Table 1.

Overview of the context, process of implementation, and outcomes in participating homes

	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
	Pride in existing menus	Strong resistance to external guidelines	Located on city outskirts	Rural setting	Health-conscious staff
	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`
		Empowered staff	Manager and head cook have experience of Slimming World1
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
				New manager undermined implementation of guidelines by making changes based on her own preferences and ideas
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
		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
		Emphasis on implementing the nutrition guidelines	Variable levels of involvement of cooks		Cooks happy to let study dietitian take the lead
					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
	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
	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
	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
	Cooks waiting for study team to leave before devising new hybrid menus		Reduction in number of client falls reported by manager

¹Slimming World is a UK slimming organisation.