Eating and drinking well in care: good practice guidance for older people

Food and fluid on offer should be:

• varied and nutritious and reflect food preferences and any specific dietary needs for the individual
• well prepared, cooked and attractively presented
• evenly spaced throughout the person's wakened day – aim for a minimum of four hours between each main meal but individual preference needs to be taken into account
• based on individual ‘nutritional’ needs which offer access/choice to a range of food & fluids that meet those needs.

Dining with dignity, creating the dining experience:

• tables should be set to a standard of what you would expect when you eat out in a nice restaurant
• noise and distraction should be kept to a minimum
• consideration should be given to protecting the person’s mealtimes with a named person taking control of the dining room to coordinate activity and to make sure all staff ensure residents get enough to eat and drink.  Some services call them a ‘mealtime coordinator’.  Protecting mealtimes requires cooperation from visiting professional too, as being aware that disrupting a person’s meal can have a significant impact on whether they get a full meal or not and longer term health and well being issues
• staff should be aware of how to assist someone to eat and drink and remember eating and drinking is a social experience that gives staff and people using services the chance to really connect.

It is recognised that good nutritional care, adequate hydration and enjoyable mealtimes can dramatically improve the general health and well-being of older people, as well as increasing their resistance to disease and their recovery from any illness, trauma or surgery.

It is important that care service staff are able to demonstrate and evidence good food and fluid knowledge. This should be supported by up to date policies and procedures that take account of the Health and Social Care Standards (2017), relevant best practice and Scottish legislation.

Health and Social Care Standards

The Scottish Government published Health and Social Care Standards: My Support, My Life in June 2017. The new Standards set out what we should expect when using health, social care or social work services in Scotland. They seek to provide better outcomes for everyone; to ensure that individuals are treated with respect and dignity, and that the basic human rights we are all entitled to are upheld.

There are specific standards for eating and drinking (see below) and these should be taken into account when looking at people’s eating and drinking care needs:

Eating and drinking

1.33 I can choose suitably presented and healthy meals and snacks, including fresh fruit and vegetables, and participate in menu planning.

1.34 If I need help with eating and drinking, this is carried out in a dignified way and personal preferences are respected. 

1.35 I can enjoy unhurried snack and meal times in as relaxed an atmosphere as possible.

1.36 If I wish, I can share snacks and meals alongside other people using and working in the service if appropriate.

1.37 My meals and snacks meet my cultural and dietary needs, beliefs and preferences. 

1.38 If appropriate, I can choose to make my own meals, snacks and drinks, with support if I need it, and can choose to grow, cook and eat my own food where possible.

1.39 I can drink fresh water at all times. 

Acknowledgments

We would like to acknowledge the invaluable input and guidance given from a range of stakeholders in pulling all this information together namely:

• Residents who took part in the ‘strictly come dining’ experience that helped create some of the menus included in the menu and recipe section
• Meallmore Ltd
• Trust Housing
• The Mungo Foundation
• Scottish Care Integration Leads
• Vegetarian for Life
• Food Standards Scotland
• Food for Life Scotland
• NHS Highland and the wider NHS Dietetic Leads from across Scotland
• NHS Greater Glasgow and Clyde

Working group

This site is just the start and we would love to hear your stories on how you help people who use your services to enjoy the experience of eating and drinking and what impact it has on their quality of life.  If we all teach, we all learn.

• find out what I like to eat and drink but remember my tastes might change over time, so ask me regularly
• find out what portion size I prefer and when I like to eat my main meal, or if I prefer frequent smaller meals throughout my wakened day
• find out how my favourite food and drink choices can be adapted to meet my current needs. For example, made sweeter or more savoury; the texture adjusted so I can eat safely; what would make it look more appetising to me if the texture has to be modified (for example, moulds, scoops, cutters)
• involve my family and named carers to ensure you fully understand my eating and drinking needs and habits
• use the information you gather to get me the support I need.

Film clips 

To help you in implementing the above key messages in your own service, we have produced a number of films to support you in putting the above learning into action. 

David Blackwood, Regional Catering Manager for Meallmore Ltd. 

In this first clip David talks about the importance of being creative when involving residents in creating menus of foods and fluids they want to eat and drink. 

In this next clip he discusses what services need to know when therapeutic diets are required. 

Liz Campbell, Care Home Manager

Liz talks about the importance of creating the right dining experience that promotes the social aspects of eating and drinking. 

Evelyn Newman, NHS Highland Dietitian 

In her first clip Evelyn talks about using food and fluid to start conversations and reminisce. 

In the second clip she talks about a whole team approach to involving people experiencing care in planning menus. 

Kate Boyce, Director of Lifestrong Learning Ltd.

In her first clip Kate talks about food and fluid choices for all. 

In the next clip she discusses the importance of involving people in all aspects of eating and drinking as things change. 

Kim Stringer, Director of Vegetarian for Life

In this first clip Kim talks about the importance of honouring food and fluid beliefs and values. 

In the second clip she talks about getting creative when providing vegetarian foods and fluids and the importance of presentation. 

Related resources

• Food Fortification for Vegans
• Veganism: More than just a diet
• Food Fortification 
• Vegan rescue pack
• Menu planning cycle assessment tool - Sample
• MenuCal
• Malnutrition Universal Screening Tool (MUST)
• Paper arm bands
• Textured food and fluid template to record information
• Nutritional Care Communication Tool for people from care homes being admitted to and discharged from hospital
• Food and fluid: Things to consider before accepting a person who requires a therapeutic and/or faith/cultural diet
• Water for healthy ageing: Hydration best practice toolkit for care homes
• International Dysphagia Diet Standardisation Initiative - A group of volunteers from diverse professions including nutrition & dietetics, medicine, speech pathology, occupational therapy, nursing, patient safety, engineering, food science & technology from around the world who came together to develop international standardised terminology and definitions for texture modified foods and thickened liquids for persons with dysphagia

• liaise with catering/kitchen staff to make sure my special dietary requirements are catered for
• if I can’t tell you want I want to eat and drink, be creative. For example, ‘show and tell’ what is on the menus and hold taster sessions, recording my response (facial expressions, gestures) to foods and fluids
• make sure my plan of care reflects my likes and dislikes and what texture my food and fluid should be, using the national descriptors
• involve the right people at the right time to get me the help I need, for example a speech and language therapist (SALT), a dietitian or occupational therapist
• the food that I eat and drink should help me maintain my health and wellbeing. For example, by reducing the risk of constipation, dehydration and skin breakdown.

Film clips 

To help you in implementing the above key messages in your own service, we have produced a number of films to support you in putting the above learning into action. 

David Blackwood, Regional Catering Manager for Meallmore Ltd. 

In this first clip David discusses the wider health benefits of eating and drinking well.

In this next clip he talks about the importance of communication to meet the food and fluid needs of people experiencing care. 

Sarah Duley, Food for Life Development Manager

Sarah focusses on soil to plate and how good food can transform lives for those experiencing care. 

Evelyn Newman, NHS Highland Dietitian 

In this first clip Evelyn focusses on the importance of a whole team approach to involving people experiencing care in planning menus. 

In this second clip she discusses the role of a dietitian and how a dietitian can help. 

Kate Boyce, Director of Lifestrong Learning Ltd. 

In her first clip Kate talks about the impact of food and fluid on bowel and bladder health.

In her second clip she discusses who can help people experiencing care to eat and drink well. 

Kim Stringer, Director of Vegetarian for Life

In this clip Kim talks about getting creative when providing vegetarian foods and fluids and the importance of presentation. 

Related resources

• Communication and Mealtimes Toolkit 
• 10 second pause menu choice sheet
• 10 second pause tool for meal times 
• Nil by Mouth Care Homes SOP example
• Nutritional Care Communication Tool for people from care homes being admitted to and discharged from hospital
• Food and fluid: Things to consider before accepting a person who requires a therapeutic and/or faith/cultural diet 

• what adaptations do I need to help me to eat and drink independent? For example, adapted cutlery, crockery, seating support
• give me time to eat but make sure my hot food stays at the right temperature to keep it appetising. For example, use heated plates or consider smaller portions with the option of further helpings
• give me time to chew and swallow and give me your full attention when you are helping me
• make sure salt and pepper, other condiments and small jugs of water or other fluids are within reach, so I help myself or you can help me
• if I am eating and drinking on the move, make sure you know how much I am eating and drinking to help you make decisions about me. For example, what help do I need if I am losing weight or not eating enough.

Film clips 

To help you in implementing the above key messages in your own service, we have produced a number of films to support you in putting the above learning into action. 

David Blackwood, Regional Catering Manager for Meallmore Ltd. 

David talks about the impact that the five food and fluid key messages could have if put into practice. 

Evelyn Newman, NHS Highland Dietitian

In this clip Evelyn talks about what staff need to think about when assisting people experiencing care to eat and drink. 

Related resources

• Food and fluid: Things to consider before accepting a person who requires a therapeutic and/or faith/cultural diet
• Aids to assist eating and drinking

• find out what makes the best dining experience for me and what I don't like, including who I enjoy sitting beside and who I would rather not sit beside
• be aware of the noise levels and any distractions, adjust them as appropriate to help me focus on eating and drinking
• make sure that I have been offered and/or used the toilet before I sit down to eat and that I have washed my hands
• set the table for me the way I would like it set, no matter where I decide to take my meal
• if you are helping me to eat and drink, sit beside me and take your time. If I am unable to talk to you, observe my facial expressions and gestures to know when I am ready for more or have had enough.

Film clips 

To help you in implementing the above key messages in your own service, we have produced a number of films to support you in putting the above learning into action. 

David Blackwood, Regional Catering Manager for Meallmore Ltd. 

In this clip David discusses the importance of creating a positive mealtime experience. 

Evelyn Newman, NHS Highland Dietitian

In this first clip Evelyn talks about the social aspects of eating and drinking. 

In her second clip she discusses what staff need to think about when assisting people experiencing care to eat and drink. 

Related resources

• Principles of protected meal times
• Aids to assist eating and drinking
• Making Meals Matter poster for display
• Is your care home dementia friendly? EHE Environmental Assessment Tool
• Is your housing dementia friendly? EHE Environmental Assessment Tool
• Mealtime Coordinator Care Homes SOP

• know what my MUST score is and what it is telling you – take appropriate actions. For example, fortifying my food to add calories
• eating something is better than nothing and I may not prefer the ideal healthy diet. Respect my preferences but continue to offer me healthy choices
• if I prefer not to sit for meals give me finger foods that I can carry around with me while I eat, or give me a named container I can snack from
• ensure I can help myself throughout the day. For example, have ‘fluid stations’
• make sure food and fluid is available all day so I can eat and drink when I want to. For example access to fluid stations, snack boxes
• when preparing me for my meals, if required make sure I have the correct glasses on and hearing aids in, as this will help me enjoy and take part in my dining experience.

Film clips 

To help you in implementing the above key messages in your own service, we have produced a number of films to support you in putting the above learning into action. 

David Blackwood, Regional Catering Manager for Meallmore Ltd. 

In his first clip David talks about fortifying food and fluid. 

In the second clip he discusses a food first approach, suggesting that when supplements are needed they should be chilled and well presented.

Liz Campbell, Care Home Manager

In her first clip Liz discusses the role of the care home manager in quality assuring the mealtime experience. 

In the second clip she talks about the importance of a food first approach to improve food and fluid intake. 

Evelyn Newman, NHS Highland Dietitian

In this clip Evelyn talks about the social aspects of eating and drinking. 

Related resources

• Principles of safe and effective nutritional care
• Nutrition for Older Vegetarians and Vegans
• Vegan rescue pack
• Food fortification for vegans
• MenuCal
• Food in hospitals: National Catering and Nutrition Specification for Food and Fluid Provision in Hospitals in Scotland
• Caring for Smiles - Guide for Care Homes
• Vitamin D guidance
• Water for healthy ageing: Hydration best practice toolkit for care homes
• International Dysphagia Diet Standardisation Initiative - A group of volunteers from diverse professions including nutrition & dietetics, medicine, speech pathology, occupational therapy, nursing, patient safety, engineering, food science & technology from around the world who came together to develop international standardised terminology and definitions for texture modified foods and thickened liquids for persons with dysphagia

This section provides examples of good ideas and opportunities for learning within food and fluid. 

Programmes and initiatives

Community food sharing project Meal Makers

Meal Makers is a new service launched by the award winning charity Food Train who have been supporting older people in Scotland for over 21 years.

The community food sharing project started as a pilot project in Dundee in August 2014 and proved to be an instant hit across the city. It has since been launched in Glasgow, Perth and Kinross, Renfrewshire, Edinburgh, Stirling, North Ayrshire and the Scottish Borders. The idea behind Meal Makers is really simple – they connect people who love cooking and want to be active in their community (‘Cooks’), with older (55+) neighbours (‘Diners’), who would appreciate home cooked food delivered to them every now and again.

So how does this work in practice? Well, when a Meal Makers cook is preparing their evening meal for themselves and their family, they will prepare one extra portion of their home cooking and take it round to an older neighbour at a time which suits both parties. Not only does the project provide a way for older adults to enjoy freshly prepared nutritious home cooking (particularly older adults who might find it difficult to enjoy home cooking otherwise), but it also helps bring communities together and combats the social isolation experienced by many members of the older population. How often meals are shared, and when they are shared is left entirely up to the Cook and Diner to decide between themselves. Meals are most commonly shared on a weekly basis, but they can occur fortnightly, monthly or just now and again.

Since launching the project over 330 Cook and Diner matches have been made, and over 6,700 meals have been shared with older people through the project. Diners really enjoy participating in the project as they get to meet friendly neighbours, and get to enjoy their lovely home cooking. Cooks, on the other hand, really enjoy the flexibility the project allows – they like the way Meal Makers turns an everyday activity like cooking into a volunteering opportunity that they can do in their local community, and at a time in which they can fit around their busy schedule.

Food for Life Better Care

Food for Life Better Care is a programme of Soil Association Scotland. The Soil Association is testing a framework that supports the provision of nutritious, sustainable food and activities that benefit residents, staff and the wider community.

The programme is exploring how good food can improve the health and wellbeing of older people in care homes. The programme is focussing on how

• good food can address residents complex nutritional needs and reduce the risk of malnutrition and dehydration
• food growing and therapeutic activities provide a more stimulating environment that supports physical and mental health and wellbeing. 

The following short film 'Good Food in Care Homes' showcases and supports food growing and use of therapeutic activities involving volunteer gardens. It has been produced by the Scottish Soil Association and Food for Life.

In this next video, Sarah Duley, Food for Life Development Manager talks about the food for life served here initiative. 

News stories

Jelly hydration treats for people with dementia 

An award-winning hydrating treat for people with dementia is the subject of a video feature on the BBC News website. Jelly Drops, invented by Lewis Horny, are designed to help address dehydration issues among people with dementia by offering an engaging and easy to eat treat.

Sunday lunch is a recipe for fun

Read about how staff and management in a care home wanted to recreate that homely feel for residents by introducing traditional Sunday lunches that everyone could be a part of.

Film clips

Sarah Duley, Food for Life Development Manager

In this clip Sarah talks about the importance of good food principles in helping to improve care.

Kate Boyce, Director of Lifestrong Learning Ltd.

In this clip Kate talks about what care staff can do to help people experiencing care to eat and drink well.

NHS Fife Dietetics and Speech and Language Therapy for adults with a learning disability

In this clip NHS Fife's Dietetics and Speech and Language Therapy for adults with a learning disability team provide helpful advice for preparing nutritional meals for people with eating and drinking difficulties. This content was informed by the Care Inspectorate's Food and Fluid Pocket Guide. 

This clip by NHS Fife's Dietetics and Speech and Language Therapy for adults with a learning disability team is on awareness of high risk foods when supporting someone with an eating and drinking difficulty.

Caring for vegetarians and vegans living with dementia

In this section you will find recipes and resources for different tastes, diets, and traditions. 

Menu planning templates

The templates below can be used within your service all year round. 

Menu planning - Spring

Menu planning - Summer

Menu Planning - Autumn

Menu Planning - Winter

Recipe websites

Asian cooking 

Asia Recipe provides over 600 pages of content including recipes from the countries of Asia, along with country information. 

Community Food and Health (Scotland) 

Community Food and Health (Scotland) (CFHS) aims to ensure that everyone in Scotland has the opportunity, ability and confidence to access a healthy and acceptable diet for themselves, their families and communities. Their website has lots of information around eating well in the community, including recipes.

Hundreds of community food initiatives in Scotland are using food as a vehicle to tackle inequalities in health and diet in their local communities. One of the ways of improving take up of a healthy diet is to build confidence and skills in cooking and preparing food. CFHS has produced a recipe book, which community food initiatives have contributed to with their own recipes. Some of the work they have been undertaking through healthy eating and awareness sessions are detailed in 'The poaching, frying, mashing and roasting recipe book'. Their recipes have been tried and tested by babies in weaning programmes, schoolchildren, young people in Youth Clubs, parents, families and older people.

Textured diets

In April 2018 the roll out of the 2018 International Dysphagia Diet Standardisation Initiative (IDDSI) descriptors began. Although some of our examples under this section may make reference to the previous descriptors of 2012, we have decided to keep the video clips in as they demonstrate that most food can be texturised to look appetising and similar to the food that would be eaten by those people experiencing care who do not require their food to be textured. This approach will help older people to eat and drink well, even though they require their food to be modified.

More information about the 2018 IDDSI descriptors can be found here.

You can access the full playlist of demonstrations for textured diets here.

Traditional Scottish Dishes

Traditional Scottish dishes like haggis and porridge are well known and have a long history. But modern Scottish food is all about fresh flavours, quality ingredients and mixing the old with the new. This site has chosen a selection of  Scottish recipes to try, many of them created by famous Scottish chefs.

Vegetarian and vegan cooking

Vegetarian for Life (VfL) is one of the leading authorities on diet and healthy living advice for older vegans and vegetarians. Their website includes a number of recipes organised into categories such as budget recipes, main meals, festive recipes and breakfast ideas. It also provides a list of other suggested vegetarian recipe websites. 

The Vegan Society works towards making veganism an easily adopted and widely recognised approach to reducing animal and human suffering. The website has a lifestyle section and within it there are a range of free vegan recipes.

101 cooks provides ideas around vegetarian cooking to help integrate the power of lots of vegetables and whole foods into everyday meals. The recipes you’ll find here are vegetarian, often vegan, written with the home cook in mind. 

Vegetarian Times provides access to free vegetarian recipes.

Food fortification for vegans

As appetite may lesson with age, potentially leading to weight loss, it can be helpful to enrich the calorie content of food. This guide, produced by Vegetarian for Life in 2017, is intended to suggest ways that food items commonly used to enrich food may easily be made vegan.

Film clips 

The following film clips may be useful to you when considering menu options. 

Community Voices SpeakOut Video 

The film clip below explores the specific needs of individuals to inform adult social care services.

Vegetarian for Life

The next film demonstrates how a few simple changes can transform the standard of life for Len Till, a vegan who deserves more than limp lettuce. The film was commissioned by Vegetarian for Life, a charity dedicated to improving the quality of life for older vegetarians and vegans.

Cookery Demonstrations for vegetarian recipes

You may find the following cookery demonstrations for vegetarian recipes useful. 

Tofu Choc Puds 

Versatile Stew

Fake Steaks

Smokey Mediterranean Shepherd's Pie

Other resources

The Art of Care Home Baking

A book featuring all 20 winning entries from a novelty cake challenge undertaken by care homes across the UK to celebrate the Queen's 90th birthday. The book features a number of recipes and stories of how the winning care homes created their cakes. 

Are you drinking enough water? Why is keeping hydrated important for all, no matter your age? This section provides ideas and suggestions on how to encourage everyone working in and living in a care home to drink more.

Film clips

Jackie Dennis, Care Inspectorate Improvement Adviser highlights why drinking more water reduces the incidence of urinary tract infections as well as wider benefits on health and well being.

Lesley Shepherd, Chair of Scottish UTI Network promotes the national hydration campaign resources and how they can help.

Ernie Duncan, Lay Member of Working Group suggests why drinking more water can help keep you healthy 

Other resources

Scottish UTI Network - SUTIN aims to link practitioners working at all levels to enable shared learning and a cohesive approach to urinary tract infection (UTI) work within Scotland. In addition, the Network seeks to co-ordinate guidance, quality improvement tools, surveillance, education, training and research.

Jelly hydration treats for people with dementia

An award-winning hydrating treat for people with dementia is the subject of a video feature on the BBC News website. Jelly Drops, invented by Lewis Horny, are designed to help address dehydration issues among people with dementia by offering an engaging and easy to eat treat.

Food Train/Eat Well Age Well, Dundee Health and Social Care Partnership and NHS Tayside have developed a new national training resource designed to support care at home staff with identifying if someone is at risk of becoming under-nourished, and how to support older people who may be struggling to eat and drink well at home. Malnutrition is largely preventable and treatable through early intervention and screening, and carers and care at home organisations can play a vital role in identifying malnutrition risk and supporting older people living at home.

The training is available online and consists of eight videos and a workbook which cover topics such as what can cause malnutrition, how to spot signs and symptoms and simple tips to boost appetite. It can be completed by an individual care worker or used by a service provider as induction or on going training for a group of carers.

You can view the videos here
The workbook is available here