Food First Care Home Award. Nutritional Care Standards in your Locality

Transcription

1 Food First Care Home Award Nutritional Care Standards in your Locality Version 2: January 2014

2 Introduction The Food First team work with care homes in your locality to support staff to provide all service users with excellent nutritional care in line with Care Quality Commission (CQC) Outcome 5: Meeting Nutritional Needs. An award scheme was set up by the Food First team to reward best practice. All care homes meeting the expectations listed throughout this booklet will be awarded with a Food First Care Home certificate, which is valid for one year. This booklet includes all of the resources you require to work towards Food First Care Home accreditation including: MUST Management Guidelines (see page 9) Blank Monthly Nutritional Needs (see page 10) Blank Nourishing Drinks Record Chart (see page 11) Blank MUST recording form (see page 12) Requesting a Referral to the Nutrition & Dietetic Service (see page 8) Audit Process A member of the Food First team will visit your care home and review the standard of nutritional care being delivered in your home at regular intervals throughout the year. This will consist of checking that the Malnutrition Universal Screening Tool (MUST) has been used to screen all service users (see Screening from page 2), assessing the accuracy of MUST documentation and ensuring that appropriate care planning has been put in place (see MUST Management Guidelines and Care Planning from page 4). The audits should take no longer than 30 minutes to complete. Audits will be repeated until certificate status has been achieved, and then at 3-6 month intervals thereafter. The Food First team will provide you with suggested measures to take in order for your care home to become certified. The findings from the audits will be documented by the Food First team for data collection purposes and used to support the provision of an effective service. All audit information used is completely anonymous and will not be identifiable to your care home or service users. Training The Food First team offer free in house malnutrition and dehydration training sessions (including MUST) to all members of staff. We advise a minimum of 80% of your management, care and kitchen staff complete training annually to receive the most up to date knowledge and resources, and will provide as many sessions as required. The training is 2 hours in length and we ask for a minimum of 5 off-duty attendees per session. Those who complete the training will receive an attendance certificate and individual copies of all resources. To arrange training contact the Food First team on or foodfirst@sept.nhs.uk 1

3 Screening Nutritional risk screening using the Malnutrition Universal Screening Tool (MUST) is to be completed within hours of admission to the care home and then continued monthly for all service users (see Example MUST on pages 5-6). MUST screening consists of 5 steps including Step 1: BMI score, Step 2: Weight loss score, Step 3: Acute disease effect score, Step 4: Overall risk of malnutrition and Step 5: Management guidelines. Refer to Food First Resource Pack for more information. Step 1: BMI Calculate Body Mass Index (BMI) score using the most recent weight recorded in kilograms (kg) and height recorded in metres (m) for your service user. Use a BMI chart or the following equation to calculate BMI score: BMI = weight (kg) height (m) height (m) Weight: Measure weight on at least a monthly basis for all service users using suitable, calibrated weighing scales (eg. seated, hoist or wheelchair scales). Record weight on the same date each month (within 5 days), at the same time of day, and in light clothing. Make sure the floor surface is level. Record weekly/fortnightly weights on a separate weight recording form to MUST. If weight is not obtainable, use the alternative measurements guide (see Food First Resource Pack) to obtain an estimated BMI category from mid upper arm circumference (MUAC). Height: A standing measurement in metres should be taken using a stadiometer or tape measure secured to a wall to obtain an actual height on admission to the home. Height measurements do not need to be repeated. If an actual height is not obtainable, ask your service user or their carer how tall they are to obtain a reported height. If a reported height is not available or inaccurate, use the alternative measurements guide (see Food First Resource Pack) to obtain an estimated height from ulna length. Tip: Set a weighing day in your care home so you can ensure that all of your service users are weighed at the same time each month (eg. 1 st day of each month). 2

4 Record a Step 1 MUST score of 0, 1 or 2 depending on BMI category: The overweight range on the MUST BMI chart is displayed in white. A BMI score >30kg/m 2 (> more than) falls in this section and will be given a Step 1 MUST score of 0, signifying low risk of malnutrition. The healthy ideal range on the MUST BMI chart is displayed in green. A BMI score of >20kg/m 2 will also be given a Step 1 MUST score of 0, signifying low risk of malnutrition. The underweight ranges on the MUST BMI chart are displayed in yellow and red. A BMI score of between kg/m 2 shown in yellow will be given a Step 1 MUST score of 1, signifying medium risk of malnutrition. A BMI score <18.5 kg/m 2 (< less than) shown in red will be given a Step 1 MUST score of 2, signifying high risk of malnutrition. Step 2: Weight Loss It is normal for weight to fluctuate over time. Calculate weight loss as a percentage using the most recent weight and weight from 3 months ago. Use the MUST weight loss score chart to identify how much weight is acceptable for a service user to lose in a 3 month period, aiming for a weight loss of <5% (less than 5%) which indicates weight stability. A weight loss of <5%, displayed in green, will be given a Step 2 MUST score of 0 signifying low risk of malnutrition. If a service user gains weight over a 3 month period, record weight change over 3 months as a positive number (eg. +1.3kg) or gained and document the weight loss percentage as <5%, and a Step 2 MUST score of 0 signifying low risk of malnutrition. If a service user s weight remains the same over a 3 month period, record weight change over 3 months as 0kg or stable and document the weight loss percentage as <5%, and a Step 2 MUST score of 0 signifying low risk of malnutrition. If a service user has lost weight over a 3 month period, record weight change over 3 months as a negative number (eg. -2.7kg). Use the MUST weight loss score chart to identify the weight loss percentage range (<5%, 5-10% or >10%). A weight loss of 5-10% displayed in yellow is becoming clinically significant. A weight loss of 5-10% will be given a Step 2 MUST score of 1, signifying medium risk of malnutrition. A weight loss of >10% (more than 10%) displayed in red is clinically significant. A weight loss of >10% will be given a Step 2 MUST score of 2, signifying high risk of malnutrition. If no weight history is available within the last 3-6 months, complete step 1 and step 3* only and record the reason why step 2 is unavailable in the weight change over 3 months section on the recording form. This may occur when you have a new service user, or if you were previously unable to record weight (see Example MUST on page 5). 3

5 Step 3: Acute Disease Effect *Please note: Step 3 is very unlikely to occur outside of hospital and therefore is often not included on MUST forms or other community MUST documentation. Step 3 states: if patient is acutely ill and there has been or is likely to be no nutritional intake for >5 (more than 5) days 2. For Step 3 service users must meet both of the following criteria: be critically ill, have swallowing difficulties (e.g. after stroke), or head injuries or are undergoing gastrointestinal surgery and there has been, or is likely to be no nutritional intake at all for the next 5 days or more. If Step 3 is included on your MUST documentation and your service user meets both these specific criteria, record a Step 3 MUST score of 2. In most circumstances this score will not apply and if so simply record a Step 3 MUST score of 0. Step 4: Overall Risk of Malnutrition Add together scores from Step 1 + Step 2 (+ Step 3 if used) to calculate overall risk of malnutrition; the lower the score, the lower the risk of malnutrition. An overall MUST score of 0 indicates a low risk of malnutrition. An overall MUST score of 1 indicates medium risk of malnutrition. An overall MUST score of 2 or more indicates high risk of malnutrition. The highest possible MUST score is 4 unless, in rare circumstances, where Step 3 has been used then the maximum overall score is 6. Step 5: Management Guidelines & Care Planning Based upon the overall risk of malnutrition score from Step 4 follow the corresponding MUST Management Guidelines (see page 9). A service user s diet may need to change dependant on their MUST score. Nutrition care plans should be updated on a monthly basis as a minimum to report the findings from the MUST assessment. This should include person specific action plans based on the MUST Management Guidelines. Care staff are expected to communicate regularly with kitchen staff to ensure all service users are receiving the appropriate diet. The Monthly Nutritional Needs and Nourishing Drinks Record Chart (see pages 10-11) can be used to strengthen communication. Tip: Set a good example! Sit down in the dining room and eat your meals with your service users to encourage them to eat and drink well. 4

6 End of Life Care The MUST assessment is not applicable for those whose death is imminent as there is no nutritional benefit expected. Your main priority at this time would be to ensure these service users are as comfortable as possible. MUST Form Example MUST Documentation for New Service Users Name Jane Briggs DOB 16/06/1940 Height 1.60m Actual / Reported / Estimated from ulna length (please circle) Date Weight (kg) BMI Step 1 MUST (0,1,2) Weight change over 3 months (kg) %Weight loss over 3 months (<5%, 5-10%, >10%) Step 2 MUST (0,1,2) Total MUST (Step 1 + Step 2) (0,1,2,3,4) Nutritional Risk (0=Low, 1=Med, 2+=High) Action Taken Initials 26/10/ kg 19 1 weight change is unknown - new service user 1 26/11/ kg 19 1 weight change is unknown - new service 1 user 26/12/ kg 18 2 weight change is unknown - new service 2 user 26/01/ kg kg 5-10% 1 3 Try to ensure Jane settles into the home. Try nourishing drinks. Discuss Jane's likes, dislikes and preferences. Continue nourishing drinks. Increase Jane's calorie intake further by kcal per day. Speak to Food First team. Increase daily intake by calories. KP PN CF NB Sheet no: "MUST" Nutritional Screening Recording Form Mandatory screening for all residents on a 3 monthy basis. Follow management guidelines in Step 5 located on reverse of Tab 6. Weights must be recorded on appropriate the Weight Recording Form according to risk rating. Resident's name: Jane Briggs Date of Birth: 16 / 06 / 1940 Home: Bedfordshire House House/Unit: Bluebell Weight on admission: 48.6kg Admission BMI: 19kg/m² Height: 1.60 m Scoring guidance on reverse of tab 6. Eating and Drinking How measured: Reported Date Time Weight (kilos) Step Weight loss in last 3 months Step 3. Step 4 & 5. BMI Amount lost % lost Total score Risk rating 01/10/ Unknown - new service user 0 1 Med P.Potts 01/11/ Unknown - new service user 0 1 Med L.Krisp 01/12/ Unknown - new service user 0 2 High L.Smith 01/01/ Tip: Use family photographs of a service user to determine what their usual healthy weight is. 5

7 Example MUST Documentation for Existing Service Users MUST Form Name Brian McDonald DOB 09/11/1942 Height 1.78m Actual / Reported / Estimated from ulna length (please circle) Ulna length: 29.0cm Date Weight (kg) BMI Step 1 MUST (0,1,2) Weight change over 3 months (kg) %Weight loss over 3 months (<5%, 5-10%, >10%) Step 2 MUST (0,1,2) Total MUST (Step 1 + Step 2) (0,1,2,3,4) Nutritional Risk (0=Low, 1=Med, 2+=High) Action Taken Initials 06/10/ kg kg <5% /11/12 89kg kg <5% /12/ kg kg <5% /01/ kg kg <5% /02/ kg kg <5% /03/ kg kg 5-10% 1 1 Continue to offer Brian a healthy balanced diet. Offer Brian foods he enjoys to maintain a healthy BMI. Brian has been diagnosed with dementia; needs prompting to eat Prompt Brian to sit and eat meals. Tends to walk off during meals. Brian walks around and doesn t finish most meals. Leave snacks. Offer Brian finger foods and extra snacks. CF LF LG FB EC VK Sheet no: "MUST" Nutritional Screening Recording Form Mandatory screening for all residents on a 3 monthy basis. Follow management guidelines in Step 5 located on reverse of Tab 6. Weights must be recorded on appropriate the Weight Recording Form according to risk rating. Resident's name: Brian McDonald Date of Birth: 09 / 11 /1942 Home: Bedfordshire House House/Unit: Lily Weight on admission: 92.3kg Height: 1.78m How measured: 29.0cm Ulna Admission BMI: 29kg/m² Scoring guidance on reverse of tab 6. Eating and Drinking Date Time Weight (kilos) months BMI Amount lost Step 3. % lost Total score Risk rating 01/11/ <5% Low J.Peters 01/12/ Gained <5% Low P.Potts 01/01/ Gained <5% Low K.Lower 01/02/ Stable <5% Low L.Smith 01/03/ <5% Low L.Krisp 01/04/ Step Weight loss in last 3 Step 4 & 5. 6

8 Modified Texture Diets A modified texture diet should only be given if this is the preference of the service user or if this has been advised by a healthcare professional, such as a Speech & Language Therapist (SALT) or other qualified professional. The need for a modified texture diet should be reviewed regularly as the service user s requirements may change. Modified texture diets should encourage good oral intake and should remain appetising. Maintaining colour, flavour and appearance is important throughout all aspects of nutritional care. A puree diet should be smooth, lump free and moist without being too runny. Some foods are naturally this texture however other foods will need to be processed to get the right consistency. A sieve, food processor or liquidiser will help you to prepare puree foods and using high calorie fluids such as sauces, gravy, cream or fortified milk will prevent diluting meals. A puree diet maybe required if a risk of choking and/or aspiration of food into the lungs has been identified. Puree foods should: Require no chewing. Hold their shape. Not separate or become runny. Soft Diet A soft diet does not need to be pureed or sieved and many foods are a soft consistency naturally. These foods can be broken into small lumps by your tongue, not your teeth. Soft food is easily mashed with a fork and requires little chewing. A soft diet may be necessary if you are unwell, have dental problems, or become tired quickly when eating. Refer to the Food First Fortified Soft Diet resource for more information. Soft foods should: Be chewed easily. Require no blending or mincing. Not be hard, dry or crumbly. Puree Diet To maintain appearance of puree meals ensure foods are processed separately and made to look appetising in order to maximise oral intake. Piping bags, food moulds or ice cream scoops can help resemble food and improve appearance. Refer to the Food First Fortified Puree Diet resource for more information. 7

9 Requesting a Referral to the Nutrition & Dietetic Service When considering a referral to the Nutrition & Dietetic Service for a service user, take note of how their weight or diet is impacting on any of the following: Quality of life Activities of daily living Mobility General health Providing the following information will make it easier for your local GP or Dietetic Service to process and deal with your request in a timely manner. Current weight (kg) Height (m) Weight history from last 3 months Current MUST score Relevant medication Diagnosis Brief reason for referral Any steps already taken to minimise weight loss or improve dietary intake, e.g. nourishing drinks, extra snacks or a change in the dining environment Oral Nutritional Supplements (ONS) Oral nutritional supplements (ONS) are only intended for short-term use with service users at high risk of malnutrition who cannot meet their nutritional requirements and stabilise their weight using food alone. ONS do not replace meals and should be taken in addition to a fortified diet. Taking ONS between mealtimes, e.g. mid-morning and before bedtime, will help service users avoid feeling too full to eat their meals. Once opened ONS can be kept for up to 4 hours at room temperature or up to 24 hours in a refrigerator. After this time they should be disposed of. ONS are a prescribed medication and therefore the amount offered and the amount actually taken must be recorded. ONS are generally intended for short term use only. If used long term they tend to replace food and limit the options available if weight loss occurs in the future, e.g. due to a period of ill health. 8

10 0 = LOW RISK: MUST Management Guidelines Calculate a Malnutrition Universal Screening Tool (MUST) score each month and follow the guidelines below depending on what nutritional risk score has been recorded. Aim to maintain a healthy weight and follow a balanced diet. If overweight (BMI >30kg/m 2 ), encourage healthier alternatives for meals and snacks and inspire to participate in physical activity. 1 = MEDIUM RISK: Aim to increase oral intake by an extra 500kcal per day to prevent further weight loss or to achieve and maintain a healthy BMI (>20kg/m 2 ). At least 2 nourishing drinks, snacks or a fortified diet are offered as per the service user s preference. Record food and fluid intake for at least 3 days to highlight problem areas; be specific when recording quantities consumed. Follow fortified diet plan for at least one month to encourage weight gain or maintenance. 2+ = HIGH RISK: Aim to increase oral intake by an extra kcal per day to prevent further weight loss and to achieve and maintain a healthy BMI (>20kg/m 2 ). At least 2 nourishing drinks, snacks and a fortified diet are offered as per the service user s preference. Record food and fluid intake for at least 3 days to highlight problem areas; be specific when recording quantities consumed. If weight is stable or increases after one month of following a fortified diet, continue to follow the above plan until MUST score is lowered. For all service users who continue to lose weight after one month of following a fortified diet plan follow your local policy regarding onward referral. Tip: Always consider the reason why weight loss has occurred when completing a nutritional care plan. Refer to the Food First Resource Pack for more information. 9

11 Monthly Nutritional Needs It is important to communicate with all members of staff to ensure that all service users receive food and drink that meet their nutritional needs; consider texture, calorie content and other dietary requirements. This form can be used to record the nutritional needs of all service users and passed onto kitchen staff (please note: this may not apply to those who are fed via a tube feed). Service User's Name MUST (0=Low, 1=Med, 2+=High) Food Texture (normal, soft, puree) Diet Type (fortified, healthy, weight loss) Diabetic (Yes / No) Allergies (Yes / No) if yes, please state For the month of: Date completed: / / Completed by: Job title: Received by: Job title: 10

12 Nourishing Drinks Record Chart In addition to balanced meals, nourishing drinks may be useful for individuals who require extra calories to gain weight. For those at risk of malnutrition, try to offer at least 2 nourishing drinks per day (see Super Shakes resource for recipe examples). Name: D.O.B: / / Room number: Date 12/10/12 Date 12/10/12 Time Time Nourishing drink offered? (tick) Banana Example 250ml (tick) Banana 250ml Nourishing drink offered? L.Smith L.Smith 11

13 MUST Form: Complete the Malnutrition Universal Screening Tool (MUST) on a monthly basis for all service users. Use the MUST flowchart, BMI and percentage weight loss charts (see Food First Resource Pack) to complete, and use the form below to record your findings. MUST Form Name: Name Height: metres Actual (m)/ actual Reported / reported / Estimated / estimated from ulna from length ulna (please length (please circle) circle) DOB D.O.B: / / Ulna length: cm (if appropriate) Date Weight (kg) BMI Step 1 MUST (0,1,2) Weight change over 3 months* (kg) %Weight loss over 3 months (<5%, 5-10%, >10%) Step 2 MUST (0,1,2) Total MUST (Step 1 + Step 2) (0,1,2,3,4) Nutritional Risk (0=Low, 1=Med, 2+=High) Action Taken Initials *in Jan = use Oct weight, in Feb = use Nov weight, in Mar = use Dec weight, in Apr = use Jan weight, in May = use Feb weight, in June = use Mar weight, in July = use Apr weight, in Aug = use May weight, in Sept = use Jun weight, in Oct = use Jul weight, in Nov = Aug weight, in Dec = use Sept weight MUST recording form developed by Food First team - SEPT Community Health Services Bedfordshire - any queries contact foodfirst@sept.nhs.uk or

14 Food First Care Home Award Expectations Your care home is expected to continuously work towards implementing, and sustaining the nutritional care standards listed in order to achieve, and maintain the Food First Care Home award. Refer to the supporting Food First Care Home Award document and the Food First Resource Pack for further information. Food fortification is first line treatment for those at risk of malnutrition and a proactive approach to managing the nutritional status of all service users is taken by your whole team. A minimum of 80% of management, care and kitchen staff are trained annually on how and why to use the Malnutrition Universal Screening Tool (MUST); it is your responsibility to contact the Food First team if you require further training on or foodfirst@sept.nhs.uk. All service users are screened for malnutrition within hours of admission to the home and on a monthly basis using MUST. Any additional weights are to be recorded on a separate weight recording form. All care plans must be kept up to date. All documentation within each service user s care plan should be recorded in kilograms (kg) and meters (m) only. Staff are able to correctly calculate a monthly MUST score and document fully on the MUST recording form. MUST Management Guidelines are followed appropriately for all service users based on the overall MUST score. Clear nutritional plans are presented in care plans and communicated between care and kitchen staff. All service users taking oral nutritional supplements are under regular review by the Nutrition & Dietetic service. Care Home: Care Home Management signed: date: / / printed: Food First Representative signed: date: / / printed: 13

15 Food First Care Home Award Bupa Care Home Expectations Your care home is expected to continuously work towards implementing, and sustaining the nutritional care standards listed in order to achieve, and maintain the Food First Care Home award. Refer to the supporting Food First Care Home Award document and the Food First Resource Pack for further information. Food fortification is first line treatment for those at risk of malnutrition and a proactive approach to managing the nutritional status of all service users is taken by your whole team. A minimum of 80% of management, care and kitchen staff are trained annually on how and why to use the Malnutrition Universal Screening Tool (MUST); it is your responsibility to contact the Food First team if you require further training on or foodfirst@sept.nhs.uk. All service users are screened for malnutrition within 24 hours of admission to the home and on a monthly basis using MUST. Any additional weights are to be recorded on the Bupa Weight Recording Form. All care plans must be kept up to date. All documentation within each service user s care plan should be recorded in kilograms (kg) and meters (m) only. Staff are able to correctly calculate a monthly MUST score and document fully on the Bupa MUST Nutritional Screening Recording Form. MUST Management Guidelines are followed appropriately for all service users based on the overall MUST score. Clear nutritional plans are presented in care plans and communicated between care and kitchen staff. All service users taking oral nutritional supplements are under regular review by the Nutrition & Dietetic service. Care Home: Care Home Management signed: date: / / printed: Food First Representative signed: date: / / Agreed by Bupa representative: printed: Signed: Nicola Hills, Quality Manager, Bupa Care Services U 14

16 Notes Page Contact the Food First team on or if you would like further information or training. 15