Nutrition and Hydration
Scope of this chapter
This chapter applies to care homes and all other settings where staff have a role in supporting people to prepare or consume food and drink.
First and foremost, nutrition (food) and hydration (drink) are essential for life itself. But eating and drinking also has many other functions, and it is important that we understand and maximise the positive impact that it can have on a person’s overall wellbeing.
- When a diet is healthy it can also have significant benefits for physical wellbeing. For example, increased energy levels and reduced risk of many serious health conditions (e.g., heart disease, diabetes, cancer, stroke);
- Consuming food and drink that is enjoyable can improve mental wellbeing. They can boost mood and bring great pleasure, especially when someone eats/drinks what they like, how they like it and when they like;
- For some people, food is an important part of their religious or cultural identity.
Relevant Regulations
Related Chapters and Guidance
- Choice and Control
- Culturally Appropriate Care and Support
- Dignity and Respect
- Food Safety and Hygiene
- Medication Support
- Promoting Independence and Strengths
- University of Bedfordshire: Alcohol management in care homes – a good practice guide for care staff
Amendment
In March 2024, a link to Alcohol management in care homes: A good practice guide for care staff was added to section 2 ‘Assessing Risks’ and the Related Chapters and Guidance.
Needs and preferences must be established before the service begins.
A formal review of needs, preferences and risks should take place annually, and whenever there are signs that needs, preferences or risks have changed.
At each provision of food and drink, staff should observe the person’s reaction to it and ask appropriate questions to enable feedback.
For example:
- Was that OK?
- Did you enjoy that?
- Did I cook it correctly?
- Did I give you enough?
- Is there anything I could do differently next time?
- Is there anything different you would like to try?
If a menu is used, feedback on menu options should be sought regularly from the person, families and the staff team. Menus should vary and change in response to feedback, changing needs and changing preferences.
Needs
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Preparing food and drink - what can the person do independently and what do they need support with? |
People often need support with only one or two elements of a task. Break the task down and maximise opportunities for independence. Examples:
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Allergies |
It is important to know if the person has any known allergies. For further guidance see: Food Safety and Hygiene |
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Consistency of food and drink |
Many people will be able to eat food prepared normally, but some people will need it prepared in a different way, often to reduce the risk of choking. Examples:
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Supplements |
Some people need to supplement their diet with vitamins or high calorie drinks like Fortisip. These should only be given by staff when approved by a relevant health professional. |
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Cultural needs |
Cultural needs should always be regarded as needs to be met, not as preferences. Examples:
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Eating and drinking- what can the person do independently and what do they need support with? |
It is important to only provide support when someone needs it. This promotes independence and dignity. Examples:
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Aids used to promote independence and safety |
A person may need specialist adaptations or equipment to help maintain their independence and dignity when cooking, eating and drinking. For example:
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Medication and food interdependencies |
Some medication must be taken with, before or after food. Some food and drink cannot be consumed when taking a particular medication. Medication may need to be crumbled into food/drink. Note: Staff should only ever crumble medication if it has been agreed by a medical professional after applying the best interest principle of the Mental Capacity Act 2005. |
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Specialist needs |
For example:
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Known issues and risks |
For example:
See assessing risk below. |
Preferences
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Likes/dislikes For example, favourite food and drinks, foods least liked, foods would like to try, treats and snacks as well as meals |
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Portion size For example, big portions, small portions, likes second helpings |
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Presentation For example, likes food displayed in a certain way, some food not to touch others, certain bowl/plate/mug, likes gravy on the side not ready poured |
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Eating patterns For example, likes certain food and drink at certain times, likes to eat little and often rather than big meals, likes to eat a take-away every Friday etc. |
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Eating routine For example, likes to change before/after eating, wash hands, likes privacy while eating, likes to watch TV, likes to clean teeth after eating etc. |
All needs and preferences must be recorded in the individual care or support plan and communicated to staff.
When needs and preferences have been understood, an appropriate and proportionate assessment of any identified food and drink related risks must be carried out.
For example:
- Risk of eating too much/not enough;
- Risk of forgetting to eat;
- Risk of choking/aspiration;
- Risks around any non-oral routes of nutrition e.g., a PEG;
- Contraindications for medication;
- Risk of allergic reactions;
- Risks relating to conditions such as diabetes, Crohn's, gastric ulcers etc.
Risks should be assessed in a person-centred way, with participation of the person.
There is a chapter of this Handbook dedicated to risk assessment.
See: Risk Assessment (person-centred)
Depending on the nature of the risks, specialist support may need to be requested. For example, from a Speech and Language Therapist (SALT), Dietician or Community Nurse.
Alcohol in care homes: For many people living in a care home, drinking alcohol is important. Alcohol can bring a variety of benefits including increased wellbeing, mood and confidence, aiding relaxation and sleep, improving appetite and enhancing social participation. However, there can also be risks, including medication interactions, confusion, falls and injuries and dehydration. The University of Bedfordshire carried out a study and has developed a good practice guide for care staff in relation to alcohol.
See: Alcohol management in care homes – a good practice guide for care staff.
Support should be provided in line with the individual care or support plan, having full regard for strategies to manage identified risks.
All food and drink should be prepared in accordance with the guidance of the Food Standards Agency. This is explained in a dedicated chapter of this Handbook.
Support should promote independence and maximise choice and control at all times.
People should be able to make a choice about what to eat or drink. This requires them to have more than one option.
Dignity and respect must be always upheld:
- Mealtimes should not be rushed;
- People should be able to eat where they want to e.g., in private.
Non-oral routes of providing nutrition and hydration are normally implemented when someone’s swallowing function is severely impaired and they are at significant risk of malnutrition, choking or aspiration.
Decisions to use non-oral routes must be made by a specialist health clinician and are not undertaken lightly. They pose high risk of infection and also take away any enjoyment that the person had from the act of eating and drinking itself.
Non-oral routes include:
- Nasogastric tube feeding;
- Percutaneous Endoscopic Gastronomy (PEG tube);
- Parenteral nutrition (intravenous feeding).
These methods must only be used by staff who have had specialist training and been deemed competent by a relevant health professional.
Staff must be aware of signs and indicators that there could be a problem with the equipment itself, or an infection in the person, and able to take appropriate action swiftly.
It is not necessary to record food and drink intake unless:
- Medication is also being given;
- It is being given through a non-oral route;
- A Dietician or other health professional has asked for a record to be made;
- You have noticed that the person is starting to struggle swallowing, eating more or less than normal or showing signs of food intolerance and this is starting to have an impact on their health or mental wellbeing. In this instance records are important evidence to support any specialist referrals that may be needed.
Any records that are made must be kept securely and with full regard for confidentiality.
Staff should always encourage a person to eat or drink. However, everyone has days where they feel unwell, or just don’t feel like eating or drinking much.
Everyone has the right to refuse food or drink.
If a person has capacity to make this decision it should always be respected. Where the person lacks capacity to make decisions around eating and drinking, they should be supported by prompts and encouragement.
Medical advice should be sought if;
- There are symptoms and signs that the person’s refusal is linked to illness;
- The person is already underweight;
- They repeatedly refuse to eat or drink;
- Refusing to eat or drink is affecting medication;
- Refusing to eat or drink is impacting on an existing health condition e.g., diabetes;
- They experience significant weight loss.
Eating disorders
An eating disorder is a mental health condition where the person uses the control of food to cope with feelings and other situations.
The most common types of eating disorders are:
- Anorexia nervosa - trying to control weight by not eating enough, exercising too much, or both;
- Bulimia - eating way too much then taking drastic action not to put on weight, for example being sick;
- Binge eating disorder - eating large amounts of food until feeling uncomfortably full.
Another less common type of eating disorder is ARFID (Avoidant/restrictive food intake disorder). This is when someone avoids certain foods and/or limits how much of it they eat.
Possible reasons for ARFID are:
- Negative feelings over the smell, taste or texture of certain foods;
- A response to a past experience with food that was upsetting, for example, choking or being sick after eating something.
Eating disorders require medical attention and support. People with an eating disorder should have an allocated medical or mental health professional that you can reach out to if you are concerned that there has been a deterioration in their condition.
Last Updated: February 22, 2024
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