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Good hydration as an integrated element of high quality care in residential and domiciliary care settings

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Nothing quite brings the importance of water to the fore like a heatwave. Although a number of miserably damp British summers of recent years have been noteworthy for floods, the potential exists for prolonged dry spells with the right conditions for temperatures to reach well in excess of the seasonal average. Under heatwave conditions the elderly, those with long-term illnesses, complex medical conditions and children may all be at high risk. Cardiovascular and respiratory illnesses pose the greatest threats.

Although pollution is a factor, the most significant issue is dehydration. To the untrained or inexperienced, in care homes or domiciliary care settings, dehydration may not always be clear or obvious and steps to ensure adequate hydration may be an oversight.

The scale of the problem here was revealed in January 2013 when a Parliamentary question showed that in 2011-12, 168 care home residents were admitted to hospital with a primary diagnosis of dehydration, an average of more than three a week. Many suspect this figure is the tip of the iceberg; it does not include those where dehydration is a secondary symptom, and hospitals do not always record whether patients have been admitted from a care home.

This is completely in contrast with acute or palliative settings; hydration has been identified as a significant factor in the decision to abolish the use of the Liverpool Care Pathway (LCP). The LCP has attracted much criticism, and through depriving patients of fluids, been branded “inhumane”, not least of all by witnesses that observed its effects on relatives, first hand.

To many it seems almost logical to consider hydration as part of the wider subject of nutrition. In the compliance guide ‘Essential Standards of Quality and Safety’ this is exactly what the CQC does in Outcome 5. However, in the opinion of some, hydration is of even more fundamental importance and deserves to be allowed to stand alone and considered in its own right.

In this guide we discuss how QCS compliance management recognises the importance of good hydration and enables those providing residential and domiciliary care to ensure that hydration is tightly integrated within the overarching objective of providing high quality care.

QCS compliance management and good hydration

There are essentially four areas of the QCS compliance management system where hydration is integrated to ensure that it is not overlooked as a component of providing good care.

Nutrition policy and procedure

The QCS compliance management system contains a Nutrition Policy and Procedure. This sets out best practice and also contains basic information on a balanced diet. Hydration is an essential consideration of a healthy diet.

It’s not just about fluids. Diet and food play a significant role in the hydration balance of the body. Chapter 3 of the British Dietetic Association publication ‘The Nutrition and Hydration Digest: Improving Outcomes through Food Beverage Services’ provides valuable guidance on the value of diet in hydration.

The QCS policy lists some common foodstuffs in descending order of hydration value. This enables caterers and care support workers to recommend and incorporate the best foods to support good hydration within service users’ diets.

Hydration and personal care plans

The format of the QCS Care Planning system allows the development of detailed individualised hydration planning strategies. It also provides for the practical delivery of the hydration strategy.

With QCS care planning is individualised and allows the assessor and Service User to explore food and beverage preferences. Once recorded, the care planner is able to select from the list the foods and beverages which best support hydration while maximising acceptability to service users, and build these into staff instructions.

The QCS care planning format enables the mental health of each Service User to be evaluated during the care planning assessment process. This provides the opportunity to consider and care plan the hydration strategies that are likely to be most successful with service users and provides better support for good hydration than ‘template’ approaches.

For example, for younger adults the consistent supply of cold, low calorie carbonated drinks is likely to support good hydration, while for an older person a regular supply of hot tea may be a better approach.

Reputable internet sites such as those of the NHS are an excellent source of reference for maintaining hydration and general support of care planning:

  • For hydration, each idea can be tested against the information recorded on each Service User’s preferences, personality and needs to ascertain which are likely to be successful
  • Researching the health conditions of the Service User provides significant benefits to help to make care planning effective

Fluid intake and output recording

The care records of the QCS system include fluid intake and output recording and generally, they are used where detailed management is required.

To ensure service user safety and wellbeing it is essential that health and social care support staff are educated and trained to understand the importance of hydration balance and are able to recognise the symptoms and prevent dehydration.

This is critical. The failure of care staff to adequately care plan for hydration, or failure to carry out care planned instruction may be classified as neglectful care. This may hold serious consequences for the service provider and care workers concerned.

Recording food and drink intake and urinary output is the only evidence to indicate that adequate hydration care has taken place. Besides forming an audit trail of a service user’s hydration, such records are also used by expert health professionals such as qualified nurses and doctors to diagnose the service user’s health state more correctly.

Publications such as those of the European Hydration Institute provide easy-to-understand materials for use in informal in-house training sessions, allowing carers to understand the issues, their importance, and their part in maintaining healthy hydration.

Mock Inspection Toolkit

The QCS Mock Inspection Toolkit (MIT) enables service providers to prepare for announced and unannounced inspections by conducting outcome-related inspection tasks on a regular basis.

The MIT consists of content, activities and exercises that ensure that the required compliance activities are covered.

  • Workbooks are provided which through completion enable service providers to chart progress and to review performance against Outcomes.
  • A guide to documentation and supporting evidence enables you to review the important requirements for recording and auditing.
  • Examples of positive outcomes enable review and understanding of good experiences.
  • Questions are provided, framed as examples of what an inspector might ask in an inspection situation. Understand how inspectors frame questions for:
    • Service users
    • Relatives
    • Staff


  • The support of individual service user hydration and the provision of competent care and support are fundamental to health and life itself.
  • Dehydration causes unnecessary suffering to those who are dependent on our care and can lead ultimately to their demise.
  • We must all be vigilant, accountable and conscientious in our prevention of this unnecessary threatening condition.
  • QCS compliance management integrates hydration to ensure that this essential component of high quality care is always treated with the importance it deserves.

About QCS

Quality Compliance Systems (QCS) offers a unique approach to CQC Compliance with an online based service specifically tailored to the individual needs of your organisation.

Whether you are an established Care Provider, Dental Practice , GP Surgery or a start-up organisation, our service is provided with the aim of ensuring that all aspects of compliance are being attended to.

Our industry experts continually update existing policies and procedures, whilst introducing new ones in response to the latest changes issued by the Care Quality Commission (England) and the SCSWIS(Scotland).

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Further reading and references

CQC regulatory guidelines

March 2010

Essential Standards of Quality and Safety Guide

The Care Quality Commission


Training, education and guidance

British Dietetic Association

'The Nutrition and Hydration Digest: Improving Outcomes through Food Beverage Services'

European Hydration Institute


Press article

January 2013

‘Scandal of dehydrated pensioners rushed to hospital because their care homes did not give them a drink’

Daily Mail Online




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