Residential aged care food services discussion paper

As we know, there is not a 'one-size-fits-all' approach to providing excellent dining experiences in aged care. What works well in one service may not work well in others. What works well for some residents in a service may not for others. Continuous improvement is necessary – but will not come without understanding of and commitment to the importance of the issue. This discussion paper was commissioned to review the literature and provide evidence-based practice examples that will support providers to explore new ideas to improve meals, nutrition and the dining experience for consumers at their residential aged care services.

I encourage providers to engage with the ideas and concepts presented in the paper, try different approaches to improve the overall dining experience for their own unique consumers, and tailor their practices to align with current consumer needs and the capacity of their services.

I also hope that this paper leads to meaningful conversations about food, dining and nutrition in aged care, and inspires providers to share their ideas, insights and experiences with their peers.

I would like to thank Health Outcomes International (HOI) for their research efforts in the preparation of this paper. This paper complements the analysis of consumer complaints about food and dining in residential aged care HOI undertook for the Commission.

Dr Melanie Wroth

Chief Clinical Advisor

Food, drink and the broader dining experience play a critical role in supporting an older person's quality of life within the residential aged care service (RACS) setting. Health and quality standards pertaining to food are in place to ensure resident good health and wellbeing as well as appropriate nutrition and hydration. Multiple stakeholders are involved in the production and supply of meals to residents in the aged care service setting. These include management, cooks, chefs, caterers, external providers, food service managers, dietitians, speech pathologists, nurses, volunteers, and direct care workers ¹. RACSs face ongoing challenges in their endeavours to maintain a home-like environment for residents whilst concurrently seeking to meet individual dietary needs and preferences². Furthermore, the organisation, residents and family may possess divergent objectives and expectations regarding food services which can introduce tensions within the service. For example, the organisation may view mealtimes as a process through which adequate nutrition and hydration is provided as a key component of care, whereas residents may view mealtimes as a source of daily pleasure and comfort ³ .

The Royal Commission into Aged Care Quality and Safety Final Report released in 2021 identified food and nutrition as a priority area of attention ⁴. As part of feedback specific to food services in particular, it was suggested that increased spending was likely necessary to improve the quality of food in these settings ⁴. In response to this recommendation, a basic daily fee supplement of an additional $10 per day, per resident has been introduced by the Australian Government from 1 July 2021. The new supplement supports aged care providers to deliver better care and services to residents, with a focus on food and nutrition This has since been replaced by the AN-ACC funding model which became operations on 1 October 2022 ^{(a) 5}. This is promising as earlier research has argued that funding cuts to the aged care industry have significantly impacted catering budgets and aged care staffing levels: both of which may have affected the nutritional status of aged care residents to date ⁶.

Mealtimes not only support good physical health, but a sense of social wellbeing, comfort, routine and familiarity for older people living in residential aged care services. Food can provide continuation of long-standing traditions, practices and preferences and help retain identity and sense of normality.

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Quality and choice of meals are significant moderators of food intake, satisfaction and quality of life within residential aged care.

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Person-centred dining promotes the health and wellbeing of RACS residents. Nutrient intake and satisfaction with food services can be enhanced by acknowledging food preferences, promoting choice and accessibility of food, improving food quality and providing a "home-like" dining environment. 

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Interventions introduced to improve dining services within RACS have encompassed efforts to improve food consumption, nutrition and hydration, weight management satisfaction and cultural change.  

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Quality improvement specific to food services within RACS settings will be multidimensional and involve organisational leadership, staff, residents and their families. Evidence suggests that effective interventions are likely to be multifaceted, including staff development, creating small and homelike environments and underpinned by organisational policies that promote good practice specific to food services ¹⁵.

As with any other domain of care in this setting, the design and delivery of food services are opportunities to promote resident wellbeing and personhood ¹⁵.

A summary of activities or points of focus is presented below.

1. Improved Meal Choice and Quality

Appetite is clearly linked to the enjoyment and consumption of foods and can exercise an important influence over food service satisfaction. Therefore, menus should focus on promoting appetite by maximising flavours and aromas.

Choice, including food choice, is fundamental to the Aged Care Quality Standards.

Food presentation is also a key component of high-quality food service in residential aged care as satisfaction with meals contributes to food intake. Food provided must be nutritious, familiar, culturally appropriate, well presented and part of a positive mealtime experience ⁸.

Regular and formalised collection and review of individual dietary, cultural, religious and personal food preferences will support satisfaction in meals provided and encourage those with poorer appetites to eat. It may also include observation of particular cultural or religious events.

2. Alternative Food Service Delivery Models and Innovation

To promote food intake, as well as resident satisfaction, alternative models of food service delivery can be considered.

Dining experiences that reflect a "normal" home life in some way can provide comfort and familiarity. Residents should be enabled to make their meal choice at the point of service, or as close as possible, rather than ordering prior to mealtimes.

Innovative methods, such as assisted buffets, carts and room service, are potential options.

A buffet-style meal service allows residents to make their own food selections from a variety of food choices. Food handling is reduced and food temperatures are maintained, resulting in improved food quality (e.g., taste and texture)⁴¹.

It may also entail the introduction of a "family" or "domestic home-like" care model, through which residents are involved in the weekly menu design, shopping in some cases and preparation of meals in small groups.

3. Evidence-based Menu Planning and Assessment

Meal planning be based on meeting the specific nutrition and dietary needs of older adults.

Where not in place at present it is recommended that dietitians and speech pathologists regularly review menu options to ensure these align with older adult dietary requirements, nutritional needs and safety of food consumption for residents experiencing issues with chewing or swallowing. This may include the use of the newly developed Menu and Mealtime Quality Assessment for Residential Aged Care Tool by Dietitians Australia (which aligns with current quality standards).

Speech Pathologists can advise on the consistency of foods and beverages specific to a modified texture menu for people with dysphagia (swallowing issues). Organisations are also encouraged to review budget allocation to ensure food services are allocated sufficient funds to purchase the necessary type, quantity, variety and quality of food necessary to fulfil necessary daily nutritional requirements and satiation, as well engage appropriately skilled staff to prepare and deliver quality meals.

4. Routine Malnutrition Screening

Older people are at increased risk of unplanned weight loss and malnutrition. However, these risks can be greatly reduced by having evidence-based care strategies in place.

Multiple validated nutrition screening tools are available to determine the nutritional status of adults within aged care settings. Improved nutrition may be further supported through the establishment of a multidisciplinary team to plan, implement and monitor food and nutrition services, with input from accredited dietitians.

5. Support for Independent Food and Drink Consumption

Accessibility of food may be further promoted through the provision of assistive mealtime eating and drinking utensils and placing food within sight and reach of the resident to encourage autonomy. This includes the removal of plastic wrap, opening sachets or other assistance. It also refers to the consideration of portion size, consistency and manageability.

Independent eating should be encouraged as feasible through ongoing assessment of those individuals who may need assistance to eat particular meals and the degree to which this assistance is necessary. It is suggested that appropriately trained and experienced staff, as per particular task associated with meal preparation, serving and assistance with eating, be available during mealtimes to ensure residents receive their meals within a timely and safe manner.

6. Food Delivery, Timing and Temperature Management

Food service timing and delivery be considered to better accommodate resident needs and staff availability. This could include greater flexibility of mealtimes to enable increased time with each resident as necessary.

The temperature of meals can be monitored through the use of appropriate food utensils, crockery and other equipment to accommodate distance from kitchen to dining room or individual rooms across the service and processes of delivery to individual residents regularly reviewed for opportunities for greater efficiency.

7. Ongoing quality review and consumer feedback mechanisms

Residents should be encouraged to contribute to menu design and food options available to improve choice and variety of meals offered, including those on modified or specialised diets.

Obtaining more detailed feedback from residents can help food service managers in identifying specific aspects of the food or service that are causing dissatisfaction. Results of quality evaluation surveys should be used to benchmark and focus the food service's strategies to enhance quality performance and customer satisfaction ²².

Surveys, comment cards, and personal interviews are some suggested methods to obtain valuable feedback about the food and service quality from residents ³³.

8. 24-hour Dining and Access to Fluids

Services to ensure snacks such as fruit or other nutritious food items are available throughout the day and between meals for residents ("24-hour dining") as appropriate. These may include yoghurt tubs, custard pots, cheese and crackers.

To prevent dehydration, ready access to water, and other fluids for all residents is critical. This may include consideration of how this fluid is provided (to ensure resident can consume independently or with minimal assistance as needed), encouragement and support to regularly drink water for those who may need reminders, provision of preferred fluids (understanding what the resident would like to drink) and regular replenishment of water and drinking utensils (cups, straws, beakers or squeeze bottles). Daily fluid intake and sources should be monitored and recorded.

9. Dining Room Ambience

A "homelike" dining environment can improve resident enjoyment of mealtimes and contribute to a sense of comfort and familiarity. Evidence also indicates that well-designed physical settings play an important role in creating a person-centred dining environment to optimise the mealtime experience of residents.

Dining room environmental changes can include appropriate lighting, comfortable furniture, or playing music during mealtimes. Dining rooms, including furniture, equipment, crockery and utensils require regular review for cleanliness and hygienic practices associated with meal service.

Validated audit tools exist to support assessment of residential aged care dining environments.

Residents and family can also provide feedback on the dining room itself as to how ambience and environment may be improved.

10. Increased Emphasis on Oral Health

Greater emphasis to be placed on ensuring oral hygiene, including frequent brushing of teeth and daily denture cleaning, to prevent issues with eating for residents. This may also entail seeking necessary care to respond to other issues affecting food and liquid intake such as dry mouth or ill-fitting dentures.

The establishment of a multidisciplinary team with members of the dental profession, speech pathologists and dietitians may contribute to the management the oral health, swallowing and hydration of aged care residents.

(a) https://www.health.gov.au/topics/aged-care/providing-aged-care-services/funding-for-aged-care-service-providers/basic-daily-fee-supplements-for-aged-care - accessed 8 December 2022

1. Pankhurst, M., A. Yaxley, and M. Miller, Identification and Critical Appraisal of Food Service Satisfaction Questionnaires for Use in Nursing Homes: A Systematic Review. Journal of the Academy of Nutrition and Dietetics, 2021. 121(9): p. 1793-1812.e1.
2. Abbey, K.L., Australian Residential Aged Care Foodservices. Menu design, quality and standards – A time for action, in School of Human Movements and Nutrition Studies 2015, University of Queensland.
3. Evans, B.C., N.L. Crogan, and J.A. Shultz, The meaning of mealtimes: connection to the social world of the nursing home. J Gerontol Nurs, 2005. 31(2): p. 11-7.
4. Royal Commission into Aged Care Quality and Safety, Final Report: Care, Dignity and Respect. Volume 1 Summary and recommendations. 2021: Commonwealth Government.
5. DoH. Basic daily fee supplements for aged care. 2021; Available from: https://www.health.gov.au/health-topics/aged-care/providing-aged-care-s….
6. Hugo, C., et al., What does it cost to feed aged care residents in Australia? Nutrition & Dietetics, 2018. 75(1): p. 6-10.
7. Iuliano, S., et al., Dairy food supplementation may reduce malnutrition risk in institutionalised elderly. The British journal of nutrition, 2017. 117(1): p. 142-147.
8. Dietitians Australia, Menu Planning and Innovation in Aged Care- Position Statement. 2020: Dieticians Australia.
9. Tamura, B.K., et al., Factors Associated With Weight Loss, Low BMI, and Malnutrition Among Nursing Home Patients: A Systematic Review of the Literature. Journal of the American Medical Directors Association, 2013. 14(9): p. 649-655.
10. Greenwood, C.E., et al., Behavioral disturbances, not cognitive deterioration, are associated with altered food selection in seniors with Alzheimer's disease. J Gerontol A Biol Sci Med Sci, 2005. 60(4): p. 499-505.
11. Bartl, R. and C. Bunney, Best Practice Food and Nutrition Manual for Aged Care Homes Edition 2.2. 2015: Central Coast Local Health District: NSW Government.
12. Dietitians Australia, Oral Health, Swallowing & Hydration in Aged Care- Position Statement. 2020: Dieticians Australia.
13. Vic Health, Healthy and high-quality food in public hospitals and aged care facilities: Audit overview. 2021: Department of Health, Victoria.
14. Watkins, R., et al., Exploring residents' experiences of mealtimes in care homes: A qualitative interview study. BMC geriatrics, 2017. 17(1): p. 141-141.
15. Hung, L. and H. Chaudhury, Exploring personhood in dining experiences of residents with dementia in long-term care facilities. Journal of Aging Studies, 2011. 25(1): p. 1-12.
16. Curtis, M.P., et al., Satisfaction with care among community residential care residents. J Aging Health, 2005. 17(1): p. 3-27.
17. Joung, H.-W., E.-K. Choi, and B.K. Goh, The Impact of Perceived Service and Food Quality on Behavioral Intentions in Continuing Care Retirement Communities: A Mediating Effect of Satisfaction. Journal of Quality Assurance in Hospitality & Tourism, 2015. 16(3): p. 221-234.
18. Goh, B.K., et al., Residents' Satisfaction with Foodservice at a Continuing Care Retirement Community: A Pilot Study. Journal of Quality Assurance in Hospitality & Tourism, 2013. 14(2): p. 185-199.
19. Crogan, N.L., et al., Food choice can improve nursing home resident meal service satisfaction and nutritional status. J Gerontol Nurs, 2013. 39(5): p. 38-45.
20. Chaulagain, S., J. Li, and A. Pizam, What matters, and what matters most? Exploring resident satisfaction in continuing care retirement communities. International Journal of Contemporary Hospitality Management, 2022. ahead-of-print(ahead-of-print).
21. Wright, O.R.L., et al., Determinants of foodservice satisfaction for patients in geriatrics/rehabilitation and residents in residential aged care. Health Expectations, 2013. 16(3): p. 251-265.
22. Seo, S. and C.W. Shanklin, Important Food and Service Quality Attributes of Dining Service in Continuing Care Retirement Communities. Journal of Foodservice Business Research, 2005. 8(4): p. 69-86.
23. O'Hara, P.A., et al., Taste, Temperature, and Presentation Predict Satisfaction with Foodservices in a Canadian Continuing-Care Hospital. Journal of the American Dietetic Association, 1997. 97(4): p. 401-405.
24. Simmons, S.F., P. Cleeton, and T. Porchak, Resident Complaints About the Nursing Home Food Service: Relationship to Cognitive Status. The Journals of Gerontology: Series B, 2009. 64B(3): p. 324-327.
25. Lopez, K.J. and S.L. Dupuis, Exploring meanings and experiences of wellness from residents living in long-term care homes. World Leisure Journal, 2014. 56(2): p. 141-150.
26. Bailey, A., S. Bailey, and M. Bernoth, 'I'd rather die happy': residents' experiences with food regulations, risk and food choice in residential aged care. A qualitative study. Contemporary Nurse : a Journal for the Australian Nursing Profession, 2017. 53(6): p. 597-606.
27. Shahar, S., K.Y. Chee, and W.C.P. Wan Chik, Food intakes and preferences of hospitalised geriatric patients. BMC Geriatrics, 2002. 2(1): p. 3.
28. Abbey, K.L., O.R. Wright, and S. Capra, Menu Planning in Residential Aged Care-The Level of Choice and Quality of Planning of Meals Available to Residents. Nutrients, 2015. 7(9): p. 7580-92.
29. Boelsma, F., et al., "Small" things matter: Residents' involvement in practice improvements in long-term care facilities. Journal of Aging Studies, 2014. 31: p. 45-53.
30. Reimer, H., Providing person-centred mealtime care for long term care residents with dementia. 2012, University of Guelph.
31. Winterburn, S., Residents' choice of and control over food in care homes. Nurs Older People, 2009. 21(3): p. 34-7; quiz 38.
32. Desai, J., et al., Changes in Type of Foodservice and Dining Room Environment Preferentially Benefit Institutionalized Seniors with Low Body Mass Indexes. Journal of the American Dietetic Association, 2007. 107(5): p. 808-814.
33. Vincent, E., Ongoing nutrition assessment, menu modification, and personal service improve food consumption in assisted-living facilities. J Am Diet Assoc, 2008. 108(5): p. 792-3.
34. Lewis, A., A. Kitson, and G. Harvey, Improving oral health for older people in the home care setting: An exploratory implementation study. Australasian Journal on Ageing, 2016. 35(4): p. 273-280.
35. Malhi, H., Dysphagia: warning signs and management. Br J Nurs, 2016. 25(10): p. 546-9.
36. Donini, L.M., C. Savina, and C. Cannella, Eating Habits and Appetite Control in the Elderly: The Anorexia of Aging. International Psychogeriatrics, 2003. 15(1): p. 73-87.
37. Chaudhury, H., L. Hung, and M. Badger, The Role of Physical Environment in Supporting Person-centered Dining in Long-Term Care: A Review of the Literature. American Journal of Alzheimer's Disease & Other Dementias®, 2013. 28(5): p. 491-500.
38. Hung, L., The dining experience of residents with dementia in long-term care facilities. 2008, Simon Fraser University (Canada): Ann Arbor. p. 152.
39. Cartwright, J., et al., Montessori mealtimes for dementia: A pathway to person-centred care. Dementia, 2022. 21(4): p. 1098-1119.
40. Young, K.W.H., et al., A Randomized, Crossover Trial of High-Carbohydrate Foods in Nursing Home Residents With Alzheimer's Disease: Associations Among Intervention Response, Body Mass Index, and Behavioral and Cognitive Function. The Journals of Gerontology: Series A, 2005. 60(8): p. 1039-1045.
41. Remsburg, R.E., et al., Impact of a buffet-style dinning program on weight and biochemical indicators of nutritional status in nursing home residents: A pilot study. American Dietetic Association. Journal of the American Dietetic Association, 2001. 101(12): p. 1460-3.
42. Shatenstein, B. and G. Ferland, Absence of Nutritional or Clinical Consequences of Decentralized Bulk Food Portioning in Elderly Nursing Home Residents with Dementia in Montreal. Journal of the American Dietetic Association, 2000. 100(11): p. 1354-1360.
43. Brush, J.A., R.A. MEEHAN, and M.P. CALKINS, Using the environment to improve intake for people with dementia. Alzheimer's Care Today, 2002. 3(4): p. 330-338.
44. Altus, D.E., K.K. Engelman PhD, and R.M. Mathews, Using family-style meals to increase participation and communication in persons with dementia. 2002, SLACK Incorporated Thorofare, NJ. p. 47-53.
45. Bhat, C.J., A. Wagle, and S. Ousey, Culture Change: Improving Quality of Life by Enhancing Dining Experience. Journal of the American Dietetic Association, 2011. 111(9, Supplement): p. A109.