MUST score, weights and fluid charts: nutrition and hydration in care homes

Every resident in a care home needs a MUST score on admission and monthly, a weight recorded at least monthly and weekly for anyone at risk, and a fluid chart only where there is a clinical reason for one, with a target and a trigger. Food charts run for a defined period to answer a specific question. All three feed into a nutrition and hydration section of the care plan that says what the person needs, what they like, and what staff do when intake drops.

The short answer

The MUST score is the malnutrition universal screening tool used across the NHS and care homes. It combines BMI, unplanned weight loss and the effect of acute illness into a score of 0 (low risk), 1 (medium risk) or 2 and above (high risk), and each band has a set of actions. Weights are the input that keeps the score honest, so weigh accurately and on schedule. Fluid charts fail when they are started for everyone, have no target, and are filled in from memory at the end of the shift; they work when they are started for a reason, have a target and a trigger, are recorded at the time of the drink and are totalled and acted on. Food charts should answer a question, such as how much is this person actually eating, over a set number of days. All of it belongs in the care plan and all of it is evidence under Regulation 14.

Why nutrition and hydration matter more than the paperwork suggests

Malnutrition and dehydration are behind a large share of what goes wrong in care homes: falls, pressure ulcers, urinary infections, delirium, constipation, hospital admissions and slow recovery from anything. They are also the problems inspectors can see for themselves. A resident who has visibly lost weight, a jug of water out of reach, a mealtime with nobody helping the people who need it, a MUST score that has said high risk for six months with nothing done. None of that needs a records audit to find.

Regulation 14 requires providers to meet nutritional and hydration needs, which means assessing them, planning for them, meeting them and recording that you did. The record matters because weight loss is slow and silent. Nobody notices 4kg over three months without a set of scales and a chart.

In learning disability and mental health services the picture is different. Residents may be underweight from a lifetime of poor intake, or overweight from medication and inactivity, or both at different times. Swallowing problems are common and often undiagnosed. The MUST tool still applies, but the care plan has to fit the person.

At a glance: MUST bands and what to do

These are the BAPEN care home pathways. Local dietetic services may add steps, such as a first-line food fortification period before referral, so check what your ICB expects and record it in your policy.

What the MUST tool is and where it comes from

MUST stands for Malnutrition Universal Screening Tool. It was developed by BAPEN, the British Association for Parenteral and Enteral Nutrition, and it is the screening tool NICE recommends for adults in hospitals, care homes and the community. It was designed to be completed by care staff in a few minutes, using a set of scales, a height measurement and a simple question about illness.

It is a screening tool, not a full nutritional assessment. A high score means refer and act; it does not tell you why the person is losing weight. That question, whether it is depression, dementia, a swallowing problem, a sore mouth, medication, cancer or simply food they do not like, is for the care plan review and the GP.

It is also universal, which means everyone gets one, including the resident who looks well nourished. Weight loss in an overweight person is still weight loss and still scores.

How to calculate the MUST score step by step

There are five steps. The first three produce numbers, the fourth adds them up and the fifth decides what to do. A MUST score calculator or a BMI MUST score calculator built into your records system does the arithmetic, but staff need to understand it so they can spot an error.

1. BMI score. Measure height and weight and calculate BMI. Score 0 for a BMI of 20 or above, 1 for 18.5 to 20, and 2 for below 18.5.
2. Weight loss score. Compare the current weight with the weight three to six months ago and work out the percentage lost. Score 0 for less than 5 percent, 1 for 5 to 10 percent, and 2 for more than 10 percent. Only unplanned loss counts.
3. Acute disease score. Score 2 if the person is acutely ill and has had, or is likely to have, no nutritional intake for more than five days. This step rarely applies in a care home outside of serious illness.
4. Add the three scores. 0 is low risk, 1 is medium risk, 2 or more is high risk.
5. Follow the management pathway for the band, record it in the care plan and set the date of the next screen.

For a worked example with the percentage arithmetic, see how to calculate the MUST score.

When you cannot weigh or measure someone

Some residents cannot stand on scales, cannot be measured for height, or will not agree to either. BAPEN provides alternatives and they should be in your policy so staff do not simply leave the box empty.

For height, measure ulna length from the elbow to the wrist bone and read the estimated height from the BAPEN table, or use knee height, or use a documented height from a previous record. For BMI when no weight is available, measure mid upper arm circumference: below 23.5cm suggests a BMI under 20, above 32cm suggests a BMI over 30. For weight loss, look at whether clothes, belts, rings and dentures have become loose, ask the person and their family, and record a subjective judgement.

Sit-on and hoist scales solve most of the weighing problem in nursing homes and are worth the cost. Whatever method you use, record it on the assessment. An inspector will accept an estimated BMI with a stated method; they will not accept a blank.

Weights: the input that keeps MUST honest

The MUST score is only as good as the weights behind it. Weigh everyone monthly, weekly for anyone at medium or high risk or anyone with a rising Waterlow score or a pressure ulcer, and on the same scales at the same time of day in similar clothing. Calibrate the scales annually and record it.

Look at the trend, not the number. A loss of 1kg in a month means little on its own; a loss of 1kg every month for four months is 5 percent or more for most residents and should already have triggered action. Plot the weights or use a system that shows them as a line so the trend is obvious to whoever opens the record.

Set a trigger. Most homes use a loss of 2kg or more between weighings, or 5 percent over three months, as the point at which the senior is told and the MUST score is repeated outside the schedule. Write the trigger in the care plan so it does not depend on someone noticing.

Who needs a fluid chart

Not everyone. A home that runs fluid charts on every resident is running charts nobody reads, and the resident who really needs one is lost in the pile. Start a chart where there is a reason.

• Recent dehydration, urinary tract infection, delirium or constipation.
• A MUST score of 1 or more, or noticeable weight loss.
• Dysphagia or thickened fluids, where intake is often well below what staff assume.
• Medicines that affect fluid balance, such as diuretics, lithium or laxatives.
• Confusion, low mood or a learning disability that means the person will not drink unprompted.
• A fluid restriction set by a doctor, where the chart proves the limit is being kept.
• End of life, where the record supports comfort decisions.
• A request from the GP, district nurse or dietitian.

Record the reason on the chart and in the care plan, and set a review date. When the reason has gone, stop the chart and say so.

Set a target and a trigger

A fluid chart without a target is a diary. Most adults need around 1.5 to 2 litres a day from drinks, more in hot weather or with a fever, less where a doctor has set a restriction. Set the target for the person, write it at the top of the chart, and write the trigger below it: the level at which staff act before the day is over.

A typical trigger is below 1,000ml by 6pm, or less than half the target by mid-afternoon. When the trigger is reached, the action is specific: offer a drink every 30 minutes, try the drinks the person actually likes, tell the senior, and record the response. If the total is still short at the end of the day, the senior escalates: two consecutive days under target means the GP or district nurse is told.

Write the target and trigger in the care plan too. Staff should not need to remember whether 1,200ml is fine for this resident, and an inspector should be able to see that the number on the chart matches the number in the plan.

Why fluid charts fail and how to fix each cause

Recorded from memory

The chart lives in the office, so staff fill it in at the end of the shift from memory. Fix: record at the point of the drink, on a device or a chart kept by the resident, and make the entry take ten seconds.

Cups without volumes

Staff write cup of tea. Fix: measure every cup, beaker and glass in the home once, put a laminated list on the kitchen wall, and record in millilitres.

Offered recorded as drunk

A full cup is put down and a full cup is recorded. Fix: record what was actually taken, and record refusals with what was tried instead.

Never totalled

The chart is complete but nobody adds it up, so the trigger never fires. Fix: total per shift and at the end of the day, and put the total in handover. A digital daily log that keeps a running total against the target removes this failure entirely.

Started for everyone

Thirty charts and no time. Fix: charts for a reason, with a review date.

Recording at the point of the drink

The single change that improves fluid charts more than any other is recording at the moment the drink is taken, in the room, by the person who gave it. Everything else is a workaround for not doing that. On paper that means the chart travels with the drinks round or sits in the resident's room. On a device it means the carer taps the resident, the drink and the volume before moving on.

Include everything that counts: tea, coffee, water, squash, milk, soup, jelly, ice cream and thickened drinks. Do not include the water used to swallow medicines unless it is a meaningful volume, and be consistent about it. Record the time, because a chart that shows 1,500ml all delivered between 4pm and 8pm tells a different story from the same volume spread across the day.

Make refusals visible. A resident who refuses every drink from one member of staff and accepts them from another is telling you something about approach, not about thirst.

Food charts that say something useful

A food chart should answer a question. The usual one is how much is this person really eating, asked because MUST is 1 or 2, weight is falling, or the plate keeps coming back full. Run it for three days, or seven where intake varies a lot, and record what was offered, what was eaten as a fraction or in plain words, and why the rest was left.

Portion fractions are more useful than descriptions. Ate half, left the meat, said it was tough tells the cook and the dietitian something. Ate well tells nobody anything. Record snacks and supplements too, because they are often where the calories are.

At the end of the period someone reviews the chart and writes a conclusion in the care plan. Intake adequate, no further action, repeat MUST monthly. Or intake below need, referred to dietitian, food fortification started, weekly weights. A food chart that is completed and never reviewed is worse than no chart, because it shows the home collected the evidence and ignored it.

Food fortification and first-line actions

For medium and high MUST scores, the first actions are usually in the kitchen rather than the pharmacy. Food fortification means adding energy and protein to the food the person already eats: full-fat milk and cream in porridge, mash and soups, grated cheese on vegetables, butter on everything, milk powder stirred into milky drinks. Small portions offered more often, with snacks between meals, work better than a large plate that overwhelms.

Offer the foods the person actually likes, at the times they want them, in a place where they are comfortable. Many residents eat more at breakfast than at any other meal. Some eat better with company, some alone. Some need a plate guard, an adapted cup or a coloured plate that makes the food visible. Some need someone to sit with them for the whole meal, which needs planning at mealtimes.

Record what you tried and whether it worked. When you refer to the dietitian, the referral is far more useful if it says what has already been done.

Referral: GP, dietitian and speech and language therapy

A MUST score of 2 or more, or a medium score with a food chart showing poor intake, means a referral to the GP and dietitian. Send the MUST history, the weight trend, the food chart and a note of what you have tried. Ask the GP to consider causes: medication, depression, dental pain, thyroid, infection, constipation, or something more serious.

Refer to speech and language therapy for any sign of swallowing difficulty: coughing at meals, a wet voice after drinks, food left in the mouth, repeated chest infections, or a resident who is eating slowly and avoiding certain textures. Weight loss and dehydration are often the first visible signs of dysphagia. See choking risk, dysphagia and IDDSI levels.

Record each referral with the date, the response and the outcome, and chase it. A dietitian referral sitting unanswered for eight weeks is a common finding and it is the home's job to follow up.

Oral nutritional supplements

Supplements have a place, but they are prescribed after food-first measures have been tried and they need to be given as prescribed and recorded on the MAR. Common failures are supplements that are prescribed and not given because they are kept in the kitchen and forgotten, supplements given instead of meals rather than in addition, and supplements that continue for a year with no review.

Put the supplement on the MAR chart like any other medicine, with the time and the amount taken, so refusals and missed doses are visible. Review with the GP or dietitian every three months: is weight stable, is the person eating better, can the supplement stop. Your eMAR should show supplement adherence alongside everything else.

Where a resident is on thickened fluids, check that the supplement is thickened to the right IDDSI level and record it.

Hydration across the day

Most dehydration in care homes is not about refusal; it is about opportunity. Drinks are offered at set rounds and at meals, and the hours in between are dry. Residents who cannot reach a jug, cannot pour, cannot see the cup or cannot remember to drink go without. Fix the opportunity first.

Offer a drink at every contact, not just at rounds. Put drinks within reach and in a cup the person can use. Use drinks the person likes: many residents will take far more of a squash or a milky coffee than they will of water. Offer high-water foods such as jelly, ice cream, melon, soup and yoghurt. Run a drinks trolley mid-morning and mid-afternoon with choice on it. Prompt and, where needed, sit and help.

Hot weather changes the target. Have a hot weather plan that raises the trigger, adds rounds and checks the residents most at risk more often. Record that it was used.

Dysphagia and thickened fluids

Residents on thickened fluids are the group most likely to be dehydrated, because thickened drinks are less pleasant, take longer, and are often left half finished. Every resident on thickened fluids should have a fluid chart while the risk is being established, and the chart should show the IDDSI level of each drink alongside the volume.

Check that staff are thickening consistently, using the measured scoop and the timing on the product instructions, and that drinks are the right level rather than simply thick. Over-thickened drinks are refused; under-thickened drinks are aspirated. The speech and language therapy plan sets the level and the care plan should state it clearly with the IDDSI number.

Pre-thickened drinks and thickened water jugs left in the room can help, but only if the person can and will drink them without help. Record which approach works.

Learning disability and mental health services

Nutrition in these services is rarely about frailty and often about long-standing patterns: a resident who has always eaten the same three foods, someone whose antipsychotic drives appetite and weight gain, a person whose intake collapses during a depressive episode, someone with autism whose sensory needs rule out most textures, or a resident who drinks litres of fluid a day for reasons that need medical review.

MUST still applies and still needs doing monthly. But the care plan has to cover the individual picture: the foods that are accepted, the sensory issues, the support to make choices, the link between mood and intake, and where weight gain is the risk, the plan for activity and healthy choices without taking away autonomy. Annual health checks with the GP should include weight and BMI, and the record should show the discussion.

Capacity matters. A resident with capacity can choose to eat badly. Record the conversation, the support offered and their decision, and keep offering.

What the care plan needs to say

The nutrition and hydration section of the care plan should let a new member of staff feed the person well on their first shift. Include:

• Current MUST score and band, current weight, the trend and the weighing schedule.
• Any diagnosis affecting eating: dysphagia with the IDDSI levels, diabetes, coeliac disease, allergies.
• Likes, dislikes, cultural and religious requirements, and the foods that always work.
• Support needed: prompting, cutting up, adapted cutlery or cups, full assistance, positioning.
• Where and with whom the person prefers to eat, and the times that suit them.
• Fluid target, trigger and the action when it is reached.
• Supplements, fortification and any restriction.
• What to watch for and when to escalate: refusal over two days, weight loss beyond the trigger, coughing at meals.

Review it monthly with the MUST score and after any change. A care record that holds MUST, BMI and weights next to the food and fluid charts, as Kiwi does in its health monitoring, lets the reviewer see the whole picture on one screen instead of across three folders. See care records.

Mealtimes as evidence

Inspectors observe a mealtime at almost every inspection, and it tells them more than any chart. They watch whether residents who need help get it, whether that help is unhurried and at eye level, whether choices are real, whether food looks and smells good, whether people on modified diets get something that looks like food, whether drinks are on the table and topped up, and whether staff talk to residents or to each other.

Protected mealtimes help, with all available staff in the dining room and non-urgent tasks stopped. So does a manager who eats with residents from time to time. So does a system where the kitchen knows each person's IDDSI level, allergies and preferences from the care plan rather than from a whiteboard that was last updated in spring.

Record mealtime observations occasionally as part of your own audit, with what went well and what you changed.

Monthly nutrition audit

Once a month, before the governance meeting, check the following and record the result.

1. Every resident has a MUST score dated within the last month.
2. Every resident has a weight dated within the last month, and high-risk residents have weekly weights.
3. Every medium and high score has the pathway actions recorded in the care plan.
4. Every open fluid chart has a reason, a target, a trigger, daily totals and a review date.
5. Every food chart started in the month has a written conclusion.
6. Every dietitian and speech and language therapy referral has a response or a chase recorded.
7. Weight trends across the home: how many residents lost more than 2kg, and what happened for each.
8. Supplements on the MAR are being given and have a review date.

Write a one-paragraph summary with the numbers and the actions. Kept month on month, this is the governance evidence that turns a Regulation 14 question into a short conversation. Your CQC compliance file is the place for it.

Common mistakes

• MUST scores carried forward without a new weight, so the score never changes.
• Height never measured, so BMI is a guess and the score is wrong from the start.
• Fluid charts on every resident, filled in at the end of the shift, never totalled.
• No target or trigger on the chart, so a poor day produces no action.
• Food charts run for weeks with no conclusion written anywhere.
• Supplements kept in the kitchen and given when someone remembers, with no MAR record.
• Referrals made and never chased.
• Weight loss noticed by a relative before it was noticed by the home.

What good looks like on inspection day

An inspector will ask how many residents are at high risk of malnutrition and what you are doing about each one. Have the number ready and be able to open two or three records and show the MUST history, the weight trend, the care plan actions, the charts and the referrals. They will check that the fluid target on the chart matches the plan, that totals are done and that a day under the trigger produced an action.

They will watch a mealtime and talk to residents and relatives about the food. They will look in the fridge and the kitchen for allergen and IDDSI information and ask the cook how they know what each person needs. They may ask a carer what a MUST score of 2 means and what they would do if a resident refused all drinks for a day.

Be ready to show the monthly audit and give an example of a resident whose weight stabilised because of something the home changed. That story, backed by the record, is the strongest evidence you can offer.

Final conclusion

Nutrition and hydration are where good intentions go to die in paperwork. The fix is not more charts but the right ones: a MUST score that uses a real weight every month, weights that are looked at as a trend, fluid charts started for a reason with a target and a trigger, food charts that answer a question and end with a conclusion, and a care plan that tells staff what to do. Record at the time, total every day, act on the trigger, chase the referral and audit it monthly. Do that and nobody in your home will lose weight without you knowing and without something being done about it.

Frequently asked

How do you calculate a MUST score?

Add three numbers. Score the BMI (0 for 20 or above, 1 for 18.5 to 20, 2 for under 18.5), score unplanned weight loss over the last three to six months (0 for under 5 percent, 1 for 5 to 10 percent, 2 for over 10 percent), and add 2 if the person is acutely ill and has had, or is likely to have, no intake for more than five days. A total of 0 is low risk, 1 is medium and 2 or more is high risk.

How often should MUST be done in a care home?

On admission and then monthly for everyone, because that is the interval BAPEN recommends for care homes. Repeat it sooner after illness, a hospital stay, a change in appetite or a noticeable change in clothing fit. High-risk residents are weighed weekly and the score is reviewed with each weight.

How much fluid should a care home resident have each day?

Around 1.5 to 2 litres for most adults unless a doctor has set a restriction, for example in heart failure or kidney disease. Set an individual target on the chart rather than a generic one, and set a trigger below which staff must act and escalate.

Who needs a fluid chart?

Anyone with a clinical reason: recent dehydration or urinary infection, a MUST score of 1 or more, swallowing difficulties, a medicine that affects fluid balance, confusion that stops them drinking unprompted, or a request from the GP or district nurse. Charts run for a defined period with a review date, not for everyone forever.

What do you do if a resident's MUST score is 2?

A score of 2 or more is high risk. Refer to the GP and dietitian, start weekly weights and a food and fluid chart, fortify food, offer snacks and check the swallow, and set a goal in the care plan such as stopping further loss. Review the plan monthly and record what changed.

Can you do MUST if the resident cannot be weighed?

Yes. BAPEN provides alternative measures: ulna length to estimate height, mid upper arm circumference to estimate BMI category, and a subjective assessment of weight loss from clothing, jewellery and the person's own account. Record which method you used and why.

Do fluid charts need to be added up?

Yes, at least once per shift and always at the end of the day, with the total compared against the target. A chart that is filled in but never totalled cannot trigger action. The daily total and whether the trigger was reached should be visible in the handover.

Sources

• BAPEN: Malnutrition Universal Screening Tool (MUST) and explanatory booklet
• NICE CG32 Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition
• NICE Quality Standard QS24 Nutrition support in adults
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 14 Meeting nutritional and hydration needs
• The Eatwell Guide (Public Health England)
• British Dietetic Association: Nutrition and hydration in care homes resources
• IDDSI framework