Recurring concern
Inadequate management of patients' nutrition and hydration needs
- Reports that mention this concern
- 39
- Times this concern has been raised
- 44
- Stated actions linked to this concern
- 80
What this concern includes
Includes failures of controls specifically dedicated to assessing, monitoring, recording, providing or reviewing patients' food and fluid intake and nutritional or hydration needs, including risk assessments, nutrition or fluid charts, prompting, prescribed nutritional support and escalation of inadequate intake.
What is not included
- Excludes medication, electrolyte or disease-specific treatment concerns unless the asserted deficiency directly concerns nutrition or hydration needs.
- Excludes generic clinical record-keeping, staffing or care-planning deficiencies unless they directly impair the nutrition and hydration process.
- Excludes food-service or dietary provision failures where no patient-specific nutrition or hydration safety need is identified.
- Excludes malnutrition-only concerns that do not materially involve the broader nutrition and hydration management process.
- Excludes isolated fluid-balance recording failures where the concern is limited to fluid records and does not support the wider nutrition and hydration condition.
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Reports and published responses 39 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to provide adequate dietary and fluid intake support
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Caring Moss Cottage Ltd
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Caring Moss Cottage Ltd
Train all care staff and nurses in communication, documentation, reporting, nutrition, malnutrition and dehydration.
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Caring Moss Cottage Ltd
Disseminate relevant record-keeping, care, nutrition, hydration, bowel-care, accountability, delegation and leadership policies through the quality compliance software reading list.
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Caring Moss Cottage Ltd
Revise daily handovers to record dietary intake, fluid consumption and elimination for earlier intervention.
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Caring Moss Cottage Ltd
Add fluid-balance charts and bowel activity to the manager’s daily walk-round checks.
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Concerns raised1
Failure of intentional rounding and nursing practices to ensure adequate hydration and nutrition for vulnerable ward patients
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Manchester University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Manchester University NHS Foundation Trust
Continue enhanced auditing of appropriate food-chart commencement for three months to assure consistent nutrition monitoring across WTWA hospitals.
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Manchester University NHS Foundation Trust
Provide additional nutrition and hydration monitoring through quality and safety walk rounds led by nursing directors, with real-time feedback.
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Manchester University NHS Foundation Trust
Formalise Ward Manager and Matron walkarounds to increase assurance of mealtime preparedness and real-time patient feedback.
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Manchester University NHS Foundation Trust
Increase the volume and frequency of peer dining audits from March 2026, reporting results through senior nursing and nutrition governance.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Manchester University NHS Foundation Trust
The Trust considers its comprehensive care approach, including nutrition and hydration support for vulnerable patients, sufficient to address the concern.
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Concerns raised1
Insufficient nutritional support for inpatients
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- East Sussex Healthcare NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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East Sussex Healthcare NHS Trust
Require admission and weekly MUST screening, real-time monitoring, automatic Dietetics referral for high risk or poor intake, and multidisciplinary review of repeated nutrition or hydration refusal.
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East Sussex Healthcare NHS Trust
Continue quarterly audits of MUST compliance, referral timeliness, and weight monitoring, with results reported through governance arrangements.
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East Sussex Healthcare NHS Trust
Run a BETU nutrition-improvement pilot using additional Dietetic staffing, equipment review, and strategies to improve nutrition, then roll learning out across the Trust.
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Concerns raised1
Failure to accurately and completely record fluid and food intake
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- University Hospitals of Northamptonshire NHS Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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University Hospitals of Northamptonshire NHS Group
Use electronic fluid-balance charts in Nevercentre to improve accessibility, calculation and documentation accuracy.
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University Hospitals of Northamptonshire NHS Group
Roll out updated food-and-fluid charts across both hospitals, including prompts for chart commencement, visitor-provided food and oral nutritional supplements.
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University Hospitals of Northamptonshire NHS Group
Audit MUST completion and the accuracy of food-and-fluid charts through Nutrition Nurses and use findings to monitor compliance.
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University Hospitals of Northamptonshire NHS Group
Deliver evaluated monthly nutrition and hydration training through the Clinical Skills Nursing Programme, including documentation standards.
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Concerns raised1
Failure to monitor and record malnutrition-risk interventions
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Frimley Health NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Frimley Health NHS Foundation Trust
Require Divisional Directors of Nursing to provide assurance that patients’ nutrition and hydration needs are assessed, met and accurately recorded.
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Frimley Health NHS Foundation Trust
Develop and deliver updated nutrition and hydration training covering documentation, mealtimes, trays, diets and supplements, with area-level compliance monitoring.
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Frimley Health NHS Foundation Trust
Amend Epic care flowsheets to capture food and fluid intake in greater detail and disseminate supporting safety communications.
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Frimley Health NHS Foundation Trust
Implement a weight-loss flag that triggers a multidisciplinary swarm huddle and individualised care planning, with compliance monitoring.
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Frimley Health NHS Foundation Trust
Run the Harm Free Care audit programme to monitor food-chart completion, nutritional care and significant-weight-loss escalation.
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Concerns raised1
Inadequate assessments of hydration status for ward patients
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Deliver ongoing education and training on fluid balance and hydration assessment through Medicine and Quality Improvement teams.
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Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Host a multidisciplinary Gastroenterology Masterclass addressing comprehensive nutrition and hydration assessment and fluid-intake monitoring.
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Concerns raised1
Failure to formally monitor dietary intake
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Aneurin Bevan University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Aneurin Bevan University LHB
Embed strengthened nutrition documentation and compliance monitoring within the Quality Management System.
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Aneurin Bevan University LHB
Develop and deploy a Gold Standard food chart with a supporting staff briefing.
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Aneurin Bevan University LHB
Reinforce red trays and visual identifiers for patients requiring dietary monitoring.
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Aneurin Bevan University LHB
Use AMaT data to assess and improve ward-level compliance with food-chart use.
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Aneurin Bevan University LHB
Explore environmental barriers to dietary monitoring, including early tray clearance and single-room isolation.
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Concerns raised1
Failure to escalate concerns about reduced food intake
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Care Quality Commission
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Care Quality Commission
Undertake an unannounced assessment covering visit duration, nutrition and hydration, health monitoring, escalation, record keeping, governance, safeguarding and decision-making.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Care Quality Commission
The January 2020 inspection found no concerns about supporting people with eating, drinking, nutrition or hydration needs.
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Concerns raised2
Failure to ensure the recorded and implemented diet reflects identified nutritional needs
Failure to implement and maintain food charts after malnutrition risk assessment
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- York and Scarborough Teaching Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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York and Scarborough Teaching Hospitals NHS Foundation Trust
Consolidate eating, drinking and nutrition assessments into one Nucleus section.
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York and Scarborough Teaching Hospitals NHS Foundation Trust
Carry out quality-improvement work addressing poor compliance with nutritional assessment and food-chart requirements.
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Concerns raised1
Poor quality of fluid and nutrition charts
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Care Quality Commission
- Qualia Care Limited (In Administration
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Care Quality Commission
Conduct an assessment and inspection of Downshaw Lodge to verify required changes, including staff training, accurate needs assessment, care planning, and documentation.
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Qualia Care Limited (In Administration
Complete an IMPACT audit of documentation, nutrition and fluid-recording practice.
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Qualia Care Limited (In Administration
Train staff in MUST, fluid and nutrition care, documentation, record-keeping and dietary-risk escalation.
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Qualia Care Limited (In Administration
Conduct regular management spot checks and dip-sampling of care records to verify documentation compliance and identify training needs.
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Qualia Care Limited (In Administration
Monitor fluid and food intake charts and provide detailed handovers at every shift change.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Care Quality Commission
Existing provider actions, multi-agency oversight and available documentation processes were considered sufficient to address identified care and recording risks.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026