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Should we audit nutritional care in care homes?
A range of policies and guidance documents have been produced in the UK highlighting the need to ensure people in hospital or residential care receive good quality, nutritious foods and fluids. Despite this guidance, there are still reports that suggest the experiences of service users are variable. People living in care homes may not always receive the best nutritional care, from the provision of nutritionally adequate and enjoyable meals to the implementation of nutritional support pathways for those at risk of malnutrition.
Concerns over nutritional care, coupled with the increasing amount of guidance about nutritional care, highlight the importance of care providers to be able to assess, and where necessary enhance, the quality of nutritional care they are delivering. Clinical audit can be used as a model for achieving this.
Audits can improve the care provided
The Healthcare Quality Improvement Partnership (HQIP) runs the National Clinical Audit and Patient Outcomes Programme, which is a set of national clinical audits that measure healthcare practice on specific conditions against accepted standards. These give care providers benchmarked reports on performance, with the aim of improving the care provided.
HQIP commissioned a group at King’s College London to support the design of a national audit of nutritional care in health and social care settings. This was based upon the factors suggested by the Essence of Care Benchmarks for Food and Nutrition, as well as an additional 15 key papers that included guidance or standards for nutritional care in hospitals or care homes.
The project group identified a set of audit criteria covering all aspects of the nutritional care pathway, including identification of risk of malnutrition, implementation of nutritional care plans, referral to healthcare professionals for further nutritional assessment and nutritional support strategies.
Audit tools have been developed
A series of audit tools were developed, and reviewed by the project steering group, the project advisory board, a care home support team and a district general hospital’s nutrition team. The tools included:
An organisational level audit tool covering care homes’ nutritional policies and procedures.
A staff questionnaire aimed at identifying the training needs and knowledge of staff (of all grades) in relation to various aspects of nutritional care.
A residents’ records audit tool aimed at capturing information on nutritional care, from screening for nutritional risk and assessment of nutritional needs and preferences to the setting and review of nutritional care plans and referral to healthcare professionals.
A patients’ and residents’ experiences questionnaire aimed at capturing information on patient/resident perception of the nutritional care received.
Significant challenges were noted in identifying appropriate outcome measures. The link between nutritional care and specific nutritional outcomes is complex, and desirable outcomes are difficult to define. Direct patient or user experience of nutritional care, for example, enjoyment of meals, is an important outcome. Other potential important outcomes include measures of body weight or weight change. Additionally, non-nutritional outcomes that may be influenced by nutrition, such as healing and psychological wellbeing, may be important to consider.
Audit tools should link to CQC requirements
Of course, from a care home perspective, such an audit tool would be most favourable if there was clear linkage between data collected for audit and information required for a CQC inspection.