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Managing Malnutrition in care homes

At a time when some care homes are being criticised for having service users who have suffered from malnutrition, it is pleasing to hear of a new innovation to prevent the problem.

A care home in Shrewsbury has won an award for the innovative and fun ways it encourages residents to eat well. Briarfields in Raby Crescent, a residential home for older people run by Coverage Care, scooped the 2018 Think Food award from the NHS Shropshire Clinical Commissioning Group.

Think Food is a practical pathway to signpost care homes in the treatment of malnutrition with everyday food and drinks.

Older people can suffer from malnutrition for a variety of reasons from ill-fitting dentures, a poor swallow, having difficulty feeding, a medical condition, or their mental state.

Briarfields has introduced a number of initiatives to ensure that residents who are identified to be at risk of under eating can up their calorie intake in a healthy way.

Home manager Denise Morris said: “The Think Food pathway has become a key pillar of our care and all our staff are aware of how it fits in with our day to day operation.

“We always have fruit and cake available and residents can also visit our ‘shop’ to buy a range of snacks. We have a hydration trolley in the summer offering smoothies and fruit, which is a novelty for residents and encourages them to take on extra fluid. We also do special activities like film afternoons where they can have ice cream and popcorn.

“For those people that have specific dietary needs we create individual plans to ensure they are eating enough. For instance, we have one resident with dementia who was burning off a lot of calories, as she was very active walking around the building. She liked to stop in reception so we placed a special jar of treats for her there which helped her to take on the extra food she needed.”

Coverage Care Chief Executive David Coull praised the Briarfields team for its win.

He said: “Denise and her team are to be applauded for the proactive and innovative way they are tackling potential dietary issues among residents. Eating well is crucial if older people are to stay as fit and as healthy as possible and everyone at Briarfields is working hard to make that happen.”

The home was presented with a food hamper for residents and staff for the way it has adopted the Think Food approach.

Managing malnutrition

While malnutrition can refer to either over or undernutrition we are referring here specifically to undernutrition; a deficiency of energy, protein and other nutrients that causes adverse effects on the body (shape, size and composition), the way it functions and clinical outcomes. Most malnutrition is disease-related, although some social and mechanical (e.g. dentition) factors can also have an impact.

Malnutrition can be identified using a validated screening tool such as the ‘Malnutrition Universal Screening Tool’ (‘MUST’) – see professionals using screening tools should have appropriate skills and training.

In most cases malnutrition is a treatable condition that can be managed using first line dietary advice to optimise food.

Managers can obtain The Malnutrition Pathway that is a practical guide to support healthcare professionals in the community to identify and manage individuals at risk of malnutrition and particularly disease-related malnutrition, including the appropriate use of oral nutritional supplements (ONS)


I guess we would all subscribe to the notion that you are what you eat. But just as food is essential for health strength and well-being, eating should also be a sociable and enjoyable occasion.

Briarfields Care Home in Shrewsbury has shown a novel but practical way of engaging service users in the importance of food by following the Think Food Pathway as a means of preventing malnutrition.

In most cases malnutrition is a treatable condition that can be managed using first line dietary advice to optimise food. Managing malnutrition should be at the heart of a service users care plan where there is identified risk of malnutrition. The Malnutrition Pathway will provide care home managers and their staff with a practical guide on the management of malnutrition.

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

MPs concern about the standard of quality in care homes

A recent poll commissioned by Independent Age survey found that more than half (51%) of Tory MPs and four in five Labour MPs (83%) were concerned that the quality of care homes would deteriorate over the next year without Government action.

Janet Morrison, Chief Executive of Independent Age, the older people’s charity, said: “MPs in England are strikingly pessimistic about the quality of care homes in their constituencies.

Older people who need residential or nursing care need to be given a meaningful choice when it comes to their care, so it is worrying that so many MPs expect the quality of care homes in their area to get worse next year if nothing is done.

“This is a stark reminder of the challenge facing Jeremy Hunt in his new expanded role as Secretary of State for Health and Social Care. The quality and cost of all types of care must be addressed in the forthcoming social care Green Paper for both the long and short term. With so many MPs seemingly having lost faith in their local care homes market, it’s time to get on with finding a solution.”

Prime Minister Theresa May is facing increasing pressure from Tory MPs to address the growing health and social care crisis.

Sarah Wollaston, who heads the Commons Health Committee, said: “We need a clear understanding from PM that NHS, public health and social care are inextricably linked and urgency of the need to review current and long-term funding as a single system.”

More than four in five (82%) Conservatives and nine in 10 (92%) Labour MPs said older people should be given the choice of at least one Good or Outstanding CQC rated home.

More than one third (37%) of Tories and over two-thirds (68%) of Labour MPs do not believe the care home market is functioning well in their constituency.

Two-thirds (66%) of MPs believe that elderly people should be offered legal protection from being only offered homes that are ‘Requires Improvement or Inadequate’.

Independent Age’s research found councils are not routinely taking into account CQC ratings when arranging care home visits.

A Which? survey published last week revealed that one in four English care homes are rated Requires Improvement or Inadequate.

Cllr Izzi Seccombe, Chairman of the Local Government Association’s Community Wellbeing Board, said: “This telling survey is further evidence that the social care crisis is rising up the worry list of MPs of all parties and cannot be ignored. It follows the recent publication of the Competition and Markets Authority report on the care home market, which further underlined the significant funding shortfall facing the sector.

“MPs are rightly concerned that the quality and choice of care homes will get worse unless immediate action is taken to tackle social care underfunding.”

Independent Age is calling for the social care Green Paper to set out clear solutions for a fairer, more transparent and sustainable care system that will instill confidence in MPs across all parties, as well as older people and their families, to show that the government has fully comprehended and taken on board all the issues surrounding social care.

About the survey

ComRes interviewed 119 MPs with constituencies in England online and by paper self- completion questionnaire between 14 th  November and 11 th  December 2017. Data was weighted to be representative of the House of Commons by party and region. ComRes is a member of the British Polling Council and abides by its rules.


This survey is one of many that highlights concern about the standard of quality in care homes. The views of the MPs who took part in the survey should be taken seriously, in the hope that they will bring pressure to bear on the government about the needs of social care with the forthcoming Green Paper.

The notion at long last of an inextricably linked NHS, public health and social care service appears to be gaining momentum. This can only be good for those who require services along with those who provide them.

The survey also raised concern about the choice available for those requiring a care home placement. MPs are concerned that some local authorities are only offering placements in care homes rated ‘Requires Improvement or Inadequate’ the MPs believe people should be offered legal protection when only offered homes with this rating.

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

Is staff burnout in care homes leading to neglect?

A study, published in PLOS ONE, following a survey carried out by University of London Psychiatrists of responses from care home staff who had witnessed positive or negative behaviours in their daily work. Care home staff were asked anonymously about positive and negative behaviours they had done or had witnessed colleagues doing.

Dr Claudia Cooper (UCL Psychiatry), the study’s lead author, said: “We found low rates of verbal and physical abuse; the abusive behaviours reported were largely matters of neglect.

“These behaviours were most common in care homes that also had high rates of staff burnout, which suggests it’s a consequence of staff who are under pressure and unable to provide the level of care they would like to offer.”

From 92 care homes across England, 1,544 care home staff responded to the survey. The staff were asked whether they had, in the past three months, witnessed a range of positive and negative behaviours. Their responses were linked to data from each care home describing a measure of burnout in care home staff.

Some negative behaviours were categorised as ‘abusive’, using a standard definition, and based on the behaviour reported, rather than the intention of the care home staff. The most common abusive behaviours were:

  • making a service user wait for care (26% of staff reported that happening);
  • avoiding a service user with challenging behaviour (25%);
  • giving service users insufficient time for food (19%);
  • and taking insufficient care when moving service users (11%).

Verbal abuse was reported by 5% of respondents, and physical abuse by 1.1%. At least some abuse was identified in 91 of the 92 care homes.

Positive behaviours were reported to be much more common than abusive behaviours, however some positive but time-consuming behaviours were notably infrequent. For instance, more than one in three care home staff were rarely aware of a service user being taken outside of the home for their enjoyment, and 15% said activities were almost never planned around a service user’s interests.

“Most care homes, and their staff, strive to provide person-centred care, meaning that care is designed around a person’s needs, which requires getting to know the service user and their desires and values. But due to resources and organisational realities, care can often become more task-focused, despite intentions and aspirations to deliver person-centred care,” said co-author Dr Penny Rapaport (UCL Psychiatry).

“Carers can’t just be told that care should be person-centred – they need to be given the support and training that will enable them to deliver it,” she said.

The study is part of the UCL MARQUE cohort study, which is also looking into cost-effective interventions to improve the quality of care for people with dementia, and will be using this anonymous reporting as a measure of how well training interventions are working.

More than two thirds of care homes service user’s suffer from dementia. Agitated behaviours such as pacing, shouting or lashing out are more common in dementia, and can make provision of person-centred care very challenging for care staff to deliver, often with minimal training and limited resources.

“With the right training, care home staff may be able to deliver more effective care that doesn’t need to be more expensive or time-consuming. If they understand and know how to respond to behaviour, they may be able to do more without greater resources,” said the study’s senior author, Professor Gill Livingston (UCL Psychiatry).

Dr Doug Brown, Chief Policy and Research Officer at Alzheimer’s Society, commented: “70% of people living in care homes have dementia, and it’s clear from these findings that they’re bearing the brunt of a chronically underfunded social care system.

“It’s upsetting but unsurprising that abusive behaviours were more common in homes with higher staff burnout. We’ve heard through our helpline of people with dementia not being fed, or not getting the drugs, they need, because a carer isn’t properly trained, or a care home is too short-staffed.

“By 2021, a million people in the UK will have dementia. The government must act now, with meaningful investment and reform, or we risk the system collapsing completely and people with dementia continuing to suffer needlessly.”


The study carried out by UCL provides evidence of the pressures that care staff who provide a service for people with dementia are under. Some of the negative responses from care home staff relate to time consuming tasks, which may suggest they have insufficient time to carry them out. However, whatever the reason this is still tantamount to neglect.

The notion of person centered care comes under threat in these situations through lack of funding and availability of resources. and it is disturbing to learn that some service users never leave the care home.

If we are to avoid staff burnout, and ensure service users quality of life, managers must provide staff training in person centered care planning and supervision, that ensures staff know what is expected of them and receive the necessary support to carry out their role.

The study was conducted by researchers at UCL and the Camden and Islington NHS Foundation Trust, and funded by the Economic and Social Research Council and the National Institute for Health Research.

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

The seven key principles to reform social care

Jeremy Hunt speaking at BASW’s World Social Work Day event. Picture: Joe Newman

The social care industry has been looking for some time to gain an insight into the governments thinking on the future of social care. It may well be that this week we were given some insight.

Jeremy Hunt, Health and Social Care Secretary speaking to the British Association of Social Workers conference in Westminster, said we need a relentless and unswerving focus on providing the highest standards of care – whatever a person’s age or condition.

Too many people experience care that is not of the quality we would all want for our own Mum or Dad. “We need a relentless and unswerving focus on providing the highest standards of care – whatever a person’s age or condition. This means a commitment to tackle poor care with minimum standards enforced throughout the system, so that those using social care services are always kept safe and treated with the highest standards of dignity and compassion.”

He went on to say that fixing the broken social care system “will take time” and acknowledged there had been “stalled reform programmes” in the past as he set out plans for reform. Giving his first speech since his department was given full responsibility for social care in January, Mr Hunt said the solution will be found in embracing the “changes in technology and medicine that are profoundly reshaping our world.” Setting out the seven key principles to reform social care which will be detailed in a Green Paper to be published in the summer.

Seven key principles

One of the Green Paper’s key principles will be a sustainable funding model. Other principles set out in the Green Paper include: the quality and safety of services, the integration of the health and social care systems, control for those receiving support, valuing the workforce, providing better practical support for families and carers and ensuring greater security for all. The new system of funding social care will be capped. Asked directly if that meant there would be a cap on what any individual had to pay, he replied: “Yes.” But his remarks disappointed those who had hoped for a tax-funded system that would give social care parity with the NHS. He insisted the element of personal responsibility envisaged in the original National Assistance Act 70 years ago would stay.

The health and social care secretary said: “The way that our current charging system operates is far from fair.” This is particularly true for families faced with the randomness and unpredictability of care, and the punitive consequences that come from developing certain conditions over others.

“If you develop dementia and require long-term residential care you are likely to have to use a significant chunk of your savings and the equity in your home to pay for that care. But if you require long-term treatment for cancer you won’t find anything like the same cost.”

Hunt acknowledges that the principles will not succeed unless the systems we establish embrace the changes in technology and medicine that are profoundly reshaping our world, he said. “By reforming the system in line with these principles everyone – whatever their age – can be confident in our care and support system. Confident that they will be in control, confident that they will have quality care and confident that wider society will support them.”

The need for action now

Hunt is under pressure to do something now. This month Sir Stephen Houghton, the leader of Barnsley council in South Yorkshire, said the postcode lottery was turning a historic economic divide into a serious social one. “If you happen to live in a poorer area you’re more likely to receive lower-quality care in old age or if you suffer from a long-term disability. People should be entitled to the same quality of service no matter where they live,” he said.

Hunt acknowledged “the daily pressure” faced by local authorities and said: “We need to recognise that with 1 million more over-75s in 10 years’ time they are going to need more money, and we are going to have to find a way of helping them to source it.”

Niall Dickson, chief executive of the NHS Confederation, which represents organisations across the healthcare sector, said: “Warm words are always welcome but let us hope this speech represents new thinking in a government which like the rest of the political class has been understandably distracted by Brexit. The signs are that the Secretary of State understands what is needed – but the challenge of convincing his cabinet colleagues remains.”

Jeremy Hughes, Alzheimer’s Society chief executive, said: “Jeremy Hunt’s seven principles must not be wishful thinking for those impoverished by having dementia. The Government must now commit the funding to make good on these principles. “Without the necessary funding, vulnerable people will continue to struggle needlessly. By 2021, a million people in the UK will have dementia, and we need urgent action to create a system that can meet that challenge.”


The seven key principles that will form the framework of the Green Paper due to be published in the summer of 2018 should be given a cautious welcome. After all, it could be argued that the reneged promised cap on social care frees cost this government a large majority at the last election. However, it is just possible that the pressure of the Government to deliver on these principles this time may result in a solution to the problems of social care for fear of losing the next election. I have no doubt that Jeremy Hunt is sincere in trying to achieve change, but he cannot do anything without the support of the Prime Minister and her colleagues. This issue should be above party politics. Let us hope that the Jeremy Hunt principles lead to much needed action.

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

The importance of hand hygiene in social care settings

Hands are the most common way in which microorganisms can be transported and subsequently cause infection. In order to prevent the spread of microorganisms to those who might develop serious infections by this route, hand hygiene must be performed effectively.

There is considerable evidence that Service User contact results in contamination of health care professional’s hands by pathogens that cause health care associated infections (HCAI). Effective hand hygiene is recognized as the single most important procedure for significantly reducing/preventing infection, leading to improved morbidity/mortality rates.

A recent study in France has shown that good hand hygiene practice was particularly valuable during periods where infections were active within the community. In the UK this winter we have seen increased pressures on our health services as a result of the influenza outbreak (the so called Australian Flu).

In France during January to March, France like the UK experienced a widespread influenza outbreak. Care homes that took part in the study which had implemented additional measures reported a 30% lower mortality rate than the control group.

It seems prudent then to continue to raise awareness of social care staff in the UK to the importance of effective hand hygiene in social care settings.

In most care settings, staff receive training in infection control including hand hygiene. But over time, staff can become complacent and underestimate what poor hand hygiene can cause to vulnerable Service Users.

In 2017 the World Health Organisation ran a campaign designed to improve hand hygiene and highlighted:

The 5 moments of hand hygiene at the point of care:

1.       Before Service User contact

2.       Before Clean/Aseptic procedures

3.       After body fluid exposure/risk

4.       After touching a Service User

5.       After touching a Service User surroundings.

Correct technique for hand hygiene:

Bare Below the Elbow.

The Department of Health (2007, 2010) state that hand hygiene is not performed effectively if sleeves and cuffs are close to wrists.

Bare Below the Elbow means:

  • No long-sleeved clothing (or capacity to fold above elbow)
  • No wrist watches
  • No bracelets or wrist bands
  • No rings except one plain wedding band
  • No nail varnish, false nails, nail jewellery or nail extensions
  • Natural nails must be kept short and neat

Hand decontamination using an effective technique, will ensure that all surfaces of the hands are covered. Clinical staff must use the Ayliffe (6 steps) hand hygiene technique. Lancaster university have produced a video on how to use the technique.

Protection of Service Users

An audit should be carried out to ensure alcohol hand gel units readily available. They should be easily accessible and available in sufficient quantities if they are to be used effectively. Consideration should be given to the provision of additional dispensers if needed, or pocket-sized bottles of hand rub where required to supplement these, particularly during outbreaks. The Service should also ensure that sinks are equipped with a suitable hand sanitiser and paper towels to ensure hands can be washed thoroughly.

Regular spot checks should be undertaken to observe staff practice that ensures staff are sanitising their hands between all episodes of personal care. The spot checks should also include checks on hand washing technique and knowledge of when gloves and other personal protective equipment (PPE) should be used.

Staff Training

Although Infection prevention and control training (including hand hygiene) is a mandatory requirement for care staff. The manager should ensure that regular refresher courses are made available to staff to ensure the continuation of best practice.


There is a great deal of evidence that the failure of care staff to carry out correct handwashing techniques can have serious consequences in the spread of infection and on the lives of Service Users. The World Health Organisation, NICE and a whole raft of research including the French study show how important it is that care staff follow the correct procedures for handwashing.

Given the pressures that care staff are under it is easy for them to become complacent when carrying out correct hand washing techniques. It is the duty of managers to ensure that staff are following best practice and have the resources available to carry out the task. Increasing staff awareness of the importance of hand hygiene along with refresher training will help to prevent contamination and infection.

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