Title Inpatient Services: Nutritional Care Policy Description of document This policy seeks to provide assurance that Norfolk Community Health and Care NHS Trust (NCH&C) will ensure that the nutritional needs of patients are being met Scope This policy applies to all staff and volunteers working within NCH&C involved at any stage of the process to provide nutrition to in-patients and will refer to NCH&C or the organisation from this point forward. The scope of this policy applies across all NCH&C s In-patient services and aims to set a benchmark for standards of delivery of nutritional care. It is expected that there will be separate policies which cover specialist areas, such as artificial nutritional support, nutritional supplements and obesity. In-patient services should develop their own local protocols/procedures for implementation of this policy. For the purposes of this document nutrition refers to both food and fluid intake. This policy should be considered when service level agreements for food services are established. Prepared by Karen Pope - Integrated Governance Manager Deborah Wooller - Modern Matron Development and Lead Nurse for Specialist Rehabilitation Sheila Merriman Specialist Dietitian Fotoula Blias - Speech and Language Therapy Lead Impact Assessment (Equalities and Environmental) Other relevant approved documents Evidence base / Legislation No negative impact assessed. Only positive impact likely as acts as a benchmark for good nutritional care to meet patients individual needs NCH&C Protected Meal Times Policy NCH&C Incident Management Policy NCH&C Risk Management Policy NCH&C Essence of Care Strategy Level of Evidence: A 10 key characteristics of good nutritional care. www.npsa.nhs.uk NCH&C Page 1 of 20 ver 1.0 July 2011
Malnutrition Universal Screening Tool http://www.bapen.org.uk/musttoolkit.html NHSLA Risk Managment. Standards / CQC Regulation Consultation on document Training implications Finance implications Monitoring and audit Care Quality Commission Outcome 5 Meeting nutritional needs (Regulation 14 of the Health and Social Care Act 2008 (Regulating Activities) Regulations 2009) Outcome 11 Safety, availability and suitability of equipment (Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2009) Patient Environment Audit Team ( PEAT) and Nutrition Group Staff within each Business Unit via the Assistant Director Please refer to Section 9 of this document. Are there any financial implications associated with the implementation of this Policy? Yes No Proactive Monitoring: This policy will be monitored as part of the NCH&C clinical procedural document monitoring programme 6 months prior to its review date using the Proactive Monitoring Tool at Appendix F. Inclusion within the programme will be agreed by the Clinical Audit Team. Reactive Monitoring: Following a relevant significant incident, complaint, RCA or Alert a review of the compliance and implementation of this procedural document must be effected immediately by using the Reactive Monitoring Tool at Appendix G. This audit tool (Appendix G) will also be used to supplement the use of the Essence of Care Nutrition Benchmark and Patient Environment Action Team Assessments. Services will develop local protocols / procedures which will reflect the standards set by this policy and will have an audit tool to monitor performance against the standards described in the services local protocol. Audit results will be shared locally via the Business Unit Clinical Governance Meetings and reported to the trust s board. Responsibilities The Chief Executive is ultimately responsible for the delivery of safe, nutritious food and accordingly must ensure appropriate arrangements are in place regardless of how or by whom the service is being provided. The Assistant Director of Community Rehabilitation is responsible for ensuring that the processes and systems are in NCH&C Page 2 of 20 ver 1.0 July 2011
place to support the delivery of safe nutritious food with in the In-patient Business Unit Modern Matrons are responsible for ensuring that the processes to deliver safe and nutritious food are in place within the Community Unit for which they have responsibility. Nursing staff are responsible for ensuring quality patient care that delivers safe and nutritious food to all the patients with in the In-patient Community Units. Dietitians assess individual patients, referred by medical or nursing staff and develop appropriate nutrition care plans. If appropriate, they also work with family and/or carers. They liaise with Caterers and Housekeepers to advise on the provision of food and drinks appropriate to the needs of the individual. Dietitians act as a resource and offer regular training sessions to nursing staff. The aim of the Dietitian is that all patients will be in the best possible nutritional health as this aids recovery from illness and can help prevent a relapse. Speech and Language Therapists are specialists in the area of assessment, diagnosis and treatment of swallowing difficulties. Upon receipt of a referral, by either a member of the medical or nursing team, the Speech and Language Therapist meet with individual patients to assess their swallow. Once assessed, the patient and those involved in the patient s care are advised on:- The safest food and drink consistencies Modification of diet (including ensuring there is an awareness of the risk of weight loss if on a pureed diet) Bolus size Correct positioning for oral intake Timing of oral intake Safest form of medication (tablet or syrup form) Environmental issues relating to eating and drinking Therapeutic techniques to make eating and drinking easier and safer The Speech and Language Therapist will then liaise with members of the multidisciplinary team and if necessary refer on for further video fluoroscopic investigations or to Ear, Nose and Throat, Dietetics and/or Gastroenterology departments. It is also the Speech and Language Therapists responsibility to provide regular training to the multidisciplinary team and those involved in the care of the patient. The Catering Team have responsibility to ensure, through a NCH&C Page 3 of 20 ver 1.0 July 2011
service level agreement arrangement, that patients will be provided with 3 meals per day: breakfast, main lunchtime meal and light evening meal with elements of choice, to ensure their dietary and nutritional requirements are met. Reference and guidance materials are supplied to allow specific diets to be followed. Meals are regenerated at ward level which allows patients to choose just before or at the point of service. A minimum of 7 beverages are provided throughout the day; snacks are available and additional beverages are provided on request. NCH&C will focus on the needs of their patients/service users, designing services around them and offering them choice and involvement. NCH&C will encourage people to be involved in all aspects of food and beverage service, for example, menu planning and inspection. Consideration will be given to the needs of individuals by ensuring that special dietary, religious and cultural needs are catered for. Implementation Staff will be notified of this procedural documents existence via NCH&C s Monthly Briefing Exchange and in line with their duties managers are to bring this document to the attention of staff to whom it relates. A copy of this document will also be available on NCH&C s Intranet Dissemination Approved by Authorised by Review date and by whom Is there any reason why any part of this document should not be available on the public web site? Yes No Deborah Beresford, Acting Assistant Director of Community rehabilitation (Date) Clinical Policies Group (Date) February 2014, or sooner should changes to legislation or guidance require it, PEAT and Nutrition Group Date of issue July 2011 NCH&C Page 4 of 20 ver 1.0 July 2011
Inpatient Services: Nutritional Care Policy Contents Section Page 1 Introduction 7 2 Purpose 8 3 Safe Delivery of Food Service and Nutritional Care 9 Protected Mealtimes : An environment conducive to people 10 4 enjoying their meals and being able to safely consume their food and drink is maintained 5 Multi-Disciplinary Approach to Nutritional care 10 6 Nutritional Screening 11 7 Facility and Service Design 11 8 Nutritional Care Plan 12 9 Training 12 10 Bibliography 14 Appendices Appendix A Patient Information Leaflets 15 Appendix B Malnutrition Universal Screening Tool (MUST) 15 Appendix C Must Care Plan (Inpatient) 15 Appendix D Nutrition Pathway 15 Appendix E Standards for Equipment and Environmental Design Appendix F Proactive Monitoring Tool 16 Appendix G Reactive Monitoring Tool 20 NCH&C Page 5 of 20 ver 1.0 July 2011
Version Control (To be completed by policy owner) Version Date Author Status Comment 0.1 30.12.09 Karen Pope Draft First Draft 0.2 30.12.09 Karen Pope Draft Amended first draft following review with D. Wooller. 5.3 deleted for insertion into Protected Mealtimes policy. 7.2, 7.4.1, 7.5.3, 9.4.2, 9.4.4, 9.4.5, 10.3, 10.4 deleted. 7.5.2, 9.3 9.4 moved to appendix. 8.2 8.4 and 10.5 deleted and to be covered in training. 11.6 11.10 deleted and to be covered by a statement from training dept re how training will be delivered. 12.2 12.4 deleted and ref made to PPI strategy. Section 13 deleted and included thro policy in appropriate sections. 0.3 31.12.09 Karen Pope Draft Summary written 0.4 27.01.2010 Sheila Merriman Draft Comments from Dieticians all changes tracked 0.5 05 Feb. 10 Deborah Wooller Draft Tracked in blue 0.6 11 th May 2010 Deborah Wooller Andrea Elsdon Draft Further review and removal of tracking 0.7 05/01/2011 Hannah Rose Draft Re-formatting in to new template. 0.8 21/01/11 Deborah Wooller Draft Added comments from SLT and catering Evidence added 0.9 21/01/11 Hannah Rose Draft Reformatting inclusion of Appendix G sent for consultation. 0.10 14/02/10 Deborah Wooller Draft Removed some text and made changes in response to comments following circulation 1.0 21.07.2011 Hannah Rose Approved Confirmation of approval and sent for publication. NCH&C Page 6 of 20 ver 1.0 July 2011
1. Introduction 1.1 Meeting the nutritional needs of service users is an integral part of effective healthcare. Research has shown that a service user who is malnourished when admitted to hospital tends to have a longer hospital stay, experience more complications and has a greater risk of dying than a person with the same illness whose nutritional status is not compromised. 1.2 The National Health Service (NHS) Plan states all hospitals will have a hospital nutrition policy to improve the outcome of care for patients. 1.3 The Department of Health s publication Essence of Care provides a toolkit for benchmarking care. These include benchmarks for food and nutrition and health promotion. 1.4 The Council of Europe Resolution 12/11/2003: Food and Nutritional Care in Hospitals requires that NCH&C has a policy for food service and nutritional care, which is centred on the needs of service users, and is performance managed in line with the governance and regulatory framework. The Resolution sets out the 10 key characteristics of good nutritional care in hospitals and requires that NHS organisations have a nutritional care policy and plan to improve the food, fluid and nutritional care given to service users. 1.5 The Care Quality Commission s (CQC) Outcome 5: Meeting nutritional needs requires that people using the service are supported to have adequate nutrition and hydration. Providers who comply with the regulations will: 1.5.1 Reduce the risk of poor nutrition and dehydration by encouraging and supporting people to receive adequate nutrition and hydration. 1.5.2 Provide choices of food and drink for people to meet their diverse needs making sure the food and drink they provide is nutritionally balanced and supports their health. 1.6 The CQC s Outcome11: Safety, availability and suitability of equipment requires that people using the service and people who work in or visit the premises: 1.6.1 Are not at risk of harm from unsafe or unsuitable equipment (medical and non-medical equipment, furnishings or fittings). 1.6.2 Benefit from equipment that is comfortable and meets their needs. This is because providers who comply with the regulations will make sure that equipment: 1.6.2.1 is suitable for its purpose 1.6.2.2 is available 1.6.2.3 is properly maintained 1.6.2.4 is used correctly and safely 1.6.2.5 promotes independence 1.6.2.6 is comfortable. NCH&C Page 7 of 20 ver 1.0 July 2011
1.6.2.7 Follow published guidance about how to use medical devices safely. 2. Purpose 2.1 The purpose of this policy is to set standards for nutritional care provided by NCH&C to inpatients. The delivery of care must meet the standards set out by the Care Quality Commission in its Outcomes 5 and 11 and meet the standards in the Council for Europe s Resolution: Food and Nutritional Care in Hospitals. The Resolution describes 10 Key Characteristics of good nutritional care in hospitals: 2.1.1 All patients are screened on admission to identify the patients who are malnourished or at risk of becoming malnourished. All patients are re-screened weekly. 2.1.2 All patients have a care plan which identifies their nutritional care needs and how they are to be met. 2.1.3 The hospital includes specific guidance on food services and nutritional care in its Clinical Governance arrangements. 2.1.4 Patients are involved in the planning and monitoring arrangements for food service provision. 2.1.5 Wards implement protected mealtimes to provide an environment conducive to patients enjoying and being able to eat their food. 2.1.6 All staff have the appropriate skills and competencies needed to ensure that patient s nutritional needs are met. All staff receive regular training on nutritional care and management. 2.1.7 Hospital facilities are designed to be flexible and patient centred with the aim of providing and delivering an excellent experience of food service and nutritional care 24 hours a day, every day. 2.1.8 The hospital has a policy for food service and nutritional care which is patient centred and performance managed in line with national governance frameworks. 2.1.9 Food service and nutritional care is delivered to the patient safely. 2.1.10 The Inpatient Services support a multi-disciplinary approach to nutritional care and values the contribution of all staff groups. NCH&C Page 8 of 20 ver 1.0 July 2011
3. Safe Delivery of Food Service and Nutritional Care 3.1 Poor nutritional care can threaten the safety of service users in all care and community settings. 3.2 To allow safety issues around nutrition to be identified and action taken to improve care, it is important that all incidents are reported, including issues such as: 3.2.1 Availability of equipment, for example, weighing scales for nutritional screening or specialised cutlery and crockery; 3.2.2 Lack of assistance at mealtimes; 3.2.3 Lack of nutritional screening. 3.3 Incidents will be reported using the Incident Report Form - IR1 (See NCH&C Incident Management Policy) this will enable the organisation to identify potential solutions to problems. Reports made via this route are also fed through to the NPSA, allowing national trends and patterns to be identified, and solutions to be developed to prevent similar incidents happening elsewhere. 3.4 Services will proactively manage risks associated with poor nutritional care by carrying out risk assessments around the safe delivery of food services and nutritional care. 4. Protected Mealtimes 4.1 The NCH&C In patient Services will conform to the Protected Mealtimes Policy and ensure that an environment conducive to people enjoying their meals and being able to safely consume their food and drink is maintained. 5. Multi-disciplinary Approach to Nutritional Care 5.1 Appropriate nutritional care is vital for service users. Safe and effective nutritional care can only be delivered if all those involved work together, valuing the contribution of all staff, people using the service, carers and volunteers. 5.2 NCH&C will have a nutritional steering group (PEAT and Nutrition) with representatives from all members of staff involved in the care of service users, including doctors, dieticians, nurses, pharmacists, caterers, other allied health and social care professionals, and service user representation. The steering groups should have executive level representation to meet with the requirements of the Council for Europe Resolution. NCH&C Page 9 of 20 ver 1.0 July 2011
5.3 The NCH&C steering group (PEAT and Nutrition) has developed this nutritional care policy and will monitor the outcomes. 6. Nutritional Screening 6.1 All service users entering NCH&C inpatient services will be screened to identify those who are malnourished, at risk of becoming malnourished, or are obese, using a validated screening tool. The Malnutrition Universal Screening Tool, MUST (Appendix B) will be used in the NCH&C Inpatient Community Units and The Specialist Palliative care screening tool (Appendix D) within that service. 6.2 The result of the screening should be used as required to create a care/support plan to ensure that service users receive the nutritional care they need. 6.3 NCH&C staff will have access to the appropriate resources to undertake nutritional screening; this includes access to weighing scales that are regularly calibrated (see Medical Devices Policy) and tape measures. 6.4 Treatment and care should take account of individual needs and preference. Service users requiring therapeutic diets should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professional. 6.5 First Line dietary advice leaflets are available on the Knowledge Norfolk website. 7. Facility and Service Design 7.1 NCH&C staff will ensure inpatients have access to food and beverages (including water) at all times, thus ensuring good nutritional care is achieved. This can be achieved through well-designed facilities (the built environment) and service delivery (system design). 7.2 NCH&C staff will ensure the design of facilities (including kitchens) and service delivery supports good nutritional care by using the standards set out in Appendix E to guide the development of new facilities and services. 7.3 NCH&C is committed through its systems and processes to providing 24-hour accessible food and beverage provision. 7.4 Information about NCH&C facilities, food, beverage and nutrition options will be accessible to all service users/patients and carers. The information will be available in a wide range of formats, including appropriate languages, via the internet, and in written form. NCH&C Page 10 of 20 ver 1.0 July 2011
8. Nutritional Care Plan. 8.1 For each service user identified as needing a therapeutic diet a nutritional care plan will be created identifying their specific nutritional needs and how these needs will be met using the format at Appendix C. NCH&C staff will liaise with the service user, their family/carer to inform and share this process. 8.2 The care plan should be used to inform discharge documentation and enable the correct transfer of nutritional care information between health and social care settings. 8.3 NCH&C staff will monitor/keep records of food and fluid intake as indicated by clinical need. 8.4 NCH&C staff will monitor and review nutritional intervention and care plans weekly. 9. Training 9.1 All people providing nutritional care should have the appropriate skills and competencies to ensure that service users in receipt of support services receive good nutritional care. Training in itself is not just a key characteristic of good nutritional care; it also underpins all of the others.. 9.2 NCH&C staff identified for this training includes: 9.2.1 Staff or volunteers who assess and provide for service user care and nutritional needs and/or undertake nutritional screening (social work staff, doctors, nurses, midwives, pharmacists); 9.2.2 Those who prepare or deliver food to service users (catering, home care, community meals staff); 9.2.3 Those who assist service users with their own preparation or consumption of food (day centre, care or housekeeping staff); 9.2.4 At a different level, those involved in contracting services, inspection and regulation. 9.3 The training requirements are; 9.3.1 Core learning units on Nutrition and Dysphagia are available through NCH&C Intranet. These are to be completed with in the first year following circulation of this policy (or with in first 6 months for new employees) and 3 yearly thereafter. NCH&C Page 11 of 20 ver 1.0 July 2011
9.3.2 All staff who work with food handling must complete food hygiene training on a 3 yearly basis. 9.3.3 All clinical staff that assess patient nutrition will be trained in the MUST. The teach yourself training package created by the dietetic department will be available for use in induction and as an update for staff where need for a refresher is identified. The dietetic department offer face to face training to the units, on request, and the monthly MUST audits can be used to determine if such updates are required. 9.6.3 Every In patient Unit will have a designated Nutritional Link Nurse. The link nurse group will be lead and facilitated by the dietetic department as part of the service level agreement with NCH&C.The link nurse will attend the regular nutritional update sessions run for this group by the dietetic department which will be designed to meet identified need. They will be responsible for ensuring this information is shared with their unit as required. 9.6.4 Puree, Hydration and Nutrition training (PHAN) will be available to NCH&C staff from the dietetic department and it is expected that registered and unregistered nursing staff including ward housekeepers working in the In patient Units will attend this training. 10. Bibliography 10.1 The NHS Plan: A plan for Investment, a plan for reform. HMSO London 2000 http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspol icyandguidance/dh_4002960 10.2 The Care Quality Commission http://www.cqc.org.uk 10.3 Department of Health. Essence of Care : Food and Nutrition Benchmark, 2003 http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspol icyandguidance/dh_4005475 10.4 Department of Health. Improving Nutritional Care: A joint action plan from the Department of Health and Nutrition Summit stakeholders http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspoli cyandguidance/dh_079931 10.5 National Institute for Health and Clinical Excellence (NICE) 2006. Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. www.nice.org.uk/cg032 NCH&C Page 12 of 20 ver 1.0 July 2011
10.6 The Council of Europe. Resolution 12/11/2003 Food and Nutritional Care in Hospitals. Council of Europe 2003 http://www.nrls.npsa.nhs.uk/resources/?entryid45=59865&q=0%c2%acnutritio n%c2%ac 10.7 Hospital Caterers Association. Better Hospital Food www.hospitalcaterers.org/better-hospital-food/ 10.8 Hospital Caterers Association. Good Practice Guide: Healthcare Food and Beverage Service Standards http://www.hospitalcaterers.org 10.9 Malnutrition Universal Screening Tool http://www.bapen.org.uk/musttoolkit.html 10.10 Hydration Best Practice Toolkit http://www.rcn.org.uk/nutritionnow NCH&C Page 13 of 20 ver 1.0 July 2011
Appendix A: Patient Information A Guide to eating well with a small appetite A guide to eating well with diabetes and a small appetite High protein, high calorie recipes Appendix B: Malnutrition Universal Screening Tool (MUST) Appendix C: MUST Nutritional Care Plan (Inpatient) Appendix D: Nutrition Pathway Appendix E: Standards for Equipment and Environmental Design NCH&C Page 14 of 20 ver 1.0 July 2011
Policy Monitoring Tool Appendix F This is a generic monitoring tool to be used with any of the NCH&C policies. Please ensure that you complete one form per Service or Business Unit (as appropriate). Completed forms must be returned to: Hannah Rose Quality and Compliance Officer, Quality and Risk Team, Elliot House, 130 Ber Street, Norwich NR1 3FR, hannah.rose@norfolk-pct.nhs.uk Full title of policy that you are monitoring (and version) Service Manager / Team Leader / Modern Matron (Name and Designation) Name of Business Unit Name of Team / Service Job Title Date of form completion 1. Is a copy of this policy easily available to all members of staff? *(Please use the tick boxes and provide further details in the space below) - Yes, paper copy - Yes, on the intranet - No, there was no copy easily available... NCH&C Page 15 of 20 ver 1.0 July 2011
2. Have all relevant members of your staff read and implemented this policy? *(Please use the tick boxes and provide further details in the space below) - Yes - No... 3. Is the guidance provided within this policy easy to understand? *(Please use the tick boxes and provide further details in the space below) - Yes - No 4. Is there any information missing from this policy that should be included when the policy is revised? *(Please use the tick boxes and provide further details in the space below) - Yes - No 5. If you have raised any concerns about the content of this policy, were your concerns documented on a relevant risk register? *(Please use the tick boxes and provide further details in the space below) NCH&C Page 16 of 20 ver 1.0 July 2011
- Yes - No - Not Applicable 6. Have you had any problems implementing this policy, e.g. financial, resources, staff availability, training needs? *(Please use the tick boxes and provide further details in the space below) - Yes - No 7. If you answered yes to question 6, were these problems documented on a relevant risk register? *(Please use the tick boxes and provide further details in the space below) - Yes - No - Not Applicable... 8. Are there dissemination processes in place in order to ensure that all appropriate members of staff receive a new/ revised policy? *(Please use the tick boxes and provide further details in the space below) - Yes - No... NCH&C Page 17 of 20 ver 1.0 July 2011
9. Have there been any incidents/ risks reported which directly relate to this policy? *(If yes please provide generalised and brief details, such as location area/ specialism s that issues occurred in. An example could be: A medication error in the Inpatient business unit, which was picked up on and corrected on the same day). - Yes - No... Thank you for your valued contribution to collecting this data. NCH&C Page 18 of 20 ver 1.0 July 2011
Appendix G Reactive Monitoring Tool Business Unit: Professional Group/Team: Date: Completed by (name and job title): For each question please put a or next to the response that is appropriate to your team. Please note that NA = Not Applicable Question Response Yes No N/A 1. Have all incidents regarding availability of equipment, lack of assistance at meal times and lack of nutritional screening been reported using IR1? 2. Have risk assessments been completed for the following risks? a) Choking b) Dehydration c) Nil by Mouth d) Inappropriate diet e) Catering services f) Incorrect artificial nutrition g) Missed meals h) Transfer of care i) Pressure ulcers 3. Has the patient been offered an environment that is conducive to eating and enjoying their meals? 4. Are staff focused on encouraging and supporting a safe meal experience? 5. Is a pre-meal service check undertaken by staff with the catering team to clarify: a) Who is eating? b) If any special diets are required? c) Who needs assistance during the meal service? 6. Upon entering NCH&C Inpatient Services, was the patient screened to identify if they were malnourished, at risk of becoming malnourished or obese using a validated screening tool? 7. Were the results of the screening tool used to create a care/support plan? 8. Did staff have access to the appropriate resources to undertake nutritional screening? 9. Have the weighing scales been regularly calibrated? NCH&C Page 19 of 20 ver 1.0 July 2011
10. Have people requiring therapeutic diets had the opportunity to make informed decisions about their care and treatment? 11. Have staff ensured that inpatients have access to food and beverages (including water) at all times? 12. Have staff ensured the design of facilities (including kitchens) and service delivery supports good nutritional care? 13. Are food and beverages available 24 hours a day? 14. Is information about NCH&C facilities, food, beverage and nutrition options available to all service users/patients and carers? 15. Is the information available in a wide range of formats including appropriate languages? 16. If the patient has been identified as needing a therapeutic diet, has a nutritional care plan been created identifying their specific nutritional needs? 17. Have the person and their family/carer been informed of the nutritional care plan? 18. Has all food and fluid intake been recorded? 19. Has the nutritional intervention and care plan been reviewed weekly? 20. Have all staff and volunteers received regular training in nutritional care and management? 21. Did the training include the understanding that peoples diets must meet their individual needs? 22. Has a speech and Language Therapist met with the patient to assess their swallow? 23. Has the patient been provided 3 meals per day? 24. Has the patient been provided a minimum of 7 beverages per day?. NCH&C Page 20 of 20 ver 1.0 July 2011