Written by Sophia Cornelius, Development Dietitian at apetito

Through this article, I will be discussing the importance of care homes providing personalised nutritional plans for residents to ensure health, wellbeing, and quality of life – providing useful advice for staff/managers. This follows real-life evidence found through the “Nourishing Lives” collaborative research report conducted by apetito and Care England where it was seen that most care homes find catering for extensive nutritional diversity challenging to achieve – despite its importance.

Care homes offer a crucial sanctuary for individuals who can no longer live independently due to escalating care needs or safety concerns. As we age, our bodies naturally deteriorate, leading to increased dependence and a range of health conditions that necessitate specialised support. Consequently, care home residents tend to be older, with over 80% of those in England and Wales being aged 65 or above. These age-related health conditions often result in complex dietary needs, requiring meticulous meal planning and nutritional support to maintain their health and well-being. These facilities play an essential role in ensuring the well-being and safety of our ageing population, providing a supportive environment tailored to their unique needs.

Personalised nutrition pathways are an invaluable tool that homes should utilise for supporting residents to not only meet their nutritional needs but also enjoy mealtimes and have a positive dining experience. Mealtimes are undoubtedly an important time of the day within care homes, as not only can food be a highlight of someone’s day but it’s an opportunity for residents to engage with one another.

The value placed on this time of day amplifies the importance of care homes providing a positive dining experience, however, for staff, this can become increasingly challenging when catering for different specialist dietary needs. The Nourishing Lives report found that every care home surveyed had between 3% and 19% of residents living with a specialist dietary need. Yet, 19% of care homes said they find it challenging to provide residents with a balanced diet across wide-ranging resident’s needs.

Some conditions that require specialist diets, such as dysphagia, increase the risk of malnutrition, one of the consequences which could create greater dependence and further the strain on a home’s staff. Personalised nutrition pathways can support care homes to better understand the needs of their residents and therefore more easily plan their catering to help with preventing malnutrition.

One aspect of a personalised nutrition pathway is assessing residents’ nutritional status, which enables early detection or prevention of malnutrition. BAPEN designed the malnutrition universal screening tool which provides a step-by-step pathway to identify someone’s risk of malnutrition or if they are malnourished3. Based on this score the pathway provides guidance on management to support in the development of care plans. Assessment of a resident’s nutritional status, using MUST or an alternative validated screening, should be done on admission and then at least once a month thereafter.

Screening tools are often a necessity for residents to receive more specialist input from healthcare professionals (HCP’s). These tools function as a form of triaging, and if not completed properly services may decline referrals. It is crucial for care homes to seek support from HCP’s when needed, as their expertise allows them to provide specialist patient-centred support to residents. Collaborating with HCP’s ensures that residents receive the best possible care.

Accurate use of screening tools is not only best practice for the health and wellbeing of residents, but it is also useful for audits. For instance, MUST scores provide a measurable way of identifying if the catering provision within a home is meeting the nutritional needs of their residents.

Another aspect of a personalised nutrition pathway is Nutrition and Hydration Care Plans. These are key to ensuring the nutritional pathway is in fact personalised to the resident and should be completed with the resident and/or family where possible. Regulation 14 of The Health and Social Care Act 2008 states that care plans should be completed upon admission as part of an initial assessment to identify the resident's overall care needs and must be reviewed regularly to ensure adequate nutrition and hydration to support good health5. Regularly reviewing allows for quick responses to any changes in an individual's needs, which can vary with age and health. These plans should accurately reflect the evolving needs and preferences of the residents.

Nutrition and Hydration Care Plans should detail the person's likes and dislikes, allergies and intolerances, need for assistance when eating including adaptive cutlery, and dining preferences. If completed in detail and reviewed regularly these plans provide an invaluable tool to support residents to eat well within your care home.

Identifying a resident's specialist dietary needs is the first step in ensuring they receive adequate food provision. Staff training is crucial for accurately completing these documents and ensuring the safety of residents. Managers are responsible for organising sufficient training for all staff members and regular audits should be conducted to identify any weaknesses in training and address areas for improvement. External training opportunities, such as in-house sessions with a dietitian, can enhance understanding and emphasise the importance of accurately completing these documents.

As already mentioned, and identified within the Nourishing Lives report, specialist diets are highly prevalent in care homes, however, confidence in catering for these residents is low. The consequence of this can be grave, either through unsafe food being provided or residents only being offered very limited choice, resulting in monotony and menu fatigue. Allergens and texture modified diets are particularly challenging and the consequence of not being able to provide for residents on these diets is great.

Allergen awareness has improved since the introduction of Natasha’s Law in October 2021. This states that food prepacked for direct sale (PPDS) must be labelled with the name of the food and a full ingredients list with the allergens emphasised, providing even more peace of mind when using pre-prepared meals.

The Nourishing Lives report found that three-quarters of care homes have altered their approach to catering for allergens following the introduction of this law in ways such as having clear allergen lists displayed on menus and recording residents' needs carefully with more readily available lists to staff.

It is essential that care homes have a robust allergy management policy in place to ensure the health and safety of residents. This policy should include procedures for identifying residents with food allergies upon admission, documenting their allergies, and implementing measures to prevent cross-contamination and accidental exposure. The Food Standards Agency (FSA) state that a resident’s dietary needs should be documented in their care plan and processes put in place to ensure their needs are communicated to those serving the food.

One way to reduce the risk of a resident having an allergic reaction is through comprehensive staff training on food allergies, including how to recognise symptoms of an allergic reaction, how to read food labels effectively, and how to handle and prepare allergen-free meals safely (avoiding cross-contamination). Despite improved awareness and management of allergens, catering for residents with allergies remains challenging and very prevalent, with up to 1 in 4 residents living with allergies and requiring ‘free-from’ meals at most care homes.

One challenge that poses significant risk to residents with severe allergies is cross-contamination. Cross-contamination is when a ‘safe food’ has been exposed to an allergen containing food and can occur at any point when food is being handled, including preparation, cooking, storage and serving. Therefore, it can be challenging to avoid, especially if homes are scratch cooking for many residents with varying dietary needs and allergies.

Using pre-prepared meals can help to mitigate some of these risks for care homes as they will have been produced in a strictly controlled environment, safely packed, and labelled – providing a safe and more convenient option when catering for diverse dietary needs.

Whether scratch cooking or pre-packaged allergen free meals, regular risk assessments of the care home's food handling and preparation processes should be conducted. This can help identify potential hazards and areas for improvement in managing food allergies.

Personalised nutrition pathways can support care homes to implement appropriate measures, so they can effectively cater to the dietary needs of each resident and navigate food allergies creating a safe dining environment for all residents.

Another common specialist diet seen in care homes is texture modified diets, which are used for the management of swallowing difficulties (dysphagia). Individuals living with dysphagia have a heightened risk of malnutrition due to an array of physical and psychological factors such as a fear of choking causing food avoidance, aversion to texture modified meals, mealtime fatigue and embarrassment, all of which negatively impact food intake.

Dysphagia is highly prevalent in care homes. The Nourishing Lives report found 8 out of 10 homes surveyed reported having residents living with dysphagia and 1 in 3 of these they believed was suffering from malnutrition as a result.

One factor that can have a significant impact on an individual’s nutritional intake, as well as their mealtime enjoyment, is meal presentation, with 7 out of 10 care homes believing that the “joy of eating” was lost when serving residents pureed food, due to it being poorly presented2. This statistic highlights the importance of visually appealing texture modified meals to ensure that individuals living with dysphagia meet their nutritional requirements. Many people ‘eat with their eyes’ and therefore poor meal presentation can lead to a reduced intake or refusal of meals altogether due to its key role in appetite stimulation.

The visual appeal of a texture modified meal can further impact the mealtime experience due to feelings of embarrassment. The noticeable difference in a texture modified meal may draw attention to an individual's clinical condition, exposing them to judgment from others and making the mealtime a source of social anxiety. This can potentially lead to the avoidance of social situations altogether, which, in turn, can negatively impact the mental well-being of residents living with dysphagia. It is therefore important from both a physical and emotional perspective to consider the visual appearance of a modified meal to best support those in your care.

In a social setting, if an individual can eat a safe texture modified meal that closely resembles a regular textured dish, it may reduce these feelings of embarrassment and social anxiety, allowing for a more positive and comfortable mealtime experience. Also, providing a visually appealing meal has shown to increase meal consumption from 25% to 75%.

Presentation is just one of many factors that can support people living with dysphagia to eat well. Portion size can also impact nutritional intake since individuals living with dysphagia may often struggle with mealtime fatigue. Therefore, it is essential they have access to nutritionally dense meals in smaller portions. Choice and variety are also essential to support a balanced diet and prevent boredom, allowing residents to make meal choices based on their preferences each day - which is likely to lead to better intake.

Dysphagia is not a static condition, it can change for the better or worse, and for this reason, it is essential to work with Speech and Language Therapists (SLTs) who will provide an assessment and recommend the most suitable texture.

Staff should be trained on the different food textures, which are defined by the International Dysphagia Diet Standardisation Initiative (IDDSI). It is essential that they understand the severity of not providing the recommended texture and that any adaptions, for example, adding normal gravy to a Level 4 Purée meal, will affect the texture, and therefore the safety, of the meal – with the potential for fatal consequences.

In conclusion, care homes play a pivotal role in supporting the health and well-being of their residents. The implementation of personalised nutritional pathways is essential in addressing the complex dietary needs of these residents, ensuring they receive the necessary nutritional support whilst also enjoying their meals. Additionally, comprehensive staff training and collaboration with healthcare professionals are vital in managing specialist diets, thereby reducing risks and improving care quality. By prioritising these strategies, care homes can create a safe and supportive environment that promotes the physical and emotional well-being of their residents, ultimately leading to better health outcomes and a higher quality of life.

Get your copy of the Nourishing Lives Research Report from apetito.link/CE-Research-24 Discover more about apetito’s care home services and world leading texture modified meal ranges at apetito.link/carehomes