Care home mealtime support
Failure to provide adequate support and encouragement to residents during mealtimes in care settings, impacting nutrition and welfare.
Source spread
Where this theme appears
This theme appears across 8 independent accountability sources, so the source mix matters as much as the headline total.
1 inquiry rec
20 PFD reports
2 committee recs
29 CQC actions
15 IMB recs
1 IMB report
9 PHSO decisions
7 LGO/SPSO decisions
Browse by source
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.
Prevention of Future Deaths reports(20)
Dorothy Clarkson
Concerns: The coroner noted issues with the procedure for providing food to residents requiring special preparation and assistance, and a lack of appropriate ongoing professional development training for nursing staff.
Overdue
John Bartle
Concerns: The family perceived a lack of staff over a Bank Holiday weekend, leading to delayed interventions, poor nutritional support, and inadequate pain control. Concerns were also raised about poor communication from nursing staff.
Overdue
Pamela Thurston
Concerns: The coroner identified insufficient direct supervision during mealtimes for a resident with dementia, who choked after being given toast following a 17-hour period without food. Her care plan was also not updated despite a prior related incident.
Response (Thurston): • The organisation issued a memorandum to all Home Managers, Regional Managers, and Head of Operations outlining requirements for timely meals, choking risk assessments, and supervision of at-risk service users … (AI summary)
Overdue
Margaret Rogerson
Concerns: The coroner noted a lack of staff training in patient feeding mechanisms, techniques, and associated risks, including no refresher training. Additionally, no training was available for family members on safe feeding practices.
Overdue
Barbara Haley
Concerns: Concerns were raised that a resident, assessed as high risk of choking and on a soft diet, was provided unsuitable food items and left unattended while eating.
Overdue
Jane Parker
Concerns: Care home assistants demonstrated a poor understanding of modified diets and the importance of escalating choking episodes to SALT. The system for preparing and marking food for residents with specific dietary requirements was also inadequate.
Overdue
Kathleen Smith
Concerns: Staff lacked sufficient training in first aid, assisting choking residents, and preparing special dietary foods. There was also inadequate management oversight regarding staff deployment for residents at risk of choking.
Response (Coed Duon Care Home): • Several staff members have completed first aid courses, ensuring at least one qualified First Aider is on duty. • All current staff have been trained in basic dysphagia awareness, … (AI summary)
Responded
Catherine Best
Concerns: An inadequate regime of supplemented nasogastric tube feeding resulted in inconsistent calorie intake for the patient, who was challenging and not always able to consume sufficient calories orally.
Response (Swansea Bay University Health Board): • The Health Board updated its policy on the insertion and management of nasogastric feeding tubes in 2018 and delivered competency-based training. • Guidance on the management of refeeding syndrome … (AI summary)
Responded
Louise Cooper
Concerns: The coroner raised concerns about the lack of availability of sustained daily supported eating for patients with anorexia nervosa. This treatment, recommended by clinicians, could be more effective and less costly than repeated inpatient admissions.
Overdue
Helen Burnell
Concerns: The coroner identified that staff did not adequately recognise choking risks for adults with autism and learning disabilities. Improved training for staff and managers on choking risks and adherence to mealtime recommendations is needed.
Overdue
Lilian Shearing
Concerns: The coroner noted that no risk assessment was undertaken for the deceased's poor fluid intake upon admission to the care home, and omissions were made from the fluid intake chart. Policies and assessments for fluid and nutritional intake were not in place to cover this eventuality.
Response (Tanglewood Cloverleaf Care Home): • The care home reviewed and amended its Nutrition & Hydration policy to include current practice for monitoring and recording intake, supporting residents who decline food/fluids, and managing fluid targets. … (AI summary)
Responded
Frederick King
Concerns: The coroner noted inadequate fluid intake for the resident, especially during a heatwave and in the days before death. Concerns were also raised about inadequate record keeping and the absence of a manager at the care home for three days prior to the death.
Response (CQC): • CQC conducted focused inspections of Birchwood Care Home in April and July 2022, which resulted in updated ratings. • CQC requested and received a detailed response from the provider … (AI summary)
Responded
John Lee
Concerns: The coroner noted concerns that dementia patients at the Trust may not be receiving mouth care on each occasion they eat, which presents a risk of future deaths.
Response (Surrey and Sussex Healthcare NHS Trust): • The Trust commissioned a review of mouth care for dementia patients, involving a Consultant Admiral Nurse for Dementia and other specialists. • The Trust will establish a Food Strategy … (AI summary)
Responded
Maureen Woollen
Concerns: The coroner identified a lack of processes to ensure prompt medical attention for residents and full utilisation of care notes for recording injuries and incidents. Concerns were also raised regarding the absence of falls risk assessments on admission.
Response (Sheffcare): • Sheffcare reviewed and updated its admissions policy and falls prevention policy on 1 July 2024, requiring falls risk assessments prior to or on admission and reiterating procedures for seeking … (AI summary)
Responded
John Howlett
Concerns: The coroner noted a patient spent 22 hours in an A&E corridor due to capacity issues, which was a widespread problem. Additionally, the care home lacked robust systems to monitor the patient's nutritional status and fluid intake.
Response (Department of Health and Social Care): • Tameside and Glossop Integrated Care NHS Foundation Trust completed redevelopment of its urgent and emergency departments and implemented measures to improve patient flow and reduce waiting times. • The … (AI summary)
Response (CQC): • The CQC stated that the concern regarding a patient waiting 22 hours in a corridor due to capacity issues sits outside its remit. • The CQC conducted an assessment … (AI summary)
Responded
James Astley
Concerns: The coroner noted insufficient completion of nutrition and fluid documentation, including MUST charts, leading to inadequate monitoring of Mr Astley's intake. Overall documentation at the care home also lacked detail.
Response (CQC): • The Care Quality Commission (CQC) reviewed the provider's response to the Regulation 28 report, which included actions taken regarding documentation, oversight, communication, and training. • The CQC commenced an … (AI summary)
Responded
Marina Waldron
Concerns: The coroner raised concerns regarding the poor management of MW’s nutritional needs during her hospital admission. This included a failure to heed family concerns, formally monitor dietary intake, or respond to signs of malnutrition, with dietary interventions considered too late.
Response (Aneurin Bevan University Health Board): • A dedicated governance structure for nutrition and hydration has been established, comprising a strategic group and two operational sub-groups. • This framework has supported the implementation of key improvement … (AI summary)
Responded
Joan Whitworth
Concerns: The coroner identified concerns regarding the speech and language therapy assessment process and insufficient training for care home staff in basic life support, nutritional risk assessment, and specific dietary requirements.
Response (Hill Care Group): • The organisation implemented an electronic training platform with expiry alerts and automated compliance reports for staff training. • It reviewed and updated induction processes for agency staff, including checks … (AI summary)
Response (Northumbria Healthcare NHS Foundation Trust): • The Trust stated that changes to the electronic Speech and Language Therapy (SALT) referral form are due to come into effect in October 2025, including revised questions on coughing, … (AI summary)
Responded
Alfred Sparrow
Concerns: The coroner noted that staff at The Meadows Nursing Home did not consistently provide assistance with Mr. Sparrow's food and fluid intake, and that care notes contained false entries. This raised concerns about the accuracy of record-keeping and the thoroughness of internal investigations.
Response (Cardinal Healthcare): • A review of all resident care plans is underway, and staff are receiving additional training on documenting mealtime assistance. • A new care planning system, Care Vision, is being … (AI summary)
Responded
Bruce Caulfield
Concerns: The coroner identified delays in medical review after a family member raised concerns about a patient's condition. Further concerns included insufficient nursing practices for vulnerable patients' hydration and nutrition, and that comparable communication improvements may not be Trust-wide.
Response (Manchester University NHS Foundation Trust): • Discussions are taking place in March 2026 to ensure all ward teams document family concerns in patient records, and an action will be overseen for ward areas to re-read … (AI summary)
Responded
Select committee recommendations(2)
#11 — Support menstrual health by providing WASH services, menstrual products, and age-appropriate education on menstruation.
Recommendation: The FCDO should support menstrual health by supporting the provision of WASH services and infrastructure and access to menstrual products. In particular, the FCDO should ensure that its work in the education and WASH sectors complement its SRHR work in …
Response attribution not verified
#10 — Inadequate menstrual health information and WASH services hinder women and girls in low-income countries.
Recommendation: To meet menstrual health needs, women and girls must be able to access accurate, timely and age-appropriate information about menstruation. In addition, they need access to WASH services and inclusive infrastructure. Without adequate services and facilities, managing menstruation can be …
Response attribution not verified
CQC inspection actions(29)
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
IMB individual recommendations(15)
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
In Progress
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
In Progress
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
Implemented
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
In Progress
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
PHSO casework decisions(9)
P-002916 — Barts Health NHS Trust
Ms P complained the Trust failed to prescribe pneumonia medication, provide pain relief/antibiotics, offer suitable food, withdrew antibiotics without consent, and poorly communicated her father's deterioration.
NHS in England
Sep 2024
P-003071 — University Hospitals of North Midlands NHS Trust
Mrs C complained the Trust inappropriately managed her husband's eating and nausea, insensitively discussed palliative care, administered midazolam, and did not call her before his death, believing this hastened his death.
NHS in England
Oct 2024
P-004409 — Kingston and Richmond NHS Foundation Trust
A man complained his vulnerable father with dementia received insufficient assistance with eating and drinking, poor oral care, and inadequate communication from staff.
NHS in England
Dec 2025
P-004422 — Calderdale and Huddersfield NHS Foundation Trust
A wife complained about multiple aspects of her husband's care, including nutrition, medication, ward placement, and communication, impacting his recovery.
NHS in England
Dec 2025
P-001890 — Sandwell and West Birmingham Hospitals NHS Trust
Mr R complained his father received incorrect pureed food from the Trust, which he believes led to pneumonia and ultimately caused his father’s death.
NHS in England
Mar 2023
P-003464 — Cambridgeshire and Peterborough NHS Foundation Trust
Miss P complained the Trust failed to appropriately mobilise her mother, mismanaged her nutritional needs, and prevented family visits, allegedly contributing to her mother's deterioration and death.
NHS in England
Mar 2025
P-003427 — Croydon Health Services NHS Trust
Mr H alleged the Trust failed to provide his mother with adequate nutrition and proper diabetes control, including medication errors, which he believes hindered her recovery and cancer treatment.
NHS in England
Partly Upheld
Mar 2025
P-003662 — Bedfordshire Hospitals NHS Foundation Trust
Mrs L complained the Trust failed to support her father's nutrition, oral care, and mobility, or provide physiotherapy after discharge, which she believes led to his death.
NHS in England
Partly Upheld
Jul 2025
P-002760 — Royal Devon University Healthcare NHS Foundation Trust
Mr R complained about his father's care, including being left shoeless, unclean sheets, cold food, an open window, staff comments about his mother, and poor communication of his death.
NHS in England
Jul 2024
LGO / SPSO decisions(7)
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