Food, Fluid and Nutritional Care in Hospitals

Transcription

1 National Overview ~ April 2010 Food, Fluid and Nutritional Care in Hospitals

2 NHS Quality Improvement Scotland (NHS QIS) is committed to equality and diversity. We have assessed the performance assessment function for likely impact on the six equality groups defined by age, disability, gender, race, religion/belief and sexual orientation. For this equality and diversity impact assessment, please see our website ( The full report in electronic or paper form is available on request from the NHS QIS Equality and Diversity Officer. NHS QIS would like to thank NHS Grampian for the contribution of images to this document. NHS Quality Improvement Scotland 2010 ISBN First published April 2010 You can copy or reproduce the information in this document for use within NHSScotland and for educational purposes. You must not make a profit using information in this document. Commercial organisations must get our written permission before reproducing this document. Information contained in this report has been supplied by NHS boards/nhs organisations, or taken from current NHS board/nhs organisation sources, unless otherwise stated, and is believed to be reliable on publication.

3 National Overview ~ April 2010 Food, Fluid and Nutritional Care in Hospitals

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5 Introduction and acknowledgements NHS QIS vision is of an NHS that achieves excellence in the care of every patient every time. It leads the use of knowledge to promote improvement in the quality of healthcare for the people of Scotland and performs three key functions: providing advice and guidance on effective clinical practice, including setting standards driving and supporting implementation of improvements in quality, and assessing the performance of the NHS, reporting and publishing the findings. In addition, NHS QIS also has central responsibility for patient safety and clinical governance across NHSScotland. Within this remit, it develops and runs a national system of quality assurance of clinical services. For each service, NHS QIS establishes a project group to: develop and consult on the standards and self-assessment framework oversee the process of external peer review, and report findings to the NHS QIS board. The food, fluid and nutritional care in hospitals project group was established in December 2001 under the chairmanship of Ms Philippa Grant (NHS QIS Board member until 31 December 2005). The standards for food, fluid and nutritional care in hospitals were developed by this group and published in September 2003 following extensive consultation. Copies of the standards are available on the NHS QIS website ( Peer review visits to all NHS board areas in Scotland, including two special health boards providing direct patient care, were conducted between March 2009 and October 2009 to assess performance against the standards. A local report on each NHS board visit, including a detailed assessment of their performance against each standard, has also been published and is available on the website. NHS QIS gratefully acknowledges the work of the food, fluid and nutritional care in hospitals project group for overseeing the project from its inception to the publication of this report. In addition, the contribution made by every member of the peer review teams was crucial to the success of the visit programme. 3

6 Introduction and acknowledgements To those NHSScotland staff who contributed to the peer review visits, NHS QIS wishes to record its thanks; in particular, the liaison co-ordinators, local review facilitators and lead clinicians in NHS boards who were responsible for preparing staff locally for peer review visits and for the compilation of comprehensive self-assessment material prior to visits. This report, based on the NHS QIS local report for each NHS board area, presents a national overview of food, fluid and nutritional care in hospital services within NHSScotland, reporting on the performance across Scotland against the standards and includes relevant examples of local initiatives taking place at local level. 4

7 Contents Introduction and acknowledgements 3 Executive summary 7 1 Setting the scene Background on the review of food, fluid and nutritional care in hospitals The NHS Quality Improvement Scotland approach to assessment Frequently asked questions Useful contacts 18 2 National performance against the standards Detailed findings against the standards 23 Standard 1: Policy and strategy 23 Standard 2: Assessment, screening and care planning 28 Standard 3: Planning and delivery of food and fluid 33 Standard 4: Provision of food and fluid to patients 37 Standard 5: Patient information and communication 40 Standard 6: Education and training for staff 43 3 Appendices 47 Appendix 1 NHS board performance against the food, fluid and nutritional care in hospitals standards 48 Appendix 2 Food, fluid and nutritional care in hospitals external validation panel members 49 Appendix 3 The quality assurance process 50 Appendix 4 NHS boards reviewed 51 Appendix 5: Key developments in food, fluid and nutritional care 52 Appendix 6 Food, fluid and nutritional care in hospitals review team members 53 Appendix 7 Glossary 57 5

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9 Introduction Executive summary and Acknowlegements Introduction Good nutritional care is a fundamental part of good clinical care. For the first time, NHS Scotland has put in place a strategic nutritional care improvement programme which brings together all the key partners and includes clinical standards and guidance, implementation support and measures. Not only does this far-sighted approach bring immediate benefits to patients and NHS staff, it paves the way proactively to meeting the future needs of our ageing population. This report focuses on a specific element of this programme: the outcome of the second review of NHS board performance against the NHS Quality Improvement Scotland (NHS QIS) standards for food, fluid and nutritional care in hospitals. There are over half a million inpatient admissions every year to Scotland s hospitals and the standards are challenging. They need to be implemented across all wards, specialties and departments and they apply to every patient admitted. The key facts below highlight the benefits of taking a structured approach to making sure nutritional care meets these standards. Our findings will inform local and national improvement programmes and set the direction for even higher standards of nutritional care. Key facts Malnutrition affects over 10% of older people (British Association for Parenteral and Enteral Nutrition [BAPEN], 2006; European Nutrition for Health Alliance [ENHA], 2006). Malnutrition is estimated to cost the UK over 7.3 billion a year. Over half of this cost is spent on people aged 65 years and over (BAPEN, 2006). Malnourished patients stay in hospital for much longer, are three times as likely to develop complications during surgery and have a higher mortality rate (The MUST report, BAPEN, 2003; Age Concern, 2006; BBC, 2006). Six out of 10 older people are at risk of becoming malnourished, or their situation getting worse, in hospital (BAPEN, 2003; Age Concern, 2006; BBC, 2006). Up to 14% of older people aged over 65 years in the UK are malnourished (BAPEN, 2003; ENHA, 2006; Age Concern, 2006). Patients over the age of 80 admitted to hospital have a five times higher prevalence of malnutrition than those under the age of 50 (BAPEN, 2003). Malnutrition can be treated effectively (The MUST report, BAPEN, 2003). 7

10 Executive summary Key findings The first review took place in 2005 and concentrated on standards 1, 2 and 6 which cover: the infrastructure NHS boards need to have in place to provide good nutritional care (Standard 1); assessment, screening and care planning (Standard 2); and education and training for staff (Standard 6). At that time we saw evidence of progress in every NHS board. The importance of good nutritional care was clearly understood but was lacking a co-ordinated approach that is risk assessed and proportionate, spanning each NHS board. We also recognised the need to make sure the whole care team is convinced that nutritional care is part of clinical care, rather than solely a hotel service. The second review took place in 2009 when we revisited progress against standards 1, 2 and 6 and also reviewed the remaining three standards (3, 4 and 5). These cover planning and delivery of food and fluid (Standard 3); providing food and fluid to patients (Standard 4); and patient information and communication (Standard 6). Between the two reviews, an intensive support programme was put in place which included the appointment of nutrition champions in every NHS board and strengthened collaborative working between catering and clinical staff so that aims and goals were shared and understood. Our four-point performance assessment scale evolved between the first and second reviews. Initially it was based on development, implementation, monitoring and reviewing, and with the support of NHS we have developed this further to better describe progress in implementation and improvement. We set NHS boards five challenges after the first review and progress against these is recorded below. Implementation of nutritional assessment, screening and care planning by 2009: this has been achieved by almost every NHS board in Scotland. Planning and implementation of improved care for patients with complex nutritional needs: this has been achieved by most NHS boards, although some organisations find it challenging to formalise access to all key members of the complex nutritional care team. Including nutritional care in job/personal development plans (as appropriate): this has been achieved across Scotland. Demonstrating leadership commitment and reporting to the Board: this has been achieved in every NHS board. Ensure budgets and resources are allocated to underpin improvement: nutritional care is clearly funded across NHSScotland. However, while it is relatively straightforward to budget for catering and supplement requirements, it is less easy to define and cost clinical requirements. 8

11 All the NHS boards have risen to these challenges and significant progress has been made since This has provided a strong foundation for work on standards 3, 4 and 5. For Standard 3, all but one NHS board is well into the implementation and monitoring phase of planning and delivering food and fluid. In particular, protected mealtimes have been introduced in all NHSScotland hospitals so that patients and care staff have the time they need without interruptions for tests, drug rounds or visits that could result in missed meals. Further, the nutrition champions have introduced a hydration policy which has resulted in a more formal method of making sure care staff know how much fluid a patient needs and whether this has been provided and taken. For standards 4 and 5, all NHS boards have made good progress in implementing the standards, supported by the Nutritional Analysis Database developed by Health Facilities Scotland (HFS), and the Improving Nutritional Care Toolkit. As a result, there is good evidence that nutritional care in NHSScotland is improving and this in turn will improve clinical outcomes such as length of stay, reduced complications and better long-term health. Conclusions and recommendations The NHS QIS standards for food, fluid and nutritional care in hospitals were published in 2003 and they remain relevant to this day. Since then, NHS boards have worked steadily on implementing these, supported by a number of national activities and initiatives. Collectively, these aim to: raise awareness of the link between nutrition and good health, and that malnutrition can be prevented make sure guidance is available across all sectors, public and private support nutritional screening for all patients, paying particular attention to those known to be vulnerable provide relevant training packages for frontline staff, and support practice development and improvement of services. As a result of effective joint working, we are well on our way to meeting the high standards we have set for nutritional care in hospitals. In particular, NHS boards are to be commended on implementing the malnutrition universal screening tool (MUST) screening tool: as a result we can identify those most at risk of malnutrition and other nutrition-related problems. Our big challenge is to roll out this approach across community and primary care and although the standards are directed at inpatient care, they provide many useful building blocks together with the support resources that have been developed. There are already examples of where this is happening such as in NHS Tayside where a public health approach is being adopted to cover the whole population of the NHS board. 9

12 Executive summary We recommend that NHS boards continue to work towards achieving the NHS QIS standards as part of their broader nutritional strategic plans. The materials developed to support this work are now well developed and the joint working between NHS Education for Scotland, NHS Quality Improvement Scotland and NHS National Services Scotland notably Health Facilities Scotland continues to support the aims listed above. The key challenge is to move the agenda across into community and primary care. Finally, we must not underestimate the critical role of the nutrition champions. Appointed from , they have provided the coordination needed at ward level to achieve these high standards of care and they are an important part of building in the sustainability we need to maintain and exceed these. 10

13 Chapter 1 Setting the scene

14 1 Setting the scene 1.1 Background on the review of food, fluid and nutritional care in hospitals In September 2000, the Clinical Resource and Audit Group and the Centre for Health and Social Research published a report on the nutrition of elderly people and nutritional aspects of their care in long term settings report. This report clearly stated that nutritional care in NHSScotland needed to improve. In response to this, NHS QIS set up a five year programme that aimed to improve the quality of care by: setting standards for nutritional care enabling and supporting healthcare professionals to meet these, and assessing and reporting on progress towards meeting these standards. Best practice statements for nursing and midwifery staff (and other members of multidisciplinary teams) were developed to guide practice and promote a consistent and cohesive approach to nutritional care. Two best practice statements were published in 2002, nutritional assessment and referral in the care of adults in hospital and nutrition for physically frail older people. These focused on assessment and care planning, diet and nutrition, the care environment, referrals, training and education, and nursing management. These were followed by the publication in September 2003 of clinical standards on food, fluid, and nutritional care in hospitals (FFNCH), focusing on the same core elements as the best practice statements. A phased approach to the review of standards was adopted and, from June 2005 to February 2006, every NHS board was visited to assess performance against standards 1, 2 and 6. In August 2006, a series of NHS board reports was published together with a national overview that spelled out recommendations for further improving the quality of nutritional care in Scotland. In 2007, it was agreed that a collaborative work programme to support NHS boards in making further progress and sustainable improvements in nutritional care across NHSScotland should be established and co-ordinated by NHS QIS. The key stakeholders: NHS Education for Scotland, Health Facilities Scotland and NHS QIS, as part of the Improving Nutritional Care Programme (INCP), were brought together to take an integrated approach to the provision of nutrition across NHSScotland. 12

15 The INCP has delivered: a capability framework and educational initiatives which ensure that all healthcare staff groups involved in the provision of food and fluid have the knowledge, skills and capability to optimise nutritional care as part of the patient experience (led by NHS Education for Scotland) a practice development programme of work, building on the issues identified during the first review against the standards and the Audit Scotland Report Catering for Patients a Follow Up Report (led by NHS QIS) a monitoring tool to support delivery of the national catering and nutrition specification for hospitals in Scotland - Food in Hospitals (led by Health Facilities Scotland), and a nutrition analysis database which will be rolled out across NHSScotland in 2010 (led by Health Facilities Scotland). As part of the INCP, NHS QIS committed to a further review of performance against the remaining FFNCH standards (3, 4 and 5) in and progress against standards 1, 2 and 6. 13

16 1 Setting the scene 1.2 The NHS Quality Improvement Scotland approach to assessment NHS QIS uses a methodology which draws upon other quality assurance models to enable it, in partnership with healthcare professionals and members of the public, to develop standards for clinical services and to assess performance across NHSScotland against these standards. Further information and definitions of the terms used in the standards and the assessment of performance are contained in Appendix 7. Review process The review process has two key parts: local self-assessment followed by external peer review. First, each NHS board self-evaluates its performance against the standards and submits this to NHS QIS. This information is then used to inform the on-site visit by an external peer review team. The peer review team, through discussions with staff, validates the information and agrees on the level of performance achieved by the NHS board. NHS board reports are published following each visit. Each review team is led by an experienced reviewer, who is responsible for guiding the team and ensuring that team members are in agreement about the level of assessment reached. The composition of each team varies, and members have no connection with the NHS board they are reviewing. Both of these factors facilitate the sharing of good practice across NHSScotland, and ensure that each review team assesses performance against the standards rather than make comparisons between one NHS board and another. Performance assessment scale In 2005, NHS QIS introduced a four-point performance assessment scale for assessing the FFNCH standards. The scale provided a snapshot view of NHS boards performance in relation to the standards at a single point in time. In 2008, after consultation with NHS boards, it was agreed to revise the scale in order to better reflect the cycle of continuous quality improvement that NHS boards are now engaged in. 14

17 In 2009, NHS QIS internal quality assurance mechanisms highlighted that the 2008 scale did not accurately reflect the breadth and scope of the work which NHS boards had undertaken since the last cycle of reviews. As a result, a further revision was made to the scale and mid-point scores were introduced for the Implementation and Monitoring categories. The revised scale was retrospectively applied to all NHS board local reports, and agreed by an external validation panel in December The chart below outlines the final performance assessment scale applied. Monitoring (measured on the scale based on the criteria): Spread of planned monitoring Embedding of monitoring process Impact of findings from monitoring on implementation Implementation (measured on the scale based on the criteria): Strategic approach to implementation Components implemented Level of embedding Breadth across the organisation y 1 x

18 1 Setting the scene 1.3 Frequently asked questions Q Why is it important to screen for undernutrition? A Whilst a significant part of Scotland s population is now at risk of obesity, studies consistently show that up to 40% of patients admitted to hospital are either at risk of, or have already developed undernutrition. Under nutrition is usually due to an inadequate intake of basic food components but can also result in vitamin and mineral deficiencies. The most common reason for people developing undernutrition is that illness effects appetite so that ill people tend to eat less and therefore, cannot meet their nutritional needs. Serious illness such as infection, or injuries such as burns, also result in an increased demand for nutrients and can make matters worse. Screening for undernutrition allows hospital staff to identify those at risk and begin appropriate support. This can aid recovery, reduces the risk of complications and may reduce the number of re-admissions. Q How are menus developed in hospitals? A Each hospital in NHSScotland is unique, and provides nutritional care for a population specific to its geographical area, and areas of expertise. As a result of this, each NHS board in Scotland has been encouraged to develop its own menus to enable patients within hospitals to be able to choose food and fluid options which are familiar and appealing to them. Each NHS board has a planning group in place which oversees the development of menus appropriate for its patient groups based upon patient feedback, consultation and surveys. Q What are protected/managed mealtimes? A Protected/managed mealtimes is an initiative being rolled out across NHSScotland to ensure that all patients are able to eat their meals in hospital without interruption, by the halting of all non-essential staff activity, both clinical and non clinical, during mealtimes. Many NHS boards have extended this policy to change visiting hours, allowing patients to be able to eat and drink without interruption. Q How do hospitals ensure that food is served in a way appropriate to patients? A Each year, NHSScotland admits over half a million inpatients to its hospitals, and each of these patients requires a meal which is both appetising and served in a way which is acceptable to them. NHS boards have developed a series of individual procedures to ensure that all food delivered to patients is of the highest quality, and of an appropriate temperature and texture for consumption. The design of these procedures is based upon the unique environment in each hospital and aims to ensure that food is delivered from the kitchens to patients as quickly as possible. 16

19 Q What happens if I require a special diet? A NHSScotland is committed to ensuring that all patients who are admitted to hospital are given meal choices which are appropriate for their diet. NHS boards have procedures in place to ensure that options are available for patients with special dietary requirements, or who require a special meal due to cultural, religious or ethnic requirements. Q How do I know what foods or fluids I can bring into hospital? A Patients being admitted to hospital and their visitors can bring some items of food and fluid in to hospital for consumption however, some restrictions are necessary in the interest of patient safety. Food prepared outside the hospital cannot always be guaranteed to meet food hygiene standards particularly if re-heating is required. Not all patients can eat safely. For example a patient who has had an accident or stroke, which affects a patients ability to swallow, while other patients maybe fasted for surgery or to allow tests to be performed. Some patients also require special diets. NHS boards have therefore prepared guidance for patients and visitors and this can be supplied either before admission or by request to the ward or hospital. Q How can I make sure that my feedback regarding hospital food is taken into consideration? A NHS boards in Scotland are committed to ensuring that patients are satisfied with the meals provided to them, and to using patient feedback to improve menus. NHS boards have complaints and communications policies, and patient survey forms to provide feedback on the quality of food and fluid provided. 17

20 1 Setting the scene 1.4 Useful contacts The British Association for Parenteral and Enteral Nutrition Secure Hold Business Centre Studley Road REDDITCH Worcestershire B98 7LG Phone: Website: The British Dietetic Association British Dietetic Association 5th Floor, Charles House 148/9 Great Charles Street Queensway BIRMINGHAM B3 3HT Phone: Website: The British Nutrition Foundation High Holborn House High Holborn LONDON WC1V 6RQ Phone: Website: Food Standards Agency 6th Floor St Magnus House 25 Guild Street ABERDEEN AB11 6NJ Phone: Website: 18

21 Hospital Caterers Association East of Scotland Branch Secretary Ian Bow Food Production Manager Perth Royal Infirmary PERTH PH1 1NX Phone: West of Scotland Branch Secretary Janice Gillan Catering Manager Crosshouse Hospital KILMARNOCK KA2 0BE Phone: Website: Royal Environmental Health Institute of Scotland 3 Manor Place EDINBURGH EH3 7DH Phone: Website: 19

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23 Chapter 2 National performance against the standards

24 2 National performance against the standards This section presents the findings across Scotland in terms of performance against the individual standards. As the standards apply to all NHSScotland hospitals, each NHS board that is responsible for the management of hospitals must implement the standards throughout the NHS board area. The standards require that there is a strategic approach to providing food, fluid and nutritional care in hospitals. A number of examples of innovative local solutions are highlighted at the end of each standard section. These examples are not exhaustive every review team noted examples of good practice during visits and these were often in place in more than one NHS board. Challenges are also listed and there is certainly scope for change and improvements in the process providing appropriate food and fluid for patients. This is recognised by healthcare professionals and by patients and their friends and families, and whilst in the past there was limited patient involvement in food, fluid and nutritional care, there are now many examples of successful partnership working. Feedback from those reviewed and those in review teams is sought after every visit and nearly all people responded. Overwhelmingly, those involved in the review process report that the opportunity to network and the time to consider different ways of addressing shared issues has been valuable. Giving the public and the service the chance to review the way care is provided has been fundamental to the approach taken and is a starting point for many activities including: identifying good practice disseminating good practice stimulating multidisciplinary working involving those who use the service; and, perhaps most importantly reviving the appetite to ensure that both the provision of patient care is balanced by the monitoring of that care against key performance standards, and that the quality of care is continually improved. Sixteen NHS boards, including two special health boards with direct patient contact, were reviewed to assess performance against the standards, and this national overview summarises the 16 local reports. A report detailing the local findings for each NHS board reviewed has been produced. The local reports are available on the website ( 22

25 2.1 Detailed findings against the standards Standard 1: Policy and strategy Standard statement Each NHS board has a policy, and a strategic and co-ordinated approach, to ensure that all patients in hospitals have food and fluid delivered effectively and receive a high quality of nutritional care. A majority of NHS boards have now developed and implemented comprehensive policy and strategy documents which address all the requirements of the NHS QIS standards. A co-ordinated and strategic approach to the evaluation of these documents is evident in some NHS boards. All NHS boards have developed a policy and strategy document for nutritional care. While two NHS boards were still working on draft documentation, the remaining 14 boards have ratified documentation which has been disseminated and implemented throughout the NHS board area, with five NHS boards at an advance stage of implementation. Most NHS boards have developed policy and strategy documents which clearly outline the requirements of the FFNCH standards, and the steps taken to ensure these requirements have been met, including health population requirement studies, appropriate risk assessment and Board level input. We found: Action plans for nutritional care are now routinely in use across the NHS boards, and the use of a financial framework to underpin the action plan was noted in several NHS boards. In several cases, while NHS boards did not possess a specific financial framework document, clear evidence of financial support from Board level managers was evident, in order to finance nutritional care improvements. A culture of awareness of nutritional care issues is developing across NHSScotland, with enthusiastic input from Board, communications, equality and diversity, and public partnership groups noted in much of the work being carried out to monitor the success of nutritional care policies and strategies. There were several examples of direct patient group input into the development of strategic documentation and public information leaflets. Multidisciplinary nutritional care groups are accessible in all NHS boards and are taking responsibility for overseeing nutritional care initiatives for the NHS boards. The structure and remit of these groups varies greatly from board to board, depending upon the patient population, environment and geographical issues faced. Staff on these groups were found to be committed and enthusiastic about the delivery of quality nutritional care, however in several NHS boards, many nutritional care groups rely upon key individuals to achieve a majority of their work plans. 23

26 2 National performance against the standards In the majority of NHS boards, nutritional care groups have a full membership of staff, however some do not have the full core membership required by the standard. In general, these NHS boards reported difficulties in securing medical staff and public representation to the nutritional care groups, or a lack of consistent attendance from existing group members; an issue highlighted in the previous FFNCH review. Active medical membership is required to ensure that effective dialogue between colleagues is achieved in order to influence the development of policy and strategy documentation. Nutritional care is a prominent priority for Board level consideration, and several NHS boards nutritional care groups are now producing extensive annual reports of progress made towards the standards. Evidence was produced to show that these reports are being considered by Boards, and are playing a significant role in securing investment in nutritional care initiatives. When complex nutritional care is required, such as enteral or parenteral tube feeding, patients should have access to a multidisciplinary clinical nutritional support team to oversee their care. While not all NHS boards have a clinical nutritional care support team in place, significant progress has been made in networking and information sharing by clinical staff to ensure that clinicians can be advised by appropriate staff in the treatment of their patients. Standard 1: Policy and strategy 16 Number of NHS boards Performance Assessment Scale Score 24

27 Progress against 2006 recommendations It was evident across a majority of NHS boards that recommendations from the previous NHS QIS review have been acted upon, and nutritional care is prominent on NHS board agendas. Several NHS boards have shown a notable change in culture towards nutrition. NHS boards should demonstrate clear commitment to meeting the national standards by including nutritional care objectives in their action plans. All NHS boards were able to demonstrate that nutritional care plans are in use by the nutritional care teams. A majority of action plans were under regular review, and used to drive forward improvements in the quality of nutritional care. NHS boards need to develop, finalise, implement and monitor nutritional care policies and strategic plans to progress the provision of nutritional care in NHSScotland. This work should be undertaken within agreed timescales. All NHS boards were able to demonstrate progress with the development of policies and strategies. Many NHS boards are at the implementation phase with a few NHS boards able to demonstrate that they are evaluating the effectiveness of these arrangements. NHS boards must provide financial frameworks (budgets) to underpin the implementation of the nutritional care strategic plan and the implementation of the national standards. The majority of NHS boards have made a financial commitment to underpin the implementation of their strategic plans and the standards. However, only two NHS boards had a formal, ratified framework in place. NHS boards should assess the nutritional care policy and strategic plan in line with their risk management strategy, which should be based on the principles of the Australia/New Zealand risk management standards, purchased by NHS QIS for NHSScotland. A large number of NHS boards are taking a risk-based approach to assessing the nutritional care policy and strategic plan, and there has been an increased involvement in nutritional care groups by Board members. Training to support a variety of staff with risk assessment and risk management is also in place. 25

28 2 National performance against the standards NHS boards should ensure that nutritional care groups have the required membership, including active medical representation and lay representation. Lines of accountability between nutritional care groups and Boards should be reviewed to ensure that: there is effective development, implementation and revision of the policy and strategic plan the Board is made aware of progress and constraints, and clear communication channels are in place. Multidisciplinary nutritional care groups are operational in each NHS board area, however representation from medical staff and public partner groups remains an issue for many NHS boards. All nutritional care groups were able to demonstrate clear lines of accountability to their Board for assurance. NHS boards need to urgently address the lack of formal clinical nutritional support teams and specialist nutrition nurses that can best provide patients with complex nutritional support needs. Clinical nutritional support teams are now operational in a majority of NHS board areas, and in NHS boards where teams are not routinely required (for example the Island NHS boards), partnership agreements are in place with other NHS boards to support patient transfer. Good practice should be shared across NHSScotland. Healthcare professionals should maintain their effective networking and link closely with their NHS board s clinical governance and risk management structures and other professional networks, including the Scottish Managed Clinical Network (MCN) for Home Parenteral Nutrition, for support. The majority of NHS boards were able to demonstrate that clinical governance and risk management staff are routinely engaging with nutritional care groups. The establishment of the nutrition champions network has facilitated the sharing of good practice across NHS boards, and there was evidence of joint working on the development of tools to support implementation of the standards, for example the NHSScotland Hydration Policy. 26

29 Recommendations NHS boards should: evaluate the effectiveness of their strategic plans for the provision of nutritional care to patients to ensure that they remain fit for purpose. ensure that nutritional care groups have the required membership, including active medical and lay representation. develop formal financial frameworks to underpin the implementation of strategic plans. It s happening locally: NHS Grampian The NHS board holds board-wide core food, fluid and nutritional care awareness workshops where the nutritional care policy is discussed. The policy and strategic action plan are accessible to staff via the intranet and the policy is also available to the public on the NHS Grampian website. NHS Lothian Following significant funding from the Board, the complex nutritional care team has been expanded to cover patients admitted to both the Royal Infirmary of Edinburgh and the Western General Hospital, Edinburgh. The complex nutritional care teams within these hospitals are seen as a particular strength of NHS Lothian due to the expertise and geographical coverage of the teams. The State Hospitals Board for Scotland The NHS board undertook a population needs assessment which identified that obesity-related illness was a concern for a majority of the patient population at the State Hospital. As a result, the NHS board has restructured its previous nutritional care groups to create the nutrition and weight management group; a multidisciplinary group which takes on responsibility for all nutritional care planning and activity for the NHS board, with a specific focus on the management of obesity. The group has developed a comprehensive action plan based upon its previous nutrition groups. 27

30 2 National performance against the standards Standard 2: Assessment, screening and care planning Standard statement When a person is admitted to hospital, an assessment is carried out. Screening for risk of undernutrition is undertaken, both on admission and on an ongoing basis. A care plan is developed, implemented and evaluated. Most NHS boards have made significant progress in the development and implementation of a system for the assessment, screening and nutritional care planning for hospital inpatients. Fifteen NHS boards have now developed and implemented an effective system for screening for undernutrition in patients. Of these, six NHS boards are at an advanced stage of implementation. Five NHS boards were noted to be monitoring the effectiveness of their screening and care planning arrangements, indicating that these NHS boards are now showing a strategic and co-ordinated approach to care planning. We found: Areas for recording a patient s nutritional care status in medical/nursing assessments vary greatly across sites within NHS boards, and also from board to board. While several NHS boards do not use a single unitary patient admissions document, efforts are made to ensure that the information recorded is consistent across the NHS board area. Most NHS boards are now routinely recording a patient s height and weight, eating and drinking likes/dislikes, food allergies and the need for a therapeutic diet, cultural/ethnic/religious requirements, social/environmental mealtime requirements, physical difficulties with eating and drinking, and the need for equipment to help with eating and drinking within one day of admission. Significant progress has been made throughout NHSScotland to ensure that all patients are screened for risk of undernutrition using a validated screening tool. MUST is now implemented as a national screening tool for undernutrition across NHSScotland. There are a variety of initiatives across many NHS boards to extend its use further into the community. NHS boards are also providing guidance on repeat screenings in medical or nursing notes, depending on the NHS board, and clear guidance is given to staff to ensure guidance can be located by all clinical staff involved in patient care. Clear referral pathways have been developed by a majority of NHS boards, advising clinical staff on the need for referral to specialist services if a patient is identified as being at risk of undernutrition. Agreed timescales for referral were evident in the referral documentation and guidance for immediate referral was available for urgent cases. 28

31 Significant progress has been made by NHSScotland towards improved care planning, with most NHS boards now using multidisciplinary care plans to ensure all clinical staff are fully aware of a patient s nutritional needs. Care plans include the outcome of initial assessment, screening for risk of undernutrition, advised frequency of repeat screenings and actions taken as a consequence of any repeat screenings. Discharge planning has also improved significantly throughout NHSScotland, however several NHS boards are not yet at the stage where discharge planning is co-ordinated fully. Much of the discharge planning taking place at present does not involve the patient, or carer in its development, and often lacks significant detail regarding continued improvement in nutrition after leaving hospital. Standard 2: Assessment, screening and care planning 16 Number of NHS boards Performance Assessment Scale Score Progress against 2006 recommendations NHS boards should continue to implement Standard 1 and provide the central vision, policy and strategy for implementation of Standard 2. Significant progress has been made in the implementation of a strategic and co-ordinated policy and strategy for food, fluid and nutritional care in hospitals, which has resulted in improvement in assessment, screening and care planning. 29

32 2 National performance against the standards NHS boards should ensure that all assessment, care planning and discharge documentation includes the nutrition information required by the standard, and that this information is completed and acted upon. A national core nutrition data set should be developed. A majority of NHS boards are now systematically recording the nutrition information required by Standard 2, and using this information to improve patient care. In NHS boards where consistent medical admission documentation is not used, insertions to the documents are used to ensure a core data set is recorded. NHS boards should ensure that a multidisciplinary care plan and a discharge plan, which include the required nutritional care information, are developed for each patient. Most NHS boards have multidisciplinary care plans which include the required nutritional care information. While discharge plans were not so advanced in many of the NHS boards, there are plans in place to improve this documentation. NHS boards should adopt a consistent approach to implement validated screening tools in all appropriate ward areas, to streamline staff training, and to enable progress to be easily assessed throughout the patient s stay in hospital. All NHS boards, with the exception of the State Hospitals Board for Scotland, have now implemented MUST as a screening tool for undernutrition. Scotland is the first country to undertake the adoption of a national validated screening tool, and has implemented an ambitious programme of training for staff in its use. NHS boards should establish, through the NHS Knowledge and Skills Framework, core nutrition knowledge and skills for assessment, screening and care planning for nutritional care to ensure these processes and procedures are embedded across the organisation. Through NHS Education for Scotland, and the nutrition champion network, extensive training and development activity is being carried out throughout NHSScotland on the use of MUST to identify patients at risk of undernutrition. A wide range of training and development initiatives are in place, including formal training workshops, mentoring and cascaded learning. 30

33 NHS boards should continue to audit and self-assess their compliance with Standard 2 as part of their clinical effectiveness audit programme. Most NHS boards are undertaking audit activity to monitor compliance with Standard 2, however much of this activity is focused on MUST compliance, rather than all of the information required by the standard. NHS QIS and NES should explore the potential for developing educational materials to address the patient safety aspects of risk assessment and nutrition. NHS Education for Scotland has developed, in conjunction with the nutrition champion network, a range of educational materials, which are available on its website ( Recommendations NHS boards: must maintain the focus on improving nutritional care which has been supported through the INCP. NHS boards are encouraged to build on the work of the INCP and the nutrition champions to further embed assessment, screening and care planning to improve outcomes for patients. should ensure that patients are involved in their discharge planning and that this is co-ordinated to ensure that patients nutritional needs are managed within the community. should continue to improve discharge documentation to include goals for patients to improve their nutritional status. It s happening locally: NHS Lanarkshire NHS Lanarkshire has a programme of annual board-wide audits to monitor compliance with patient screening. The audit results are reviewed and any necessary actions are included in the food, fluid and nutritional care action plan. The annual audit also assesses the availability of screening equipment to ensure that staff have the necessary tools, such as weighing scales, to facilitate patient screening. 31

34 2 National performance against the standards NHSScotland The work of the nutrition champion network is a real strength for NHSScotland. The enthusiasm and dedication of the nutrition champions was evident in all of the NHS boards, and the significant progress made by the network in the improvement of nutritional care is commended. The State Hospitals Board for Scotland Due to the unique population at the State Hospital, risk of undernutrition is extremely low, while risk of obesity-related illness is high. The State Hospital is currently undertaking an exercise to develop a screening tool specific to its inpatient needs, and will be undertaking a series of validation exercises in the future to establish this tool for use in such an environment. 32

35 Standard 3: Planning and delivery of food and fluid Standard statement There are formalised structures and processes in place to plan the provision and delivery of food and fluid. Most NHS boards have made significant progress in the development and implementation of systems for the planning and delivery of food and fluid to hospital inpatients. Fifteen NHS boards have implemented an effective system for ensuring the delivery of food and fluid to patients. Of these, nine NHS boards are at an advanced stage of implementation and five NHS boards were monitoring the effectiveness of their menu planning and delivery arrangements. This indicates that these NHS boards are showing a strategic and co-ordinated approach to ensuring that patients receive a well-planned meal delivered in a timely manner. We found: All NHS boards have a planning group which is responsible for the implementation of a protocol, or local protocols, for the provision of food and fluid to patients. Membership of the planning groups is multidisciplinary, however difficulties have arisen in many NHS board areas in securing regular medical and public representation. In most NHS boards, planning groups work closely with patient and public involvement groups to ensure that feedback on menu proposals is received. However, in some areas, there are challenges in involving specific patient or ethnic groups identified by population assessments. The remit of each planning group has been developed to best serve the needs of the population within the NHS board area. Each group takes responsibility for overseeing a local assessment of need, producing local food chain protocols, menu planning, ensuring that food and fluid served to patients is acceptable to them, setting meal times, ensuring appropriate snacks are available and undertaking the ongoing monitoring of food and fluid provided to patients. Planning groups were found to operate both as nutritional care groups, and as separate groups responsible solely for operational management of nutritional care needs in hospitals. Analysis of food and fluid for nutritional content was found to vary widely between NHS boards. In several NHS boards, all meals offered have been analysed to provide clear information on nutritional content, whilst in some smaller NHS boards, nutritional analysis of the food and fluid they serve to patients has not been undertaken. 33

36 2 National performance against the standards Each planning group was found to engage differently with the public. Some groups maintain constant patient representation in their membership and rely upon public partnership forums to feedback on any changes to the menus, while others have used more innovative ways to engage the public in their menu planning activities. Food production and delivery arrangements in a majority of hospitals are robust and mature, with staff confident that food and fluid are being provided in a timely and acceptable manner to patients. All NHS boards have implemented procedures for the delivery of the correct meals to the wards, for responding when an incorrect meal is provided and to ensure that if a patient misses a meal, they are provided with a meal that meets their needs. Systems for the provision of meals are well established throughout all NHS boards, however a few NHS boards would benefit from having formal documentation of processes in place to support new members of staff. Similarly, in all NHS boards, the nurse in charge of each ward has a process in place to ensure that the correct meals are received on the ward, meals are delivered to the right patients at the right temperature, there is adequate time for patients to each and drink, staff are available to support patients who require help to eat and drink, and to monitor patients intake of food and fluid. However many NHS boards have not formalised and documented the process. All NHS boards have now introduced managed or protected mealtime policies intended to halt all non-essential staff activity during patient mealtimes. Implementation of these initiatives has been supported and driven forward by the nutrition champions network. In several NHS boards, these policies have been extended to prevent visitors to the wards during mealtimes, allowing patients time to eat and drink all of their meals without distraction. Several NHS boards have been prevented from being able to ensure that an adequate number of staff are available to assist patients with eating and drinking due to staffing constraints. In order to address this, NHS boards have developed a range of systems to ensure that all patients requiring assistance receive it, including using heated trolleys to keep food warm until staff are able to assist a patient, and using a coloured tray to identify patients who need assistance. All NHS boards in Scotland have protocols in place for the provision of therapeutic diets, including oral nutritional supplements and for high-energy and high-protein food and fluid. Protocols vary across NHS boards, but in a majority of NHS boards these are clearly documented and offer appropriate guidance to staff on the use of therapeutic diets. 34

37 Similarly, protocols exist in all NHS boards to provide meals outwith the planned menu, for example to vegans, although several NHS boards require to formalise and document these protocols. Standard 3: Planning and delivery of food and fluid 16 Number of NHS boards Performance Assessment Scale Score Recommendations NHS boards: must continue to analyse the full range of dishes on offer to patients and provide information on the nutritional content of their dishes to allow patients to make informed choices about the meals they choose. NHS boards will be supported to analyse dishes with the introduction of the Nutrition Analysis Database of nutritionally analysed dishes which is due to be rolled out in should formalise and document processes for the delivery of food and fluid to patients. should continue to seek innovative ways of engaging with patients and the public in order to involve a wide cross section of the local population in their planning arrangements. 35

38 2 National performance against the standards It s happening locally: NHS Forth Valley The NHS board has appointed a catering monitoring officer responsible for visiting patients in the wards to gather feedback on the food provided. The officer gathers face to face feedback on the meals served and liaises with both the planning groups and catering staff to feedback comments and compliments, and to suggest possible changes to the menus. NHS Shetland The NHS board has undertaken an initiative to involve the public in its menu planning by taking food samples and a heated hospital trolley to a local food festival. Members of the public were able to see first hand how food is transported in the NHS board s hospitals, and were also able to sample and feedback on several menu options first hand. The State Hospitals Board for Scotland The State Hospital is using a traffic light system to code patient menus, indicating the nutritional content of the meals provided, in order for patients to identify healthy options and make informed choices about their diet. 36

39 Standard 4: Provision of food and fluid to patients Standard statement Food and fluid are provided in a way that is acceptable to patients. All NHS boards have made significant progress in the development and implementation of systems for the provision of food and fluid to hospital patients. All NHS boards have now implemented an effective system for screening the delivery of food and fluid to patients. One NHS board was still in the early stages of implementation of these systems, with seven NHS boards identified as being at an advanced stage of implementation. Nine NHS boards were noted to be monitoring the effectiveness of their arrangements for the provision of food and fluid, indicating that these NHS boards are showing a strategic and co-ordinated approach to ensuring that patients have access to meals they find acceptable. We found: It was clearly evident that many NHS boards have designed and developed menu systems which allow patients as much choice as possible for the food and fluid options they require. In the majority of NHS boards, patients have at least two or more options available to them for meal choice and portion size for main meals, and this is available through both plated and bulk meal services. Many NHS boards have made efforts to make menus as flexible as possible to allow for texture modification of a majority of meals on offer. There was also clear evidence of careful planning of menus to allow vegetarian menu choices. NHS board staff are aware that for many patients, particularly those who are long-stay patients, choosing their food and fluid options can be a highlight of the day, as such, all patients, who are capable of choosing their own meals, are allowed to do so. Patients who require assistance to choose food and fluid options will be helped by a member of staff who is familiar with the patient s dietary requirements, or by a friend or relative. Each NHS board operates a food delivery system which is suitable for the geography and environment of the hospitals. Most NHS boards are able to support patients to select their menu choice no more than two meals in advance, and in several NHS boards, patients are able to select their meal option, or change their mind about meal options at the point of delivery. Some NHS boards have found the target to serve food no more than two meals in advance challenging and are exploring ways to allow this flexibility of choice. All NHS boards have protocols in place for the timely and efficient delivery of food and fluid from the kitchen to the wards. All food is routinely monitored 37

40 2 National performance against the standards for temperature upon leaving the kitchens and regular testing of temperature takes place on the wards to ensure food remains at the correct temperature when delivered to patients. Several NHS boards have upgraded delivery trolleys to ensure that food is kept warm until served to a patient. Texture modification, which takes place in the kitchens of a majority of hospitals, is provided to national speech and language therapy standards. All hospital menus have been developed to allow patients to choose meals which are appetising and have a good colour balance. Due to patient choice, colour balance of dishes cannot always be guaranteed as patients are able to choose their meal. A range of accompaniments are available for use in wards, however some NHS boards have opted to restrict the amount of salt available for patient use. All NHS boards have arrangements in place for ensuring that patients are provided with equipment and utensils for eating and drinking which meet their needs. Several NHS boards reported that specialised equipment for eating and drinking is kept on wards where patients are likely to require it, whilst others arrange specialised equipment through the speech and language therapists. All NHS boards can provide patients with fresh drinking water, where clinically appropriate, at all times. Clear guidance is now available for hospital staff on providing drinking water through the NHSScotland Hydration Policy recently introduced by the nutrition champion network. Due to operational restrictions, not all patients are given the opportunity to eat and drink away from their bedside. However, in NHS boards that have space, several initiatives have been established to allow patients access to a dining room. Standard 4: Provision of food and fluid to patients 16 Number of NHS boards Performance Assessment Scale Score

41 Recommendations NHS boards: must ensure that patients are able to choose their meal option as close to the serving of the meal as possible. should ensure that agreed national descriptors in relation to texture modified diets are reflected within their documentation. should monitor the effectiveness of the arrangements in place for the provision of food and fluid to patients to ensure that these remain fit for purpose. It s happening locally: NHS Fife In order to develop a more accurate method of measuring and monitoring the fluid intake of patients in a ward setting, the NHS board has developed an A5 poster for the kitchen, and small credit card sized cards for staff to carry individually, to ensure that all staff are using the same measurements when updating fluid balance charts. NHS Orkney Following significant investment from the Board, the NHS board has completed a programme of refurbishment of its kitchens, and has purchased new food delivery trolleys in order to ensure that all food is kept at an appropriate temperature throughout the delivery process. 39

42 2 National performance against the standards Standard 5: Patient information and communication Standard statement Patients have the opportunity to discuss, and are given information about, their nutritional care, food and fluid. Patient views are sought and inform decisions made about the nutritional care, food and fluid. All NHS boards have made significant progress in the development and implementation of systems for the communication of information to inpatients. All NHS boards have implemented an effective system of patient communication. Of these, five NHS boards are still in the early stages of implementation, with six NHS boards identified as being at an advanced stage of implementation. Four NHS boards were monitoring the effectiveness of their arrangements for communication of patient information. We found: All NHS boards have developed patient literature designed to inform hospital inpatients of key information they will need on nutritional care during their hospital stay. Most NHS boards are able to provide a separate leaflet on hospital food, in addition to a general inpatient information booklet. The content of patient information leaflets is generally good, with a majority of NHS boards providing appropriate detail on: how to order meals; mealtimes; the content of meals and choices available; facilities available for eating meals; the opportunities available for preparing and consuming food and fluid; how to obtain assistance with eating and drinking if required; how to obtain special equipment for eating and drinking if required; the procedure for obtaining a meal if one is missed; and how to make a comment or compliment about the nutritional care, food and fluid provided. NHS boards have ensured that appropriate information has been developed on special diets, and as a reflection of this, staff on wards are able to provide clear, informative guidance to patients on the food and fluid appropriate for them to consume. Several NHS boards are now at the stage where they have begun to monitor the systems they are using to communicate this information, and are beginning to revise and improve existing documentation to ensure information is delivered as clearly as possible. Robust systems are in place across NHSScotland to communicate to patients what food and fluid types they, and their visitors, are able to bring into hospital. All NHS boards have developed posters to display in ward areas to advise patients which food and fluids cannot be brought onto wards for both health and safety reasons. 40

43 Each NHS board has developed systems for advising patients and, where appropriate, carers, on the food and fluids they can eat, and those that they should avoid, if they require a special diet. In addition to patient information from specialist services such as dietetics, a majority of NHS boards maintain a diet folder in each ward, containing information on special diets, and leaflets for patients and carers on appropriate foods. Well-developed feedback systems are in place in all NHS boards, enabling patients to give comments and compliments to catering staff on the quality of food and fluid provided. Patients are invited to comment on food and fluid in regular patient surveys, while many NHS boards have developed a feedback area on menu cards to allow patients to comment on food and fluid as quickly as possible after a meal. Patient feedback is also a regular topic at planning group meetings, enabling NHS boards to improve and review menus based upon patient opinion. Standard 5: Patient information and communication 16 Number of NHS boards Performance Assessment Scale Score Recommendations NHS boards: must ensure that all staff recognise the importance of good nutritional care in patient recovery and are trained to be able to support patients in their nutritional care choices in the event that patients are unable to view written information. should involve patients and members of the public in monitoring the effectiveness of information materials to ensure that they are fit for purpose. 41

44 2 National performance against the standards It s happening locally: NHS Grampian The NHS board developed a system where patients can feedback on the standard of food and fluid during their stay in hospital, by using a page on the NHS board website after leaving the hospital. This has enabled patients who were too ill, or did not have time during their stay, to feedback information. NHS Lothian An extensive audit of the NHS board s patient information systems has been undertaken in order to establish how successfully staff are communicating key nutritional care information messages to patients. The NHS board has used this to target areas for improvement and has been able to show, through further audit, improvement in the quality of information being delivered. 42

45 Standard 6: Education and training for staff Standard statement Staff are given appropriate education and training about nutritional care, food and fluid. Most NHS boards have made significant progress in the development and implementation of a programme of nutritional care training for staff. Fourteen NHS boards have implemented an effective programme encompassing all relevant staff groups. Of these, thirteen NHS boards are at the stage of implementation of these systems, with one NHS board identified as being at an advanced stage of implementation. One NHS board was monitoring the effectiveness of its nutritional care training arrangements, indicating that a majority of NHS boards are at the stage of embedding staff training in relation to nutritional care. We found: NHS board staff are aware of the importance of nutritional care for patients health and quality of life. Staff involved in the provision of food and fluid to patients have a good general awareness of the local protocols and processes for food delivery, meal and snack times, and procedures for ordering missed meals, however there is a lack of formal documentation to guide staff. A training needs assessment has been carried out within some NHS boards to inform the development of an NHS board nutrition education strategy/action plan, and a number of others are planning to undertake this assessment. Most NHS boards cover nutrition components as part of local induction and ward orientation, and a several NHS boards have also included, or are in the process of including, nutrition components in corporate induction. Many NHS boards are developing comprehensive training programmes for staff which are delivered, and supported by nutritional care professionals. Short in-house training courses delivered by dietitians, speech and language therapists, and doctors were in place in almost all NHS boards. A variety of nutrition courses have been developed in collaboration with local colleges and universities, which are tailored to meet staff s nutrition education needs. These include topics on nutritional support, undernutrition, screening tools and therapeutic dietary needs. NHS boards are continuing to meet their statutory requirements in health and safety and food hygiene training. Some NHS boards have further developed health and safety and food hygiene training programmes for a wider staff group. 43

46 2 National performance against the standards All NHS boards are experiencing ongoing difficulties in releasing staff to attend nutrition education and training. A record of completion of nutrition training, and training needs still to be met, is not available in many NHS boards. Most NHS boards do not have a co-ordinated and structured approach to the provision of nutrition education and training across the organisation. Standard 6: Education and training for staff 16 Number of NHS boards Performance Assessment Scale Score Progress against 2006 recommendations NHS boards should develop and implement a Board education and training programme which is monitored to assess the impact of staff nutrition awareness, education and training on patient care. Nine NHS boards have a programme of nutritional care education and training in place. Most of these NHS boards are at the early stages of implementation, and need to develop the programme further to include all staff involved in the food chain. NHS boards should include the resource for nutrition education and training programmes within the financial plan to ensure all staff who provide nutritional care receive training commensurate with their duties. Many NHS boards, which have developed a formal training plan for nutritional care, have secured appropriate funding to ensure that staff can be trained, and one NHS board has produced a formal financial framework for education and training of staff. 44

47 NHS boards should share knowledge, experience and good practice in developing and implementing nutrition courses through the existing national networks, eg the NHS QIS clinical governance network, the risk management network, the allied health professions clinical effectiveness network, and the practice development link nurses and midwives network. The establishment of the nutrition champion network has facilitated the sharing of knowledge amongst NHS boards in areas such as MUST training and the development of the NHSScotland Hydration Policy. NHS boards should consider standards 3, 4 and 5 when assessing training needs and developing education and training programmes. NHS boards have developed formal education and training plans covering the whole food chain, with particular emphasis on the quality of food being served to patients. Training is now being delivered for diet cooks and in areas such as texture modification, in addition to more traditional training on basic nutritional care. NHS boards should ensure that nutritional care groups carry out formal nutrition training needs analyses. Generally NHS boards have not yet carried out a formal nutrition training needs analysis. A training needs assessment has been carried out within some NHS boards to inform the development of an NHS board nutrition education strategy/action plan, and a number of others are planning to undertake this assessment. NHS boards should continue to make Partners in Active Continuous Education (PACE) learning packs in nutritional care available to staff and provide support for completion. Many NHS boards are still reliant upon PACE learning packs in nutritional care, however these packs have now been discontinued, and several NHS boards have yet to develop or secure an alternative for staff training. Core nutrition competencies should be developed. Medical and nursing undergraduate training should include comprehensive nutritional care components. Medical and nursing postgraduate training in nutrition should also be reviewed, with emphasis on recognising the serious consequences of both over and undernutrition. Several NHS boards have now developed strong links with local universities to ensure that medical and undergraduate nursing training includes nutritional care components. 45

48 2 National performance against the standards Recommendations NHS boards should: ensure that appropriate steps are taken to allow staff to be released for nutritional education and training as part of their professional development. develop a structured and detailed training plan, which covers all staff involved in the food chain, for example cooks, porters, nurses, etc. It s happening locally: NHS Fife Nutritional training has been incorporated into compulsory training modules for all medical staff. NHS Greater Glasgow and Clyde The NHS board held a Food, Fluid and Nutritional Care Roadshow in all of its acute hospitals to raise awareness among staff. The topics covered information on MUST, the e-learning module, the importance of good nutrition, the mealtime environment and proposed changes to menus and snack provision. 46

49 Chapter 3 Appendices