Care home staff be trained in screening the elderly for malnutrition.

In January 2018 a report by the All-Party Parliamentary Group on Hunger an influential cross-party group of MPs called for care home staff to be trained in screening the elderly for malnutrition. The recommendation follows on from evidence given to the group by Managing Adult Malnutrition in the Community who estimate that 35% of people recently admitted to care homes are malnourished. This chimed with the oral evidence given to the MPs by the Hertfordshire Independent Living Service, which found that approximately 40% of people referred on to its books are malnourished.

The evidence received suggests that malnutrition is most likely to arise amongst older people following an accumulation of setbacks – bereavement, illness, a loss of community transport services, and a nearby shop closing, for example – which leave them unable easily to access food. Over and above these cumulative setbacks.

What is malnutrition?

Malnutrition arises when a person’s body does not gain the nutrients it needs to function properly. Older people are particularly at risk of becoming malnourished, due to a range of unique medical, physical, and social reasons.

The World Health Organisation defines malnutrition as: ‘deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients.

On the most recent estimate, the report claims that 1.3m older people were malnourished or at risk of malnutrition at a cost of £11.9bn to health and social care services.

The cross-party group estimates this figure will rise to £13bn by 2020 and £15.7bn by 2030.


The report calls on Secretary of State for Health and Social Care Jeremy Hunt to ensure that care staff are trained to use the Malnutrition Universal Screening Tool, or an equivalent mechanism, to identify older people who are at risk of malnutrition and ensure they receive appropriate food and support to improve their condition.

The report recommends social care providers are given the duty and appropriate funding to ensure elderly people at risk of malnutrition receive at least one hot meal a day with nutritional supplements if necessary.

Care providers should also be given responsibility to ensure older people receive the necessary help to prepare meals and undertake any other activities that can help keep malnutrition at bay.

On a practical level care services should carry out a nutritional assessment as part of the assessment process or when there are concerns about a person’s loss of weight or lack of appetite. This is advocated in the Bettal Quality Management System.


The Report goes into some detail about the outcome of savings through the introduction of screening for malnutrition. It does not take into account the cost of carrying the process out. That would involve: undertaking the screening, documenting evidence on appropriate decisions on how to pursue the diagnosis underlying any malnutrition or risk of malnutrition, intervention plans to combat the malnutrition and timelines for review and or re measurement.

Criticism of the report

Margaret Wilcox, President of ADASS, was critical of the report’s findings, arguing it was the “wrong approach” to impose a further duty on social care providers.

“The way forward is to deliver more personalised care, and that requires more resources, not more rules,” she said.

“Placing more duties on already-pressured social care staff to tackle one issue, rather than providing the funding needed to address the underlying care crisis, will hinder rather than help.

“If new duties are imposed, then as a bare minimum social care providers must be given adequate funding to ensure they are effectively carried out, otherwise sorting out one human tragedy will create another, as resources are pushed from pillar to post.”


All-Party Parliamentary Group on Hunger highlights the growing problem of malnutrition. It is a shocking indictment of our society that according to Managing Adult Malnutrition in the Community 35% and the Hertfordshire Independent Living Service who estimate that approximately 40% of people admitted to care homes suffer from malnutrition.

It is good practice to carry out an assessment of a person’s nutritional needs on being admitted to a care service, including with their consent measuring height and weight.

However, we must also take into account the costs of carrying out the process and staff training. With or without extra funding social care services have a duty to care, and must embrace the full meaning of safeguarding to ensure that people who use their services do not go undernourished.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

Is the new Government cash injection for social care just another stop gap measure?

Local Authority Councils have welcomed the government’s decision to give them an extra £150m in funding for social care over the next financial year, but warned it was a temporary measure that would not alleviate wider pressures.

The cash injection was announced by Sajid Javid, the community’s secretary, in a written ministerial statement outlining the local government finance settlement for 2018-19.

After “listening to representations”, Javid said, he was committing an extra £150m over the year for social care, to be allocated on the basis of relative needs. The money will come from an expected underspend elsewhere in his department.

It is hard not to see the money as a response to the actions that are now being taken by Councils that in order to provide social care they are having to massively control their spending on other services.

It follows the decision last week by the Conservative-run Northamptonshire county council to signal it as near to effective bankruptcy after admitting “severe financial challenges”, particularly over social care.

The council issued a section 114 notice imposing financial controls and banning spending on all services except statutory obligations to safeguard vulnerable people.

The government has also faced pressure from some of its MPs to boost funding. The Shrewsbury and Atcham MP, Daniel Kawczynski, tweeted on Monday that he was having “difficult discussions” over the local government finance settlement.

The new cash means the government has given councils £9.4bn in dedicated funding for adult social care over three years, the statement said. The wider issue of social care needed “a sustainable settlement for the future”, Javid said, adding that a long-planned green paper on the subject due this summer would set out further plans.

Responding to the settlement, Gary Porter, the Conservative peer who chairs the Local Government Association (LGA), said the £150m “is recognition of the LGA’s warning about the urgent need for the government to further try and help councils tackle some of the immediate social care pressures they face”.

The money was, however, “a temporary measure and needs to be compared against an annual social care funding gap of £2.3bn by 2020”, Lord Porter said.

He added: “Core central government funding to councils will be further reduced by half over the next two years and almost phased out completely by the end of the decade.

“We have warned that councils also face an unprecedented surge in demand for children’s services and homelessness support. This is leaving increasingly less money for councils to fund other services, like fixing potholes, cleaning streets and running leisure centers and libraries.”

This financial year, Porter said, some councils were “perilously close to the financial edge”, even with the possibility of raising some extra council tax revenue.

Paul Carter, the leader of Conservative-run Kent council, and chair of the County Councils Network, said his organisation welcomed the extra money in the funding settlement.

He said: “While this funding provides some new resource for this coming financial year we must continue to work with ministers, who understand the enormity of the financial challenges facing counties, to deliver a long-term sustainable and fair funding solution to meet the estimated £2.54bn funding gap for counties.”

Councils have repeatedly warned that they face an increasing financial crisis caused by a combination of a significant reduction since 2010 of their support from central government and an increase in their statutory obligations, notably on providing social care to an ageing population.

Longer-term plans to tackle the crisis over funding social care were delayed after Theresa May swiftly ditched an election manifesto proposal to increase the amount people would have to contribute themselves.

In November, it was announced that the green paper outlining plans for the sector would be published this summer.


The cash injection of £150 million although given a cautious welcome by councils does little to address the funding gap in Local Authority funding. It can be seen more or less as a response to prevent some councils from declaring themselves bankrupt and unable to provide services for vulnerable people. It is one of a number of stop gap measures introduced by the Government to give it time to prepare the green paper outlining plans for the social care sector due to be published this summer. In the meantime, the rationing of social care will continue.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

Validation Therapy for people with dementia

All staff who care for people with dementia, particularly advanced dementia, are very aware that it can be a particularly difficult challenge. With the progression of the condition service users withdraw into themselves more and more, they don’t let anyone come near them and they no longer remember recent events.

However, in order to meet people’s needs, staff must have some means of communicating with the person – either verbally or non-verbally. Dementia Support suggest there is another method that can help those who care for people with dementia to make a positive connection with them. This method, developed by Naomi Feil in the 1980s, is known as Validation Therapy, and it enables staff to react effectively in response to a service user’s behavior.

By using the Validation method, staff can reduce tension between themselves and those in their care, and begin to develop a closer relationship with them. One critical element of validation, for example, is that it shows that you have respect for who they are and that you accept their current feelings and expression of their emotions.

The central belief and goal of Validation Therapy is that people with dementia should always be taken seriously – no matter what they say, feel or how they act.

Objectives and goals of validation therapy

Whenever you use the Validation method, you are making a connection with the feelings of those in your care. Knowing their Life History, therefore, plays an important role in providing this advanced level of care.

The objectives of Validation Therapy will give staff an understanding of what the approach is trying to achieve:

Cognitive Goals: Improves the persons capabilities
Physical Goals: Improves their wellbeing
Emotional and Personal Goals: Resolves any past conflicts
Social Goals: prevents social isolation of the person

In order to achieve these goals staff should aim to meet the following intermediate goals:

Convey the persons esteem
Reinforce their identity and self-respect
Maintain dignity
Reduce stress
Improve wellbeing
Revive past emotions
Establish effective communication
Communicate at the emotional level.

The aim of Dementia Care & Support, is always to give managers practical, step-by-step advice so that they and their staff can learn quickly and effectively how to apply advanced care techniques in their daily work. Rather than offering unnecessary theory, here are their fast-track tips for implementing the Validation Method in your care service:

First, observe the person in your care

Within a short period of time, you’ll notice certain behavioural patterns that recur time and again. You’ll then be able to draw on these later.

Convey to them a feeling of their own esteem

Esteem is a prerequisite for gaining their confidence. You can express your esteem for them by:

• Giving them your full attention
• Showing them that “I have time for you”
• Adopting and reflecting back to them their manner of expressing themselves and their body language
• Being tactile and being close to them.

But don’t overdo it and be sure to express only genuine feelings. Even if people with dementia often give the impression of being confused and disoriented, they’re still exceptionally sensitive to feelings and moods. They will pick up on the exact tone of your voice and the intention behind it.

When using Validation Therapy, there are a set of rules of communication that you can follow that are especially appropriate to the feelings and behavior traits of people with dementia. Dementia: Care & Support have put together the following checklist for you to use in your care home.

Validation therapy also encourages carers not to contradict the person with dementia and to instead enter their world, rather than trying to bring them (usually unsuccessfully) into your own.

‘Validation is about being in the moment with the person,’ explains Julia Pitkin, one of the first validation practitioners in the UK. ‘Being corrected can make a person feel devalued.’ Whether you call it special care or validation therapy, both approaches recommend using distraction techniques rather than lying.

So, for example, if a service user keeps asking where her husband is, instead of reminding her he died five years ago, you could say, ‘it sounds like you’re really missing him, how did you meet? Can I see some wedding photos?’

Empathy and respect are what matters, say supporters of both approaches. Feeling listened to and supported, they argue, helps people with dementia regain their dignity and feel a greater sense of calmness and peace.


Managers and staff are always on the lookout for new approaches to engaging and communicating with people who suffer from dementia. Validation Therapy is not new, but the benefits of this approach are now being recognized. There is a great deal of literature available on this topic if managers are interested. Including: Dementia Care and Support for Care Home Personnel.

There is also a video by Naomi Feil available on YouTube here.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director

Social care services can contribute to easing pressure on NHS

Severe pressures in hospitals this winter has seen thousands of operations cancelled, causing social care leaders to urge NHS bosses to ‘start listening’ and let care homes do more to help.

Elderly people are among those who are most at risk of illnesses such as flu during the winter months. NHS England has said hospitals, GPs, ambulances and other NHS services have been extremely challenged this winter, and have reported higher levels of respiratory illness and flu.

In the final week of 2017, the NHS 111 helpline received more than 480,000 calls.

Martin Green, chief executive of Care England, which represents independent care home providers, said: “The NHS Acute Trusts could significantly reduce winter pressures by establishing long-term relationships with independent care providers. The care sector has been saying this for years and yet again the NHS has not listened and is in yet another crisis”.

Health secretary Jeremy Hunt apologised to patients following a decision to postpone tens of thousands of operations in January because the NHS is struggling to cope with a surge in patients this winter.

Non-urgent treatments had already been cancelled until mid-January, but this has now been extended to the end of the month.

Handover delays outside A&E departments stop ambulances from getting to new emergencies. The handover of patient by ambulances at A&E departments is supposed to take no more than 15 minutes.

Almost 5,000 people were left waiting in ambulances outside A&E departments for one hour in the last week of December, as 12 hospital trusts revealed they had no beds free. These health trusts were operating at 100 per cent, well above the recommended 85 per cent.

A&E staff can’t move patients out of their department and onto hospital wards, because hospitals can’t discharge patients from their wards into the community. Shropshire County Council is working with care homes to ensure patients don’t stay in hospital any longer than necessary. The council is working to cut the number of patients delayed in hospital, known as a Delayed Transfer of Care (DToC).

At the end of December, Shropshire’s A&E departments got hospital staff from other wards to help with the volume of emergency patients it received and had already commissioned extra beds in care homes, which are block purchased to ensure they are there when needed.

The Shropshire-based care home The Uplands offers nursing and specialist dementia care. It is run by Marches Care and has been drafted in to help this winter. Mandy Thorn, the managing director of Marches Care and vice-chair of the National Care Association (NCA), which is made up of small-and medium-sized care providers says: “If care homes were more involved in local winter planning, which is actually a year-round issue, we would probably see less of a problem with DToC.”

She believes this would be possible if they are “engaged early enough and sensible and respectful contract discussions take place – around block contracts at a price that reflects the additional support that short-term admissions require.”

She says when it comes to care homes being used to address winter pressures it’s “a patchy picture across the country”.

“Smaller independent providers are not always considered when local authorities and CCGs get together to discuss their response to winter pressures. When health and care professionals get together to respond to hospital bed pressures, not every local area takes into account the residential and nursing beds that may be available.”

According to figures from the Institute of Public Care, from April 2012 and April 2017, the number of care home beds available fell by 3,769. Add to this a major staff retention and recruitment problem in the care sector and the country’s ability to respond to a winter NHS crisis gets more challenging.

Market intelligence

Responding to criticism from the care sector that some care homes’ beds are ignored in different parts of the country, Colin Noble, the leader of Suffolk council and health and social care spokesman for the County Councils Network, (made up of 27 county councils and 10 unitary councils), told “I think it comes down to market intelligence.

“Every single day we are working with every single care home. It’s a question of how much of a silo between CCGs [Clinical Commissioning Groups] and councils exists in an area. Local authorities know all of their care homes but that’s not always the case for CCGs.

“It’s a matter of CCGs using the council’s market intelligence about care homes.”

Job satisfaction

Mandy Thorne puts it simply. “Staff in my care home report increased job satisfaction because they see people admitted to us from hospital needing significant support who then leave to go home after a couple of weeks because they are well enough to return to their own homes.

“Long-term residents have also benefited because they can interact with a wider variety of people who come into the care home, and who by seeing people get better and go home they can be more motivated to do more themselves.”


Is it not time that we saw a closer working relationship between social care and the NHS to reduce the pressures of bed blocking. In Shropshire they have set a good example of forward planning, by block booking care home beds in advance. Colin Noble highlights the importance of market intelligence to alleviate the problem and Mandy Thorne suggests that more consideration needs to be given to smaller providers. Surely, making better use of what social care can offer will be of benefit to patients and hospitals and reduce the crises experienced by the NHS each winter. Come on NHS is it not time you started listening.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

The importance of exercise to service users in care and nursing homes

The importance of keeping people who use social care services active is highlighted in a recent study published in The Journal of Physiology. Older people who are inactive or sedentary for any period of time can rapidly lose muscle mass and mobility. Researchers have been able to document for the first time how the same period of inactivity has a greater and more severe impact on the muscle power of the lower limbs of the elderly than young people, which is essential for movements like climbing the stairs.

The disuse of muscles due to a sedentary lifestyle or short periods of inactivity caused by hospitalisation can dramatically enhance the decline in muscle mass, metabolic health and functional capacity. This loss of muscle power caused by disuse can be especially detrimental in the elderly.

The research, conducted by the University of Udine in conjunction with the University of Padova, involved studying the impact of complete inactivity in a group of elderly subjects that were bedridden in a hospital environment for 2 weeks, and their results were compared with young subjects.

In the elderly subjects, there was a difference in single muscle fibre response to disuse, a more pronounced loss of muscle mass and a change in how muscle contraction is controlled by the nervous system compared to young individuals. Furthermore, the recovery phase was more difficult in the elderly group.

Carlo Reggiani, the lead investigator on the project commented on the findings: “While clinical and epidemiological data on inactivity in the elderly are abundant, experiments on disuse and inactivity are seldom performed in elderly for several reasons. The results obtained are relevant not only to understand the inactivity-dependent enhancement of the decline (in muscle mass, metabolic health and functional capacity) but also to design new rehabilitation protocols where timing and intensity of the sessions are optimized.”

It is not uncommon for service users in care homes to sit for long periods of time, and in some cases because of ill health can be confined to their beds. As the aforementioned report shows inactivity and lack of exercise can have serious consequences for service user’s health and wellbeing and ultimately their quality of life.

The value of physical activity

Further evidence of the importance of an exercise program for service users comes from a taskforce report, under the auspices of The International Association of Gerontology and Geriatrics. Its recommendations on physical exercise concludes that beside activities of daily living dependency service users in social care services face other important medical challenges. Dementia care, behavioral and psychological symptoms of dementia falls, pain, the use of potentially harmful drugs (e.g., antipsychotics), and mood (particularly depression), and quality of life are often recognized by staff and experts as crucial issues for the care of service users.

Exercise training has the potential to improve many of the above-mentioned issues. Recent studies also suggest that exercise is of benefit for the mobility and physical function of people with dementia.

One of the key challenges for staff is to maintain service users’ functional ability, which is made up of subjects’ intrinsic capacity and environmental characteristics and the ability to cope with their functional limitations for as long as possible.

Overall physical activity has been shown to protect against activities of daily living disability. Experts in care home research and clinical care, with the support of the International Association of Gerontology and Geriatrics and the World Health Organization, have already recognized the importance of exercise for the quality of care of people who live in care homes.

Scientific evidence has shown that exercise training, i.e. a subset of physical activity that is planned, structured, repetitive, and purposeful, being generally used to improve/maintain physical and functional capacities, has been found to have positive effects on the ability to perform activities of daily living.


Motivation and pleasure are the key aspects to take into account when attempting to increase overall activity levels of service users. To increase service users’ motivation, it is important to build awareness of the importance of replacing sedentary time with physically demanding activities, even if those activities are of light-intensity (e.g. walking slowly). Staff should attempt to promote service users’ physical engagement during social and daily life activities. Building awareness should target both the service users themselves as well as staff, other healthcare professionals (including the primary care physician), service users’ family, and policy makers.

Proposed recommendations to increase overall activity levels

According to the International Association of Gerontology and Geriatrics, when considering the crucial importance of enhancing the overall levels of activity in the daily life of service users, the manager should consider:

1)   To adopt strategies for breaking the sedentary time of service users. Establishing short breaks (2-5 minutes) twice or three times a day is probably feasible in a care home setting.

2)   To systematically use simple strategies to stimulate service users to move: walking to the lunch/dining hall rather than using wheelchairs for people who are able to ambulate, and organizing events that require service users going out from their rooms.

3)   To avoid chemical and physical restraints as much as possible since they result in bed and chair-rest.

4)   To optimize the utilization of the architecture and equipment in order to promote mobility.

5)   Staff, should organise group activities that are motivating and pleasant, for example promoting chair exercises and dancing where appropriate.

6)   To use innovative solutions, such as using animal interventions and new technologies, in order to increase service users’ motivation and pleasure and, then, overall activity levels. Animal interventions have been shown to be effective in increasing physical activity in institutionalized older adults.

7)   The use of robots which have been shown to decrease feelings of loneliness and improve participation in activities.


The importance of exercise to service users in care and nursing is now supported by numerous health advisory studies worldwide. Managers of care and nursing homes should ensure that assessment of service user’s physical activity and a program of appropriate physical exercise forms part of the service user’s person centred care plan.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy