Maintaining good nutrition and hydration in care home residents is proven to improve overall physical and mental health. Eating well for older adults and individuals in care homes differs slightly from the general population.

Nutrition & Hydration Care Plan:

Good quality care/support plans are essential to underpin safe, effective, compassionate, high-quality care. They should clearly communicate:

• the right information
• to the right people (including catering teams)
• when they need it

to ensure person-centred safe care and treatment is provided. 

Time should be taken to ensure they are as detailed as possible and that the right assessments have been considered.

Care plans should be regularly updated and shared with all relevant teams within the care home.

A clear and detailed nutrition and hydration care plan should be produced for every resident before they move into the care setting. This should be reviewed and updated at admission and then regularly reviewed and updated during their stay.

Residents’ nutrition and hydration care plans should consider their support and environmental preferences and their dietary needs. 
 

Hydration

Availability of drinks

Drinks should be available everywhere at all times. There should always be a range of options that meet all needs and preferences.

Opportunistic drinks

When medications are provided, a full glass of fluid should be given, rather than just a few sips.

Accessibility

Help and support to access a drink and help whilst drinking should be provided. This may mean using adapted drinking cups/glasses to support the resident.

Social interaction

Drinking with others can encourage drinking.

Cup and glass sizes

Know the volume of cups, mugs and glasses used within the care home so they know how many each resident needs to be encouraged to drink each day. 

Residents should be encouraged to drink between 1.5-2L a day.

Attractive options

Try to make the drink look appealing and recognisable to encourage intake.

Reassurance

Residents may need to be discreetly reminded that there is support if fear of incontinence is a barrier to drinking well.

Education

Support the resident, relatives and carers to understand the importance of drinking regularly 

 

Nutrition

• Ensure a diet which contains all food groups (protein, carbohydrates, fats, fruit and vegetables, and milk-based products or fortified alternatives)
• Prioritise protein at mealtimes
• Ensure sources of calcium, folate and B12 in the diet or appropriate supplementation if this is not possible
• Take a Vitamin D supplement – particularly in winter
• Provide 3 meals a day and a daytime and evening snack
• Meals should be balanced and meet all residents' nutritional requirements
• Choice should be available at each mealtime. 

 

Religious and cultural diets:

The UK is a multiracial and multicultural society. Both religion and culture impact on people’s food choices. This can also vary depending on what is and is not appropriate for their faith to varying degrees. It is therefore important not to make assumptions about an individual resident’s food choices; there is no ‘one size fits all’.

It is essential to understand the individual residents to support a person-centred approach to meeting their needs and respecting and ensuring their values are understood and upheld.

Food culture is different from religious dietary requirements and instead relates to behaviours, attitudes and traditions of people or societies that surround the production and consumption of food.

Neither religious nor cultural requirements restrict the ability to eat a healthy balanced diet. 

 

Vegetarian and vegan diets:

A resident may choose to eat a vegetarian or vegan diet for moral, religious, cultural or health reasons. The Health and Social Care Act 2008 states 'when a person has specific dietary requirements relating to moral or ethical beliefs, these requirements must be fully considered and met'.

It is important to ensure individual resident’s diet preferences are established on admission in order to support personalised choices, beliefs and values.

If a resident loses capacity to make decisions regarding their food and drink choices and there is any difficulty around what foods should be offered, healthcare professional advice should be sought and the resident’s best interests explored to continue to ensure the residents’ beliefs and values are upheld.

Eating is often a social experience and care homes should ensure mealtimes are an enjoyable experience and suitable to all residents.

 

 

 

Individuals living in care homes are at higher risk of developing malnutrition and dehydration and the consequences of this is higher and include sarcopenia (the loss of muscle mass and strength as a result of ageing), reduced wound healing, reduced ability to fight infection, urinary tract infections, low blood pressure, confusion, falls and low mood.  

Malnutrition:

Regular screening for malnutrition can reduce the risk.

• Weigh residents weekly
• Screen for malnutrition weekly using the ‘MUST’ Calculator | BAPEN - MUST scores can be calculated manually or calculated within electronic notes systems
• Whilst MUST remains the best method for screening for malnutrition, sometimes it can be challenging to get an accurate weight or weight history. If MUST cannot be completed, subjective tools such as the Patients Association Nutrition Checklist can be used instead. Please note this should only be used where calculation of MUST is not possible.
   

If risk of malnutrition is identified:

• Implement a nutritional care plan if available
• Consider factors which may be causing malnutrition. These may be social, physical or medication factors
• Offer higher energy and protein meal options
• Offer nutrient dense snacks
• Offer nutrient dense drinks including milk-based drinks and homemade milkshakes (RD040-Food First Homemade Supplements.pdf)
• If after the above has been trialled for at least 2 weeks with no improvement in weight or intake, consider prescription of first line oral nutritional supplements (Coventry and Warwickshire Area Prescribing Committee Formulary). Please note only first line supplements should be prescribed without Dietetic input
• For patients with dysphagia (difficulty swallowing), ensure that any food, drink or supplement offered are suitable for residents’ IDDSI recommendations. 

 

Dehydration:

There is no reliable screening tool to identify dehydration. If risk of dehydration is suspected:

• Consider factors that may be causing dehydration
• Ensure a range of drinks are always available everywhere
• Provide a full glass of drink with medication
• Provide help and support with drinking if needed
• Ensure residents understand the importance of hydration.

Reassure residents if fear of incontinence is a barrier to intake.  

Dementia:

Residents with dementia are more likely to experience difficulty eating and drinking and are at higher risk of malnutrition and dehydration. More information on supporting individuals with dementia can be found here: eating-and-drinking-well-carers-guide.pdf

Diabetes:

It is estimated that 25% of the care home population has diabetes. In view of how common malnutrition, frailty, sarcopenia and other health conditions are for care home residents, it is recommended:

• A food and diet approach for healthcare professionals and carers supporting older adults with diabetes in care homes
• All residents with diabetes have a person-centred, individualised care plan that clearly outlines their:
  • nursing and nutritional needs
  • medication requirements
  • triggers for a hospital admission
  • frequency of blood glucose monitoring and equipment to be used
  • individual blood glucose targets. 

It is advised that care homes liaise with dietitians and the wider multidisciplinary team to determine the nutritional needs and priorities for residents with diabetes.

Where a resident may be at risk of malnutrition, advice is not to unnecessarily restrict food options, and optimising dietary intake using a food-based approach will usually be the priority. The benefits and risks of any dietary restrictions should be considered by the resident or in their best interests if they are unable to make this decision themselves. 

Other nutritional concerns
Residents living with Cardiovascular Disease or Obesity should be supported in making food choices appropriate for their condition. Where individuals with these conditions are identified with malnutrition, treating the malnutrition may take priority and therefore it may be appropriate to avoid previous food restriction advice. The benefits and risks should be considered for each individual. 

For Coventry:

• If a resident is identified as having a MUST of 2 or more and there is no improvement in 2 weeks following the above advice, consider making a referral to UHCW Community Dietitians via the e-referral system or via email to: communitydietitians@uhcw.nhs.uk
• On referral, please provide weight, weight history, BMI and MUST as well as any care plans in place
• Dietetic reviews will be completed face to face or virtually, depending on clinical need
• Any patient receiving enteral feeding should be known to the dietitian. If you have any concerns with an enterally fed patient, please contact the dietitians via the email above. 
   

For Warwickshire:

• Lots of information can be found on the Warwickshire dieticians webpages: Dietetics (Adult) :: South Warwickshire University NHS Foundation Trust
• There is an offer of free training from the Community Dietitian Team for Warwickshire care homes – email: dietitians@swft.nhs.uk

• NICE guidelines for malnutrition
• BDA Eating, Drinking and Ageing well
• Frailty information leaflet for residents
• BDA Care home Digest
• Dietetics (Adult): South Warwickshire University NHS Foundation Trust
• International Dysphagia Diet Standardisation Initiative (IDDSI)