making enough effort to help patients make mealtimes an enjoyable and worthwhile experience. In the light of the ward being a rehab ward there is no doubt there is need for considerable impetus where the value of mealtimes and quality of food is key to patient recovery and overall wellbeing There appeared to be little ownership and pride in the ward. The team is aware there are changes being made here and we only hope things begin to improve The team had some concerns that supplements are not actively or consciously being used. There was no clear or confident answer from staff when asked about the use of butter and fortified foods (however the chef advised that full fat milk is used in all cooking). The chef had no contact with dieticians since Christmas Bridport Hospital Treating patients with dignity, care and respect during mealtimes Nothing to add at this time Melstock House (Forston Clinic) Calm and relaxed mealtime environment A new shelved trolley would be safer than the one in situ Hand wipes could be offered prior to meal times Staff need to be better informed about the MUST as three individuals were vague about the procedure The catering review could be viewed as a pilot and a subsequent survey by patients and staff might indicate some room for improvement 17
Victoria Hospital Well organised, well executed meal times Choice of food and beverages excellent with sufficient staff to assist patient to eat Healthcare assistants have best information and knowledge of patient s needs and dietary likes and dislikes. They are also well informed of MUST tool Nothing to add at this time. Weymouth Community Hospital The Enriched Care Planning is a great tool but the information could also be shared with carers/relatives on discharge as it may assist with the way in which their family member is supported Good interaction by staff with patients during the meal There is more waste using outside caterers then with onsite kitchens and less flexibility Picture menus would be a great advantage to patients with or without communication difficulties Using a person s name and naming food is an advantage when supporting and prompting someone to eat Verbal and light touch prompts might have helped in some instances Napkins supplied to all patients would be preferable rather than waiting to use them to wipe away stains later or using the green plastic aprons The distraction of a television is well documented therefore having a TV on should only be for those who prefer or request it 18
6. Conclusion Although the focus of this piece of work was on observing the mealtime experience of people in hospital and care settings it became apparent through talking with carers, relatives and staff that more support for people on discharge (from acute and community hospitals) would enhance the well-being of vulnerable people returning home after illness and help prevent readmission. This support could/should include information on nutrition and hydration, useful contacts and basic food boxes. is aware that much work is being done to improve discharge processes and procedures for patients and hopes the following recommendations will be taken on board as work on this area progresses. The LINk is also aware of the work currently being done across Dorset to raise awareness of malnutrition in the care setting, provide staff training on the use of tools such as MUST and to ensure people, especially vulnerable people, are given the nutritional care they need and are supported with dignity and respect. The findings from the Enter & View visits should help to inform this work. The LINk hopes that the individual premises visited will acknowledge the observations made and will take action where issues have been raised under. It is also hoped that the good practices will be disseminated across all areas and changes made where required. The Enter & View visits highlighted that where kitchens are on site in community hospitals, the quality and flexibility of the mealtime experience is much better for patients (and staff). It also appears, and it would be interesting to have some figures on this, that on-site kitchens are more cost effective as there is less waste. It is hoped that any future plans for community hospitals do not include removal of on-site kitchens. Learning together and partnership working between local NHS and Local Authority has improved over the past few years and continues to do so. It is hoped that by undertaking visits to both hospital and care settings and documenting the observations made in this report will allow staff from both areas to learn from what happens in different settings. Good practice in the care home environment can be taken on board in the hospital setting and vice versa. It is hoped that this will enhance the partnership work already being done. would like to reiterate that this project only observed the care provided over mealtimes and did not look at any other aspect of care either in the hospital or care settings. It should also be noted that the findings are only a snap shot of one mealtime at each location and therefore may not reflect the situation at other times or days of the week. The LINk hopes to extend this piece of work into the private care home sector. A meeting of the Enter & View volunteers will take place some time in late autumn 2011 to discuss a possible schedule of visits starting in 2012. Given that LINks will cease to be in operation from October 2012 (when the new Healthwatch is in place) the project is unlikely to be able to visit all the care homes but may cover a random selection in each district. 19
7. Recommendations 1. Those people who have been assessed at risk of malnutrition, whilst in acute or community hospital setting, should be provided with information on nutrition and hydration upon discharge (or the information provided to carers and relatives as appropriate). Information could also include details of local lunch clubs, support groups, befrienders groups and other useful contacts. Action for NHS Dorset, DCHFT and DHUFT 2. Where possible basic food boxes could be provided for people discharged from hospital returning to an empty home. Content of boxes needs to reflect the needs of the patient and their circumstances. Sugar, jam, tinned foods are often items that people have in store cupboards. Perishable items such as milk, bread, eggs and cheese are not and these are the items most likely to be required upon return home. Action for NHS Dorset, DCHFT and DHUFT 3. There should be better communication and sharing of patient nutritional information/requirements between care homes, community hospitals and acute trusts especially where people have been assessed of being at risk of malnutrition. Information should also include, where possible, person s food preferences and requirements such as whether they are left handed. Action for NHS Dorset, DCHFT, DHUFT and DCC 4. More training could be provided for care and hospital staff in how to help someone with eating, how to feed a vulnerable person and feeding techniques. Action for NHS Dorset, DCHFT, DHUFT and DCC 5. MUST awareness and training could be implemented more robustly in some of the hospital settings and monitored for effectiveness. Action for DCHFT and DCHFT 6. Information about good nutrition and nutritional support could be available for patients, relatives and carers in GP practices. Action for NHS Dorset 20
7. The voluntary sector could be provided with more opportunity to receive information/training about nutrition and hydration of vulnerable people. Carers and relatives need to be empowered to provide the best possible support for their cared for person(s). This in turn will prevent many unnecessary hospital admissions. Action for NHS Dorset, DCHFT, DHUFT and DCC 8. Community hospitals should be encouraged to look into making more use of their kitchens where these are on site. The example of Swanage community hospital supplying food for the local primary school should be upheld as best practice. Supporting these hospitals to become community kitchens should be built in to future plans where possible. Action for NHS Dorset and DCHFT 21
8. Summary The report represents a snap shot of mealtime experiences across Dorset hospital and care settings. It identifies areas of good practice and areas for improvement and provides a number of recommendations for commissioners and providers to take forward. The believes that the recommendations, developed as they are from actual observations, offer an opportunity for local NHS providers, local authority providers and the voluntary sector to work together to enhance awareness of nutritional care, raise awareness of the support and information that is available and provide more opportunities for patients, carers and relatives to receive the support and information they need to remain well. 22
Appendix 1 Feedback from POPP lunch clubs 23
Appendix 2 Full Findings from Enter & View Visits Findings from 20 visits attached as separate pdf. documents 24
Glossary of Terms BAPEN - British Association for Parenteral & Enteral Nutrition CPN - Community Psychiatric Nurse CRB - Criminal Records Bureau DCC - Dorset County Council DCHFT - Dorset County Hospital NHS Foundation Trust DHUFT - Dorset HealthCare University NHS Foundation Trust HCA - Healthcare Assistant LINk - Local Involvement Network MUST - Malnutrition Universal Screening Tool NICE - National Institute for Clinical Excellent OT - Occupational Therapist OTA - Occupational Therapist Assistant POPP - Partnership for Older People Programme SALT - Speech and Language Therapist About this report This report was commissioned by the Dorset Local Involvement Network (), supported by Host Help and Care. For more information about the see www.makesachange.org.uk. The supporting research and report for this project was overseen and written by Annie Dimmick, Development Officer at the. 25