4 October, 9.00am
The findings of the Wales Audit Office Hospital Catering and Patient Nutrition study: the implications for older people.
Evidence from the Older People’s Commissioner for Wales
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United Nations Principles for Older Persons Principle 1 Older persons should have access to adequate food and water... through the provision of... family and community support and self-help.
Principle 11
Older persons should have access to health care to help them to maintain or regain the optimum level of physical, mental and emotional well-being...
Principle 14
Older persons should be able to enjoy human rights and fundamental freedoms when residing in any shelter, care or treatment facility, including full respect for their dignity, beliefs, needs and privacy...
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1. Introduction
The Older People’s Commissioner for Wales has been invited to give evidence on the implications for older people in Wales of the issues raised in the Wales Audit Office’s report ‘Hospital Catering and Patient Nutrition’.
The
information presented here is drawn from evidence gathered during
the Commissioner’s ‘Dignified Care?’ Review of
older people’s hospital experience, which was published on 14
March 2011. A copy of this report is available from www.olderpeoplewales.com.
2. Background
Evidence from the ‘Dignified Care?’ Hospital Review
The ‘Dignified Care?’ Review was conducted under s. 3 of theCommissioner for Older People (Wales) Act 2006, which allows the Commissioner to review the effect on older people of functions delivered by Welsh public bodies and providers.
Between January 2008 and December 2009 there were over 228,000 instances where an older person spent five or more days in hospital.[1]
The Review concentrated on hospital inpatient care because of strong concerns raised by older people about the impact of poor hospital experiences. The Review focused on the experiences of older people who were, or had been, hospital inpatients for at least five days within the previous two years. The Commissioner’s call for evidence led to her receiving 163 pieces of evidence from older people across Wales and 19 pieces of evidence from the relatives or carers of an older person.
Between mid September and mid November 2010 the Review Panel of Inquiry conducted a series of sixteen hospital visits throughout Wales. The visits covered at least one district general hospital or one community hospital in each Health Board and Trust area. During the site visits over 200 older patients, relatives and staff were spoken to in at least two different settings (where these existed): a Care of the Elderly ward; and an acute medical and/or surgical ward. We received evidence from all 7 Local Health Boards.
The following organisations also submitted evidence:
· A Dignified Revolution
· Age Concern Cardiff & Vale
· Age Concern Gwent Advocacy Service
· Age Cymru
· British Geriatric Society Cymru Wales
· Cardiff & Vale Community Health Council
· Carers Wales
· Healthcare Inspectorate Wales
· Neath Port Talbot Council for Voluntary Service
· Royal College of Nursing Wales
· Vale of Glamorgan Older Peoples’ Strategy Forum Health Group
· Welsh Language Board
Evidence from older people contacting us apart from the Review
An older person wrote to us regarding concerns about the nutrition of older people. He said that the needs of those with colitis or Crohn's Disease were not being met in hospitals. Another person sent us an email she had received from an older person in hospital whose dietary needs have not been taken into consideration. The email said that coeliac sufferers’ dietary needs were not being met in hospital.
3. The experiences of older people
The evidence collated by the Commissioner during the Review showed mixed perspectives amongst older people about hospital food and mealtime experiences.
These are some of the points made:
· Some older people enjoyed hospital food and felt they had all the help they needed to eat it.
· Sometimes the most basic requirements were unmet, e.g. the loss by the hospital of people’s dentures or glasses, making it even more difficult for some older people to locate or eat their food.
· It is the level of assistance with eating and drinking which most impacts the older person.
· Nutritional quality, whilst very important, is irrelevant if food never reaches the patient’s mouth because they have not been helped to eat it. (Providing appropriate and timely assistance with eating and drinking was an issue of concern raised by a significant number of people.)
· Uneaten food may be wrongly documented as a refusal to eat.
· Staff often lack time to provide assistance with eating.
· Protected mealtimes have brought some positive changes yet some relatives and carers now feel excluded from mealtimes or feel their offers of help are rejected.
· Older people have mixed feelings about the ‘red tray’ system. Some feel it is used inconsistently; others feel it is too obvious a system that is embarrassing – they would prefer something more discreet.
· One hospital ward re-designated a Health Care Assistant post to a Housekeeper role. This seemed to work well in helping mealtimes run smoothly and in a more relaxed manner (see text from the Report below).
· Giving appropriate assistance with eating and drinking is vital to patient recovery, and failure to do so is unacceptable. Part of the way forward must lie in strengthened ward leadership, and through listening to the experiences of older people, and their relatives and carers.
Text from ‘Dignified Care?’ report, pages 52-54:
“Both the quality of food and the assistance offered with eating and drinking featured throughout our evidence gathering. Other organisations, most recently the Wales Audit Office, are focusing their attention on all aspects of hospital catering, including food quality and preparation; therefore we do not cover these issues in detail here. In the context of our findings, it is the level of assistance with eating and drinking which most impacts on older people’s dignity and respect.
The nutritional quality of food is irrelevant if people cannot physically eat it, and providing appropriate and timely assistance with eating and drinking was an issue of concern raised by a significant number of people.
We heard evidence of food remaining uneaten on trays with no assistance on offer, or of patients struggling to feed themselves being helped by other people’s visitors. One organisation told us that uneaten food is sometimes documented as a refusal to eat, despite the need for assistance not having been met. A carer who expressed concern about the level of help on the ward was told that staff lacked time to provide assistance with eating for all those that need it.
“There was no account taken that he was unable to see, had severe trembling of hands, and as a result, was unable to pick up the container of water to drink if he had wanted to...I then spoke to a Staff nurse about this and other issues, and she informed me that she was too busy to do such tasks as she had 28 other patients to look after” (relative)
“one patient had advanced Parkinson's disease and it was impossible for her to feed herself and it was distressing to watch her attempts to do so; visitors to other patients had to help her.” (relative)
We were told of an instance in which an older person had to wait at least four days for a decision to provide liquidised food to be actioned. Another family told us that insufficient support with eating had led to their relative being put on a feed peg - as a consequence the individual has been unable to feed himself orally following discharge. This is not acceptable.
The Welsh Assembly Government now requires hospitals to implement protected mealtimes and we saw that this has brought some positive results. It was generally viewed by staff as a good development, allowing patients to eat without interruption and giving them the best chance of getting the nutrition they need. Staff felt protected mealtimes provided a quiet and relaxed atmosphere in which patients are afforded time to enjoy meals, emphasising the importance of mealtimes as part of the people’s care.
“Protected meal time introduction has been welcomed and should improve how we meet the nutritional needs of patients. We help patients to make a good choice from the menus” (staff)
However, it was worrying that some relatives and carers told us that they had been prevented from providing assistance with eating to an older person because of the protected mealtimes policy. They expressed concern that staff simply did not have the time to ensure the right sort of support was being given, and yet their willingness to help was being rejected.
“My 82 year old mother went in every day for 4 weeks to feed him his lunch as he couldn't do it himself. However, when he was moved into a ward, she was stopped from doing so” (relative)
“It is stated at the entrance to the ward that visiting is not allowed during mealtimes to allow staff to assist patients to eat...(the older person) told me that she was never assisted even when she requested this, despite her weakness and the insistence of staff that she should eat” ”(relative)
“no staff attended the four-bed ward during meal times to offer assistance... when we pressed for assistance to be given at meal times [when family were not allowed to visit which was the wider ward policy], Mum told us “she rushed and just stuffed the food in my mouth without letting me finish a mouthful”. (relative)
We heard a variety of opinions of the use of the Red Tray system, which is designed to identify those patients needing assistance at mealtimes by placing their food on a red tray. One organisation told us that the use of red trays was not consistent. Some staff found the system helpful, others felt it could be stigmatising and used other methods, such as discreet signs near beds, to identify those who need assistance.
To try and address people’s needs at mealtimes, one ward we visited had re-designated a Health Care Assistant post to a Housekeeper role, focusing predominately on meeting the needs of patients at mealtimes. The Housekeeper works during lunch time and evening meals, and takes the practical steps which help mealtimes run smoothly - checking menus, clearing bed tables and making patients comfortable and ready to eat before the meals arrive on the ward. This role gives increased opportunity to interact with patients and their visitors and has been widely welcomed. It has significantly reduced the time taken to serve meals, helping to create an improved environment during mealtimes, and ensures the regular monitoring of patients nutritional intake. Additional funding is now being sought to roll out the system to other wards.
Giving appropriate assistance with eating and drinking is vital to patient recovery, and failure to do so is unacceptable. Part of the way forward must lie in strengthened ward leadership, and through listening to the experiences of older people, and their relatives and carers.”
4. Ensuring patients’ nutritional needs are met
WAO recommendations 1a, b, c, d, e
Some evidence the Commissioner received detailed failures to complete fluid and food charts, or sporadic, inaccurate completion of such records.
This was a source of great concern to relatives and carers who were often unable to be present at mealtimes and therefore had little by way of reassurance that their loved one’s needs were being met. Several accounts given to us told of significant weight loss and dehydration during hospital stays.
Older people and relatives gave examples of failures to cater for dietary conditions (e.g. celiac disease; lactose intolerance; diabetes) and dietary choices (an older vegetarian with dementia being fed meat dishes).
Also, we have several accounts of inappropriate food being given to people with swallowing difficulties, and guidelines not being followed. This included one example of a relative finding an older person choking, and having to perform life saving action in the absence of nursing staff; and another in which a patient developed aspiration pneumonia after feeding guidelines were not followed resulting in the patient choking and vomiting.
The Commissioner’s recommendations in ‘Dignified Care?’ included a call for Health Boards and the Trust, and their Board members, to demonstrate how they take account of and act upon patient experience (Recommendation 10). The results of the monitoring exercises outlined in Recommendation 1c should also be shared at Board level enabling executive leadership to be shown when addressing any required actions.
All nursing staff involved in caring for older people should also be aware of the compliance audits results in order to help them identify areas for continuing improvement.
Skills development and training for staff who care for older people was identified in ‘Dignified Care?’ as a crucial issue. As a result, through Recommendation 12 the Commissioner called on the Welsh Government, Health Boards and the Trust to ensure that appropriate levels of knowledge and skills are acquired through continuing education and training.
5. Improving patients’ mealtimes experience
WAO Report , Recommendations 3 b and c
The Commissioner notes in support of these recommendations that the appropriate use of volunteers could provide valuable support and resource.
The Commissioner’s ‘Dignified Care?’ Review Panel of Inquiry saw encouraging and inspiring examples of volunteers contributing positively to older people’s hospital experience:
“Some hospitals use volunteers to assist patients by providing company, encouragement and running errands, as well as supporting staff.
Examples of good practice we were told of included the well regarded volunteer schemes.
The older people we spoke to were very complimentary about their interactions with volunteers and how the volunteers were able to spend time with them. These schemes have worked well, successfully involving a range of volunteers who have been well accepted as part of the multi-disciplinary team.
Every Health Board and the Trust should be making much more imaginative use of volunteers. The ward manager should see and treat them as part of the team. Volunteers can provide good social support, but the boundary with what constitutes the rehabilitation and treatment plan should remain clear. There should be clarity of role, recruitment and training, to optimise the benefits and reduce any inappropriate use of volunteers.
There is great potential for imaginative use of volunteers to support and engage with older patients. Such initiatives should be further developed and encouraged.” (p.58, ‘Dignified Care?’)
Volunteers could be used to help busy staff with mealtimes – volunteers can include family members, carers or others.
6. Effective service planning and monitoring
WAO recommendation 11
The experience of older patients, their families and carers should be captured more effectively and used to drive improvements in care.
“The need to be more responsive to the individual requirements of older people in hospital is a cross-cutting theme in our report. We have found significant cause for concern in, for example, the areas of continence care, assistance with eating and drinking, communication and arrangements for discharge. We have also found that there is considerable variation in the quality of care across Wales and even within the same hospital. We did find examples of very good practice.
However, in other areas, standards of care must be raised to meet that of the very best wards and hospitals.
Knowledge of the experience of older people in hospital and whether they are treated with dignity and respect is essential in order to help drive change, to identify good and poor practice, to determine progress, and to assist learning and improvement across the NHS. We found that the current arrangements for capturing the experiences of patients were not sufficient to allow their voices to be heard; they do not collect adequate numbers for robust analysis, or allow for comparison between organisations. This has implications for considering experiences of patients in general, but as noted elsewhere, the majority of patients are older people.
There should not be a reliance on complaints as the main means of understanding the patient experience. Many people are either reluctant to complain, cannot complain because of their illness, or do not have relatives or carers to advocate on their behalf. We recognise that there are efforts being made in some places to collect patient experience data, but more needs to be done.” (p.20, ‘Dignified Care?’)21
The Welsh Assembly Government should lead on, develop and implement a clear, consistent mechanism through which Health Boards and the Trust will capture and act on the experiences of older patients, including those unable to speak for themselves. This mechanism would allow qualitative data about older people’s experience to be captured, understood and used to drive organisational learning and positive change. Results should be made publicly available in a form allowing ease of understanding and comparisons over time, on a Wales wide and on a Health Board and Trust basis. Health Boards and the Trust must demonstrate, for example, through Board meeting records, how they have taken account of and acted on, their patient experience results. Board members should also play a direct role in assessing the patient experience through means that include regular ward visits to both speak to patients and their families and observe care delivery.
7. Conclusion
Older people make up the vast majority of patients who spend prolonged periods of time in hospital, therefore the matter of mealtimes and patient nutrition are of great concern to the Commissioner. There are many changes that need to be made – some of them mere common sense and compassion – to better meet the needs of older people in hospital in Wales. The Commissioner calls for the following action to be taken:
Seek the views and experiences of patients, families and carers because this is vital
Through her ‘Dignified Care?’ Review, the Commissioner has already called for the Welsh Government to capture more effectively the experiences of older patients, their families and carers whilst in hospital.
The Welsh Government should drive forward improvements in care – see Recommendation 10 of the ‘Dignified Care?’ Report (p. 20). The Wales Audit Office report states that a more comprehensive and co-ordinated approach needs to be developed to seek the views of patients and their families and to use them to help plan and develop catering services (WAO Recommendation 4, p.51). These two reports make the same point – that planning is taking place without the input of those who are most affected by the results of the planning.
Further develop the use of volunteers in hospitals
The Commissioner has called on Health Boards and Velindre NHS Trust to ensure that their hospitals further develop imaginative volunteer programmes (Recommendation 6 of the ‘Dignified Care?’ Report, p.17). The Wales Audit Office report states that not all patients get the help they need at mealtimes (WAO Report, p.34). One solution would be the use of volunteers, although there also needs to be a commitment from staff to the rights of older people to be treated with dignity and respect whilst in hospital. Hospitals across Wales should use volunteers imaginatively and appropriately.