Care home mealtime support

Failure to provide adequate support and encouragement to residents during mealtimes in care settings, impacting nutrition and welfare.

84 items 8 sources 1 inquiry
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Where this theme appears

Care home mealtime support has been flagged across 8 independent accountability sources:

1 inquiry rec 20 PFD reports 2 committee recs 29 CQC actions 1 IMB report 15 IMB recs 9 PHSO decisions 7 LGO/SPSO decisions

When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.

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Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.

Dorothy Clarkson
26 Sep 2014 · Preston & West Lancashire
Concerns: Inadequate procedures for providing food to residents needing specific preparations and assistance, alongside a lack of appropriate professional development training for nursing home staff.
Overdue
John Bartle
18 Jun 2015 · Stoke-on-Trent and North Staffordshire
Concerns: Concerns were raised about a perceived lack of staff over a bank holiday leading to delayed interventions, alongside poor nutritional support, inadequate pain control, and poor communication from nursing staff.
Overdue
Pamela Thurston
29 Mar 2016 · Norfolk
Concerns: The care home failed to update the care plan for a patient with a choking risk and left her unsupervised to eat after a 17-hour period without food, leading to choking and subsequent death.
Response (Thurston): A memorandum was sent to all Home Managers regarding timely meals, choking risk assessments, and SALT referrals. The Senior Manager Monthly Report was amended to monitor Homes' adherence to the …
Overdue
Margaret Rogerson
21 Apr 2016 · Manchester West
Concerns: Care home staff lacked adequate training in safe patient feeding techniques and associated risks, with no refresher courses. Family members also lacked access to essential feeding training.
Overdue
Barbara Haley
03 Apr 2018 · Manchester (South)
Concerns: Staff provided unsuitable food to a high-risk choking patient on a soft diet and left her unsupervised during meals, contrary to safety assessments.
Overdue
Jane Parker
25 Jul 2018 · Manchester (South)
Concerns: Care home staff had poor understanding of modified diets and lacked systems for correct food preparation and marking. There was also limited understanding of escalating choking episodes to speech and language therapy.
Overdue
Kathleen Smith
03 Jun 2019 · North Wales (East and Central)
Concerns: Care home staff lacked sufficient training in first aid for choking, assisting residents, and preparing appropriate foods for those with swallowing difficulties, compounded by inadequate management oversight.
Response (Coed Duon Care Home): Coed Duon Care Home has implemented several changes, including SALT training for staff, designation of two Dysphagia champions, creation of a diets and fluids consistency file for each resident in …
Responded
Catherine Best
15 Jul 2021 · Swansea, Neath & Port Talbot
Concerns: An inadequate nasogastric tube feeding regime resulted in inconsistent calorie intake, compromising the patient's ability to fight infection.
Response (Swansea Bay University Health Board): The Health Board has made changes to policies, procedures, guidance and training regarding nutrition and hydration since 2012. They have also adopted Clinical Standards for Inpatient Nutritional Support since 2017, …
Responded
Louise Cooper
21 Dec 2021 · Blackpool & Fylde
Concerns: The healthcare system lacks sufficient provision for sustained supported eating for anorexia nervosa patients, leading to ineffective hospital admissions and hindering patient improvement despite clinical recommendations.
Overdue
Helen Burnell
12 Aug 2022 · Somerset
Concerns: Staff lacked adequate training and recognition of choking risks for adults with autism and learning disabilities, leading to insufficient adherence to mealtime recommendations.
Overdue
Lilian Shearing
14 Sep 2022 · Lincolnshire
Concerns: Despite known poor fluid intake, no risk assessment was conducted, and fluid charts were incomplete. The care home lacked adequate policies for assessing and managing fluid and nutritional intake.
Response (Tanglewood Cloverleaf Care Home): Tanglewood Cloverleaf Care Home has enhanced monitoring and auditing processes, introduced a new e-learning platform, focused on nutrition and hydration training, employed a care plan manager, and amended the Nutrition …
Responded
Frederick King
15 Nov 2022 · Berkshire
Concerns: The care home failed to ensure adequate fluid intake for the resident, particularly during hot weather, and maintained poor records. A critical lack of on-site management was also identified.
Response (CQC): CQC conducted follow-up inspections of Birchwood Care Home after concerns were raised and rated the home as 'requires improvement' or 'inadequate' in several domains. They are keeping the service under …
Responded
John Lee
06 Dec 2023 · Surrey
Concerns: Dementia patients at the Trust are not consistently receiving mouth care after eating, posing a risk of future deaths.
Response (Surrey and Sussex Healthcare NHS Trust): The Trust has already undertaken several actions, including updating the dysphagia e-learning module, introducing a rolling training programme, and planning a swallow awareness event in March 2024. It will also …
Responded
Maureen Woollen
19 Jun 2024 · South Yorkshire West
Concerns: The care home failed to conduct a falls risk assessment on admission and did not promptly seek medical attention for injuries. Care notes were inadequately used to record incidents or monitor injury progression.
Response (Sheffcare): Sheffcare has implemented a new Person-Centred Care system, provided refresher training to staff, updated policies, and performs audits, with oversight from the new Director of Quality and Care.
Responded
John Howlett
06 Sep 2024 · Manchester South
Concerns: Systemic hospital capacity issues led to a patient waiting 22 hours in a corridor. Separately, a care home with existing safeguarding concerns failed to adequately monitor a resident's nutritional status and fluid intake.
Response (Department of Health and Social Care): DHSC reports that Tameside and Glossop Integrated Care NHS Foundation Trust completed work on re-developing its urgent care and emergency departments in July 2024, including front-door streaming, an Urgent Care …
Response (CQC): The CQC acknowledges concerns about care at The Lakes Care Centre. The provider has ceased to deliver the regulated activity of 'Treatment for Disease, Disorder or Injury' and the CQC …
Response (The Lakes Care Centre): Response consists of the text A1, A2, and A3. Unable to classify without further content.
Responded
James Astley
10 Sep 2024 · South Manchester
Concerns: Inadequate monitoring and documentation of Mr Astley's nutrition and fluid intake led to severe frailty, highlighting systemic failures in care home record-keeping.
Response (CQC): CQC commenced an inspection of Downshaw Lodge on 16 October 2024 to review matters in relation to ongoing risk and to assess documentation; findings will be published on the CQC …
Response (Downshaw Lodge): No information provided.
Responded
Marina Waldron
21 May 2025 · Gwent
Concerns: During hospital admission, there was a prolonged failure to address the patient's inadequate nutritional intake, including neglecting family concerns, not monitoring diet, and delaying proper nutritional intervention despite signs of malnutrition.
Response (Aneurin Bevan University Health Board): Aneurin Bevan University Health Board has established a governance structure focused on nutrition and hydration and is implementing an action plan including improved recording of patient capacity, review of documentation, …
Responded
Joan Whitworth
29 Jul 2025 · Northumberland
Concerns: There were inadequate Speech and Language Therapy assessments, significant gaps in staff training for Basic Life Support, first aid, and nutritional assessments, and catering staff were unaware of resident dietary restrictions, posing risks to resident safety.
Response (Hill Care Group): Hill Care Group has changed the electronic platform to record staff training, adding an alert function and automated compliance reports for the Home Manager. They have also added additional checks …
Response (Northumbria Healthcare NHS Foundation Trust): The Trust is developing a Standard Operating Procedure (SOP), expected to be completed by October 2025, to guide staff in clarifying discrepancies in referrals by requesting key documents from Care …
Responded
Alfred Sparrow
06 Aug 2024 · Worcestershire
Concerns: Staff at The Meadows Nursing Home did not always assist Mr. Sparrow with his food and fluid intake as required by his care plan; a false entry in Mr. Sparrow's notes gave rise to concern that staff might have been completing care note entries which did not reflect their actions.
Response (Cardinal Healthcare): Cardinal Healthcare has already implemented several actions, including a manual reminder system for documentation, monitoring via a 'Resident of the Day' system, reflective practice sessions for staff, and a mentorship …
Responded
Bruce Caulfield
05 Feb 2026 · Manchester South
Concerns: Concerns include delays in medical reviews after family concerns, insufficient intentional rounding impacting vulnerable patient hydration, and inconsistent communication practices for fall prevention across the Trust.
Response (Manchester University NHS Foundation Trust): Manchester University NHS Foundation Trust has updated its Adult Early Warning Score and Intentional Ward Rounding policies, with staff reminders and mandatory training rolled out. The Trust has also launched …
Responded
Clova House Residential Care Home
The provider told us they would make arrangements to ensure their weight was monitored more closely.
Must Do
Haisthorpe House
The provider must ensure people who used services are protected from the risk of inadequate nutrition and dehydration by means of the provision of support for the purposes of enabling them to eat and drink sufficient amounts to meet their …
Must Do
Ridgeway Manor Residential Care Home
People who had needs in relation to eating and drinking were not supported to eat and drink safely in a manner consistent with relevant professional guidelines.
Must Do
Newland House
People were not always provided with adequate support and encouragement to eat their meals.
Must Do
Holly House Residential Care Home
The provider must ensure people receive appropriate support to eat and drink sufficient amounts to maintain their health and well-being, including effective monitoring of nutritional needs, provision of adequate and in-date food, and clear instructions for staff.
Must Do
St Paul's Lodge
The registered person must ensure the nutritional and hydration needs of service users are met by ensuring service users receive suitable and nutritious food and hydration adequate to sustain life and good health and dietary supplements prescribed by a healthcare …
Must Do
Havilah Office
The provider did not ensure people were supported to eat and drink enough in a safe manner and in line with their preferences.
Must Do
Haisthorpe House
People who use the service were not always protected from the risk of inadequate nutrition and dehydration by means of the provision of support for the purposes of enabling them to eat and drink sufficient amounts to meet their need.
Must Do
Valewood House Nursing Home
People were not protected from the risks of inadequate nutrition and dehydration and did not receive appropriate support to enable them to eat and drink.
Must Do
Newland House
People's nutritional and hydration intake was not being accurately monitored to reduce risk of dehydration or weight loss. Appropriate action was not taken when people were found to be losing weight.
Must Do
Georgiana Care Home
We recommend the provider assesses the processes in place to monitor people's food and fluid intake to make sure they are effective. We also recommend the provider review how best to serve meals to people with specific diets to make …
Should Do
Valewood House Nursing Home
The provider must ensure people are protected from the risks of inadequate nutrition and dehydration and receive appropriate support to enable them to eat and drink.
Must Do
Rosecroft Residential Care Home
The provider should ensure that food and fluid charts for people using the service are completed in detail to monitor the types of foods and amounts people ate.
Should Do
Nicholas House
The provider must ensure that the nutritional and hydration needs of service users, including preferences and provision of appropriate nutrition, are consistently met.
Must Do
Grosvenor Hall
The provider failed to ensure people's nutritional and hydration needs were being met, monitored and recorded.
Must Do
Dr French Memorial Home Limited
Meeting nutritional and hydration needs
Must Do
Chatting Independently Limited - Rectory Drive
People were not protected from the risk of adequate nutrition and hydration by means of the provision of a choice of suitable and nutritious food and hydration, and support for the purposes of enabling people to eat and drink for …
Must Do
Bellevue Healthcare Limited
The provider must ensure people receive safe care and treatment, specifically regarding nutrition and hydration to prevent malnutrition and dehydration.
Must Do
Bellevue Healthcare Limited
The provider must ensure the nutritional and hydration needs of service users are met.
Must Do
Archers Point Residential Home
The provider must ensure people's nutrition and hydration needs are met, including accurate completion of Malnutrition Universal Screening Tools (MUST), appropriate referrals to healthcare professionals, comprehensive nutritional care plans, staff understanding of fortification strategies, offering choice of meals, and providing …
Must Do
Affinity Trust Specialist Support Division North
The provider had failed to ensure monitor and consider information related to hydration and nutrition.
Must Do
Winterton House
We recommend best practice guidelines are sought in relation to meal planning.
Should Do
Westacre Nursing Home
We recommend that the registered manager implement competency assessments to provide assurances that staff understand the training provided and are able to confidently put their learning regarding nutritional risks into practice.
Should Do
St Marys Care Centre
The provider reviews mealtime experiences to ensure people are consistently happy that their dietary needs are met.
Should Do
Ridgeway Manor Residential Care Home
We recommend the provider consider and implement best practice guidance on the preparation and presentation of texture-modified food.
Should Do
V&C Family Care Ltd
The nutritional and hydration needs of service users must be met. Paragraph (1) applies where— care or treatment involves— the meeting of the nutritional or hydration needs of service users is part of the arrangements made for the provision of …
Must Do
Quality Care Management Limited
The provider should review mealtime arrangements to ensure that this is always a positive experience for people and that they receive the support required in an unrushed, caring and dignified way.
Should Do
Park Grange Care Home
The registered provider review the process for monitoring people's food and fluid intake.
Should Do
Chatting Independently Limited - Orchard View
The provider must ensure people are protected from the risk of inadequate nutrition and hydration by means of the provision of a choice of suitable and nutritious food and hydration, and support for the purposes of enabling people to eat …
Must Do
Altcourse (2020)
The food provided to prisoners is an area that has concerned the Board for a number of years. Although there have been some improvements, particularly in the latter part of the reporting year, more still needs to be done in terms of consistency in the quality of the food, and the timely maintenance of kitchen equipment.
Governor / Director
Feltham (2024)
What steps are being taken to reduce the amount of food going missing between the kitchen and residential units?
Governor / Director
Warren Hill (2021)
The Board has noted with much concern the ongoing difficulties with the provision of food from the Hollesley Bay kitchens and asks the Prison Service to examine the provision of a kitchen on the Warren Hill site (see section 5.1).
HMPPS
Gatwick, Stansted, Luton and Lunar House (2022)
At Luton airport we observed that a C&C officer has developed a series of picture cards to assist with translation. Pictures of the food available are also now used and we are told that this system seems to have encouraged more residents to eat during their stay. The Board believes that this is an innovation which should be utilises at …
Home Office
North West and Midlands STHF (2024)
Hot food is not available for persons being detained at East Midlands airport (see section 2.3.2.2). The Board would recommend this is rectified.
Home Office
North East Midlands, Yorkshire & Humber STHF (2024)
We recommend that hot food and drink provision be reinstated at all STHFs as soon as possible.
Home Office
Send (2020)
The Board is concerned that the canteen contract operated by DHL is unsatisfactory (5.1).
HMPPS
Norwich (2020)
addressing the issues in the serveries
Governor / Director
Hewell (2020)
The Board is aware of the challenges presented in the preparation and serving of food. During the reporting year, there have been too many instances of broken kitchen machinery, limiting the range of food prepared. The Board has significant evidence, in the form of formal applications, anecdotal comments and our own observations, of unappealing food being served. A regular lack …
Governor / Director
Holme House (2022)
Food services have deteriorated for a number of reasons and we would like the Governor to help find extra funding for better quality food and also get repairs to equipment carried out in a more timely manner.
Governor / Director
Holme House (2022)
We regret that the bakery has not been able to be operational, because as well as in-house cooked bread tasting better, the kitchen budgets would be less affected by the cost of buying in poor-quality produce.
HMPPS
Thorn Cross (2023)
To reconsider the current proposals for central dining (5.1.4).
Governor / Director
East Sutton Park (2022)
To review the contents of the canteen list more regularly to ensure that it is relevant to the needs of the residents.
Governor / Director
Warren Hill (2024)
In light of ongoing concerns about the provision of food from the Hollesley Bay kitchen, the Board welcomes the progress that has been made on this front, in as much as that the proposed expansion of the number of cells at Warren Hill is fully dependent on new kitchen facilities being provided at the prison. The staff and the IMB …
HMPPS
Oakwood (2024)
How can the Director ensure that standards during service at the serveries are consistently high (hygiene, PPE, timings, equipment working correctly)?
Governor / Director
P-002916 — Barts Health NHS Trust
Ms P complains the Trust did not communicate appropriately about her father’s condition and prognosis. She also complains the Trust delayed prescribing and later withdrew medication without consent, and it did not meet her father’s nutritional needs.
NHS in England Sep 2024
P-003071 — University Hospitals of North Midlands NHS Trust
Mrs C complains that when her husband was admitted in October and November 2022, the Trust failed to manage his eating and nausea, gave him midazolam, spoke insensitively to him about end-of-life care and failed to call her before he died.
NHS in England Oct 2024
P-004409 — Kingston and Richmond NHS Foundation Trust
Mr U complains the Trust failed to support his father Mr T with eating and drinking and did not listen to his family's concerns.
NHS in England Dec 2025
P-004422 — Calderdale and Huddersfield NHS Foundation Trust
2. Mrs P has raised a number of concerns about her husband’s care and treatment which include: concerns about his fluid and nutrition intake, feeding tubes becoming blocked, her husband not being weighed appropriately, being placed on an inappropriate ward, and involving security due to her husband’s behaviour. She also …
NHS in England Dec 2025
P-001890 — Sandwell and West Birmingham Hospitals NHS Trust
Mr R complains the Trust did not give his father appropriate pureed food when he was an inpatient between August and September 2021.
NHS in England Mar 2023
P-003464 — Cambridgeshire and Peterborough NHS Foundation Trust
Miss P complains about how the Trust managed her mother’s mobility and nutritional needs during her admission.
NHS in England Mar 2025
P-003427 — Croydon Health Services NHS Trust
Mr H complained about the care his mother received as an inpatient in relation to her nutrition and diabetes.
NHS in England Partly Upheld Mar 2025
P-003662 — Bedfordshire Hospitals NHS Foundation Trust
Mrs L complained the Trust failed to provide her father, Mr M, with appropriate nutritional and continence support.
NHS in England Partly Upheld Jul 2025
P-002760 — Royal Devon University Healthcare NHS Foundation Trust
Mr R complains that during a hospital admission the Trust left his father in unclean bed sheets, gave him cold food and left him in a room with the window open on one of the coldest nights of the year, He also complains about the way Trust staff communicated that …
NHS in England Jul 2024
21-000-498b — Brighton & Hove Clinical Commissioning Group (21 000 …
Summary: The Ombudsmen found no fault by a Council, a CCG and a care home in relation to the nutritional support and personal care provided to Mrs Y. We have found fault with how nutritional risk was assessed, but this did not affect the care provided and the care home …
LGO (Local Government & … Health Not Upheld Jan 2022
21-000-498 — Brighton & Hove City Council
Summary: The Ombudsmen found no fault by a Council, a CCG and a care home in relation to the nutritional support and personal care provided to Mrs Y. We have found fault with how nutritional risk was assessed, but this did not affect the care provided and the care home …
LGO (Local Government & … Adult Care Services Upheld Jan 2022
21-013-934 — Chase House Limited
We did not uphold complaints about the late Mrs Y’s care at the end of her life. We were satisfied the Care Provider offered appropriate care around eating and drinking, obtaining health care and communicated well with the family.
LGO (Local Government & … Adult Care Services Not Upheld Apr 2022
23-009-835 — CHJB Limited
Summary: Mrs X complained CHJB Limited failed to provide the care it was contracted to provide to her mother, Mrs Y. The Care Provider is at fault because it did not properly record the care provided to Mrs Y on two occasions and did not provide her with a properly …
LGO (Local Government & … Adult Care Services Upheld Apr 2024
202203333 — East Renfrewshire Health and Social Care Partnership
C complained on behalf of a relative (A) who had a learning disability and had been prescribed a special adjusted diet according to the International Dysphagia Diet Standardisation Initiative (IDDSI) guidelines. A had choked on their food and required emergency care. C complained that A’s food, a takeaway meal, had …
SPSO (Scottish Public Se… Health and Social Care Partly Upheld Nov 2024
201100382 — Greater Glasgow and Clyde NHS Board - Acute …
Mrs C complained about the food and about failure to provide a raised toilet seat, a blanket and sleeping pills during her three-day admission to a hospital. We concluded that the board had not acted unreasonably in respect of the food provided. In respect of the other issues, we concluded …
SPSO (Scottish Public Se… Health Not Upheld Aug 2011
201005150 — Lothian NHS Board
Ms C, who is a vegan, was scheduled to have an operation in the day surgery unit (DSU) at the Royal Infirmary Edinburgh. At her pre-operative assessment she arranged for vegan food to be available. Ms C also suffers from a severe and chronic condition that is worsened by exertion, …
SPSO (Scottish Public Se… Health Partly Upheld Jul 2011
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