Jul 24, 2018

“I’d rather die happy”: Is food regulation keeping residents safe – or preventing choice?

Food plays a pivotal role in our lives. Our innate desire to eat means our time is shaped by the three meals we consume each day.

Some of us enjoy taking the time to cook and prepare our own food. The family meal is central to many of our lives. The different ways we prepare and eat food are part of what defines us.

Our interest and enjoyment of food is essential to our wellbeing – if we don’t eat, we will perish.

Our interest and enjoyment of food should not end the moment we enter aged care.

Yet all too often, while it may be unintentional, this is what is occurring – in part because of the heavy regulations that govern the way food is prepared, served, and consumed.

But there is a growing movement for change in the industry, and The Lantern Project is at the forefront of driving a new conversation about streamlining regulations, and agreeing to new priorities that allow for greater personal choice and freedom in the way food is delivered in the aged care industry.

Keeping our elderly safe, but preserving quality of life

Providing food to aged care residents is complex.

Different residents have a myriad of different food requirements, and the standards set by safe food legislation and accreditation standards (2.10: Nutrition and hydration, and 4.8: Catering, cleaning and laundry services) can make menu development and delivery complicated, and sometimes the food unpalatable.

The food authorities, which differ from state to state, can also be in conflict with the accreditation standards and even with themselves, adding layer upon layer of complexity for aged care providers.

A practice that may be accepted during an accreditation audit, such as a resident serving themselves a meal from tureens, would be highly regarded by the quality agency in Standard 2.10 Nutrition and Hydration.

This Standard states the home encourages dignity and independence during meal times. Standard 3.9 Choice and Decision Making also states that the care recipient receives and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of others.

The NSW Food Authority considers that due to the vulnerability of the residents, that one resident serving themselves from a tureen or a salad bowl, may contaminate another resident.

This would infer that all residents are contaminated and denies them their rights and is contrary to the quality agency standard 2.20 and 3.9 and also in Charter of Residents’ Rights.

In November 2017, the NSW Food Authority held a vulnerable persons industry forum.

At that forum the question was raised ‘is it alright for an aged care home to serve food to a resident, if the resident requests the food yet the food does not comply with the Food Authority’s recommendations ie soft boiled eggs.’ The answer was ‘no’, it is not, even if the resident wants the food.

Recommendation or instruction on the handling of eggs differs in New South Wales and Queensland. In New South Wales, the recommendation is to cook the eggs until the white is firm and the yolk begins to thicken. In Queensland, aged care homes are instructed to hard boil eggs.

Nick Ryan, CEO, Australian Aged Care Quality Agency, told HelloCare that when it assesses expected outcome 2.10 Nutrition and Hydration, it is looking at whether care recipients are receiving adequate nourishment and hydration.

When assessing expected outcomes 4.2 Regulatory Compliance and 4.8 Catering, Cleaning and Laundry Services, the assessment team uses information from other audits, such as those from the food safety authority, to help them make an assessment.

Food-borne disease outbreaks are rare

The rigid restrictions placed on food service in aged care facilities does mean that food-borne disease outbreaks are rare in Australia, and in fact no deaths have been directly attributed to food-borne disease for more than 15 years. Of the 3,847 gastroenteritis outbreaks reported in Australian facilities between 2001 and 2008, only 1.4 per cent were food-borne and 0.1 per cent were water-borne.

The outbreaks were associated with 23 deaths over the seven-year period, but none were directly attributed to the food-borne agent

Foods that are identified as potentially hazardous include raw and cooked meats, eggs, dairy products, protein-rich foods, seafood, cooked rice and pasta, and processed fruit and vegetables (e.g. salads).

Of course, food regulation is essential in aged care to ensure the health and safety of a vulnerable population and there are benefits of having tight rules, but how far should these regulations extend?

A spokesperson from Queensland Health told HelloCare, “Food regulations are designed to protect the health and safety of the community and are based on the risk the activity, process or food type poses to the community, while still enabling people to have a choice in their food.”

Food safety programs developed as part of a national food reform process that was aimed at reducing the incidence of food-borne illness, and targeted five “high-risk” industry sectors, including aged care.

“As residents in aged care facilities are classed as vulnerable people, businesses who supply food in aged care facilities are required to consider food safety risks as part of a food safety program.”

The importance of choice for aged care residents

Resident-centred care acknowledges that residents are valuable and competent individuals, and strives to safeguard their autonomy. This model is now synonymous with best practice in the Australian aged care industry. The philosophy is based on the concept that residents retain their autonomy while in care, and that their lives flow from their own preferences and individual choices.

Some of those choices may involve risk.

A recent study examined residents’ perceptions of food in aged care, and found that despite the overarching trend in the industry towards greater autonomy, many residents want more choice when it comes to the food they are offered.

The study involved surveys of six aged care residents from two nursing homes, and revealed a number of significant themes.

Most respondents weren’t even aware of the regulators’ key concern – ‘food risk’ – thinking that risk in food probably only applied to people with certain health conditions, such as allergies or diabetes.

The research also showed residents felt that whether or not they wanted to take risks with food was up to them. One respondent said, “As for not having the things I like, that really is our choice… You know, not the government’s choice.”

Another joked about her love of sugary foods. “As for sugar, I take the risks now, that’s my choice and I prefer to… I may as well die happy,” she said laughing.

Residents also expressed a desire to make their own choices about food, and thought regulations shouldn’t prevent their personal choice.

One resident said, “I object to the restrictions; we surely are capable of making a free choice”. Another stated, “I got this far without rules and regulations.”

“We’ve got to make what’s left of the life they’ve got enjoyable and as meaningful as possible,” says Colin McDonnell, dementia excellence practise lead with prize-winning aged care provider, Scalabrini.

“Food is the biggest component of that,” he said.

The NSW Food Authority recognises the need for choice, but notes that risks must still be carefully controlled. In the notes from a QandA session held last year, the Authority noted, “The Food Authority recognises residents’ choice is a big issue in hospitals and aged care,” but some foods present a high risk to vulnerable people.

“If you can demonstrate that the risk is addressed, there are all sorts of solutions available,” the document states.

Making nursing homes feel like ‘home’ and providing choice

Leading aged care providers are also moving towards developing facilities that foster a sense of community and that feel like ‘home’.

“The food authorities need to understand the [aged care] home is not an institution,” Professor John Pollaers, Chairman of the Aged Care Workforce Taskforce, told HelloCare.

“We’ve got to find ways to make it genuinely a home,” he said. Food is a key way to deliver normalcy and quality of life in aged care, he said.

“Food can add to quality of life” and is important to help people hold onto their sense of culture and identity.

“They [food authorities] think it’s about cleanliness and safety, but it’s about the experience,” said Prof Pollaers.

If residents can help to prepare food, eat at table, and serve and feed themselves it helps them to retain some of the normal rhythms of their life, he said.

Prof Pollaers said in some “more advanced” aged care homes, “residents are able to serve themselves, when they want, and in the quantities they want. There are always carers in attendance.”

However, the food authorities “make it difficult”, he said, and are preventing providers from offering residents choice.

Fridges usually have to be locked at night, so if residents wake and are hungry, they are not able to get themselves something to eat. Residents can’t serve themselves food at the table; all food must be presented to them on a plate.

“If people wake in the night and want to eat, they should be allowed, as though they were in their own home,” he said.

Aged care homes should allow residents to help prepare food themselves if they want to, said Prof Pollaers.

Prof Pollaers said food isn’t regulated in the home, and questioned why it needed to be so heavily regulated in aged care, which should also be ‘home’.

The industry should be looking for change that will “maximise opportunities” for the people in their care, said Prof Pollaers.

“Why not allow them to enjoy life?” he asked.

Addressing malnutrition in aged care

Rates of malnutrition are high in aged care. Malnutrition is associated with higher infection rates, loss of muscle mass, strength and function, longer hospital stays, and increased risks of disease and premature death.

Physiological changes in older people, such as a reduced sense of taste, difficulty chewing, dental problems, reduced mobility, and increased feelings of apathy, can all contribute to an increased likelihood they will not consume an adequate diet.

Older people often have reduced appetites and are less efficient at absorbing nutrients from food.

But “the good news is that food has the potential to engage the senses, stimulate the brain and boost appetite,” says Dr Cherie Hugo founder of The Lantern Project.

Engaging willing residents in food preparation, setting of dining tables and simply seeing meal options available during the serving of food, all trigger physiological responses, such as stimulating saliva production, that prepare the body for a meal. When these cues are restricted, such as cooking meals off-site, restricting dining room setup and interaction with the meal being served, sensory cues can be missed, resulting in residents having less of a desire to eat.

You have to weigh up the potential risk of food-borne illnesses, with the risk of people not eating in aged care and potentially becoming malnourished, said Dr Hugo.

Where to from here?

Aged Care Minister Ken Wyatt told HelloCare the Government will soon implement a new, single set of Aged Care Quality Standards that will increase the focus on client outcomes and satisfaction.

“A core requirement of these standards will require aged care providers to demonstrate that they support each aged care client to take risks to enable them to live the best life they can.”

The aim of the new standards is “to enable residents to take measured risks, while maintaining safety.”

The Lantern Project is in the early stages of engaging with all sides of the debate – with food authorities from the states, AACQA, as well as a Lantern collaboration members, a growing group of stakeholders committed to improving residents’ quality of life through good food in aged care.

The Lantern Project’s hope is to develop a simplified, unified set of guidelines for providers that will apply across Australia, to remove complexity for aged care providers, and enable greater choice for residents. The hope is that aged care residents in future will be able to enjoy the many benefits of the food they like to eat, to eat when they choose, to eat food prepared in the way they like it, and to sometimes be involved in that preparation, and to be able to serve food as it might be served in their own home.

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  1. Hello guys.

    Thank you so much for addressing this very relevant issue. We have for years battled with the “risk” of allowing residents choice while scratching our heads and asking why the regulators are at odds with each other.

    The “advice” we were given when we asked the accreditation agency was simple. You can choose to allow residents choice with foods, but if anything goes wrong, you will be having to answer why you didn’t provide adequate food safety…

    Of course there needs to be a reasonable discussion around peoples choices where the might impact on another person, and the cognitive ability of a resident to make this kind of choice, but most of our residents are cognitively sound, and prepared and ate food at home without killing themselves, so why should moving into residential care be any different.

    There is so much regulation in our industry that we can barely breathe as it is, and for providers who want to “innovate” by removing the “institutional” rules and operating a true home like environment for residents, the inherent risks associated with these choices mean that many choose the easier option.

    Thanks again to Caroline and the team at Hello Care for highlighting this…

  2. I would love to print for my chef but it is bring me up computer language when I try and print

      1. One size doesn’t fit all. Residents cognitively able to participate are not all that present in most facilities.
        Let’s face it, most elderly living alone in the community aren’t eating very well. Very little food, prepackaged, nutritionally poor and this evolves into poor hygiene and living conditions. Moving into residential care is moving from solitary to community based where not everyone likes everything.
        Facilities generally do a great job on food variety but like everything else people get tired of a good thing sooner or later.
        The reality is that facilities have a high proportion of residents with complicated needs, high cognitive disorders, physical inabilities and likes and dislikes.
        I recall a time years ago when we tried to take orders for lunch,three choices and residents picked. By lunchtime the next day when those meal choices arrived most of the residents we thought were able to choose informed us that they didn’t order that, we don’t want that.. etc.

        The care standards are complicated,if you meet nutrition and choice you will probably fail safety and infection control etc.

        Facilities fail standards generally because the standards conflict with each other. Facilities generally have coded exit doors to keep residents from being run over or lost but it’s considered a “restrictive practice”.
        What’s the alternative, we all want freedom but safety is expected.

  3. Can you provide advice on how we can protect meal times and enhance our clients dining experience
    Thank you

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