Ending malnutrition in care homes

18 March 2010 by
Ending malnutrition in care homes

The publication of the Nutrition Action Plan in 2007 highlighted the steps that needed to be taken to combat the rising scourge of malnutrition among the elderly. While there is still a long way to go, Janet Harmer reports on some of the care homes and local authorities that are taking steps to improve their catering offer for the elderly.

It is two and a half years since the Government published its Nutrition Action Plan aimed at combating the rise of malnutrition among the elderly.

The progress report from the Nutrition Action Plan Delivery Board, which was published last month, said progress had been achieved, but much work still needs to be done. However, it suggested that the previously published number of 2,656 people who are believed to have died from malnutrition in hospitals and care homes since 1997 may, in fact, be closer to 50,000. This worrying figure confirms the enormous responsibility placed on care caterers in preparing food for vulnerable older people who may be suffering from physical and psychological ailments.

The National Association of Care Catering (NACC) is providing all the support it can to its 500 members to ensure that the action plan's five key priorities are being met. These include raising awareness of the link between nutrition and good health, and that malnutrition can be treated; ensuring that accessible guidance is available; encouraging nutritional screening for all people using health and social care services; encouraging relevant training on the importance of nutrition; and clarifying standards and strengthening inspection and regulation.

According to NACC chairman Derek Johnson, although members can easily tap into the information provided by the association, those outside may not be so clued up about the requirements of the action plan.

"We have been running focus sessions to highlight the information and support available," he explains. "As a result, more caterers - in both independent homes and groups of care homes - and local authorities are coming to terms with the details of the plan. There is now a lot of good practice taking place."

As elderly people become more frail, their nutritional requirements increase and their appetites decrease. To help meet these needs, caterers are being steered towards a plethora of information provided by NHS Choices, the Food Standards Agency and the Five-A-Day Campaign. The importance of hydration is highlighted too, as outlined in the study carried out by the Methodist Homes for the Aged and Anglia Water (see page 38).

Further guidance is provided in the latest version of the Dignity in Care Practice Guide and in the NACC manual, Menu Planning and Special Diets in Care Homes.

When it comes to nutritional screening of the elderly, the Malnutrition Universal Screening Tool (MUST) produced by the British Association for Parenteral & Enteral Nutrition (BAPEN) is a useful means of identifying care home residents who are malnourished or at risk of malnutrition. Dorset County Council has successfully introduced the programme into its care homes (see page 38).

A key aspect of improving nutritional standards of catering for the elderly will come through the standardisation of nutritional training. Skills for Care and People 1st are currently developing national training standards for care catering staff.

"Later this year we hope to see finalised details for training in all aspects of social care, which will include core units on different dietary issues and specific needs of the elderly," says Johnson.

Ideally all catering staff will eventually receive the college-based training, which is expected to be equivalent to an NVQ level 2, but in reality it will take several years before it filters down to all staff.

"Training is a very important part of improving the nutritional content of food served to the elderly," says Johnson.

"It is essential that caterers have the right knowledge required in meeting the needs of the elderly, over and above any catering skills they may have learnt in a hotel or restaurant."

The monitoring of catering in care homes is also soon to become an essential element of ensuring that sound nutritional care is in place. The Care Quality Commission (CQC) will carry out two inspections of care homes per year - one announced and one unannounced - during which both care and catering staff will be assessed. As well as understanding the benefits of good nutrition, all staff will be expected to ensure adequate nutrition and hydration is provided and offer support with eating and drinking when required.

All care homes - whether they are run by a local authority, a major care provider such as Barchester Healthcare or BUPA Care homes, or are independently operated - need to be aware that there will soon be a new registration system for providers, to ensure they meet essential standards of nutritional quality and meet the needs of care home residents.

Failure to comply with the requirements will be an offence and the CQC will have tough enforcement powers that can be used to bring care home providers back into compliance with the requirements.

There is an enormous responsibility placed on care caterers to provide adequate nutrition for the elderly


Barchester Healthcare looks after more than 10,000 residents in 200 care homes across the UK, each caring for between five and 100 elderly people.

The company has always taken a serious approach to good quality catering and welcomed the publication of the Nutrition Action Plan as a means of ensuring consistent standards across the care catering industry.

"We focus on improving hydration and nutrition for all our residents through a well balanced diet," says Terry Tucker, director of learning, development and hospitality at Barchester Healthcare.

"We record residents' weight changes regularly and find ways of tempting even the smallest appetite. As well as offering a balanced diet, our chefs will make fresh smoothies and ice-creams, which are great for hydration."

Tucker believes that listening to the likes and dislikes of every resident is fundamental in ensuring everyone receives a nutritional meal. Prior to admission, each home collates the dietary needs of the resident and on admission, favourites dishes are identified.

"Our chefs are in the restaurants at mealtimes to encourage feedback from residents," says Tucker. "No one is rushed at mealtimes. The residents enjoy the food at their own pace, making dining an enjoyable social activity."

All chefs working for the company receive ongoing professional development, with the Barchester Chef Academy providing training on specialist dietary requirements.

"Food should be delicious as well as nutritious, to ensure that older people are getting all the vitamins and minerals they need, and so our chefs are encouraged to speak regularly to carers, nursing staff and residents to understand what is wanted and needed to provide good nutritional care."


As well as recognising that food plays an important role in the emotional and physical wellbeing of the elderly, the challenge for care home operators is balancing the cost of the chef, ingredients and facilities against the overall fees, according to Steve Geach, owner of the Oakview Care Home in Hayling Island, Hampshire.

Taking all these things into consideration, Geach introduced cook-freeze meals provided by frozen food supplier Apetito.

The result has been an improvement to both the quality of the food provision and the satisfaction of the 29 residents, as well as an additional £30,000 being added to the care home's bottom line.

Geach is impressed by the food quality, nutritional planning and breadth of range offered by Apetito, as well as the ease of preparing the products at Oakview.

"The cook-freeze facility sytem provides total flexibility around the time of service," says Geach.

"No preparation is required and usually meals can be cooked in 90 minutes, so the food is always served piping hot and at its nutritional best. The smell and visual appeal of the food stimulates our residents' appetites, which greatly encourages consumption.

"In addition, cook-freeze enables staff to offer food at times to suit individual residents if they are rehabilitating or unwell."

Geach says an added bonus of introducing the system, which has resulted in the catering staff being reduced from two to one, has been the reduction in food wastage.

"Prior to working with Apetito, we had around half a bin bag of food waste left on residents' plates each day and this has now been reduced to virtually zero," he explains.


Nutritional care is a priority in Dorset where the county council is taking steps to improve the nutritional screening and training in its seven residential care homes for the elderly and three homes for adults with learning disabilities.

All of the homes, which accommodate between 40 and 80 residents, carry out nutritional screening using the Malnutrition Universal Screening Tool (MUST), produced by the British Association for Parenteral & Enteral Nutrition (BAPEN).

"This enables both care and catering staff to take action if someone is at risk of malnutrition and provides a good means of communication if that person is moving between the home and hospital," says Sue Hawkins, care catering services manager for Dorset County Council (DCC).

Care staff and catering staff are all involved in training sessions on nutrition in residential homes, day centres and domiciliary care.

"This shows that we recognise that everyone has a role to play in the nutritional care of the elderly," says Hawkins.

As well as offering nutritional care training, at a subsidised rate, to all the elderly care homes in the private sector throughout the county, DCC is also planning to work with Dorset NHS on a pilot scheme to help reduce the risks of malnutrition amongst the elderly in the community after leaving hospital.

And finally, the Dorset NHS and local authority will be raising the profile of the importance of hydration amongst the elderly with the launch of a new project in June.

"Nutrition is a vital aspect of care and the work that is underway in Dorset is having a real impact on the lives of older people," said Andrew Archibald, head of older people's services, DCC.


A key part of the food provision within the 70 care homes and 40 housing schemes run by Methodist Homes for the Aged (MHA) is the offer of plenty of choice to ensure that all special diets and requirements are covered.

There are no standard menus - each home writes its own to ensure, again, that specific requirements are met.

All chefs throughout the group receive one day per year of nutritional training. Extra training is also carried out in conjunction with the Alzheimer's Society's Food for Thought programme, which provides advice on catering for sufferers of dementia.

MHA chefs, therefore, are aware of the importance of making food look appealing, providing small portions frequently, using insulated plates to keep food warmer for longer, and offering finger food when using cutlery proves too difficult for some residents.

The importance of good hydration has been highlighted by a project carried out by MHA in conjunction with Anglia Water at the Martins care home in Bury St Edmunds, Suffolk.

"Keeping elderly people well hydrated results in fewer falls, less confusion, fewer admissions to hospital, less problems with constipation and an overall improvement in wellbeing," says George Hampson, head of hospitality at MHA.

Health on Tap, a DVD produced as a result of the project, is now used for training purposes throughout all the MHA homes.

The introduction of a coffee shop at the Elmside care home in Hitchin, Hertfordshire, which enables residents to enjoy snacks throughout the day, has proved so popular it is now being introduced at other care homes throughout the country.


1. Food service and nutritional care is delivered safely

2. An environment conducive to people enjoying their meals and being able to safely consume food and drinks is maintained

3. The care provider supports a multi-disciplinary approach to nutritional care and valuing the contribution of all staff, people using the service, carers and volunteers working in partnership

4. The care provider includes specific guidance on food and beverage services and nutrition/hydration care in its service delivery and accountability arrangements

5. Everyone entering care services is screened to identify those who are malnourished or at risk of becoming malnourished

6. Facilities and services are designed to be flexible and centred on the needs of the people using them

7. Everyone using care services has a personal care/support plan and, where possible, has personal input to identify their nutritional care and fluids needs and how they are to be met

8. All staff/volunteers have the appropriate skills and competencies needed to ensure that the nutritional and fluids needs of people using care services are met. All staff/volunteers receive regular training on nutritional care and management

9. People using care services are involved in the planning and monitoring arrangements for food services and beverages provision

10. The care provider has a policy for food service and nutritional care, which is centred on the needs of users

Source: Nutrition Action Plan Delivery Board end of year progress report, August 2009


Chef's tip

These look great on a buffet table - use for a birthday party or special event. Use blanched leek strips instead of string to tie the parcels. Keep your filo covered with a damp cloth until needed.

(Makes 12 parcels)


  • 100g prawns
  • 100g scallops
  • 100g salmon fillet
  • Juice of ½ lime
  • 2tbs fresh chopped chives
  • Salt and freshly ground black pepper
  • Pinch of cayenne pepper, optional
  • 500g filo pastry
  • 50g butter, melted
  • 4tsp fresh chopped dill
  • 4tbs reduced fat crème fraîche
  • A few chives lightly blanched in boiling water for garnish


Image supplied by Barchester Healthcare
Image supplied by Barchester Healthcare

Rinse the salmon with cold water, drain well and microwave or poach with the lime juice until tender. Leave the fish to cool, then remove the skin and any bones, and flake into pieces.

Roughly chop the prawns and scallops. Mix with the chives, seasoning and cayenne if using.

Brush the filo pastry sheets with melted butter and cut each one into four equal-sized 4in squares. Place in stacks of two pastry squares, with the top one at a slight angle to the first.

Divide the fish mixture between filo squares. Pull the corners of the pastry up and over the filling, pinch together and tie with string. Brush the outside with any remaining butter, then bake at 190°C/gas mark 5 for 10-15 minutes until golden brown.

Meanwhile stir the chopped dill into the crème fraîche and season.

Remove the string from the pastry parcels and replace with blanched chives. Arrange on serving plates with spoonfuls of the crème fraîche. Serve with salad.

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