Nutrition - improvement actions

In her overview of the Care Quality Commission's (CQC) report on dignity and nutrition Dame Jo Williams identified three key themes that underpinned the findings:

• the role of leadership throughout an organisation in creating a culture that puts a priority on both dignity and nutrition and that supports staff to deliver care that meets the expected standard
• the importance of staff attitudes in preserving, or diminishing, dignity and "by implication, the training and management that nurture these attitudes" 
• the risks associated with under-resourcing that make poor care more likely.

(CQC 2011, p.4-5)

Examples of the types of concerns identified in the report included:

• patients not given the help they needed to eat, meaning they struggled to eat or were physically unable to eat meals
• patients being interrupted during meals and having to leave their food unfinished
• the needs of patients were not always assessed properly, which meant they didn’t always get the care they needed – for example, specialist diets
• records of food and drink were not kept accurately, so progress was not monitored
• many patients were not able to clean their hands before meals.

What is needed at organisational level

In order to mitigate risk and raise the standard of nutritional care, four things need to be present and actively pursued by any organisation (Stroud 2011):

• malnutrition needs to be actively identified through screening and assessment
• malnourished individuals and those at risk of malnutrition must have appropriate care pathways
• frontline staff in all care settings must receive appropriate training on the importance of good nutritional care
• organisations must have management structures in place to ensure best nutritional practice.

Many trusts have implemented one or more of these but have yet to achieve sustainable improvement across all four areas. A strength in one area (good screening rates consistently achieved) can mask a deficit in another (failures in delivering the care plan that is required for patients identified at risk).

The following actions have been identified by BAPEN (British Association for Parenteral and Enteral Nutrition) and the National Patient Safety Agency (NPSA) as ways in which organisations can address the deficits in nutritional care:

• there needs to be a clinical lead with responsibility for nutrition in an organisation supported by a senior manager
• patients and carers can be active in the design of nutrition services
• dedicated teams need to be formed to deliver on improvement programmes
• improvement programmes need top level backing to scale up and spread effective interventions
• educational opportunities about nutritional care need to be embedded and appraisal objectives set on aspects of nutritional care.

(BAPEN 2012).

Improvement actions across the UK

Different initiatives and programmes across the UK offer a collective source for ideas and learning about approaches and activities, and provide examples of how key elements for improvement are being implemented.

The Improving Nutritional Care Programme in Scotland, which ended in March 2012, prioritised three areas: Making meals matter - through improving meal time processes, training and introducing volunteers at meal times; self management (long term conditions) - helping people with long term conditions to self-manage their nutritional care; improving transitions - through improving communication of nutritional care in the transition between care home and hospital (Healthcare Improvement Scotland 2011). The programme has brought together the learning from activities around these priorities (Healthcare Improvement Scotland 2012).
 
The Welsh Government has developed a pathway for community settings which include those living in their own homes as well as in care homes. The pathway is presented in the form of a diagram of key questions and decisions to be faced when there is concern about a frail or vulnerable person’s eating or drinking which might arise, for example, when care is being provided for other specific reasons (Welsh Assembly Government 2011).
 
The 10 key characteristics of good nutritional care developed by the Council of Europe in 2003 have formed the basis for guidance factsheets published by the National Patient Safety Agency (NPSA) and appropriate to all healthcare environments, and for the framework for action in the Northern Ireland strategy for good nutritional care for adults in all care settings (NPSA 2009; Department of Health, Social Services and Public Safety 2011).

Specific tools and interventions

We have also collated descriptions of tools and interventions that may be used to support quality improvement. These are:

• BAPEN toolkit
• nutritional assessment
• protected mealtimes
• nutritional care communication tool
• self management.

You can also learn how others have implemented improvements to nutritional care in the section on enhancing nutritional care.

See also Discover more on nutritional care for details of RCN resources that can help you find and access further information on the above tools and interventions, and examples of implementation. 

References

These resources were last accessed on 7 December 2012. Some of them are in PDF format - see how to access PDF files.

BAPEN (2012) Toolkit for Clinical Commissioning Groups and providers in England: Malnutrition matters: meeting quality standards in nutritional care, 2nd ed. (PDF 4.6MB), Redditch: BAPEN.

CQC (2011) Dignity and nutrition inspection programme: National overview. London: CQC.

Department of Health, Social Services and Public Safety (2011) Promoting good nutrition: a strategy for good nutritional care for adults in all care settings in Northern Ireland 2011-2016. Northern Ireland government services website.

Healthcare Improvement Scotland (2011) Improving nutrition, improving care. Healthcare Improvement Scotland website.

Healthcare Improvement Scotland (2012) Improving nutrition ... improving care: Final report from the Improving Nutritional Care programme. Edinburgh: Healthcare Improvement Scotland.

NPSA (2009) Nutrition factsheets. London: NPSA.

Stroud M (2011) A lot on your plate. Health Service Journal 121(6271) 25 August. pp.26-27.

Welsh Assembly Government (2011) Nutrition in community settings. A pathway and resource pack. Cardiff: Welsh Government.