Supporting care home residents with hydration
An innovative toolkit is helping to ensure older people remain hydrated
‘My staff are more engaged and motivated when it comes to supporting our care home residents with hydration. Urinary tract infections have decreased, and unplanned hospital admissions have been reduced.’
Care home manager Gina Kidd and her staff have been using an extensive hydration toolkit, part of an ambitious project to improve patient care. The project is being led by Lesley Spall (pictured below), specialist practitioner for care homes at Lancashire Care NHS Foundation Trust. It saw her shortlisted as a finalist in the Nursing Older People category of the RCNi Nurse Awards 2016.
Initiating the project
Lesley was motivated to address local and national concerns about dehydration in older people, and set about developing an innovative set of resources, including presentations, posters and assessment tools that are bespoke to care homes.
Her behavioural-change approach focuses as much on education as it does on fluid measurement, and has been made specifically for care home staff, but created with those staff.
While undertaking her masters in advanced practice, Lesley was challenged to identify an area of practice that required improvement.
‘Care homes play an integral part in the care of some of the most vulnerable people in society,’ she says. ‘There are almost three times as many beds in care homes as in the NHS, and in central Lancashire alone, there are more than 3,000 care home beds.’
Dehydration is a common problem among older adults, with serious consequences associated with increased morbidity and mortality, she adds.
‘Older adults from care homes are often admitted to hospital for its management, although it has been recognised that dehydration in older people can be easily prevented,’ says Lesley.
‘Ensuring service users remain hydrated is absolutely crucial to maintaining their health and well-being. Yet despite a deluge of documents over recent years that have sought to improve care, there remains a lack of bespoke and practical guidance and tools to meet the needs of care home residents.
‘There has been a greater focus on malnutrition and the hospital setting, while care homes are unaware of guidance. I wanted to create something designed for care homes, which was creative, innovative and effective.’
Lesley undertook a review of practice locally, establishing baseline measures, and then held a series of stakeholder meetings before creating a steering group including care home staff. '
I had to find out what was happening in care homes, and engaged managers to see if they considered hydration a problem,' says Lesley. 'They did, and we started to discuss using a toolkit to change the culture.'
As the development, implementation and evaluation of the toolkit required commitment from staff, early adopter care homes were identified. Toolkit champions were recruited from those homes, and took part in the systematic development, design and subsequent evaluation of all of the component resources.
‘This ensured it was truly bespoke to the needs of care home staff and residents,’ says Lesley. ‘We looked at what does and doesn’t work, considering, testing and improving the different elements.’
Once the toolkit was ready, one care home was identified as the site for a 12-week pilot, which was formally evaluated. The evaluation included repeating the baseline audit from the design and construction phase, as well as gathering evaluation responses from staff, residents, families and friends at the home. The toolkit was subsequently launched in six local care homes.
Gina Kidd is general manager of Lakeview Rest Homes in Lytham St Annes. Her team uses the hydration toolkit as an integral part of their day-to-day care. She says it has significantly improved employees’ knowledge and skills.
She adds: ‘The team also appears to be drinking more, which has led to a decrease in employee sickness absence.’
Toolkit resources and strategies
The resources (see box) are available in printed and downloadable formats. They include a screening tool, as Lesley found little or no evidence of risk assessment in the homes.
The screening tool is simple, using low scores and requiring no complicated maths. There is also a seven-day booklet using a simple visual concept. ‘At any point, you can see whether a resident is at risk of becoming dehydrated,’ says Lesley. ‘It shows staff how to move a resident from red to green.’
Posters on a range of topics are displayed in homes as visual reminders.
As well as having hydration champions to ensure the changes are embedded in daily practice, Lesley undertakes support visits to ensure managers have a supply of resources and to introduce the toolkit and best-practice principles.
‘I raise awareness of the signs and symptoms of dehydration in residents, and explain assessment, monitoring and care planning,’ she says. ‘My sessions give staff strategies for those residents who can drink, can’t drink and won’t drink.
‘Staff have really embraced the toolkit, and strive to improve hydration as a key to residents’ care. In one home, they even have a “happy hour”, where staff jazz up the drinks trolley with lights, put music on and wear feather boas,’ says Lesley.
Adapting for change
Despite this enthusiasm from staff, implementing the resources has not been without challenges – one being organisational change in the service.
It quickly became evident to Lesley that her original plan to pilot the project in 10 homes had to be revisited, as well as the pilot timelines and subsequent launch.
‘Despite my despondency at what appeared to be considerable change, I had to maintain momentum and resilience, and adapt in response to the situation,’ says Lesley. ‘So I learnt to keep going. And I delegated some responsibilities to the care homes and champions.’
Care homes have traditionally had a high turnover of staff, so sustainability has also been a main theme.
‘That is why we have created such a range of tools,’ says Lesley. ‘The PowerPoint and [Adobe] Voice presentations can be used during induction, and care homes have started to embed them into that process. We also look at managers’ consistency.
‘And the champion concept has empowered staff to embed the toolkit. It is about changing the culture in care homes. Any new starters will see that hydration is important to care in the home and the champions will find the resources for them.’
The evaluation shows the resources are being used in five care homes as well as the pilot home. The statistics suggest that while not all of the resources are being used in all of the care homes as planned, a bespoke pick-and-mix toolkit is being deployed to meet the specific needs of staff and residents.
All of the respondents considered that using the resources had raised awareness of the need for adequate hydration. Furthermore, 100% of care home managers/hydration champions considered the toolkit had raised awareness of the signs and symptoms of dehydration in older people.
Lesley says that as well as these improvements, by engaging care homes throughout the toolkit’s development, it has raised awareness that they cannot work in isolation.
She adds: ‘This in turn has enabled the development of closer partnerships between care homes and local NHS providers by building networks and relationships to engage and mobilise further improvement. The clinical commissioning group (CCG) is now pledging involvement to share best practice on hydration.’
The resources have now been funded by the CCG and public health team, and are available for care homes to select which to use. All of the options can be found on Lancashire Care’s website, and Lesley has promoted the toolkit at a range of meetings.
There have been discussions with neighbouring CCGs about how their care homes can access the resource. Discussions are under way with University of Central Lancashire to arrange a presentation to pre-registration students. And Lesley has been meeting with matrons on mental health inpatient wards in her trust to see which resources are transferable.
‘I know that momentum and motivation must continue for the toolkit to remain contemporary and bespoke to the needs of care home residents, but there is a lot of interest in it,’ says Lesley. ‘It has reached far beyond the scope of the initial project plan, and I am so proud about the conversations that are now happening around hydration.’
The RCNi Nurse Awards judges were ‘hugely impressed’ by the toolkit and Lesley's work in evaluating the project from the beginning.
Hydration toolkit for care homes
The comprehensive hydration toolkit has educational, assessment and monitoring resources, as well as a range of awareness-raising posters. Importantly, it is bespoke to care homes.
An animation introduces some of the resources and case studies of residents who can drink, cannot drink and will not drink, and a cartoonist illustrates the points made.
The voiceover points out that the toolkit is based on guidance, but is created by real people with experience of working in real care homes – ‘like you’. It adds: ‘They were busy, but gave their time to develop the toolkit to make sure their residents got the basics.’
The educational components are available as PowerPoint and Adobe Voice presentations. They can be used for inductions or staff training.
Topics include dehydration in older people and the signs and symptoms of dehydration. One training presentation highlights the different strategies that can be used in care homes to improve hydration, and another the benefits of promoting hydration in these settings.
There is a self-assessment quiz on the signs and symptoms of dehydration, as well as care planning and monitoring resources.
In the absence of a nationally recognised hydration assessment tool, the project has the permission of South Essex Partnership University NHS Foundation Trust to use a tool it designed and implemented – the GULP (Gauge, Urine, Look, Plan) assessment.
Innovative and visual fluid monitoring charts have been developed. These resources are available as an individual chart or a seven-day booklet, which includes a cumulative chart and care planning guidance.
A range of posters highlight the cause, effect and potential consequences of dehydration, as well as setting out opportunities and strategies to improve residents’ fluid intake when they can drink, cannot drink or will not drink.
Care homes can access the tools through the project’s website. If care home staff email the team to register their interest in accessing the resources, Lesley calls them to discuss hydration in the care home and how the resources can help.
Toolkit in practice
Those using the hydration toolkit report it is easy to use, has helpful tips and is improving residents’ well-being.
Gina Kidd, general manager of Lakeview Rest Homes in Lytham St Annes, says: ‘The resources provided are informative, and are displayed in an easy-to-read format.’ She adds that it is particularly valuable that the resources are quick and easy to absorb given the number of training courses staff are expected to complete.
For Gina, the poster on hydration boosters has been particularly useful. These foods are high in moisture, and can help maintain good hydration status. The poster gives a comprehensive list of sweet and savoury options, and states exactly how many ml of fluid a specified portion contains.
‘We have some residents who are reluctant to drink, so the staff have been able to use this resource to think creatively to increase hydration.
‘We have also found the information about the long- and short-term effects of dehydration to be useful. It has been a real eye-opener for some of our team.
‘We total up the daily intake of hydration during the night shift and hand over information about hydration deficits to the day staff. By communicating this information, the day team is able to identify and provide extra support to the residents who need it.’
Alison Walker has worked in the care sector for more than 30 years. The care home manager says the toolkit has been positively received in her care home, Lady Elsie Finney House, Preston.
She adds: ‘It is easy to understand from a care assistant point of view. The charts instantly identify who is in danger of becoming dehydrated, and how this problem can be improved. The toolkit has improved staff awareness of infections and how important it is to push fluids throughout the day.’
Alison is a hydration champion, and has appointed another hydration champion in the home. The champion meets the cook weekly to discuss any issues raised. ‘She has taken ownership of the toolkit,’ says Alison, ‘and monitors the meal times and food served to the residents.’
Alison also uses the leaflets and presentation pack to train staff. ‘This includes promoting hydration and pressure care,’ she says. ‘It is clear information and easy for staff to put into practice – and it improves the health and well-being of vulnerable adults in our care.’
Nursing Older People would like to thank Hallmark Care Homes for sponsoring the Nursing Older People award at the RCNi Nurse Awards 2016.