The Food First team of dietitians work in partnership with social care staff across Luton, South Bedfordshire and Hertfordshire Valleys to improve management of malnutrition by educating and empowering care homes to malnutrition risk screen and implement appropriate nutritional care plans. We will train all staff to equip them with knowledge & skills to identify malnutrition risk, using the validated screening tool ‘MUST’, & create individualised care plans that take into account the need for a balanced diet that meets personal preferences.
Key dehydration risk factors are covered, recognising nutrition is more than calories. Staff are trained to acknowledge underlying reasons for poor nutritional intake so these can be addressed holistically. To ensure behaviour change, homes are audited 6 monthly against standards aligned to NICE’s Quality Standards & CQC guidelines. Homes meeting these stringent criteria are certified to celebrate success & promote maintenance of good practice.
- Nutrition support in adults (QS24)
Aims and objectives
The main aim of the Food First project is to educate & empower care staff to accurately use a validated malnutrition risk screening tool with residents monthly (meets Quality Statement 1) & create individualised nutritional care plans according to resident’s risk, preferences & underlying conditions (meets Quality Statement 2).
Training focuses on the need to document the assessment & care plan clearly so this can be shared within the home, e.g. between care & catering staff & externally, with health professionals or between settings (meets Quality Statement 3).
The aims of the initial Food First pilot in 2009 were to improve the identification & management of malnutrition in the care home setting in order to reduce reliance on prescribed sip feeds & these aims were refined with the 2012 publication of NICE Quality Standard 24.
A criticism of many projects funded to make savings by promoting food rather than sip feeds, has been on the focus to increase calories without considering other nutrients essential to good nutrition, alluded to in Quality Statement 3. To ensure complete nutritional requirements can be met through food alone, when appropriate; training involves staff from all areas, including catering & care staff, to explain how to simply introduce high calorie foods with nutritional value is understood by all. For example, using cheese or nuts as sources of high protein, considering fruit based pudding options or using dried fruits to sweeten foods while adding calories, fibre & micronutrients.
Examples of good practice have been shared between care homes, ensuring that enrichment ideas are practical & realistic. Training has covered good hydration practice since 2012, recognising fluids are often excluded when considering nutrition, yet essential for good urinary tract health, to prevent falls & reduce the risk of pressure ulcers. Using NICE quality standards & CQC guidelines to frame the training has engaged care home staff, health & social care professionals & commissioners as it clearly gives rationale for undertaking the training. By linking training to an award scheme, we have been able to record demonstrable & sustained behaviour changes by care home staff to meet these standards & guidelines, leading to more engaged management of malnutrition that is based on individual assessments & goals. As a result the team’s objective is to reduce the use of sip feeds without negatively affecting the nutritional status of care homes residents.
Reasons for implementing your project
In 2009, it was identified prescribing of sip feeds were often haphazard, not based on nutritional assessments or monitored. This led to the funding of a pilot in South Bedfordshire to tackle this issue. Initial scoping found care homes were not using a single, validated malnutrition risk screening tool, presenting the risk of miscommunication when residents were transferred between care settings, & incomplete or standardised nutritional care plans. In addition, there were errors in documentation & in some cases inappropriate equipment was used to weigh & measure residents.
The priority of commissioners was to reduce spends on sip feeds, while care homes were anxious to meet CQC guidelines & provide the best care possible to their residents within a fixed budget & limited staff time. Care home residents who we spoke to were generally passive about meeting their nutritional needs, but patients in other settings had expressed their fatigue with the limited range of sip feed choices available, while others craved more savoury options to meet their nutritional deficits.
In 2010, the pilot expanded to all older people care homes covered by Luton CCG & those in South & Mid Bedfordshire covered by Bedfordshire CCG. This represents 47 care homes with approximately 2000 residents. Due to the success of the Food First team, this was commissioned by a neighbouring CCG with no existing links to the local dietetic team (Herts Valleys CCG) in 2015 & demonstrates the work could be transferred successfully.
As training plays a key role in the Food First approach, it was developed with input of catering, nursing & dietetic staff to ensure it was relevant, appropriate & implementable. It continues to evolve based on feedback from trainees & the recipe ideas shared are based on contributions from service users & care home staff, while the dietetic team oversee suggestions to ensure they cover a range of nutrients & not just calories.
Seeing the cost of dietetic staff as an investment, there have been opportunities to make savings within the prescribing budgets of the CCGs while ensuring that care home residents are not put at greater risk of malnutrition, information is more easily & accurately collected, shared & nutritional care planning puts service users at the centre, considering their needs & choices to promote dignity & independence whenever possible.
How did you implement the project
Using NICE guidance CG32 as a basis and then adapting training to the NICE Quality Standards had the benefit of engaging stakeholders across settings as it demonstrated that this approach had the potential to improve quality and outcomes for a vulnerable patient group.
The biggest problems faced were inertia and a limited desire to change as this would require an investment by care home staff in undertaking training and making changes to their behaviour. However, NICE and CQC are well established organisations that health and social care professionals wish to meet the guidelines of and therefore these were good levers for influencing care home managers and owners to release staff to attend training and the content of the training reinforced the benefits of following through with the information, for example, understanding that better nourished residents are more likely to stay well and be more independent helped ground the theory in reality for staff. This has been particularly relevant when discussing hydration needs as a dehydrated individual can be affected in many ways.
Additionally, care home managers and staff understood that by using a malnutrition risk screening tool that can be transferred between settings, and associated nutritional care plans, they would be able to demonstrate good nutritional care in their setting and help to eliminate the “blame game” when a resident does become malnourished as they would have clear evidence of the steps taken to try and manage the risk (successfully or otherwise).
In addition, we found that the use of an award scheme used positive reinforcement to promote changes and again the knowledge that meeting the audit criteria necessary to achieve the award meant working in line with national guidance motivated care home staff, as well as ensuring that social care commissioners encouraged care staff to work towards this award. The cost of auditing award criteria has been built into the original investment in staff time and therefore has been a cost effective way of motivating, achieving and sustaining change.
The main aim of the Food First project has been to improve the identification and management of malnutrition using the validated screening tool as a starting point to create individualised care plans. Within Luton and South Bedfordshire, over 80% of care homes for older adults are meeting the audit criteria set out by the Food First team to demonstrate that they are meeting these aims and engaging in ongoing training to make this sustainable.
As a result, we have seen approximately £123,000 in savings over a 6 month period in the initial stages of the project. This was through a reduction in sip feed prescribing as care homes have had the confidence and knowledge to use real food to provide a balanced diet that is able to the met the increased nutritional needs of vulnerable individuals.
More recently, within Hertfordshire Valley, £200,208.00 of savings have been achieved in 1 year (equating to a £4 saving for every £1 invested) with no change in the malnutrition risk level of care home residents. Of the almost 3,500 senior care home residents in Hertfordshire Valley, 63% remain at low risk of malnutrition, 13% at medium risk and 17% at high risk (the remainder could not be assessed), despite a huge reduction in the use of prescribed sip feeds. This demonstrates that cost savings can be safely made and we assume that, as with the established project work in Luton and Bedfordshire, this can be maintained, or even improved upon, as care homes take on the Food First training and embed the NICE Quality Standards in to their everyday behaviour.
- Home 1 : ‘Well delivered using visual aids which has more of an impact on understanding’
- Home 2: ‘Really interesting. Found it very useful and will start updating care plans with information’
- Home 3: ‘Excellent delivery, thank you. Will use this information to help service users’ Confidence in using ‘MUST’ to identify malnutrition by care home staff increased from 31% before training to 91% post training.
Key learning points
Our key learning has been the importance of linking projects to national and well evidenced guidelines while still taking into account local input so that the project can evolve so that it meets the needs of those it is trying to serve.
Although stakeholders may have conflicting interests, putting patients at the centre of plans ensures that there is common ground between everyone and enables elements of co-production. We also found it encouraging that the project has been transferred between CCGs, avoiding replication and saving on set up costs as ideas and resources can be reused. This has enabled us to achieve a lot more than we could have done as smaller, individual projects.