NHD clinical - - n utrition in care homes
in managing those with complex issues including behavioural and
food refusal.
Under- nutrition Assessment
5. In our practical experience residential care homes appear to strug-
Name: Date of Birth: / / Date: / /
gle more than the nursing care homes in implementing screening
Problem Identified Care Plan Actions
and supporting documentation. They do however appear better at
encouraging food as a social and therapeutic need.
x Request a full blood screen to rule out undiagnosed/poorly
A medical condition is
controlled diabetes, anaemia or infection.
increasing requirements
x Ensure treatment to control / treat condition is provided
e.g. pressure sore, infection x Consider side-effects of medications. Request a medication
review
The Food for Life for Care Home resource
x Encourage 3 meals/day with snacks between meals, 2
nourishing drinks / day & 1 fortified dish at each meal
Its early development stage was to address the appropriate clini-
cal and cost effective prescription of oral nutritional supplements
x Assess oral hygiene / mouth ulcers, treat as needed
Swallowing and / or
x Check teeth / dentures – refer to Dentist if needed
(ONS) highlighted in clinical audits commenced in 2001. Appropriate chewing problems
x Discuss need to refer for swallow assessment with GP
x If soft or pureed diet is required ask kitchen to fortify all
prescribing of ONS is based on evidence of a screening for risk. This
leads to further assessment which indicates the various interventions
x Assess comfort at mealtimes e.g. need to empty bowels or
bladder, seating position, oral health
required as part of the nutritional care plan. This may include ONS,
x Consider the environment and minimise distractions
Consistently not
finishing meals despite
x Assess ability to eat and drink & level of support required
but equally further assessment of the level of assistance required support / assistance
x Use verbal and visual cues to aid sequencing at mealtimes
x Establish and encourage dietary preferences
at all meal and snack times. Consideration of observations of prac-
x Explore anxieties or communication difficulties
x If signs of depression or pain present seek medical advice
tice within care homes, the needs of both the residents and care
homes for practical nutritional guidance, all influenced Leeds Com-
x As above
Consistently refusing
x If at risk of dehydration seek medical advice and complete
munity Healthcare Nutrition & Dietetic Service’s development of the
food and /or fluid
dehydration care plan
resource to screen for ‘commonly encountered nutritional risks’, not
x If agitated at meals offer finger foods throughout the day
just ‘under–nutrition’ and to support a care pathway approach.
Constant activity/
x Assess comfort at mealtimes / reduce distractions / establish
agitation
cause of agitation
This led to the broader nutritional approach to screening, further
x Encourage 3 meals/ day with snacks between meals, 2
nourishing drinks/day & 1 fortified dish at each meal
assessments and suggested care plans with the completion of the
x Seek medical advice if depressed
resource in 2005. The resource provides guidelines and tools giv-
No interest in food /
x Minimise distractions at mealtimes, assess preferred environment
apathy / depression
ing an overview of nutritional problems; under-nutrition (malnutrition),
x Provide encouragement and support with preferred meals/snacks
undesirable weight gain (obesity), constipation, hydration and thera-
All meals & snacks are x If all above actions have been implemented for 4 weeks and
eaten yet weight is still weight has fallen request referral to Dietitian or discuss need
peutics of diabetes. It aims to improve the nutritional status of resi-
falling or underweight & to investigate other causes with GP
not gaining weight
dents though a co-ordinated approach using a care pathway which
Use above care plan actions and other observations to form care plan – see overleaf
aids screening, care planning and appropriate dietary interventions.
References: Caroline Walker Trust (1995) Eating well for older people, VOICES (1998) Eating well for older people
with dementia, Malnutrition Advisory Group (2001) Report of malnutrition among older people.
It empowers Care Home staff to implement and promote areas of Produced by Leeds Community Nutrition & Dietetic Service, NHS Leeds Updated November 2008
P:\Dewsbury Road\Dietetics\All Teams\Adult\Care Homes\Food for life pack\6. undernutrition assessment1.doc Date for Review November 2010
7
good practice and improve the management of common nutritional
problems.
ing meetings with the managers/ deputy/ training officers of the
The expected results of this initiative: care homes. Our pre-training requirements have been refined
1. screening for nutritional risk is routine in care homes across
with an expectation of care homes to involve all staff in the
Leeds;
training, e.g. senior nurses, care assistances and catering staff
2. screening leads to further assessment and management by care
to improve internal communications/food provision/nutritional
home staff for those identified at risk;
status for all residents.
3. referrals from care homes to Nutrition & Dietetic Service are more
Whilst the resource was revised in November 2008 minimal
timely and appropriate.
Food for Life training has occurred during 2008-2009 due to
staff vacancies/frozen posts with the resulting capacity chal-
Resource implementation supported with training
lenges. The implication has been an absence of the capacity
March 2006 saw its launch with citywide training events
to address an effective and efficient way of working. To ensure
targeted initially at managers of Nursing Care Homes within this vulnerable group of residents have equal access to evi-
Leeds. Since its launch, a total of 35 out of the current 147 dence based practice, dietetic advice and services to support
citywide care homes have had training (24%). The following referrals from care homes which are more timely and appropri-
factors have influenced which care homes have had ‘Food for ate and supports prevention of inappropriate hospital admis-
Life’ training delivered within their setting: sion due to malnutrition and dehydration, as well as address
• Direct requests from care home managers/training officers the growing list of care homes identified as in clinical need of
for support with caring for residents with increasing complex Food for Life training, a temporary solution was found in Oct/
medical conditions. Nov 2009. An experienced dietitian delivered training on a ses-
• Needs identified by the dietitians visiting care homes in re- sional basis with the resulting outcomes:
sponse to a GP request for a dietetic assessment which • 16 sessions of Food for Life training (two hours/session)
identifies challenges to implementing recommended dietary • to 10 care homes
interventions from systems and processes. • reaching ~120 care home staff who are delivering care to
• Leeds Community Healthcare colleagues expressed con- ~431 residents out of the ~4300 available care home beds
cerns/partnership working opportunities to support avoid- (10%)
able hospital admissions, e.g. community matrons, continu- • on completion of training all 10 care homes received both a
ing healthcare, tissue viability. report with specific recommendations and a training evalu-
• High usage of oral nutritional supplements through audits ation (including a copy for dietetic and continuing care files)
from medicine management/GP audits. with positive feedback - as care homes can use this as evi-
• Contact from Care Quality Commission (CQC). dence towards nutritional related CQC requirements
• recommended to support implementation of best practice
The delivery of the ‘Food for Life’ training of the resource raised within training which is embedded and sustained that
is found to work best when supported by pre and post train- all 10 care homes have a 3/12 post training review
NHDmag.com Feb '10 - issue 51 19
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