Hampshire County Council Adult Services Recognises the Right of the Individual Service

Practice No.
145 / Version 1 / Page 1 of 8 / New November 2008
Reference: 10/06 / HCC AS 10/06 123
HCC AS 10/06 124
Medication 25/00
New medication procedure – rolled out 2008 / National Care Standard 15.3 / NMC Code of Professional Conduct
GSCC Code of Practice
Delivery of Personal Care - Nutrition

Hampshire County Council Adult Services recognises the right of the individual service user to live a lifestyle of his/her own choosing, subject to appropriate Risk Assessment.

These guidelines address the identification of choices for nutrition, the assessment of any associated risks, and the way in which the service enables the individual to exercise those choices in such a manner as to promote self-confidence and a healthy lifestyle. They should be read in conjunction with guidelines 123 and 124:

The Philosophy of Food

The primary purpose of food is to fuel the body, which makes it the most important tool in the care planning kit. The human brain requires approximately 20% of the body’s total energy production, therefore, poor nutrition will affect all other plans and activities in which the individual might choose to participate.

Food is not only a fuel but is vital to the ability to repair damage to our bodies and maintain good health. This is particularly important as we age, when body systems tend to slow down and generally body maintenance takes longer.

Additionally, food has a further, vital, role in the maintenance of good health. It plays an important part in socialising with others, and there is strong evidence to indicate that good social networks and the support that they provide, promote good health and longer lives. This underpins the philosophy of the entire service.

‘Food to a large extent is what holds a society together’ 'Consuming Passions: The Anthropology of Eating' Farb & Armelagos 1980

Getting to know the individual

It is important to remember that everyone has their own practices and preferences around the consumption of food and drink. The most effective way to manage the nutritional needs of residents and other service users, is to make eating a pleasurable experience.

Initially, care planning should explore individual preferences such as usual meal times and patterns, likes and dislikes of particular foods, and dietary needs created by health requirements, faith or cultural considerations. (care plan S.1) Equally important are other factors such as physical discomfort and pain, which may inhibit the enjoyment of food. (care plan S.3.4; 3.5)

‘We are indeed much more than what we eat, but what we eat can nevertheless help us to be much more than what we are.’ Adelle Davis

Care Planning

Within the requirements of the Mental Capacity Act 2006, it is important to acknowledge that individuals may not be prepared to follow dietary strictures indicated by their particular health needs, such as Diabetes Mellitus or malnourishment. Where this is the case, it is the responsibility of all staff, both care and catering, to discuss these issues with the individual, their carer or advocate, formally for the care plan and informally as the opportunities arise, to try to

determine why this is the case.

Where a cause can be identified, solutions may be obvious. In other cases there is scope for all staff to be creative in suggesting and negotiating ways to overcome the obstacles. It may just be a case of sitting down with the individual, and perhaps a cup of tea, to create a relaxed atmosphere for the meal.

Initial care planning includes base line monitors of the individual entering residential care, and those with specific needs for Day Care planning. (care plan S.3.5) All new residents will have a M.U.S.T (Malnutrition Universal Screening Tool) assessment when they take up residence. The assessment will be undertaken by an appropriately trained member of staff and be reviewed at regular, agreed and documented, periods. Where there are any concerns about an individual’s health or nutrition, a full M.U.S.T assessment will be repeated. (See appendices for assessment tools) Based on the outcome of the assessment, a relevant plan for nutrition will be discussed, instituted and recorded in the care plan. (care plan S.3.5)

“Food, like a loving touch has ability to comfort." Norman Kolpas

Meal times

As with all care planning, the practices and preferences of the individual should never be assumed, and both nutritional and social needs should be considered.

Whilst there are clearly some organizational factors to consider – see practice guidelines 123 and 124, there may need to be some adjustments to ensure that nutritional needs are met.

Not all individuals may be used to eating at set times, and there is an increasing shift from the main meal being taken in the middle of the day, to being taken in the evening. Where this is of concern, the care plan needs to reflect individual requirements and to plan for enabling that person to be helped to prepare a snack or drink at an appropriate time if necessary. Equally, getting up in the night to make or request a snack or drink may be part of the plan. This will have the added advantage of promoting a better quality of sleep, undisturbed by hunger.

Whatever time a meal is taken any relevant food or fluid monitoring forms must be completed.

(See appendices)

“We'll see if tea and buns can make the world a better place.” Wind in the Willows - Kenneth Graham

Presentation

Whether served or prepared for consumption in the dining room or the individual’s bedroom, food will always be more inviting and acceptable if well presented.

· Water available to drink to assist swallowing and digestion. Water is a vital nutrient in any diet.

· All utensils and equipment clean and in good repair

· Tables set with clean cloths or placemats.

· Trays covered with clean napkins.

· Cutlery appropriate to the needs of the individual, encouraging them to eat independently.

· Cruet sets and other condiment containers.

· Cloth or paper napkins for each person.

Whenever possible, residents and service users should be encouraged to help themselves, to set the table; make and butter their own toast; help themselves to vegetables – choosing their own size of portion; pour their own tea; clear the table and where snacks have been made, to do their

own washing up, all with discreet assistance and risk assessment.

The possibility of anyone making a mess is not a valid risk and should never be used to inhibit independence. Where a cup with a saucer is considered to be a risk, the alternative is a mug and not a saucer-less cup. Anyone can be made to feel more at home by having their personal mug, washing it themselves and keeping it in their room.

Residents may also be encouraged to eat or take fluids, if, where feasible, staff are able to sit with them to create an appropriate ambience. Sharing conversation at the table may prolong the meal, but will also aid the digestion by relieving pressure to eat up and clear away.

Food...can look beautiful, taste exquisite, smell wonderful, make people feel good, bring them together…….” Rosamond Richardson, English cookery author

Assisted Eating

The need for help with eating meals makes an individual totally dependent on the helper and needs to be approached with tact and discretion. It is all too easy for the helper to slip into ‘parental’ mode and inadvertently treat the individual as a child. Even when food has to be presented in soft or liquidised form, the same principles of presentation apply.

· Always ensure the person is comfortable before the meal is served, not wanting the toilet and in a well supported position.

· Protective clothing for the individual is to prevent any mess made by the carer.

· Where possible, assist the person to sit at a table with others, leaving room for a chair for the carer.

· Explain the choices and where possible identify preferences for that meal – butter and marmalade can be sucked off soft toast and cereals can be softened with milk !

· Always have an appetising drink, or water, available.

· Sit down to help. Standing over the person can be stressful for both parties.

· Prompt the person to open their mouth. This can be done discretely if sitting next to the them.

· Allow time for the food to be swallowed before presenting another mouthful.

· Be aware of what is being rejected and what is preferred. If the food is being enjoyed the process will be much smoother. Don’t forget to record this.

· Ensure the person is included in the social interaction at the table, regardless of the perceived level of their ability to ‘join in’.

· If medication is presented to be taken with the meal, the administration of medication procedure MUST be followed.

· When the meal has been completed, make sure the person is clean and comfortable.

· Ensure that you complete any nutritional records e.g. fluid charts and sign them.

"I don't LIKE food, I LOVE it. If I don't LOVE it, I don't SWALLOW." —Food critic Anton Ego in the movie Ratatouille.

Appendices

M.U.S.T Screening Tool

M.U.S.T. Low Risk Care Plan for Malnutrition

M.U.S.T. Medium Risk Care Plan for Malnutrition

M.U.S.T. High Risk Care Plan for Malnutrition

Fluid monitoring chart

Malnutrition Universal Screening Tool

SCREEN ON ADMISSION AND MONTHLY THEREAFTER

Patient Name: ______DOB: ______
STEP 1 - BMI Score / STEP 2 - Weight Loss Score
(unplanned wt loss in 3-6 months) / STEP 3 - Acute Disease
Score
BMI> 20.0 (>30 Obese+) = 0
BMI 18.5 – 20.0 = 1
BMI <18.5 = 2 / Wt loss <5%
Wt loss 5 – 10
Wt loss >10% / = 0
= 1
= 2 / Add score of 2 if there has been or is likely to be no nutritional intake for 5 days

Add all scores

STEP 4 Overall Risk of Malnutrition
0
LOW RISK
ROUTINE CLINICAL CARE / 1
MEDIUM RISK
OBSERVE & MONITOR / 2 or more
HIGH RISK
TREAT
Admission Assessment: Date /
Reported Usual Weight (kg)
Current Weight (kg) MEASURED /REPORTED
Height (m) MEASURED /REPORTED/SURROGATE / STEP 5
START LOW, MEDIUM OR HIGH RISK CARE PLAN AS APPROPRIATE
CONTINUE TO REVIEW WEEKLY
BMI (kg/m²) CALCULATED/SURROGATE
BMI Score
Pre-Admission Weight Loss Score
Acute Disease Effect Score
MUST Score
MUST Category LOW/MEDIUM/HIGH
Initials of staff member completing tool

Monthly Re-assessments:

Date
Weight (kg)
Re-calculated BMI (kg/m²)
BMI Score
Re-Calculated Weight Loss Score
(Based on usual & current weight)
Acute Disease Effect Score
MUST Score
Category: LOW/MEDIUM/HIGH
Initials of staff member completing tool

Produced by Nutrition & Dietetics Department, Winchester & Eastleigh Healthcare NHS Trust SSD Oct 08

I:\Social Services\SSD Shared\Residential & Nursing Care\5 eating and drinking\Assessment Summary Sheet.doc oct 08.doc KH/eal

Malnutrition Universal Screening Tool

Care Plan for Patients at LOW RISK of Malnutrition

Patient Name:

DOB: Date Commenced: .……..……..

Routine Care

Arrange special diet if appropriate e.g. diabetic, gluten free etc.

Provide help and advice on food choices, eating and drinking.

If BMI>30kg/m2 encourage reducing diet.

Repeat MUST monthly.

Follow appropriate care plan.

MUST

Malnutrition Universal Screening Tool

Care Plan for Patients at MEDIUM RISK of Malnutrition

Patient Name:

DOB: Date Commenced: ….……..……

Observe

1. Treat any underlying condition e.g. nausea or constipation.

(If there is minimal fluid intake or clinical concern, follow local policy for referral to

GP)

Provide help and advice on food choices, eating and drinking.

3. Document food and fluid intake for 3 days.

Review after 3 days. If intake improved or adequate and there is no cause for clinical concern support patient to eat ‘normal’ care home food.

If no improvement in food intake follow nutrition intervention below.

Nutrition Treatment

1. Offer 1 ‘fortified’ dish at breakfast: eg fortified porridge or cereal with fortified milk.

Offer 2 ‘fortified’ dishes at lunch: eg fortified soup and fortified milk pudding.

Offer 1 ‘fortified’ dish at tea: eg fortified soup or pudding.

2. Offer a mid-afternoon and supper snack (see list).

3. Offer 2 ‘fortified’ milk drinks (see list) per day (if clients dislike milk offer

2 mugs of fortified soup or ‘Build Up’ soup per day).

4. Document food and fluid intake for 4 days.

a) If eating and taking ‘fortified’ drinks - continue

b) If eating minimal food but managing ‘fortified’ drinks increase to 4 ‘fortified’ drinks daily. If condition persists for more than 7 days and food intake does not improve, refer to GP.

c) If eating minimal food and not drinking ‘fortified’ drinks refer to GP

Repeat MUST monthly.

Follow appropriate care plan.

Malnutrition Universal Screening Tool

Care Plan for Patients at HIGH RISK of Malnutrition

Patient Name:

DOB: Date Commenced: .……..………

Treat

Treat any underlying condition e.g. nausea or constipation.

(If minimal fluid intake or clinical concern follow local policy for referral to GP)

Provide help and advice on food choices, eating and drinking.

Nutrition Treatment

1. Offer 1 ‘fortified’ dish at breakfast: eg, fortified porridge or cereal with fortified milk.

Offer 2 ‘fortified’ dishes at lunch: eg, fortified soup and fortified milk pudding.

Offer 1 ‘fortified’ dish at tea: eg, fortified soup or pudding.