Malnutrition in Later Life: Prevention and Early I ntervention

Malnutrition in Later Life: Prevention and Early I ntervention Best Practice Principles & I mplementation Guide Care Homes 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 and voluntary organisations Document purpose Title Partnership working Implementation guidance Malnutrition in Later Life: Prevention and Early Intervention. Best Practice Principles and Implementation Guide: Care Homes Author Publication date Target audience The Malnutrition Task Force May 2013 Care Home Providers, Care Home Managers, Caterers, Directors of Adult Social Care, Care Quality Commission Representatives, HealthWatch Representatives and Resident Representatives Description Contact details The Malnutrition Task Force (MTF) members This guide defines the principles of best practice, the moral, legal, quality and financial case for change and practical advice to support a wide range of health, social care and voluntary organisations in making the required changes to counter malnutrition 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 May 2013

Contents I ntroduction 5 Foreword 6 About malnutrition 7 The case for change 8 Best practice principles 1 1 I mplementing change 1 4 Making the changes 1 5 Preparing to make the change 1 6 Knowing where you are and where you want to be 1 7 Making it happen 1 9 Measuring, monitoring and embedding your changes 25 Appendices 26 References 29 Resources 31 4 May 2013

I ntroduction

Foreword Malnutrition is a major cause and consequence of poor health and older people are particularly vulnerable. 37% of people aged 70 years and over who had recently moved into a care home were found to be 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 unacceptable occurrences that contribute to malnutrition. However, these can be readily overcome and small changes can make a big difference. This guide is ambitious; 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. There has never been a more urgent need to act. The Care Quality Commission (CQC) Dignity and Nutrition inspections review 2 demonstrates that some care homes are failing to provide older people with the support they need to achieve their basic right to food and drink. The overall costs of malnutrition across society run into billions of pounds 3 in spite of proven interventions that can help prevent, identify and manage the problem and risks. By taking action we can reduce human suffering and significant costs. 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 the 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 senior leaders, teams and individuals delivering front line care to take action and make the changes needed. We urge you to act now to ensure best practice and put an end to this needless suffering and neglect of basic human rights so that older people receive the dignified, personalised care, support and treatment required to combat malnutrition. We hope this guide will help you. Dianne Jeffrey, CBE DL, Chairman, Malnutrition Task Force Jane Ashcroft, Chair, ECCA and Chief Executive, Anchor Trust 6 May 2013

About malnutrition What is malnutrition? According to NICE (National Institute for Health and Care Excellence) guidance in Nutrition support in adults (CG32), 4 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 exclusion, poor access to transport or 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 May 2013

Addressing the problem BAPEN (British Association of Parenteral and Enteral Nutrition) screening weeks showed that 37% of older people who have recently moved into care homes are already malnourished or at risk. 1 This highlights the need to prioritise the delivery of good nutrition and hydration care for all care home residents. Health care professionals and care providers are generally knowledgeable about malnutrition and dehydration. However, the CQC Dignity and Nutrition Inspections demonstrate that there is room for improvement. 2 This guide sets out a vision to transform nutrition and hydration care for older people in care homes, outlines five main principles and offers guidance on implementing changes required using the wealth of existing guides and tools readily available. This guide can also be read in conjuction with the Food and Beverage Providers guide. 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 3 The vast majority of these (approximately 93%) are living in the community, with a further 5% in care homes and 2% in hospitals 3 It is estimated that 1 in 10 people over 65 are malnourished or at risk 5 The population of people over 75 is at highest risk of malnutrition and is projected to double in the next 30 years 6 As many as 37% of older people who have recently moved into care homes are at risk of malnutrition 1 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. Figure 2 8 May 2013

Consequences of malnutrition Research has found that individuals who are malnourished will experience: increased ill health, increased hospital admissions, increased risk of infection and antibiotic use, longer recovery time from surgery and illness and increased risk of mortality 7 8 9 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 10 Malnutrition in care homes has been linked to increased hospitalisation, re admission and long term ill health 7 11 Cost of malnutrition Malnutrition leads to increased use of health and care services and the national estimated costs run into billions of pounds. 3 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 10 The financial case for change The resident s wellbeing is the highest priority and investing in good nutrition and hydration care is essential in delivering this Research has shown that the cost of treating care home residents diagnosed with malnutrition is twice that of screening and monitoring the general care home population 11 Good nutrition and hydration care is essential for residents and will also help increase independence, reduce falls, increase wellbeing and improve skin conditions to help reduce pressure sores Full occupancy is important financially. Having a great menu and excellent resident feedback about nutrition and hydration care can positively influence prospective residents in choosing a care home The levers for change Health and Social Care Act 2008 12 Care homes that provide care are governed by the Health and Social Care Act 2008 which contains 28 Essential Standards of Quality of Safety Outcomes. These standards are monitored by CQC. Care providers have a legal obligation to comply with these standards and are checked regularly through inspections. Failure to comply has significant consequences and can result in the care home being closed. Extract from Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010: "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 9 May 2013

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. Clinical Guidance Managing Adult Malnutrition in the Community pathway 16 The National Institute for Health and Care Excellence (NICE) has developed clinical guidance and quality standards relevant to nutrition for all settings, including care homes: Nutrition support in adults (CG32) 4 Patient experience in adult NHS services (QS15) 13 Nutrition support in adults (QS24) 14 (appendix 1) These outline that screening, appropriate nutritional intervention and care plans, good communication and interaction, monitoring and follow up should be integral to resident care. Need for action There is evidence of good practice already but we know from CQC inspections 2 that some organisations need to improve nutritional care. 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 15 The Care Quality Commission's (CQC) Dignity and Nutrition Inspection Programme inspected 500 care homes for the quality of nutritional care and found that 1 in 6 care homes did not meet the required standard 2 "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 May 2013

Best practice principles 1 1 May 2013

Best practice principles for nutrition and hydration care Providing best practice nutrition and hydration care revolves around five main principles. Care homes should focus on all of them to deliver the basic level of nutritional care required for residents and to meet the CQC standards. 1) Raising awareness to prevent and treat malnutrition through better education for staff and individuals Awareness: Residents, families and front line staff who provide care (including catering services) must understand the importance of nutrition and hydration and the serious consequences when neglected Education: Front line staff must receive appropriate training on the importance of good nutritional care (including optimal hydration). It is also important to be clear about the roles and responsibilities of individuals within the care home 2) Working together within and across care homes Care homes must have structures in place to ensure best practice can be delivered in an integrated way, to remove silos and barriers and bring all staff together. This includes clinicians, carers, caterers, therapists and other staff. 3) Identifying malnutrition and malnutrition risk early using the tools available Each and every resident s nutrition and hydration needs must be actively identified through screening and regular assessment 4) Developing personalised and dignified plans of care, treatment and support Malnourished or dehydrated individuals and those at risk must be on the right care pathways and must receive the right support, all with a focus on meeting individual need and choice 5) Monitoring and evaluating the impact of the care and support on the individual s outcome Regularly monitoring and reviewing the individual s progress and outcome is critical Monitoring the processes in place can help ensure good nutrition and hydration care is continually implemented Full details of the best practice principles are available in the Malnutrition Task Force's A Local Community Approach' guide. These have been slightly adapted for care homes. For the purposes of this document, we will use the term 'care home' to refer to both care and nursing homes. 1 2 May 2013

The following diagram is based on the five principles of best practice nutritional care. It is important to include ALL principles in your care. Figure 3 1 3 May 2013

I mplementing change Every care home resident should be supported to eat and drink so they are well hydrated and well nourished. This should be promoted through a positive and enjoyable dining experience at all times. There must be a focus on the whole experience of enjoying food in pleasant settings, respecting each person's dignity and managing the nutritional status, health and wellbeing of the individual. The question most teams face is how do we actually make this happen consistently for all residents? Existing resources There are many tools and guides available to support teams in implementing best practice principles. These include: Clinical and screening tools NICE's Nutrition support in adults (CG32) 4 clinical guidance NICE's Nutrition support in adults (QS24) 14 quality standards Managing Adult Malnutrition in the Community pathway 16 MUST screening tool 17 Food service tools British Dietetic Association's 'The Nutrition and Hydration Digest: Improving Outcomes through Food and Beverage Services' 18 Hospital Caterers Association Good Practice Guide 19 Fact sheets from Alzheimer's Society 29 Social Care Institute for Excellence's (SCIE) Dementia Gateway: Eating well for people with dementia 30 Educational tools Training programs and e learning available from: BAPEN 20 The British Dietetic Association 21 Royal College of Nursing 22 All of these are referenced throughout and in the resources section. Teams do not have to start from scratch to combat malnutrition. Changes will not only benefit residents but will benefit staff and organisations too. Implementing change This guide supports teams to make changes by delivering the five principles of good nutritional care and using the following framework: Preparing to make the change Knowing where you are and where want to be Making the improvements Measuring, monitoring and sustaining the changes you have made We know from experience that guides and education alone are not enough. Front line staff need support from their senior executive team managers and multi disciplinary team engagement. 1 4 May 2013

Making the changes 1 5 May 2013

Preparing to make the change At a glance Care and catering staff working together Form a powerful team Project meetings Communication The importance of care and catering staff working together Care and catering staff must work together and be involved in assessing and monitoring individuals for malnutrition risk and delivering safe, nutritious food and drink, treatment and support. Form a powerful team Addressing malnutrition and dehydration requires a multi disciplinary team approach. It is essential for all staff within the care home to work together as much as possible to make the changes required. You will need to form a team which should include as a minimum: Care home manager General Practitioner Nurses Allied Health Professionals (AHP) e.g. dietitian, speech and language therapist, occupational therapist, pharmacist Other practitioners such as activity leads Catering representative Resident representative Project meetings Establish regular meetings with the team. EXAMPLE The Dartford Primary Care Trust worked with local GPs and dietitians to ensure care home residents were screened for malnutrition and had appropriate plans of care in place. Communication Communicate what you are trying to do to get everyone (including residents) involved and emphasise how they can do so. Top Tips for Success Meeting for less time but more often can be more productive and a better use of everyone s time. Have an agenda ready so you know what to focus on. 1 6 May 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 care home team will need to establish where your services are now and develop a vision of how the service should operate in the future. The first step is to create a local sense of urgency and communicate that change needs to happen within your home. Do this by gathering evidence which tells you and others that something needs to be done differently. Care home staff need to understand the consequences of poor nutrition and hydration, which residents are at risk and why they are at risk. CQC s Regulation 14, Outcome 5, 'Meeting nutritional needs' is a good starting point. Check whether your care home meets the standard (appendix 2). Try and find some or all of the following: Prevalence of malnutrition in your care home (using the BAPEN MUST tool 17 ) The amount of residents screened on admission, are monitored regularly and have a care plan linked to their level of risk Complaints related to poor nutrition/ hydration care and support Whether residents who would benefit from oral nutritional supplements are actually receiving and drinking them. If not why not? Whether residents with a high MUST score are in receipt of nutrition support (see Managing Adult Malnutrition in the Community pathway 16 ) Have a personal look at care in your home. There is nothing more powerful than first hand experience. Consider asking residents direct questions such as: What do you think of the overall dining experience? Do you get enough to eat and drink? Do you like it? If supplements are required, have you been offered a choice of formats and flavours? You will need to observe residents with dementia at meal times; they may be unable to tell you about their experience. EXAMPLE Before implementing NICE guidance, the dietetic service in Peterborough collected baseline data on nutrition screening practices and documentation, malnutrition prevalence, nutrition support actions and health care use. 1 7 May 2013

Once you have gathered information and evidence about your services, get the team together and ask yourselves how you compare to at least one of the following: The Malnutrition Task Force Best Practice Principles NICE's Nutrition support in Adults (CG32) 4 clinical guidance NICE's Nutrition support in Adults (QS24) 14 quality standard (appendix 1) National Association of Care Catering (NACC) and English Community Care Association (ECCA) Guide on compliance with CQC standards 23 Based on those assessments, agree what you do and do not do and use this as your starting position (your baseline). To agree what changes need to happen, dedicate time to a short workshop or planning meeting to: Agree a vision of what you want best practice to look like in your area List the areas/ gaps that need changing to achieve the vision of your service Generate ideas, solutions and actions to achieve the changes required Communicate your future vision, what needs to be done to achieve it and what everyone s specific role is in making it happen EXAMPLE Local Involvement Network (LINk) in Dorset trained a team of volunteers to enter and view care homes to look at residents meal time experience and recommend improvements. Top Tips for Success Consider an organisational raid: look at the good work other organisations do and adopt it yourself (with adaptation where required). 1 8 May 2013

Making it happen At a glance Make or test changes in relation to: Raising awareness Education and training Screening and assessment Providing good nutrition, hydration and support to eat and drink Monitoring Following your vision and gap analysis, you will have collated a range of ideas and changes needed to provide excellent nutrition and hydration care for your residents and these should be based around implementing or improving the five principles of best practice. Raising awareness Raising awareness is an essential first step. Do you have any visual information that can be displayed about the importance of nutrition and hydration for both residents and staff? If not, can you create some or adapt them from other organisations? Provide a series of seminars for staff Promote nutrition through your intranet services Find examples of how other organisations are raising awareness. Check the resources section on the Malnutrition Task Force website EXAMPLE A meal provider company has a range of experts that assist with developing food types for specialist needs and often directly share this expertise with care homes. Education and training Provide staff with the relevant education and training to help them identify and manage malnutrition. A variety of training methods are available from BAPEN, the British Dietetic Association (BDA), the Royal College of Nursing (RCN) and many other organisations. See the resources section. Consider running training sessions, including some on helping people to eat and drink, and top up sessions on a regular basis. It is equally important to establish some form of testing knowledge learnt but this will need to be decided locally. Many food and supplement providers have a range of experts working with them and provide free training. Screening and assessment Implement nutrition screening across the whole of your care home. BAPEN resources are freely available and recommended by NICE. 20 EXAMPLE Dietitians in Bedfordshire introduced a Food First award scheme for local care homes. They trained more than 1000 staff in using a food-based approach. 90% of residents reported that they had moved closer to their nutritional goal. 1 9 May 2013

Providing good nutrition, hydration and support to eat and drink There is a specific guide for food and beverage services available on the Malnutrition Task Force website, but as a taster, here are a few more specific ideas for change. National Association of Care Catering (NACC) The NACC aims to improve the standard of catering for vulnerable people. They have produced a guide on how to achieve Outcome 5 meeting nutritional needs. 24 This has been translated into key steps to help you achieve best practice nutrition and hydration care in your care home. The NACC has further useful information, guidance and tips based around: 1. Nutritional analysis of a menu 2. Overall energy and nutrient content of all food and beverages together must meet minimum standards for a day 3. Support individual meal requirements including cultural and religious requirements, local custom and traditions and vegetarian preferences 4. Good nutritional outcome ensuring all dietary requirements are met 5. Hydration making drinks available See Appendix 4 for more nutrition details. Food profile and care planning considerations When a new resident moves into the home, it essential that a food profile is completed on day one (see appendix 3 for list of questions) to ensure they are not offered any food that will harm them or offend their cultural preferences. This must be done in conjunction with the resident, care staff, catering staff (and families for residents who cannot communicate). It must then be shared with all catering staff and fully understood by them. EXAMPLE A provider designed a 'foodbox' for residents with dementia who do not follow traditional meal times or patterns. A 'foodbox' is a lunch-box filled with the resident's favourite finger foods to allow a grazing or snacking diet 24 hours a day. Smaller meals and snacks Weight loss is not a normal part of ageing and should not occur just because someone has dementia. Some people with dementia may be more physically active during the day and require regular snacks or finger foods to keep on top of energy requirements. Some people may find small, frequent meals or nutritious snacks more tempting and easier to eat than three main meals a day. If the person you care for is losing weight, ask their GP for a referral to a dietitian. 'Foodbox' for residents 20 May 2013

Healthy food as a minimum Everyone should be offered a selection of food and drink that meets their daily nutritional needs. For many residents, the Food Standards Agency 'eatwell plate' 25 is very applicable (below). Figure 4 However, some residents have different needs. Some are eating for good health and others may need more energy rich food and drink based on their nutritional assessment. There are many excellent guides and tools readily available that can help with the decision making of what is right for residents who may be at risk of malnutrition. This may include (but is not limited to): Food fortification Supplements Other clinical interventions ONS can take various forms such as a juice, drink or dessert and in a variety of flavours. Difficulties for those with dementia Dementia can affect a person s relationship with food and eating. The behavioural, emotional and physical changes that take place as dementia progresses can all impact a person s eating habits and food/ drink intake. Difficulties with eating can vary in terms of onset and severity from one person to another and can be influenced by the type of dementia a person has. Some people with dementia 21 May 2013

may have difficulty recognising cutlery, food and drinks. They may struggle coordinating the movements needed to eat with a knife and fork, unwrap packets or peel fruit. They may have a poor appetite or experience taste changes. There is often a good reason when food is declined or left uneaten. Some people with dementia have difficulty communicating and this can make it hard for them to share if and why they do not want to eat, if they find chewing or swallowing difficult or if they do not like the food offered. Therefore it is vital to know the person to ensure that food can be eaten and enjoyed. Unwanted weight loss is common but a few simple adjustments at meal times can make a big difference. This guide does not intend to provide food fortification or clinical guidance because there are many excellent supporting tools that do this already available (see list on page 11). A combination of clinical, food and social solutions may be required and some running in parallel, dependent upon the severity of malnutrition, may be helpful. This is why it is important for clinical staff (GPs, therapists etc.) to work together with catering staff. Make meal times the highlight of the day and encourage visits to the dining room Care homes are communal environments but that does not mean all residents engage with the life of the scheme. Moving into a communal setting can be traumatic for some; it is often the first time they have done so. This can mean that some residents prefer to stay in their rooms, although it is important they do not become isolated. Providers must aim to make meal times the highlight of the residents day and NAPA (National Association of Providers of Activities for Older People) 26 has shown that there are many benefits, both physical and mental, in residents mobilising, leaving their rooms and visiting the dining room. Flexible meal times Keep meal times flexible for those with dementia and other needs, especially if they have difficulties with time and place. They may eat better at certain times of day. Staff need to be aware of this and make food available to suit the person. Try to create a calm and relaxed environment for meal times to make them as enjoyable as possible. Remove unwanted stimuli such as the TV or loud music to help focus attention. Try to avoid medication rounds or housekeeping activities at this time. It may be necessary to eat with the resident to model eating. This can help the person copy relevant actions that they may have forgotten how to do, or may remind them how to use their cutlery when coordination is difficult. Spending time and effort setting a table can have a big influence on someone with dementia. Use contrasting colours for cutlery, crockery and table cloths. Heavier plates with lips are less likely to slip or spill and a line on the edge of the plate will help. Use different (and solid) coloured sugar bowls and jugs which can help differentiate from cups and help with decision making. Try not to place too many items on the table at once. Toast racks and other condiments can be confusing. Person centred care The resident should always be at the heart of any decision making and feel duly 22 May 2013

consulted. Care staff should be conscious of how they interact and how they incorporate person centred care. Person centred care is all about putting the resident first and considering the whole person rather than just the task in hand, i.e., taking a holistic approach. It is not about introducing improvements in isolation, for instance just imposing a new menu cycle on the home, but consulting with the residents and relatives to build up a menu cycle that they actually want. Using photographs can help people with dementia to make choices that they may not be able to communicate otherwise. EXAMPLE A care home provider supplied juice drink dispensers with a variety of flavours for residents to access throughout the day. Choosing food in advance can cause great difficulty for a person with dementia who may struggle to recall the option they made. If meals cannot be chosen at point of service ensure there is a second option or nutritious snack available at meal times. Monitor resident weight loss and nutritional intake Monitoring a resident's weight loss is an important element of the clinical care you deliver. Ensure that you have suitable weighing equipment for everyone (including the immobile or critically ill) Ensure the scales are calibrated and conform to NPSA (National Patient Safety Agency) standards 27 Build weekly weighing into the resident's plan of care for those at risk Examples from organisations include setting a day (e.g. Weighing Wednesdays ) or using electronic resident records or visual data management systems to ensure all residents are weighed weekly. In order to do this successfully, there must be a system in place to ensure that appropriate action is taken when weight loss is identified. Prioritise and implement actions in your plan The wealth of nutritional advice available has no value unless care staff can translate it into improving residents wellbeing. Ensure these improvements are implemented in the right manner and are not just about better food and drink. It s very easy to come out of your planning meeting with enthusiasm and more changes than anyone can cope with. Prioritising ideas and actions will help with implementation and give colleagues a sense that things can change and are happening. The actions and changes required can be grouped into the following: Those with agreement within the team and are easy to implement. These become quick wins Those with agreement within the team but are harder to implement. These become actions to implement over an agreed period of time 23 May 2013

No No For testing in small pilots (2's) (4's) (1's) Important but requires time and resources (3's) Yes Yes Easy Hard Figure 5 Once you have prioritised actions, assign owners and timescales to each one. Also remember to focus on quick wins first before you start bigger and complex changes. Communicate the vision and plan to all again. If there are changes that require more thought, are harder to do or there is uncertainty of whether they will work or not, use improvement tools available in our resources section to help you test them first (pilot) before you implement. Before you make any changes, ensure that you have a baseline measure. You can then monitor whether your changes are having a positive impact over time (e.g. the number of people screened before and after the change). EXAMPLE Care homes in Islington provided training for staff to identify malnutrition. They measured progress with a questionnaire before and after training. The NHS has some tools that can help. 28 Top Tips for Success Quick wins will encourage and galvanise your team. 24 May 2013

Measuring, monitoring and embedding your changes At a glance Measure and monitor changes Ensure the changes you have made are making a positive difference and that the changes can be embedded and sustained. It s really important to be able demonstrate and realise the benefit of the changes you have made. Agree which measures will be monitored on a regular basis and set up a system for collating the right information to support this. All measures should be meaningful and reveal whether you have the right structures and processes in place for good nutritional care. The outcomes of individual people must be regularly monitored too. Consider monitoring the following: Number and % of people screened and monitored monthly Number and % of staff trained (of those required) Number and % of people with weight recorded and monitored Number of people losing weight when it could have been prevented (unintentional weight loss) Number of complaints and incidents related to poor nutritional care Feedback from residents Number of residents reaching nutritional goals Number of hospital admissions Don t forget to: Realise the benefit of the changes e.g. improved personal outcomes and experience, reduced incidents or financial savings Communicate progress against the measures to the wider team and across the health community Obtain and include resident feedback on a regular basis Sustain the new ways of working within the culture of the care home Regularly assess the structures and processes in place by using the CQC standards or best practice to see if your team or organisation is providing good nutritional care Top Tips for Success Always remember to ask receivers of care for their opinion in measuring your success. 25 May 2013

Appendices 26 May 2013

Appendices Appendix 1: NICE's Nutrition support in adults (QS24) quality standard 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: CQC 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 27 May 2013

Appendix 3: Eating and drinking guideline questions These questions are by no means exhaustive and are used to indicate the matters that should be considered when discussing food and drink requirements with residents. 1. Have you recently put on weight? 1.1. Does this cause you any concern? 2. Have you recently lost weight without planning to? 2.1. Do you know the risks of losing weight in an unplanned way? 2.1.1. How is your oral health? 2.1.2. Might your dentures be at fault? 2.2. Has your appetite changed recently? 2.3. Have there been taste changes? 2.4. Do you think your health might be at risk? 3. Do you drink 6 8 glasses of water a day? 3.1. If not what do you drink? 4. Do you need a special medical or cultural diet (e.g. diabetic, texture modified such as soft/ pureed, vegetarian etc.)? 4.1. Have you any other dietary preferences? 5. Do you have any food allergies? 6. Do you have difficulties swallowing or with choking? Appendix 4: Additional nutrition details The major dietary groups described below must be considered when planning menus so that the needs of service users at either end of the dietary spectrum from healthier to higher energy can be met: Medical /health conditions e.g. gluten free, modified texture for dysphasia etc. Healthier Eating choices should be available, which are moderate in salt, sugar, total fat and saturated fat, thus providing suitable items for people with diabetes and those managing their weight, cholesterol levels and/or blood pressure Higher Energy options should be available for those who require extra calories A code indicating a softer textured meal is useful for identifying which dishes are easier to eat for those with simple chewing difficulties Allergen content of meals must be available in accordance with UK Food labelling Regulations and Amendments (http://www.food.gov.uk/businessindustry/guidancenotes/labelregsguidance/allergenlabelguide2009#.uunad7ln gw) Fresh drinking water must be accessible at all times and a choice of hot and cold drinks offered at meal times, bed time and regular intervals in between Over the course of the day, hot and cold drinks should provide a service user with at least 1.6 litres of fluid assurance being provided through recording on care support plans 28 May 2013

References

References 1 Calculation based on BAPEN Screening weeks 2007 11 2 Available at: http://www.cqc.org.uk/public/reportssurveysandreviews/themed inspections/dignityandnutritionolderpeople 3 M. Elia, R. M. Smith, Improving Nutritional Care and Treatment: Pespectives and Recommendations from Population Groups, Patients and Carers, BAPEN, 2009 4 Nutrition Support in Adults (CG32), NICE, 2006 5 Malnutrition in Older People in the Community: Policy Recommendations for Change, European Nutrition for Health Alliance, BAPEN and ILC UK, 2006 6 National Population Projections, 2010 Based Projections, Office for National Statistics, 2011 7 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 8 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 9 M. Heismayr et al, 'Decreased food intake is a risk factor for mortality in hospitalised patients: The NutritionDay survey 2006', Clinical Nutrition, 2009, 28 10 J. F. Guest et al, 'Health economic impact of managing patients following a community based diagnosis of malnutrition in the UK', Clinical Nutrition, 2011, 30, 4 11 J. M. M. Meijers et al, 'Estimating the costs associated with malnutrition in Dutch nursing homes', Clinical Nutrition, 2012, 31, 1 12 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 13 Patient Experience in Adult NHS Services (QS15), NICE, 2012 14 Nutrition Support in Adults (QS24), NICE, 2012 15 Personal Social Services Adult Social Care Survey, England 2011 12, The NHS Information Centre, 2012 16 Available at: http://malnutritionpathway.co.uk 17 Available at: http://www.bapen.org.uk/screening for malnutrition/must/must toolkit/the must itself 18 The Nutrition and Hydration Digest: Improving Outcomes through Food and Beverage Services, The British Dietetic Association, 2012 19 Available at: http://www.hospitalcaterers.org/publications/ 20 Website at: www.bapen.org.uk 21 Website at: www.bda.uk.com 22 Website at: www.rcn.org.uk 23 How to comply with CQC Outcome 5: Meeting nutritional needs, NACC/ECCA, 2011 24 Website at: www.thenacc.co.uk 25 Available at: www.nhs.uk/livewell/goodfood/pages/eatwell plate.aspx 26 Website at: http://www.napa activities.co.uk/ 27 Available at: www.nrls.npsa.nhs.uk 28 Available at: http://www.institute.nhs.uk/quality_and_service_improvement_tools/ 29 Available at: http://alzheimers.org.uk/site/scripts/documents.php?categoryid=200367 30 Available at: http://www.scie.org.uk/publications/dementia/eating/index.asp 30 May 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. 32 May 2013

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