Table 1 Overview of the context, process of implementation, and outcomes in participating homes
| Â | Home 1 | Home 2 | Home 3 | Home 4 | Home 5 |
|---|---|---|---|---|---|
Context | Deprived ex-mining community | Isolated rural community | Strong management support | Unsettled staffing with unfilled posts | Study coincided with consultation regarding closure of the home |
| Â | Pride in existing menus | Strong resistance to external guidelines | Located on city outskirts | Rural setting | Health-conscious staff |
| Â | Compliant staff | Pride in existing menus | Keen to update menus | Changes coincided with appointment of new manager and new cook | Less emphasis on home cooking` |
| Â | Â | Empowered staff | Manager and head cook have experience of Slimming World1 | Â | Â |
Institutional support | Manager required cooks to adhere to new menus but provided little support for cooks in dealing with negative feedback | Manager delegated all responsibility to cooks and study team | Manager supportive of guidelines and required cooks to adhere to new menus | New manager keen to change menu structure | Manager instrumental in identifying key members of care staff to contribute to the process of menu development but otherwise had little hands-on involvement |
| Â | Â | Â | Â | New manager undermined implementation of guidelines by making changes based on her own preferences and ideas | Â |
Approach to introducing modified menus | Menus devised by study dietitian; emphasis on implementing the nutrition guidelines | Some attempt to engage cooks in process of menu development but insufficient time to achieve ownership | Emphasis on working towards the nutrition guidelines | Emphasis on working towards the nutrition guidelines | Emphasis on working towards the nutrition guidelines |
| Â | Â | Menus largely devised by study dietitian | Majority of menu development carried out by cooks | Majority of menu development carried out by new cook | Care staff involved in process of menu development |
| Â | Â | Emphasis on implementing the nutrition guidelines | Variable levels of involvement of cooks | Â | Cooks happy to let study dietitian take the lead |
| Â | Â | Â | Â | Â | Emphasis on changing recipes rather than dishes |
Outcomes | Cooks working to rule and abdicating responsibility for menus to the study team | Cooks refused to implement modified menus | Adherence to modified menus varied between cooks | Old cooks still providing cover tended not to stick to modified menus | Changes largely unnoticed by clients |
| Â | Modified menus perceived as too extreme and restrictive | Limited changes made | Emphasis on sticking rigidly to modified menus | Some dissatisfaction amongst clients | Some variability between cooks |
| Â | Reported client dissatisfaction | Some cooks implemented changes in ways intended to fail | Little room for cooks to exercise judgement | Cooks modified menus in light of client feedback | Care staff more engaged and supportive of changes |
| Â | Problems with loose bowels due to rapid increase in fiber | Client resistance to changes in the menu | Tendency to revert to old dishes where new dishes unpopular rather than modifying recipes | New manager changed menus while head cook on holiday in line with her own preferences and views | Â |
| Â | Cooks waiting for study team to leave before devising new hybrid menus | Â | Reduction in number of client falls reported by manager | Â | Â |