Nutrition and Hydration

Food is medicine, biography and pleasure in one. People eat poorly in care for very human reasons: dentures that hurt, food from someone else's culture, portions that intimidate, a dining room that feels like a canteen, needing help that never quite comes while the meal goes cold. "Poor appetite" is written in notes far more often than "we haven't found what she'd enjoy yet" — and the second is usually closer to the truth.

Malnutrition creeps. Half a stone quietly gone in three months means poorer healing, more falls, more infections, thinner skin. That's why screening (usually the MUST tool) matters: it turns "she seems to be eating less" into a number that demands action. Hydration creeps the other way even faster — an older body carries less water and feels thirst less, so by the time someone is confused or dizzy, they may already be significantly dehydrated.

Swallowing problems (dysphagia) are the sharp end. Food of the wrong texture or drinks of the wrong thickness can choke someone or slip silently into their lungs. Speech and language therapy (SALT) recommendations and IDDSI levels are not suggestions — they are that person's safe envelope, every drink, every snack, every visitor's chocolate bar.

• Regulation 14 (2014 Regulations): people must receive suitable, nutritious food and hydration adequate to sustain life and good health, reflecting preferences and religious or cultural needs, with support to eat and drink where needed.
• Regulation 12: choking and aspiration risks are safety risks — assessment and mitigation required.
• NICE CG32: nutrition support for adults — screening (MUST), oral nutrition support, and when to escalate.
• NICE QS24 / CG161 lineage on hydration and older people's care plus NICE NG48 for oral health in care homes (mouths matter to eating).
• IDDSI framework: the international standard for texture (levels 3–7) and drink thickness (0–4) used across UK services.
• MCA 2005: capacity around risky eating and drinking decisions; best-interests processes for feeding decisions; end-of-life nutrition ethics sit with clinical teams.

Assessors often arrive at mealtimes deliberately. They look for people getting the help they need while food is hot, choice genuinely offered (including culturally appropriate options), correct textures visibly served, fluids within reach everywhere, and accurate charts where monitoring is planned — food charts that read "ate well" for a person losing weight are a classic governance failure. Weight logs, MUST scores with actions, SALT referrals made promptly and followed exactly, and dining experiences with some dignity and life in them all feature in judgements under Regulations 14, 12 and 9.

• Screen and weigh routinely (monthly, or weekly when concerned); recalculate MUST and act: fortify, snack rounds, GP/dietitian referral per score.
• Fortify quietly: full-fat milk, cream in soup, butter in mash, cheese grated into everything, milkshakes between meals. Little and often beats big plates.
• Know each person's IDDSI level and test thickened drinks properly; keep a visible (but dignified) system so bank staff can't get it wrong — and brief families about safe treats.
• Protect eating support: sit at eye level, unhurried, hand-under-hand prompting where useful; never stand over someone spooning at their pace.
• Make hydration ambient: preferred drinks (tea counts, so does jelly and melon), favourite mugs, a drink offered at every single interaction, jugs actually within reach of the weaker hand.
• Watch for the quiet signals: clothes looser, dentures floating, leaving one food type, coughing at drinks, long lunches unfinished — and record intake honestly, in amounts ("ate half the sandwich, 150ml tea"), not adjectives.
• Mind mouths: daily oral care, denture fit, sore gums — a painful mouth starves people politely.

Example 1. A resident with dementia walks constantly and has lost 4kg in two months; she won't sit for meals. The home stops fighting it: finger food she can eat on the move — sandwiches cut small, sausage rolls, banana halves, fortified flapjack — appears along her walking route, with a smoothie offered each lap. Weight stabilises in six weeks. The plan changed shape to fit the person, not the other way round.

Example 2. A home care worker notices her client coughs wetly after tea and his voice sounds gurgly. She doesn't just thicken his drinks on her own initiative — she records it precisely, reports it the same day, and the coordinator arranges a SALT referral while advising interim caution per local protocol. Assessment confirms dysphagia; drinks go to IDDSI Level 2 with a taught technique. The cough was data, and everyone treated it that way.