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Can you prove that you meet nutritional needs?
A recent challenge to a care home client, as a result of an inspection, highlights the approach taken by the CQC under the Health and Social Care Act 2008 (updated 2012), namely that providers have flexibility in the way in which they achieve the required outcomes, but they are required by the CQC to prove that their processes can, and do, achieve the outcomes in practice.
The inspection took place in a typical mid-sized care home, registered for personal and nursing care for older people. Following a history of challenges to the catering facilities, the home had recently completely refurbished the catering areas, including storage, equipment, and surfaces; hence better food and better business. The Food Standards Agency promoted food safety system had also been introduced long ago, and was in consistent use. The home provides what everyone concerned considered to be a good standard of food; complaints, which were few in number, focussed on individual issues such as food temperature, and did not indicate any systemic inadequacy. Residents had always been offered a full choice at breakfast, including cooked breakfast available to all every day, at any time that they choose. It was not unusual to enter the home at mid-morning to find one or two residents tucking into an egg and bacon breakfast, entirely at their own choice. Lunch was also a choice, with one or two main courses on offer, plus individual variations on request. A typical small to medium sized home regime.
However, the CQC inspector asked a simple question, which the home could not answer: “Irrespective of the standard of content and presentation of the food, show me how you know that it meets the individual needs of each resident”. The fact that everyone had choice, received what they wanted, and complimented the home on its food service, did not meet the standard or his question. His point was – they may love the food, but is it meeting their nutritional needs, and if you think that it is, prove it to me.
The home realised that it had focussed too much on short term satisfaction rating, for which they could provide evidence in the form of a highly satisfactory questionnaire results and verbal feedback, and too little on the full meaning of the word “nutrition”, which includes meeting dietary needs as well as personal taste needs. The problem emanated from that all too often feature of the smaller organisation: concentration on personal relationships and a lack of system analysis and systematisation.
Fortunately they were subscribers to the QCS management system, and were able to quickly refer to the system to find out what they should be doing. Although they were long time users of the system, its prescriptions had, through personal changes, been watered down in the catering area. The prescription offered to the CQC inspector in response to the challenge was:
- Catering staff have been instructed to create a 4 week rolling menu, with the following characteristics:
- For each day a selection of at least 2 options for each of the two main meals of the day is provided, together with a relatively static list of at least 15 other options which are offered each day as a third alternative.
- The rolling menu is displayed in a prominent position in public areas of the Home, including the dining areas, together with a calendar key to indicate the current day.
- Orders for the following day’s meals will be taken each day, to enable checking of availability.
- In time, with improving staff competence, it is planned to move to a system where meals are ordered on the same day as consumption, so as to allow for less opportunity for service users to forget what they ordered. Eventually we hope to move to a system whereby choice is offered at the mealtime, a system which has been observed to satisfactorily work in a larger home.
- The current system of providing a la carte breakfast choice will continue.
- The rolling menu is to be created by:
- Surveying the service users to record and take into account their individual personal likes and dislikes.
- Surveying the care plans to take into account any nutritional instructions contained in them.
- Reviewing the dietary needs of all service users to identify common needs and requirements.
- Reviewing professional advice on the dietary requirements of the range of service users accommodated. There is some advice within the QCS management system catering policies. A professionally qualified chef will also have knowledge of good nutrition. This knowledge can be supplemented by publications such as the “Manual of Dietetic Practice by Briony Thomas and Jacki Bishop (Jul 31, 2007). Finally, locally there may be access to a dietary advice service.
- Reviewing the lists of common and individual likes, dislikes and dietary requirements to create a 4 week menu which meets the overall requirements, providing 2 options at each meantime, and a lack of repetition as far as is possible. Review the draft against professional advice and adjust as necessary to achieve overall and individual good dietary content.
- The service user review will be repeated at least quarterly and the rolling menu will be reviewed to vary it in line with changing personal and dietary requirements, and the availability of seasonal produce.
- Discharges and admissions will trigger an immediate review of the rolling menu in order to incorporate the dietary needs and requirements of the new client group, as determined by the admission assessment process and documentation.
- The cook will record in writing the daily choices made by each service user, and any variations to the food served from that choice.
- The cook will carry out a “round” of service users each day to ask for comments on the quality of the food service that day, and coaching will be given to enable that discussion to be positively critical rather than defensive. The results of these discussions will be recorded and reported to the Manager, and actions planned and put into effect where appropriate.
- The records produced by these processes will include:
- Individual service user preferences record reviewed when indicated by resident’s altered meal responses or changes are indicated in the monthly nutritional assessment
- Care plan instructions involving food preparation and service for individual service users
- A record of the development of the initial 4 week rolling menu, and how it takes into account the individual preferences
- A record of the analysis of the first draft of the rolling plan to judge its nutritional adequacy and balance
- Evidence of revisiting the rolling plan when the client group changes, or care plan instructions change
- Evidence that the rolling plan is publicised and seen by service users
- Evidence of service users daily choice
- Evidence of what each service user actually consumed at each meal
- Evidence of feedback – daily and via questionnaire
- Evidence of regular e.g. quarterly review, incorporating outcomes from individual and group resident meetings and altered individual nutritional care plans. This can be evidenced by on-going nutritional management action planning and review to evidence targets achieved.
Most of these records can be satisfied by a simple entry into the catering diary, which should be in use anyway if Safer Food Better Business is in use.
By some simple processes, which do not add significantly to workload once the initial time investment in developing the rolling menu has taken place, the service can easily and quickly prove to an inquisitive inspector that the food being served does, over a period of time, deliver both the overall nutritional needs of the average member of the client group, the individual dietary needs and personal preferences of each person that takes up the average, where these vary.
All the above relates to processes in a care home. However, domiciliary services need to achieve the same Outcome in a totally different setting. In the relatively rare cases where the care service is formally tasked with providing a nutritious food service to the service user, the processes defined above, less the group aspects, will still need to be carried out. In the more usual case where the service does not have that responsibility, and possibly only has the task of serving food which the service user has sourced themselves, then they may be relieved of the formal burden, but would be well advised to check that the service user is receiving dietary advice from a responsible source.