Hydration and nutrition is one of the most import aspects of providing care, especially in residential settings.
Dehydration and malnutrition can severely worsen a range of conditions, including ulcers, bedsores, dementia, and stroke risk.
In more extreme cases dehydration and/or malnutrition can directly cause death. Between 2003 and 2012 this killed almost 1,500 people in UK care and nursing homes.
Care providers who expose people to risk of avoidable harm by breaching regulations in this area can face hefty fines from the UK’s care inspectorates and even criminal prosecutions.
So what should you be doing to ensure good hydration and nutrition for the people you provide care to?
Nutrition and hydration in England is covered by Regulation 14 of the Health and Social Care Act 2014, which looks pretty basic at first.
For example, the regulation states that people have a right to good and nutritious food which fits their religious, cultural or personal preferences and which is adequate to sustain life and good health.
You probably knew all that already. It’s the guidance around these regulations that reveal what inspectors are really looking for:
The regulations and assessments
Everyone under your care must have their dietary and fluid needs included as part of the initial assessment. These assessments must at the very minimum identify:
• requirements to sustain life, support the agreed care and treatment, and support ongoing good health
• dietary intolerances, allergies, medication contraindications
• how to support people’s good health including the level of support needed, timing of meals, and the provision of appropriate and sufficient quantities of food and drink.
• People’s religious, cultural or ethical beliefs, e.g. kosher, halal, vegetarian, vegan and any other preferences around food and drink, including the time of day they prefer to eat.
The CQC also requires that you have a food and drink strategy in place
Detailed, extensive and person centred assessments are the foundation of good nutrition and hydration. Your resident’s needs in these areas will need to be reassessed regularly – at least every three months if there have been no incidents which acquire immediate attention.
The delivery of care
Your care plans must draw from your assessments in full, including all relevant nutritional and hydration information. Then of course, those care plans have to be followed consistently by everyone in your team.
Of the greatest importance is being aware of people’s risks of malnutrition or dehydration. These should be identified as part of the assessment and continuously monitored from then on.
As the regulatory guidance makes clear you need reliable and robust systems in place to record and successfully monitor people’s intakes. These systems must enable you to proactively identify when someone is at risk and determine what intervention to take.
The picture then, now and tomorrow
For years care homes, nursing homes and hospices have achieved this – with mixed results – using paper records. The trouble with these of course is that the odd drink or that snack can go unrecorded. The quantities or exact timings can be inaccurate or there may be inadequate levels of detail. Take this example from a care home rated Inadequate by the CQC in January 2018:
“A number of people were at risk of malnutrition or dehydration. Despite this, food and fluid charts were not always completed in detail to reflect what people had eaten and drank over a 24 period and to inform assessment of the person’s nutritional status.”
“Records viewed as part of our visit around diet and fluid intake were not always completed in full, dated or signed. They were not reviewed to ensure that concerns were highlighted and escalated. This had not been identified as part of the auditing process.”
Carers also have to ‘self-prompt’. In other words there is no system to automatically remind people, for example, that Joe needs his meal now, before he takes his medicine.
This is important because even minor deviations from the care plan can have an impact on people’s health. That is why care inspectors police obedience to care plans mercilessly. Here is what might seem like a relatively unimportant oversight:
“One person’s care plan indicated that they should have food cut up into little pieces but we saw it was not.”
This actually featured prominently in the report of another care home that the CQC rated Inadequate. The inspectors do not pull any punches when it comes to people’s food and fluid.
The eye of the beholder
With paper records the real fun begins when it is time for a handover or an audit.
The volumes of information are staggering and the process takes a huge amount of time away from senior carers and managers. That’s not all. In the back office, just as on floor of the care home, manual input of information make errors inevitable – whether on a paper form or a spreadsheet.
These errors can have a serious impact on people’s health. Incorrect information about people’s hydration and nutrition creates an incorrect picture about their condition.
Trying to detect signs of risk from your records manually is at best sub-optimal, at worst, impossible.
Now of course staff need to be trained to spot physical symptoms, but being warned ahead of time, automatically, is what allows you to act quickly and prevent any damage to people’s health.
These positive steps forward are becoming increasingly possible with the latest in care management software. These systems are helping people perform more detailed assessments, ensure people always get the food and fluid they need and proactively be alerted to any risks.
We’ve created this factsheet, explaining how nutrition and hydration management with electronic care records work. You can download it now: