1.1 What the policy is
The government will provide a free 4-month supply of daily vitamin D supplements for residents in residential and nursing care homes in England to help support their general health, in particular bone and muscle health. Each daily supplement will contain 10 micrograms (400 international units (IU)) of vitamin D. This one-off 4-month supply will be delivered directly to residential and nursing care homes from January 2021.
1.2 The importance of vitamin D for care home residents
Vitamin D helps regulate the amount of calcium and phosphate in the body. These nutrients are needed for healthy bones, teeth and muscles. Too little vitamin D can lead to bone pain and muscle weakness in adults, which may also increase the risk of falls in older people. The NHS provides general advice on vitamin D.
From around late March and early April to the end of September, most people should be able to get the vitamin D they need from sunlight as the body creates vitamin D from direct sunlight on the skin when outdoors, however during the autumn and winter we cannot make sufficient vitamin D from sunlight. Vitamin D is also found in a small number of foods, such as oily fish and liver, and some fortified foods, such as fat spreads and breakfast cereals; however, it is difficult to get enough vitamin D from food alone.
Therefore, during the autumn and winter months everyone is advised to take a 10 microgram (400 IU) supplement of vitamin D every day.
Some adults are advised to take a daily supplement containing 10 micrograms (400 IU) of vitamin D throughout the year if they are not often outdoors, for example if they are frail, housebound or living in a care home[footnote 1]. Public Health England’s (PHE) guidance on Healthier and more sustainable catering: nutrition principles also includes this recommendation. This advice is particularly important for people who have been shielding this year due to coronavirus (COVID-19), or residents who are living in care homes, because they are more likely to have been indoors over the spring and summer and so may not have been able to obtain enough vitamin D from sunlight. DHSC has therefore prioritised the provision of free vitamin D supplements to people in these groups in England.
1.3 Expectations of care home providers
Care home providers are required to meet resident’s full nutritional needs to sustain life and good health, and reduce the risks of malnutrition, in line with regulation 14 (Part A) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. In addition to provision of nutritious meals, this should include food supplements where necessary, such as vitamin D.
This year, the government will provide all nursing and residential care homes in England with a free 4-month supply of vitamin D supplements as it is likely that care home residents will have stayed indoors more than usual over spring and summer last year as a result of the national restrictions for COVID-19.
Care home providers should give residents the choice and offer the four-month supply of vitamin D supplements as part of this nutritional and hydration requirement and in line with existing procedures regarding consent and any relevant safety considerations outlined in section 2.1. All care home providers will need to record provision of vitamin D supplements and can choose the most appropriate way for their care home to do this, in line with section 3.3.
While some care homes may already support residents to take vitamin D supplements, this may be new for other care home providers and members of staff. This guidance has been produced in consultation with the Care Quality Commission to support care home providers to put the appropriate measures in place.
Where residents require support to take a supplement, care home providers must be assured that care staff are trained and competent.
1.4 Types of supplements provided to residents in care homes
Each daily supplement will contain 10 micrograms (400 IU) of vitamin D. The vitamin D supplement provided will be in a liquid form and 2 drops is equivalent to 10 micrograms.
The vitamin D supplements provided are a food supplement and are not a prescribed medicine. The supplements provided are equivalent to those that are readily available in retail outlets such as supermarkets, pharmacies and health food shops.
2. Identifying which residents should take vitamin D supplements
This section outlines the safety information that care home providers will need to check prior to offering the vitamin D supplement to resident’s and provides guidance on the steps that care providers should follow for each resident.
This section also outlines how to offer vitamin D supplements and further information on consent.
2.1 Important vitamin D safety information
There is minimal risk associated with provision of a daily 10 microgram vitamin D supplement. However, there are some rare instances where it should not be offered without having received further advice.
Care home providers must check each resident’s care plan and medicines administration record (MAR) to see if any of the information outlined in sections 2.1.1, 2.1.2, 2.1.3 and 2.1.4 applies to the resident. Care home providers should follow the guidance below on the appropriate steps that should be taken for each resident.
If care home providers do not have sufficient access to a resident’s MAR or medical conditions, they should check with the resident’s healthcare professional at their next appointment before offering vitamin D supplements.
2.1.1 Prescriptions containing vitamin D and different supplements strengths
Care staff should check each resident’s care plan and MAR to see whether they are already taking, or are prescribed, a supplement or medicine containing vitamin D by their GP or healthcare professional, for example either cholecalciferol (vitamin D3) or ergocalciferol (vitamin D2), either alone or in combination with other products – for example, calcium.
If a GP or healthcare professional has recommended that a resident takes a different amount of vitamin D, their advice should be followed.
If this applies to the resident, care staff should not offer them the additional 10 microgram vitamin D supplement.
Care staff may wish to explain to the resident why they are not being offered an additional supplement.
If the care home manager is unsure about whether the resident already takes or is prescribed a form of vitamin D, further advice should be sought from the resident’s GP or healthcare professional at the resident’s’ next appointment, before offering the supplement. It is not necessary to contact the resident’s GP or healthcare professional about the vitamin D supplements prior to their next appointment.
2.1.2 Medical conditions
Some residents may have medical conditions that mean that they may not be able to safely take as much vitamin D as the general population. Care home providers must check if any of the following medical conditions appear on a resident’s care plan or MAR:
those under the care of a renal, endocrinology or cancer specialist
people with high vitamin D levels
people with kidney stones (now or in the past)
people with too much parathyroid hormone (hyperparathyroidism),
people with cancer (some cancers can lead to high calcium levels)
people with severe kidney disease
people with a rare illness called sarcoidosis
If a resident has any of the medical conditions or treatments listed above, care staff should not offer them the 10 microgram vitamin D supplement.
Care staff may wish to explain to the resident why they are not being offered the supplement.
If a resident has any of the medical conditions listed above or if the care home manager is unsure whether the resident has any of the medical conditions listed above, further advice should be sought from the resident’s GP or healthcare professional at the resident’s next appointment, before offering the supplement. It is not necessary to contact the resident’s GP or healthcare professional about the vitamin D supplements prior to their next appointment.
Vitamin D supplements are usually well tolerated. Care providers should check the resident’s care plan and MAR for any allergies. In the rare event of any adverse reactions to the vitamin D supplements, care providers should follow the guidance outlined in section 3.6.
If a resident has an allergy to any of the listed ingredients, care staff should not offer them the additional 10 microgram vitamin D supplement.
Care staff may wish to explain to the resident why they are not being offered the supplement.
If a resident has an allergy to any of the listed ingredients or if the care home manager is unsure, further advice should be sought from the resident’s GP or healthcare professional at the resident’s next appointment, before offering the supplement. It is not necessary to contact the resident’s GP or healthcare professional about the vitamin D supplements prior to their next appointment.
2.1.4 Swallowing difficulties
Some residents may receive clinical care for swallowing difficulties and/or have specific dietary needs met through nutrition support such as a tube feed.
The vitamin D supplements provided will be in a liquid form, however further advice should be sought from appropriate healthcare professionals such as their GP, dietician, pharmacist or speech and language therapist at the next appointment or opportunity, before offering the supplement. It is not necessary to contact the appropriate healthcare professional about vitamin D supplements prior to the resident’s next appointment.
Care home staff may wish to explain to the resident that they are not being offered the supplement until further advice is sought with the appropriate healthcare professional to confirm whether they can safely take a vitamin D supplement.
2.2 Interactions with medications
While some medicines may interact with high doses of vitamin D, there are unlikely to be any interactions associated with the 10 microgram (400 IU) vitamin D supplement. These supplements are intended to supplement the diet and should not be a substitute for a varied diet.
As outlined in section 2.1.1, if the resident is already taking, or is prescribed, a medication that contains vitamin D by their GP or healthcare professional, they should not be offered the vitamin D supplement.
2.3 Consent and mental capacity
Care staff must only provide vitamin D to residents when they have provided informed consent, or on the basis of a best interest decision under the Mental Capacity Act 2005 (MCA).
All residents who are able to give informed consent are required to do so, in order to receive the vitamin D supplements. This consent should be recorded in line with existing policy in the home.
In order to take a decision about the provision of vitamin D supplements, care staff should start from a presumption of mental capacity. A resident who has capacity to make their own decision about taking the supplements must be able to understand, retain, use or weigh, and communicate the purpose of the supplements, and, the consequences of taking, or not taking the supplements, and of not making a decision about taking the supplements.
To give informed consent on whether to take the vitamin D supplements, residents need to be provided with information about the risks and benefits of taking vitamin D. This information is outlined in section 1 of this document which can be used by care home providers to help residents make an informed decision (and to assess if they have relevant mental capacity to take the decision, or not (more below).
2.3.2 Residents who may lack relevant mental capacity
Some residents may lack mental capacity to consent to take the supply of vitamin D supplements. A person aged 16 or over is protected by the empowering, decision-making framework set out under the Mental Capacity Act 2005 (MCA).
Residential and nursing care homes will have established processes for assessing a resident’s mental capacity to take specific decision at a specific time, and for taking a best interests decision if they do not have relevant capacity. Care home providers should follow their existing MCA and best interests decisions procedures and keep a record of decisions relating to vitamin D supplements in line with the MCA Code of Practice.
Where it has been established that the resident lacks capacity to consent to taking a vitamin D supplement, a best interests decision should be taken in line with the best interest checklist in section 4 of the MCA. This means that the decision-maker must consider all the relevant circumstances, including the likely health benefits to the resident, the resident’s wishes, beliefs and values, the views of their family and what the resident would have wanted if they had the capacity to make the decision themselves. The decision maker should make a record of this decision in line with existing policy in the home. Best interests decisions should be made on an individual basis.
Where appropriate, the resident’s advocates or those with power of attorney for Health and Welfare should be consulted. If there is a deputy or attorney with relevant authority then consent must be sought from them to be able to provide the supplements. Such consent can only be provided if it is in the person’s best interests.
3. Provision of vitamin D supplements
Provision of vitamin D supplements should be person-centred and care home providers should incorporate vitamin D supplement provision into existing routines and care plans which are designed to meet the nutritional and hydration needs of individual residents.
3.1 The supplement strength and frequency of provision
Two drops of the liquid vitamin D supplement make up one daily dose which is equivalent to 10 micrograms of vitamin D. This is equivalent to 400 IU of vitamin D.
Residents should not exceed the recommended dose (1 dose per day containing 10 micrograms equivalent to 400 IU). This is the amount designed to meet their nutritional needs. Taking more is not currently recommended. More information on this is in section 3.5.
3.2 Daily supplements provision
There should be individual person-centred care planning and this should ensure that the supplements are provided to the residents at the most suitable time for the individual person. You may wish to record the name of each resident on the packaging of their individual supply of the vitamin D supplement.
Timings of the supplement provision will vary from person to person. Care home providers must comply with the instructions set out on the product label.
3.3 Record of provision
Resident’s care plans should be updated to reflect whether they will be provided with a daily vitamin D supplement and how they will be supported to take it.
Care home managers, or staff with the relevant authority should record on a daily basis, whether a vitamin D supplement has been provided and taken by a resident as part of their daily care routine. Care home providers can choose where to record the provision of vitamin D supplements, so it aligns with their existing processes and it is the least burdensome approach. For example, this could include a MAR, daily notes or nutrition or dietary records.
If residents are deemed able and competent and wish to self-administer their supplements, they should be supported in doing so. A resident who self-administers should have a current risk assessment in place including safe storage. Supervision and support should be provided if a self-administration risk assessment has deemed it to be necessary.
3.5 Managing incidents
Care home staff are advised to only give one dose of vitamin D supplement a day and record it. If there is any deviation from this, it should be recorded appropriately.
If an error has taken place, it should be identified, reported, reviewed and learnt from to reduce the likelihood of reoccurrence. This may include additional staff training, competency checks, updates to policies and care plans.
If there are concerns that the error puts the resident at risk of abuse or neglect (a safeguarding issue), local safeguarding procedures should be followed.
For most adults taking up to 100 micrograms (equivalent to 4,000 IU) per day is considered safe. In a few people, taking too many vitamin D supplements over a long period of time can cause too much calcium to build up in the body (hypercalcaemia). This can weaken the bones and damage the kidneys and the heart. The NHS has more information about vitamin D, including advice on safe intakes.
The 100 microgram daily tolerable safe level of intake is set on the basis of long-term studies. The Food Standards Agency emphasise that evidence on acute toxicity is limited particularly for those with complicated health conditions.
3.6 Adverse reactions
In the rare event of any adverse reactions to the vitamin D supplement, discuss with the resident’s GP, pharmacist or other healthcare professional. Severe adverse reactions must be reported to the GP immediately. In the rare event that a serious life-threatening allergic reaction or severe adverse reaction takes place, the care home staff must dial 999 for urgent medical attention from the emergency services and administer first aid as required.
3.7 Storing the vitamin D supplements
The care provider should store the supplements securely at the correct temperature with access restricted to authorised staff. Care home providers must comply with the instructions set out on the product label.