measures could be taken. However, hygiene regulations were not always complied with, and protective clothing was not worn or removed consistently or correctly. Facilities must ensure compliance with hygiene regulations and guarantee that residents are protected from infection. In the case of MRSA, this means ensuring basic standards of hygiene by implementing appropriate personal, technical and organisational measures, as well as taking further steps such as wearing protective clothing when in contact with 65 patients. of substitute staff who do not have sufficient language skills to communicate with residents. In another facility, the complaints concerned inappropriate treatment of residents, deficiencies in cleanliness and hygiene, neglect with regard to care and the repeated theft of money and jewellery. In another facility, there were reports of chronic staff shortages, persistently high levels of sick leave and low staff morale. However, according to information provided to the resident’s committee on behalf of the facility’s management, staff working hours had been reduced due to the “dark winter period” and would be readjusted accordingly in the summer. It was also evident from the facility's complaints record that basic tasks were frequently not completed in a reliable manner or within an appropriate period of time. One resident, for example, called the fire brigade on a weekend to inform them that she had been lying in her own faeces for several hours and had not received any care. There were further complaints of breakfast not being received, morning medication not being administered, and excessive and repeated delays in the provision of hygiene care. It is unacceptable for such situations to arise for staff-related reasons. In order to ensure that the care and support provided by facilities is geared towards the individual needs and wishes of the residents, sustainable relationships between residents and caregivers are essential. This necessitates a certain level of staff consistency. It must be ensured furthermore that communication between caregivers and residents is not hindered by language problems. Frequent changes in personnel and the repeated employment of temporary staff are therefore highly detrimental to residents. Facilities should take measures which allow the staffing situation to be geared more explicitly and sustainably towards the needs of their residents. 3.2.9 – Nutrition In two of the visited facilities, the National Agency encountered fundamental deficiencies with regard to nutrition. It took particular issue with the fact that food portions were often too small, and that side dishes were often only handed out after being expressly requested by the residents. Other shortcomings included the quality of the food (oily, overcooked or underdone), its unappetising appearance, the repetition of the same menu within a short period of time, and the long lead-time (up to four weeks in some cases) for residents to choose their desired menu. An unbalanced diet, poor meal quality and insufficient quantities of food can lead to symptoms of deficiency. Care facilities have an obligation to provide proper 66 nutrition in accordance with the relevant standards . Furthermore, it must be ensured that residents are given all of the elements that make up a particular meal. Ensuring that meals have a suitable appearance is, above all, a matter of respect towards residents. Facilities should ensure there is a reasonable amount of time between the deadline for selecting a meal and the corresponding meal time. 3.2.10 – Staff 3.2.11 – Documentation Several facilities reported a less than satisfactory staffing situation. In one facility, for example, freelancers and temp workers were hired in order to tackle staff shortages. This results in the frequent use In one facility, care-related data was recorded electronically, with selected documents and information additionally recorded in paper form. Having inspected the documentation of one resident, the National Agency noted the lack of crossreferences for data that were only stored in one of the aforementioned formats. As several persons are always involved in the process of caring for each resident, there are doubts as to whether it can be guaranteed that all parties are fully informed about the relevant care data. A procedure should therefore be established whereby a person’s care data are stored in a single location. 65 Robert-Koch-Institut: Empfehlungen zur Prävention und Kontrolle von Methicillin-resistenten Staphylococcus aureus-Stämmen (MRSA) in medizinischen und pflegerischen Einrichtungen (Bundesgesundheitsblatt 6/2014). 66 Deutsches Netzwerk für Qualitätsentwicklung in der Pflege (ed.): Expertenstandard „Ernährungsmanagement zur Sicherung und Förderung der oralen Ernährung in der Pflege“, first update 2017. Deutsche Gesellschaft für Ernährung e.V.: DGE-Qualitätsstandard für die Verpflegung in stationären Senioreneinrichtungen, third edition 2015. 48