Some stark statistics as we go into the New Year – in 2015, 850,000 people were living with dementia and their number is predicted to increase. One in six of those aged over 80 will develop dementia. So as well as research into the prevention of dementia, how we look after people with this condition is incredibly important, and that most definitely includes providing a choice of nutritious, appetising meals that meet the needs and choices of individuals, and support with eating where needed. But how can we assess the quality of nutrition service? What does outstanding care look like? NHS Improvement has recently published the ‘Dementia Assessment and Improvement Framework’ that may help answer these questions.
Nutrition And Hydration Has Been Recognised As One Of The Eight Standards
The framework consists of eight standards and draws on learning from organisations that have achieved an ‘outstanding’ rating from the Care Quality Commission, and integrates policy guidance and best practice with opinion from patients and carers. The latter was captured through existing resources, including Healthwatch UK (2017), Patient Voices, the Alzheimer’s Society and meeting people and their carers living with dementia. Nutrition and hydration has been recognised as one of the eight standards in the NHS Improvement framework.
Whilst this publication has been created to support organisational leaders in the NHS to provide ‘outstanding’ care for people living with dementia during their stay in an acute, community or mental health setting, the principles described in the nutrition and hydration standard really resonate with characteristics of good quality care in care homes – Read on and see if you agree.
The standards are laid out in three basic sections; a description of what needs to be achieved to deliver ‘outstanding’ care, the relevant source (could be a policy, best practice guidance, patient and/or carer opinion), and examples of evidence that can support the standard.
The first set of nutrition and hydration standards described in the framework is derived from the NICE Clinical Guidelines Nutrition Support for Adults (CG32). This key guideline covers identifying and caring for adults who are malnourished, and concerns several organisational priorities. These include:-
- The need for relevant professionals directly involved in care to receive education and training in nutrition as relevant to their post. Supporting evidence could include: training rates; speaking to staff to assess their knowledge and skills base to meet this need; asking service users and carers if staff support enables people to meet their nutritional needs
- Ensuring that staff are aware of the need for the weight status of all to be assessed on admission (using ‘MUST’ or another validated tool). Supporting evidence could include: policy and notes review; staff being able to describe the process for this and its importance; minutes of relevant meetings (e.g. a nutrition and hydration committee meeting)
- Expert advice is available from, for example, a specialist nurse, dietitian or speech and language therapist. Related to this is that service users with dysphagia are referred to a healthcare professional with the skills to manage swallowing disorders. Supporting evidence could include: staff saying how they access expert advice; service users and carers having confidence that residents’ nutritional needs are met; a clear nutrition and hydration pathway in place; staff knowing the causes of dysphagia and able to recognise signs and symptoms.
The NICE Guideline Also Lists Oral Hygiene as a Factor to be Considered
Supporting evidence could include: service users and carers saying they get help with oral hygiene if they need it; staff being able to describe how they assess oral hygiene and the actions they take; any oral health-related clinical need being documented in the care plan; staff able to describe the process for keeping dentures safe.
Care Plans to Meet People’s Hydration and Nutritional Needs Should be in Place
The framework also highlights the finding from the 2012 Dementia Action Alliance Dementia-friendly hospital charter, that 6 out of 10 carers are concerned about the nutritional intake of a person living with dementia. In order to address this, the framework includes a nutrition standard that care plans to meet people’s hydration and nutritional needs should be in place.
A Variety of Foods Should be Available 24 Hours a Day
Finally, but no less importantly, the National Audit of Dementia (Royal College of Psychiatrists 2017) recommends that a variety of foods are available 24 hours a day, including finger foods, snacks and foods that can be provided outside the routine mealtimes. In addition, menus should be available in picture and large print or other formats if appropriate, and appropriate crockery and cutlery (e.g. coloured plates, adapted cutlery, coloured trays, water jugs with different coloured lids) available for people requiring support.
Supporting evidence could include: menu review; mealtime observation/audit.
Carers and Family Members Should be Involved
The National Audit of Dementia also stressed that carers and family members are supported to be as involved as they want to be in meeting patients’ nutritional needs.
Supporting evidence could include: observation; patients and families/carers saying they feel supported; family members/carers being encouraged to stay if they wish at mealtimes.
So we come back once more to the importance of listening to the voices of service users, their families and carers – let’s take this message into 2018 and provide the best nutrition service possible.
The Dementia Assessment and Improvement Framework is available from https://improvement.nhs.uk/resources/dementia-assessment-and-improvement-framework/