In a recent visit to Landermeads, one of the pioneering Butterfly Homes in the UK, I went into Stoppard House, which is one of the smaller families of people living with dementia in the home. Stoppard House has what has become almost an iconic large family table at the heart of the home area.  It never disappoints me!  On this occasion, it was December and so the Christmas theme was the focus. About five people living and working in the house were sitting round the table together and there was a busy, but relaxed feel. The table was just brimming with exciting items to explore – large juicy oranges, cinnamon sticks, fir cones, festive jute ribbons, candles, a bottle of red wine in a wine rack, a tea pot, a pint of milk and an old fashioned biscuit tin with Royal Family theme. There was a woman slicing the oranges on a large chopping board.  She had quite a large knife and I imagined how many health and safety focused team members I know might have reacted with anxiety to the sight!  However, her husband and a care worker were sitting right beside her, and she was slicing the fruit with great precision and pride.   She then took the prepared orange slices and put them in the over, assisted by the team member.   The smells in the room were amazing with the combination of citrus and cinnamon and cloves. They then used the dried slices to create home-made decorations with small bells, cinnamon and the fir cones.  A man sitting at the table was being helped to write Christmas cards to relatives and friends and a woman was sitting quietly cuddling her doll.  People were doing their own thing, and yet the unity of the table somehow brought everyone together.

In another care home, Whitemud in Edmonton, Alberta, Canada, I remember a lunch table where burgers and hotdogs were on the menu.   It was quite simply set up with a smart maroon tablecloth and contrasting white mats.  But what was striking was the array of options to add to your burger placed in inviting bowls on the table.  There were sliced large tomatoes, gherkins, mustard, ketchup, onions and lettuce.    When the fresh bread buns were bought to the table with the burgers, everyone was invited to ‘make their own’.    What was important to me about this table, is everything was set up to encourage choice and independence.  No assumptions were made about whether someone liked raw onions or tomato ketchup, bowls were passed around and conversation flowed.

In Shankill near Dublin in Ireland, the St Joseph’s care home team are fantastic at creating a mood through the things they put out on tables.   They decided to have a party afternoon and in the household for people living with advanced dementia, they wanted to stage the room with lots of items linked to parties – buntings, balloons etc. But what caught my eye was a table on which they had placed varieties of bottles – wine, Guiness, small ale bottles, Jameson’s whisky etc. –  and there were glasses half-filled with red and white wine also on the table. There was also a pair of dark sunglasses, a party hat, a Venetian mask and a vase of flowers.   It was stylishly presented and immediately cued everyone into the fact that an event was happening. It somehow told a story. In my mind, the half empty glasses took me back to many parties I have been to in my life where you can’t find your glass! I imagined that this might have been the same for those in the room sitting looking at the central table.

In another care home in Canberra in Australia, I remember a group of people, again in the later experiences of dementia who were sitting round a table in a small living room in the home.  The table was well located overlooking a garden.  The team had created lots of sensory items which were very visual and tactile.   There were soft toys, an abacus, a large dice, a world globe, soft fabrics, poetry books and lots of other items to explore.  In small dishes, the chef had created some exciting ‘taste plates’ – some yellow fizzy sherbet powder, fresh fruit, pieces of cheese, marshmallows etc.  They were colourful as well as very tasty!  A bird table just outside the window brought many pretty bird visitors and the gardener had placed some very large colourful plant pots within easy view from the window.  Most of the people living in this home area were often sleeping and rarely used words, but it was interesting to see their eyes and facial expressions light up when they woke up as the table offered such a feast for the senses.  For team members sitting with them, there were so many possibilities to pick up and show people.  So often those in the later experiences of their dementia sit in a very isolated way in their large reclining chairs, but there was no sense of this exclusion in this little lounge. 

Many people describe the importance of sitting round a family table particularly in our childhood or with our own children. There is something powerful about the way in which this simple piece of furniture in a room anchors, holds and connects us. The table helps us to pause and appreciate each other, to share food and conversation – and to know we are not alone.  Every table has many stories to tell.

Have you considered the magic possibilities of your tables?

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How many of us love to look through a recipe book and plan to cook a sweet treat or bake something – recipes that perhaps evoke memories from our past? We can cook whatever we want for a meal and can chose, maybe according to our mood, the weather, occasion, or time of year.

We create the mealtime experience as part of our daily routine and this is something we perhaps take for granted just how important it is in our day, for so many reasons. For those living in care settings, these moments are even more important to bring people together, but all too often it is such a busy time of the day, this can become just another task to be completed. Planning the meal, preparing the food and the table are all meaningful activities that can make a difference, especially for those living with dementia. But it doesn’t stop there – sitting down together and sharing the meal promotes togetherness, enjoyment, conversation, laughter and supports well-being. It is widely recognised that mealtimes are important events for both physical and social well-being. (Heikkilä et al 2022)

Imagine a mealtime at home where food is prepared and placed in front of you with no atmosphere, no choice or conversation – just silence whilst you eat, no sauces available to compliment your food or preference, the portion size is decided for you, too little or too much, then the plates are cleared away and everyone leaves the room?  How dull would that meal be, and would you want to come back for more?

I have been able to observe many mealtimes and seen both extremes from completely task orientated with zero atmosphere and no choice, through to a room filled with the smell of cooking, conversations, music, laughter and a very relaxed atmosphere and nobody was in a hurry to leave. What a contrast and I think it would have been an interesting study to compare the nutritional status of those people. My feeling is there would have been a marked difference.  

It has been recognised that the environment is a crucial factor that can have an impact upon people with dementia in terms of improving their quality of life. This can also be true of the dining environment. It has been suggested that a dining environment that is welcoming, relaxing and comfortable has the potential to increase food intake and social interaction, which can make the eating/feeding experience more enjoyable and thereby minimise eating/feeding difficulties in people with dementia living in care homes (Stone 2014)

We need to make mealtimes a meaningful event in the day, from the planning to the preparation and then sharing it together around a table filled with colour, happiness and conversation. We can promote independence with serving dishes and accessible condiments, a relaxing, calm atmosphere and music playing.

Simple changes can make a huge difference to people’s lives. Mealtimes are an opportunity to create something truly enjoyable and involve everyone. So be it cup of tea and a piece of cake, or a full menu providing choice, spending time together creates special moments.  How can we take more time to create more meaningful mealtimes both at home and at work, with family, friends and those we love and care for?

References

Kristiina Heikkilä PhD , Stefan Andersson PhD, Erika Lagerbielke, Carina Persson PhD, Anna Sandgren PhD, Carina Werkander Harstäde PhD; Mealtime interventions and their outcomes in care homes for older people considering the five aspects meal model: An integrative review. Geriatric Nursing Volume 47, September–October 2022, Pages 171-182

Louisa Stone; End of Life Journal, 2014, Vol 4, No 1; Clinical Practice Development

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The first, Choices in Community Living was in Edmonton, Alberta, Canada.  When I first arrived at the office, I was told that every day at 12 o’clock, we would meet and have lunch together.  My first reaction was “You’ve got to be kidding!  My lunch is my time and I want to spend it the way I want to.”  However, when we all sat round the table together, I quickly realised that it really was a time of bonding and getting to know each other outside of the usual work chat and we became a very tight knit group. Some of our group were on various stages of diets who brought in the healthy salads and raw vegetables, whilst others were comparing the various differences in takeaway and home-made meals, such as Mexican, Ukrainian, Indian etc. as we had team members from a variety of cultures.  We always shared what we brought to the table which was part of the fun.  Inevitably there were times when one of us was having a hard time in our personal lives, and this was also a time when we could really count on getting support.  When I look back, if I had not gone along with this requirement to share lunch, I would have missed something very special. In the same team, on a Friday afternoon, our Director, Nicole, would sometimes spontaneously announce that we were to turn off our computers as we were going to take a few hours out of the office to go to a local Escape Room for some fun.  She didn’t say this was for team building, but inevitably the experience meant we had to work collaboratively to crack the codes and work out the mystery.  It also involved listening to each other and sometimes letting go of control!  We would sometimes take an afternoon and go shopping together and have lunch out, paid for by the Company.  You learn a lot about people when shopping together, whether it’s in a shoe shop or a book shop.

At Meaningful Care Matters, there is a similar ethos.  Food is an important part of our Directors, Peter and Amanda’s way of showing they care.  They made quantities of home-made jams, pickles and Christmas cakes (with a family recipe) to give us for Christmas.   When we go for Team Meetings, there is always a memorable spread of delicious food.  When I have been ill, I’ve had many messages of kind support from everyone, including the offer by Peter and Amanda of sending a cleaner or some grocery shopping to help when I recently had Covid-19.  The ‘checking in’ texts meant a lot to me during this time, as it felt very genuine and was coming from place of friendship, not just a sense of ‘duty’ as a manager.

In both these teams, it has helped my commitment and sense of belonging to know I am appreciated and valued as an individual.   I have made some long-lasting friendships as a result of these experiences which have transcended the workplace.

As a leader, the learning is:

Willingness to go above and beyond to show your team members you care about them can make a big difference to morale and motivation.

As a colleague:

Being given these opportunities to get to know each other better deepens connections and creates more person-centred teams.

What will you do next to show someone in your team you care?

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Yet, in recent conversations with a number of care home staff, all condiments have been removed from tables.  This seems to be mainly because in the context of Covid19, different people touching the same bottle or salt and pepper pot represents an infection control risk.  But, there is also an underlying message that somehow ‘they’,  meaning the people living in the home and especially those living with dementia might come to some terrible harm from these condiments being easily available to them.  It is the use of the word ‘they’ and ‘them’ a lot which really makes me prickle.  Why Oh Why as we age or develop cognitive difficulties are we somehow regarded as so different to other human beings that a bottle of ketchup or vinegar is perceived as something which we really ‘shouldn’t’ be allowed?  What honestly is the worst thing which could happen?  Might someone mess up their shirt with the Ketchup or drink the vinegar?  Regarding the cross-infection risk, can we not make sure everyone has washed their hands before the meal as would be recommended anyway?

This is a small but significant example of how we take away choice, independence and control from people.  We do it because of a genuine desire to keep people safe, but in so doing, give individuals the message that they can no longer enjoy the same things we do.  It is a process of ‘othering’ which is a dangerous slippery slope. and one which we need to question regularly and rigorously.

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At the Bradbury Wellbeing Centre, a Grade 1 MCM accredited club for People Living with Dementia in Worthing, we had just this dilemma when welcoming our club members back to their mealtime experience again.

‘How do we keep our club members covid safe, engaged and linked to one another’, we asked?

It was going to be tricky with limited space and furniture – and most of all – we were worried that it wouldn’t be a great experience at all!  In fact, the need to be socially distanced could create different problems through our club members feeling disconnected and not a part of something…or even worse ‘institutionalised’!!! Eek!

In pre-Covid times,  wetimes, we were able to seat 8 people on 3 square 1mx1m tables together – and this simply wasn’t possible anymore – in effect – it would have meant 8 people required 8 tables or one each – this demonstrates the size of the problem we encountered.  On top of that – we also had to include space for our team members and volunteers to also join in the meal too.

We started off imagining that our only option was for all club members to have their own separate table – lonely and in the middle of the floor with nobody around to chat to or engage with in other ways. It was only when we started to stop thinking about it and actually designed it in real time and real space – that things became clearer.

Tip! Don’t think about it – just get on the floor, roll up your sleeves and map it out in real space.

So as a team Wwe rolled up our sleeves and got creative with the space, the furniturefurniture, and a tape measure as a team – actually trying out different arrangements with the furniture to create something that solved the problems for every element of our dilemma.

We had to use everything we had to make it work – we messed around, puffing and panting for a couple of hours – experimenting with different layouts – trying squares, and different ways of seating people in 3-4’s Covid safely.

Tip! Try connecting people visually as well as physically – for example – from side to side and diagonally – so that everyone can see someone else eating and enjoying their meal too.  AASs we know, referencing others during mealtimes is an important aid for PLWD to encourage eating. (Quote/reference)

Eventually, it became clear that a ‘cross’ shaped layout was the answer…this enabled 4 1mx1m square tables to be pushed together with one person on each end.  This enabled diners to be linked visually with one another, within earshot for conversation, all linked by a central theme and most of all Covid safe without feeling isolated and alone.

Tip! Use mitigating measures – can people sit back-to-back or side to side to reduce Covid risk, enabling more flexibility with your seating arrangements?

Once we had our safe configurationconfiguration, we worked on theming the ‘cross’ shaped layouts.  Joining the 4 tables together in this way gave us more of a central space on which to create even more interesting themes for conversation and interest. 

Another problem that we had of course, was keeping tangible and interesting items cleansed and Covid safe, but the larger central section enabled diners to have a visual shared interest which was beyond reach, with some smaller cleanable and related items closer to them too.  This meant that we reduced our risk too as items weren’t being shared with others, but it still enabled the club member to pick things up and engage directly with the theme.

There are a couple of pics here that show our current themes, which are refreshed regularly to keep club members engaged and interested.   When theming, we consider general topics that members will have connections with, e.g., gardens, games, pubs, travel, seaside, countryside……these mean we have plenty of resources to pick from and conversations around the topics are fairly easy and natural to generate as they are relatable.

We learnt through our experience to be creative, to ditch the desk and stop scratching our heads – and to dive in, roll up our sleeves and actually work within the space to solve our dining dilemma!

Gary Potter (Bradbury Wellbeing Centre, Service Manager)

Nicki Freeman (Head of Community Services)

Guild Care, Worthing

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‘Food was a source of great pleasure to Ray. Having his second Full English Breakfast of the morning or an ice-cream in the afternoon whilst watching the TV, was for him, always a delight, a pleasure and a treat.’

When Ray first arrived at Wren Hall, late one afternoon he had missed afternoon tea. The team though made sure he felt welcome. After five servings of French Toast, it was almost dinner time (or ‘Tea’ as we say). What a result!

I have used the QUIS audit tool* over the years to help us measure the quality of the lived experience of people living with dementia in care settings. Observing a mealtime is very revealing. A mealtime brings into focus so much about a care settings culture of care – it’s leadership, attitude towards freedom and choice, quality of relationships, the ability to go with the flow and how much a place really cares about it making it feel like home.

If you spent some time observing a mealtime, what do you think it would reveal? What would see, hear and feel?

Here’s some good practices I have observed:

• Staff sitting and eating with people.
• Lots of visual cues to make the dining area look it is a place to enjoy a meal.
• The main meal of the day can be the evening meal.
• Sharing a cup of tea at the end of a meal and talking about what we would like to do next.
• Two meal sittings for lunch and dinner to get rid of the ‘rush’ and create a more relaxed feel to the day
• Encouraging people for help to set the tables
• Consider portion size, some people may struggle with large portions, observe how people do, you can always offer more!
• An aperitif for everyone!

And here’s some poor practices I have observed:

• Only verbal, but no visual choice of food
• Drinks already poured into glasses before people arrive to sit down to a meal
• No salt, pepper or other condiments on the table. In some case no tablecloth or cutlery either
• Cutlery too big and heavy for people to use. People resorting to using their fingers or not eating
• Breakfast ‘finishing’ at 10.30am, lunch consisting of three courses beginning at 12.30pm.
• People being taken to lounges from 7.30am, kitchen not being open for breakfast until 8.30am
• Staff talking about people being fed (like animals at the zoo), not being supported to eat or drink
• Treating mealtimes as a task not a massive opportunity for enjoyment and connection.

We would like to think that most people would know what a good and a poor mealtime experience would look, sound and feel like. Inviting to staff to step back and just observe a mealtime is a great learning opportunity that almost compels staff to make changes.

* To find out more about QUIS audits, contact us at admin@meaningfulcarematters.com

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Before I could finish the thought, the salt and pepper presentation was swiftly followed by a talk from Peter Bewert (Managing Director of Meaningful Care Matters) about the importance of a holistic approach to care culture, which was summarised with the Jane Howard quote “Call it a clan, call it a network, call it a tribe, call it a family. Whatever you call it, whoever you are, you need one.”

Suddenly salt and pepper, which might make up several seconds of someone’s day in a care home, seemed almost irrelevant when you can create a positive care culture that makes people feel part of a clan, network, tribe, or family for the rest of their lives.

Positive care culture may not seem relevant to food at first, but when a care home achieves it, you soon realise it seeps into every aspect of daily life, of which food is often at the fore. As if to confound this point, Peter’s presentation ended with a video showcasing a Level 1 Butterfly care home in which someone working in the care home walks alongside a person living in the care home while carrying a bowl of cereal, chatting, and offering a spoonful every now and then.

When you truly get to know the people you are looking after, you unlock what is important to them and what works for them; their secret ingredient if you will. Admittedly, this secret ingredient might mean having salt and pepper on the table, but it might also mean offering them cereal while they walk, or it might even mean eating KitKats morning, noon and night, as it did for someone living in our care home.

For this person, KitKats were their comfort blanket; the look, the smell, the feel, the taste, all familiar and all that was needed to feel safe, secure and happy. It might sound like an obscure example, but so many people are comforted by specific foods. Find one that works, and it can be almost medicinal. Sometimes it is obvious, such as a hot chocolate after a wet and windy walk or an ice lolly on a hot summer’s day.

Other times, though, it is not so obvious, and often the more personal it is, the more meaningful it can be. Another person living in our care home, not long after their wife died, just stopped eating. That was, until a longstanding member of the team, a carer-turned-chef, offered to make them a breakfast of smoked salmon and scrambled eggs, which was the meal they remembered most from their honeymoon in Scotland.

The chef knew how important that food was, but they also knew how important it was to get to know that person when they first moved in. So, yes, food is indeed important, but so are chefs, and so is the culture of care and the clan, network, tribe or family that it creates.

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Favourite foods are so often reminiscent of particular people and events in our lives.  The rituals associated with family meals can also be important whether it is an everyday meal or a particular celebration.  Food is much more than something which we need to survive physically.  It also feeds our sense of identity and belonging.

When supporting older people, there is increasing talk of creating music collections which link to people’s life stories, such as the ‘Playlists for Life’ initiative.  But have we ever considered a similar focus on food – perhaps ‘Menus for a lifetime’ which charts some of the recipes, food and drink enjoyed by people in their childhood, working lives and on holidays for example?   These could perhaps be recreated and talked about as part of valuing that person’s unique story. 

Even more important perhaps is to note the food that people really dislike.  I have a particularly bad memory of eating very pungent Goat’s cheese in a restaurant in France as a child, and I have never been able to touch it since.  Some of the people we support will have similar negative associations with some food, but how will we always know and make sure that the Chef is aware of these?  

Food is also an important part of cultural identity and in some care homes, there have been great examples of where team members have brought in home-cooked recipes from the Philippines, Poland or India, for example, to share with people living and working in the home.  The great smells, tastes and conversations that result in this sensory experience can be a welcome change in the usual menu of the day!

Creating conversation starters around food in the lead up to a meal can be a great way to whet the appetite.  “What is your signature dish?”  “When you were a child, was there anything you refused to eat?” “What drink would you order at the bar on a night out?”  “What is your comfort food?”  Bringing in Recipe Books and grocery store magasines with pictures of different foods can also get people talking about meals they enjoy.

So, when thinking what might be important to you if you were to live in a care home or attend a day centre, how confident are you that others would know your ‘food heaven’ or ‘food hell’ choices?  How can we take time to find out more about these with the people we support, either by asking them directly or talking to their family and friends?  Will you maybe make my day by bringing me tomatoes on toast…?

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