- Cathy Forbes, Food First Project Lead
- Leanne Fishwick, Dietetic Team Lead
SEPT community Health Services,
Bedfordshire Nutrition and Dietetic Department, Dunstable Health Centre, Dunstable, LU6 3SJ.
- Helen Glyn-Davies – Clinical Service Manager, Nutrition and Dietetics
- Kalpana Mepani – Dietitian
- Vittoria Romano – Dietitian
- Clare Morris – Dietitian
- Lorna Faid – Dietitian
- Natasha Farleigh – Assistant Project Manager
- Lucy Gough – Assistant Dietetic Practitioner
What was the problem you were trying to address?
The project was initiated in September 2009 with the aim of improving the identification and management of malnutrition in local care homes. Data from BAPEN’s nutrition screening weeks in 2007 and 2008 had found that 30-42% of residents admitted to a care home in the last 3 months were at risk of malnutrition. However it is also widely recognised that malnutrition is under-recognised and under-treated and locally we found that although most care homes used a malnutrition screening tool, various tools were in use, errors were common and that screening did not always lead to implementation of an appropriate management plan. This is similar to results found by Bailey (2006) in an acute hospital trust. Identified barriers to following nutritional policy include poor understanding of the importance and relevance of nutritional screening and a lack of expertise in using screening tools (Rasmussen et al, 1999, Porter et al, 2009).
Therefore the project intended to create a robust system of training, audit and support to enable a culture change within social care that would make malnutrition a priority and more than a paperwork exercise. To support this, the work has linked to the harmfree care agenda since its launch in October 2011.
- Care home staff working at all levels (including management, care assistants and catering team members) aware of the consequences of malnutrition and the benefits of managing nutritional risk appropriately
- Care home staff able to complete MUST screening tool accurately and in a timely manner for all new admissions and existing residents
- Care home staff aware of how to take a Food First approach to managing malnutrition in order to promote the creation of individualised and person centred care plans
- Programme of on-going reviews of practice to ensure high standards of nutritional care achieved and maintained
- Promote a “whole home” approach to managing malnutrition
How did you create your project plan?
Initial meetings with nursing and catering representatives from a local care home to identified barriers to good nutritional care including poor communication between catering and nursing teams, lack of understanding regarding MUST screening tool despite in-house training and a need to generate interest in changing practice.
Discussions with other dietetic teams undertaking similar work raised common themes and problems.
Scoping audits at care homes revealed that not all care homes had a screening protocol in place and many did not follow the BAPEN guidance on how frequently to undertake screening. These also revealed that care homes were often unaware of errors in MUST documentation and of best practice.
Project plan has continued to be developed and refined after receiving feedback on training from key stakeholders, including council social care team, GPs, care home staff and other dietitians working locally.
Development of Food First in Bedfordshire Care Home Scheme
- Requires care homes to undertake self-reported audit of practice, attend training sessions and be audited against Food First standards
- To achieve status and receive certificate to display management must agree to Food First expectations
- Re-audits carried out 6 monthly – certificates removed if fail to meet standards
Development of Food First training
- Practical training on how to carry out MUST screening
- Introduction to local MUST management guidelines – including identifying underlying causes for poor oral intake and creating a personalised action plan
- Sharing of good practice
Development of suite of Food First supporting resources
- Evidence-based and peer reviewed information sheets on how to tackle common reasons for poor oral intake, e.g. constipation, dementia, mouth problems
- Simple and practical advice sheets on how to increase oral intake through fortified diet, nourishing drinks and snacks
- 60% of local care homes achieving Food First status
- Over a 1000 care home staff trained (total)
- Over 90% of those trained by the team have rated the quality of the training highly and 80% expect the training to have a significant impact on their future work
- Reduction in reliance on ONS, 63% patients reviewed stopped ONS as it was deemed unnecessary once an individualised care plan had been initiated. This has meant a reduction in the prescribing costs of ONS of 25-50% (depending on locality) providing the PCT’s with savings.
- Closer working relationship between nutrition and dietetics and social care
- Raised awareness of the importance of malnutrition at the highest trust levels
- Winners of trust Effective Team Award and Advancing Healthcare Leadership Award
- Short listed for Patient Safety awards
How are you going to maintain the improvement?
Cultural and organisational change being achieved will help to ensure that the work is not a “quick fix” but a sustainable approach.
The project is constantly adapting and changing to ensure that standards are maintained and further improvements are made e.g. new resource development, re-design of the way training is delivered to ensure greater engagement.
Posts currently funded to end March 2013 via savings made on ONS spend. Going forwards, funding will aim to be sought via commissioners due to improvements in nutritional care and anticipated reduction in sequelae of malnutrition and therefore improvement in patient outcomes. The project has a huge role to play in improving patient safety and helping to promote harmfree care in the community setting.
Tips for others planning similar projects
Creation of award scheme ensured consistency of approach and incentivises care homes and staff to engage in the process of training and audit. This also rewarded positive behaviour – rather than focussing on negatives in an area where bad publicity is common.
Clear focus is essential and necessary to ensure that project does not stray off course. Also required when trying to change embedded practices and opinions.
Important to get enough staff funded on the project (especially at the start) to ensure that changes can be achieved and maintained. Also, strategic and high level support essential – achieved in this case by sharing work, promoting positives whenever possible and linking to national healthcare agenda.
Care home managers from training evaluation “the programme has helped us to feel confident that we are addressing malnutrition…[working with the Food First team] gave staff a sense of self pride at doing [their] job properly”.
SEPT Chief Executive Professor Patrick Geoghegan “[the Food First team] have a passion for their work and for delivering the best patient improvement outcomes. Whilst this programme is in its infancy its impact is already demonstrating a measurable change in practice”