JUDE BARBACK looks at how aged care facilities balance legal, nutritional, and specific dietary requirements with budget, resources, and changing taste preferences when it comes to menu planning.
I once read a letter in a magazine, of the agony aunt variety, from a young twenty-something wondering what to serve her visiting eighty-something grandmother to eat. Her preconceptions of ‘old people’s food’, drawn from her limited experience of care homes, included over-cooked vegetables, mash, meat in a stew or drowned in gravy, stewed fruit, and custard. The responses from the readers ranged from scathing to enraged. Didn’t Miss Whippersnapper know that older people enjoy the same sorts of food as younger generations? Didn’t she realise they enjoyed a variety of different foods from different origins?
The heated, if rather lightweight, debate left me wondering about the difficulties that must confront the menu planners in aged care facilities. In addition to meeting legal nutritional requirements and the specific dietary needs of residents, they must also have to take into consideration the changing and varying taste preferences of older people.
Pushing all taste preferences aside for the moment, it is worth noting that the industry is fundamentally guided by the Health and Disability Services standard NZS 8126.96.36.199: A consumer’s individual food, fluids, and nutritional needs are met where this service is a component of service delivery.
The criteria underpinning this overarching standard highlight the importance of meeting recognised nutritional guidelines, any additional nutritional requirements and personal taste preferences of consumers, as well as adhering to legislation and guidelines for food procurement, preparation, storage, and delivery. It links in with the Ministry of Health’s Food and Nutrition Guidelines for Healthy Older People, which, in turn, supports the Ministry’s Health of Older People Strategy. The guidelines recommend specific numbers of serves from each of the four food groups daily – for example, at least six serves of grains, at least five serves of fruits and vegetables, at least three serves of milk (or foods made from milk), and one to two serves of meat or meat alternatives.
Facilities must also adhere to the stipulations of the Age Related Residential Care Agreement, which complies with the Food Hygiene Regulations 1974, the Health Act 1956, and the Health and Disability Commissioner Act 1994. The agreement requires ‘a food service of adequate and nutritious meals, and refreshments and snacks at morning/afternoon tea and supper times, that reflects the nutritional requirements of older people, and as much as possible takes into account the personal likes/dislikes of the Subsidised Resident, addresses medical/cultural and religious restrictions, and is served at times that reflect community norms’ (Clause D15.2).
While the agreement includes some safety clauses around food handling, it will soon become an additional legal requirement for all food providers to meet the standard in the Food Act 1981 that says they must have a written food safety programme that includes addressing any potential hazards of food preparation (based on the principles of Hazard Analysis Critical Control Point), the skills and competence of those preparing the food, and the types of food that should not be served or sold.
Some organisations follow additional standards, which may include reference to their mission statements or specific resident agreements. For example, Oceania Living’s philosophy of care document shows they will “provide food choices from which residents may make their selection and allow, within reason, the resident to make the decision of where they wish to dine.” Oceania’s dietitian, Jessica Bowden, says that in addition to the Ministry of Health guidelines, Oceania also adheres to the Australian standardised definitions and terminology for texture-modified food and fluids.
The Dietitians New Zealand Menu Audit is designed by dietitians ‘to help ensure facilities meet the requirements for certification under the Health and Disability Sector Standards and DHB Accreditation’. The audit, which also incorporates assessment of the food purchases that can assess if the facility is purchasing enough food to meet the residents’ needs, appears to keep facilities in check with regards to nutrition and dietary variety.
While it is not currently a legal requirement to have a dietitian involved in menu planning, the audit process means a dietitian is often involved by default.
Janice Petty, manager of Albert Park Residential Care in Gisborne, a 33-bed independent rest home, says they have the input of a dietitian for menu planning. Menus are sent for review and approval and any recommendations are taken into account.
“Although it’s not a legal requirement, most facilities do have the input of a dietitian as it is one thing closely scrutinised in the audit process,” she says.
Sue Prowse, manager of Rosebank Rest Home and Hospital in Ashburton, says they have a registered dietitian reviewing the menu and making recommendations if required. Their meals are constantly audited by both internal and external processes. Prowse says it is a very useful way of maintaining quality control.
“If we are lacking in some areas, like protein or calcium, for example, they inform us and suggest ideas on how we can improve on those areas. Internally, we measure plate wastage and food temperature.”
Te Ata, a small independent rest home in Te Awamutu, relies on the auditing process revise anything lacking. A nurse at Te Ata believes strongly in quality control.
“At the end of the day, it all comes down to audit process to ensure quality of care,” says a nurse at Te Ata.
This emphasis on quality control is shared by general manager Andrew Russ.
Employing a dietitian is another cost to factor in, but one that Petrina Turner-Benny, chief executive of Dietitians New Zealand, believes is definitely worth it.
“In many cases it is a perceived cost,” she says.
Turner-Benny says that many facilities fail to acknowledge the importance of including a dietitian in their service. She says many do not understand that a dietitian can help to achieve savings on food costs as well as provide the expert input into the menu planning. When tube feeding or a special diet is required, a dietitian has prescribing rights and the specialist knowledge for assessment, treatment, and monitoring of the resident.
Turner-Benny says Dietitians New Zealand is currently in the process of releasing a draft checklist to ensure optimal levels of nutrition in aged care facilities. The checklist is currently being discussed with a range of relevant bodies, including designated audit agencies and Standards New Zealand. A survey of aged care facilities will also shortly be under way, in order to better comprehend where the deficits in understanding of nutritional care lie.
As expected, most large aged care facilities with multiple sites employ dietitians to ensure standards are met across their range of facilities. Bowden, Oceania’s dietitian, says Oceania maintains nutritional standards by the use of standardised menus and recipes designed and approved by a dietitian.
This winter marks the launch of the third standardised menu for Oceania. Feedback systems have been established to understand the national resident, facility, and kitchen requirements for the menus.
A criticism sometimes voiced about standardised menus is that the one-size-fits-all approach does not for allow for flexibility in the individual facilities or fully cater to the needs of individual residents. However, Bowden says a menu policy has also been developed at Oceania to outline areas for flexibility; for example, the facilities can provide food suitable for themed days while ensuring nutritional standards are maintained.
She says individual resident requirements are maintained by dietary requirement forms completed by residents on admission to a facility and when requirements change.
Facility managers take ownership of the kitchen outcomes by way of spot checks and food service audits.
Bowden says that while the Bureau Veritas section on nutrition is useful in ensuring facilities keep necessary documentation, it is really just a snapshot of one moment in time and is unlikely to maintain nutritional standards or address ongoing quality control issues on a daily basis.
To ensure that nutritional standards are consistently met requires ongoing assessments and processes, such as training, policies, manuals, understanding of residents’ nutritional requirements by kitchen staff and the importance of these requirements, and adherence to the standardised menus.
Staff knowledge is important. A recent Otago University study about the dining environments in New Zealand rest homes found that common barriers to optimum nutrition for residents included menu changes by staff with inadequate nutritional knowledge, failing to provide adequate portion sizes to meet nutritional needs, and failing to get feedback from residents on meals.
Turner-Benny, who has had experience in the rest home sector, agrees that training is an important aspect. She stresses the importance of an annual education programme for staff on food and nutrition.
Rosebank in Ashburton is a good example of an organisation that takes education in this area seriously. Manager Sue Prowse, says training in nutrition is provided for staff along with food hygiene courses. The cooks take the food and hospitality unit standards.
Aged care providers certainly have a lot on their plates when it comes to menu planning. Meeting regulations and nutritional guidelines are only part of it.
Providers and facility managers also need to ensure staff members have the necessary resources to execute the menu. The appropriate recipes, level of skill, time to prepare the food, equipment, and capacity are all essential.
A realistic food budget is important, too, regardless of the size of the operation. Bowden says catering to the varying needs, whilst fitting into procurement and budgetary constraints, needs to be managed carefully. Financial reporting, consolidation of products, and building supplier relationships all help Oceania keep within budget.
Some facilities employ more creative strategies for enjoying luxury foods within budget. At Rosebank, for example, the residents run raffles to fund purchases for things like oysters or whitebait when they are in season.
Resident satisfaction in terms of taste, texture, temperature, familiarity, and variety are all important factors in menu planning. Nutrition expert Gaye Philpott says that from a menu planning perspective, food satisfaction is closely linked to menu variety, choice, and familiarity of foods.
“Repetitive menus are boring and likely to impact negatively on meal satisfaction and oral intakes. For this reason, it is recommended that menus for long-stay organisations are a minimum of four weeks (acute care facilities such as hospitals may operate shorter menus) and that only a limited number of dishes are repeated during the cycle and repeated only once. Ideally, there should be a separate menu for warmer and colder months, offering different choices and not merely be a rearrangement of the same meals.”
The Otago study findings tally with Philpott’s recommendations, showing that menu cycles should be at least four weeks, with menu audits by registered dietitians. The study also reveals that portion sizes should be adequate for key components of the meal, and meals and snacks should be served frequently, preferably with 24-hour availability. Choice should be available to residents, as should familiar foods according to culture, age, likes, and nutritional needs. Meal service systems should also encourage familiarity.
Worryingly, Philpott says that in reality there is often little choice at meals apart from breakfast.
“I work in many rest homes in the lower North Island and am involved in the menu planning of some major national providers, and none provide a choice at the main meal – for example, the choice between chicken casserole or roast beef – and only one offers two distinct choices at the secondary meal.”
Philpott says that while rest homes will generally cater for strong food dislikes, residents don’t usually get a lot of choice on the day.
“This will very likely change,” she says. “I don’t expect younger generations will accept no choice when they get older and need care.”
Philpott is right. The baby boomers, the next generation to descend on the aged care industry, are unlikely settle for a ‘take it or leave it’ approach to food.
Changing Taste Preferences
The baby boomers and subsequent generations are also likely to have enjoyed a diverse range of different ethnic foods, vastly differing from the overcooked vegetables, meat, and gravy stereotype. Philpott concurs. She says that while potato is currently served most days at the main meal, future generations are likely to enjoy more pasta meals or rice accompanying a curry or stir-fry.
Bowden agrees, saying that the sweet and sour chicken recipe on the Oceania menu this winter has received a lot of positive feedback from residents.
“This new generation will pose an increase of variation in the menus so that they do not develop food boredom. Choices are important so that residents who prefer a traditional ‘plain’ meal are still catered for,” says Bowden.
Oceania, like other large providers, is in constant touch with suppliers with new products and developments. Such new products can be trialled at sites to assess how readily they are accepted by residents.
Although elderly taste buds may be changing, introducing change to residents can sometimes be thwarted by the residents themselves. The Otago study found that residents claimed to enjoy the food similar to what they had eaten when they were younger – therefore reflecting age culture.
Sue Prowse has experienced this, at times, at Rosebank, where they are keen to add new flavours to reflect the growing ethnic diversity of the residents.
“Residents are not fond of too much change, which can sometimes make it difficult trying to bring in new styles of cooking. We do add new ideas into our menus and go by the feedback that we receive from the residents in whether we continue with this change,” says Prowse.
The changes are not limited to taste. It is expected that gradually residents will come to expect their main meal, which is currently served in the middle of the day at most facilities, to be served in the evening.
Te Hopai recently looked into bringing about the change but found the residents weren’t ready. Manager Pakize Sari says that after considering research that showed that it was better for residents to have their main meal in the evening due to the long wait until breakfast, especially as residents often miss the late evening supper, they surveyed their residents on whether they wanted to change. The survey showed a clear preference for keeping the main meal in the middle of the day.
Resident feedback is important. Despite the Otago findings, which show that a failure to obtain resident feedback was a barrier to optimum nutrition, the facilities I investigated all appear to have good mechanisms in place for resident feedback on any aspect of residential care, including food.
At Rosebank, annual resident satisfaction surveys include a question about the food service. At the residents’ meetings, the kitchen supervisor informs residents of any changes to the menus, with an opportunity for residents to raise issues with the menu.
At Te Hopai in Wellington, the contracted chef joins the residents’ meetings and also does the morning tea round to get daily contact with the residents.
At Albert Park Residential Care in Gisborne, manager Janice Petty says they rely on residents’ feedback via monthly residents’ meetings, where they are encouraged to discuss any thoughts on the food with the activities’ manager. There is also a suggestion box for residents and family members to use.
Balancing preference with nutrition
There are occasions when taste must give way to suitability. At Rosebank, manager Sue Prowse says although other aspects, such as budget and residents’ opinions, are taken into consideration, nutritional value is the main factor in menu planning.
Nutritionist Gaye Philpott, says that while cooking is likely to change to reflect a modern preference for crisp and crunchy vegetables, the current practice of cooking vegetables until soft is sometimes necessary because older people may have ill-fitting dentures or lack or have sore teeth.
Philpott says in order to satisfy nutritional requirements, menus should offer wholegrain breads and cereals daily, a variety of fresh and frozen vegetables over a week, including coloured and green vegetables daily, a variety of canned fruits, and access to at least one serve of raw fruit or vegetable daily. Heart-friendly fats and moderate amounts of iodised salt should be used in food preparation. Desserts based on milk and fruit, such as apple crumble and custard or creamy rice and peaches, should dominate in any week.
Dietitians New Zealand has established recommended serving sizes, which they audit against. For example, 100g cooked meat or meat alternative is a daily serving (noting that this is equivalent to 130g meat as purchased, because one can expect 25-30 per cent shrinkage and waste on cooking), which may be served between two meals when appetites are small.
The changing generations also present an increasing number of people with allergies and intolerance to certain foods. Years ago, ‘gluten-free’ was not a familiar term in rest home kitchens, but increasingly, chefs will need to be mindful of providing food that caters for people with such conditions.
Catering for different levels of care
It is no surprise that individuals will have different dietary requirements, but it does mean facilities need to be conscious of each resident’s specific needs. An aged care facility may have a variety of levels of care and differing dietary needs within each level.
The inhabitants of retirement villages tend to be younger and healthier and are generally able to prepare or purchase their own meals, rendering café/restaurant-style catering more appropriate. Meanwhile, rest home residents typically enjoy familiar foods and often prefer lighter meals.
Bowden says residents with dementia typically have high energy outputs due to higher activity levels or uncontrollable shaking. Some with dementia have restrictive food behaviours, which impacts on food acceptance.
Hospital-level residents require the most nutritional care. Bowden points to a nutrition survey across 56 hospitals in Australia and New Zealand that identified an overall malnutrition prevalence of 32 per cent, consistent with malnutrition figures in Europe and USA. Consequently, Bowden says food fortification is important. Adequate protein and energy contents of meals are needed to prevent and treat malnutrition. Medical or cognitive conditions can sometimes affect a person’s ability to safely swallow food, in which cases texture-modified meals are required. Medications can also impact on the saliva content; therefore, additional gravies and sauces are required to ease the person’s ability to consume a meal.
Residents who require texture-modified food should also be provided with an adequate and varied menu, including pureed, minced, or moist options at all meals and snacks. Similarly, alternative proteins should be provided for vegetarian residents or those who exclude certain foods for ethnic or religious reasons.
While nutritional aspects of medical conditions should certainly be taken into serious consideration, Philpott says highly restrictive diets for managing specific conditions or the risk of such conditions, such as diabetes and heart disease, are generally not necessary.
“There is good evidence that strict avoidance of sugar when a person has diabetes is unlikely to change diabetic outcomes. Adding salt at the table if it enhances a resident’s meal experience should not be shunned either. The likes of such are more important for younger people whose food choices today are very likely to influence their long-term health outcomes,” says Philpott.
There is certainly a lot to take into consideration when it comes to menu planning in aged care facilities: regulations, nutritional requirements, cost, changing tastes, resident preferences, and specific dietary requirements. Perhaps the young twenty-something who penned the letter asking what she should feed her elderly grandmother could be excused as there appears to be plenty of food for thought in this aspect of aged care.