Annual Report 2017/ 18

Powys Teaching Health Board Nutrition, Hydration & Catering Delivery Plan An Appetite to Improve Annual Report 2017/ 18

INTRODUCTION: The Purpose of this report is to update the Board on progress with the implementation of the Catering, Nutrition and Hydration Delivery Plan An Appetite to Improve, which was approved in February 2017, signalling the Board s commitment to the catering, nutrition and hydration agenda. This annual report includes achievements in 2017/ 18 against the plan, risks to delivery and key priorities for 2018/ 19. Catering, Nutrition and Hydration is an important patient safety matter and public health focus. This was highlighted in the Public Accounts Committee Report on Hospital Catering & Patient Nutrition in Wales which was issued in March 2017, a Committee at which Powys Teaching Health Board gave evidence. This was to address the risks of patient malnutrition in hospitals, as well as the needs of those considered to be nutritionally well. The report aimed to improve food and drink across the NHS so that everyone has a healthier food experience and that everyone involved in its production is properly valued and educated. The key aims of An Appetite to Improve, the Powys Teaching Health Board Delivery Plan are: To meet the nutrition and hydration needs of all patients and ensure a positive patient mealtime experience. To procure sustainable food and catering services. To ensure that food and drinks offered and provided meet patients cultural and religious needs. To promote healthier eating for staff and visitors. The Welsh Government has consistently promoted the importance of nutrition, hydration and catering as an essential part of the care patients receive in hospitals. This was promulgated further into the spotlight following the Andrews Report: Trusted to Care identifying issues with patient nutrition and hydration in ABMuHB. Welsh Government have developed a number of polices and guidance in this area, which includes the All Wales Nutrition Care Pathway, Nutrition and Hydration Awareness week, Water Keeps You Well campaign and also the All Wales Nutrition and Catering Standards for Food and Fluid Provision for Hospital Patients (2011) which, as Health Board, we were required to adopt. Both malnutrition and dehydration have substantial adverse effects on health, disease and well-being in community, residential care and hospital settings. Yet despite good evidence that specific efforts to correct the problems and improve health outcomes, they often go unrecognised and untreated. Malnutrition and

dehydration also have a substantial impact on the health economy with increased demands on General Practice services, out of hours services and increased rates of transition across pathways of care. Once in hospital patients average length of stay is three days longer (Guest et al, 2011; Stratton et al, 2003; Elia et al, 2009), mortality rates are high and failed discharges are frequent. NICE has shown that better nutritional care reduces complications and length of stay and NICE cost saving calculations show that better nutritional care is achievable with substantial savings in net NHS costs. (NICE, 2011). Definitions: Nutrition - good nutrition can help prevent disease and promote health. There are six categories of nutrients that the body needs to acquire from food: protein, carbohydrates, fat, fibre, vitamins and minerals, and water. Hydration - The process of providing adequate fluids and dehydration is the loss of water and salts essential for normal body function. Malnutrition - a state in which a deficiency, excess or imbalance of energy protein and other nutrients cause measurable adverse effects on tissue, function and clinical outcome (BAPEN) that includes the risk of a Body Mass Index (BMI) of less than 18.5kg/m2, unintentional weight loss greater than 10% within the last 3-6 months, BMI of less than 20kg/m2 and unintentional weight loss greater than 5% within the last 3-6months. At risk of malnutrition can be defined as having eaten little or nothing for 5 days and/or likely to eat little or nothing for 5 days or longer. Having poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs. The Powys Teaching Health Board Nutrition, Hydration and Catering Steering Group is composed of membership from a senior multi-disciplinary team from across the Health Board. The purpose of the Group is to co-ordinate the Health Boards whole system nutrition and catering agenda, including nutritional care and catering services, national strategy analysis and deployment and monitoring against standards and the Health Board s delivery plan. The group is co-chaired by the Assistant Director of Nursing and the Head of Facilities and Transport due to the fact that delegated executive responsibility for catering lies with the Director of Workforce, OD and Support Services and the responsibility for nutrition and hydration rests with the Director of Nursing. A Board Champion has been appointed, who plays an active role. The activity of the Catering, Nutrition and Hydration Steering Group is reported to the Patient Experience, Quality and Safety Committee, with agreement for an annual report to be presented for approval at the Board. 2017/ 18 has been a positive year in terms of implementation of the deliverables for year one of the three year plan. There have been a number of achievements made across the Health Board which, in summary, include:

Implementation of a rolling programme of nutritional audits using a 360⁰ audit tool. Introduction of John s Campaign, enabling and encouraging carers to assist at mealtimes. The hospital water jugs and beakers have changed so that they are lighter for patients to use and see. All wards are using the All Wales Fluid Balance Charts to record patient fluid intake and output. All hospitals maintain safe working environments and achieve a 4* or 5* Environmental Health (EHO) rating for hygiene. Protected Mealtimes are now embedded in all in-patient areas across the Health Board, with a consistent approach. An in-patient menu showcase was presented in October 2017 involving stakeholders, including patient representatives, with examples of items from the new patient menus. The priority in year one has been to focus on patient provision, but it is fully recognised that healthy diets are equally important for staff and visitors and this will feature as an action in the year two plan. The following pages provide a visual representation of progress over the past year in more detail, under the banners of: - Governance - Patient Experience - Nutrition - Hydration - Catering

Governance Scheme of Delegation The Chief Executive is the accountable officer for nutrition, hydration and catering. The responsibility for delivery and performance is delegated to two Directors: the Director of Nursing is responsible for nutrition & hydration and the Director of Workforce, OD and Support Services is responsible for catering. A Board Champion has been appointed, which is one of the Independent Members. The Nutrition, Hydration and Catering Steering Group is accountable to the Patient Experience, Quality & Safety Committee, a sub-committee of the Board. Primary deliverables: A vibrant multidisciplinary Nutrition, Hydration and Catering Steering Group. To monitor performance through a programme of multidisciplinary 360 audits. To report progress to the Patient Experience, Quality & Safety Committee (PEQS) bi-annually. To present an annual report for Board approval. To maintain Environmental Health inspection awards at level 4 & above What we have done: Developed a more comprehensive approach to reporting performance on catering services and patient nutrition to the PEQS Committee bi-annually. Continued to achieve >90% performance for MUST assessment for all patients within 24 hours of admission. Monitored the effectiveness of care planning for those patients at high risk of malnutrition or with specific dietary needs, through auditing. Monitored the Nutrition, Hydration and Catering provision using a 360 degree audit approach, involving multidisciplinary team members and patient representatives. Developed a suite of clinical metrics to assess nutritional status, utilising the national Health & Care Monitoring System. All hospital sites have a food hygiene rating of 4* and above. The below is an example of the results of 360 degree auditing from Machynlleth Hospital in 2018 Observations Overall Compliance Patient Satisfaction 89.66% Kitchen Hygiene & Operations 97.18% Ward Kitchen Food Hygiene 96.30% Food Quality 92.73% Nutritional Assessment 89.70% Unserved Main Meals % Total Trolley Portions Wasted % 7.14% 18.52% Plate Wastage % 1.23%

Governance The rolling programme of multidisciplinary 360 audits enable routine snapshots of a ward s overarching performance, across all domains, and interpret how they compliment each other to support patient care. The aim is that the principles of Nutrition, Hydration and Catering services are consistent across all hospitals in Powys, enabling performance to be measured and benchmarked against the standards. Key to achieving high quality is having all disciplines working collaboratively with a shared understanding of the required standards and expected outcomes. This runs through the whole service from the procurement of ingredients, effective catering/hygiene practices, to communication between staff groups, the meal time delivery including nutrition/hydration care and the patient experience. Routine assessment of these areas maintains staff focus on the profile of nutrition and hydration as a fundamental part of patients care, high standards of food and food hygiene and the reduction of food waste. Patient satisfaction is deemed to be a good indicator of the meal service team getting it right. The audit tool serves to interrogate the finite details of the meal time service and nutritional care, to pin point those areas working well and those that are perhaps not working so well and in need of support and improvement. Risks: The risks could be the ability to maintain a consistently high standard of service delivery within budget and the challenges an ageing PTHB estates pose for the maintenance of level 4+ EHO hygiene status. Next Steps: The results of 360 degree audits are to be routinely presented to the PEQS, as per the business cycle. Metrics and performance to be included in the Integrated Performance Report. Estate issues affecting EHO ratings are to be discussed at the Capital & Estates Improvement Board.

Nutrition Primary deliverables: Explore the introduction of enhanced mealtime support volunteer roles to all wards. Ensure that Powys Teaching Health Board meets national e-learning nutrition training requirements. What we have done: Red Kite Volunteers have been appointed from local colleges and are being tested in Llanidloes Hospital, in collaboration with PAVO. A rolling programme of education for all staff involved in catering and nutritional care has been developed. Educational resources for patients and visitors has been produced. In addition: John s Campaign is now embedded in all ward areas, which is an initiative welcoming carers and loved ones of patients with dementia into the wards. One of the key elements of this campaign is that it enables carers to assist at meal times. Improved the menu design, structure and planning with the involvement of services users to ensure that patient needs are fully met. Protected Mealtimes are embedded across Wards, embracing a consistent approach. The MUST national nutritional risk screening tool is in use across all Wards.

Nutrition All newly admitted patients have a nutritional screening tool score calculated within 24 hours of admission, with appropriate action taken based on the nutritional risk. Powys Teaching Health Board use the nationally recognised Malnutrition Universal Screening Tool (MUST). There is an individualised care plan for each patient identified as at nutritional risk, with dietetic involvement depending on the risk score. All wards exercise Protected Mealtimes enabling patients to eat their meals without unnecessary interruption and for staff to focus on providing assistance to those patients unable to eat independently. The Protected Mealtime guidance seeks to provide a patient-centered framework for mealtimes, specifically: To provide mealtimes free from avoidable and unnecessary interruptions. To create a quiet and relaxed atmosphere in which patients are afforded time to enjoy their meals. To promote and support the social aspects of eating and drinking. To limit ward based activities at mealtimes, both clinical and non-clinical, with the exception of those that are deemed essential. To emphasise to all staff, patients and visitors the importance of meals and mealtimes as an essential part of patient care and treatment. Red food trays are used for patients who require assistance at mealtimes or have been assessed as nutritionally compromised. All wards clearly display a poster informing visitors and staff of the times that protected mealtimes operate. John s Campaign posters are also displayed which encourage family members/carers to be actively involved in providing support for their loved ones at mealtimes, whilst also promoting the social aspects of the mealtime experience Risks: Non-compliance to training targets set by Welsh Government. Inability to attract enough volunteers to roll out the Red Kite scheme across all Wards. Next Steps: Evaluate the Red Kite Scheme in Llanidloes Hospital. Develop a plan, in collaboration with PAVO, for the attraction of more volunteers to enable scale-up. Evaluate the training provision and assess impact.

Hydration Primary deliverables: Introduce oral hydration standards to ensure that patients receive adequate oral hydration, embedding the Water keeps you well campaign across Powys. Raise awareness of Acute Kidney Injury identification, prevention and management procedures. What we have done: Implemented the Water keeps you well campaign across all wards, with PTHB being a pilot site for Wales when the campaign was introduced. Ensured a consistent use of Fluid Balance Charts, as evidenced through auditing. Actively involved in the Acute Kidney Injury identification, prevention and management 1000 Lives Improvement approach. In addition, water jugs and beakers have changed to a lighter version supporting frail patients to self-manage water intake & independence. The Nutrition, Hydration and Catering Steering Group have supported the Water keeps you well campaign, initiated by Public Health Wales, ensuring that the message reaches both patients, staff and wider public. The hospital water jugs and beakers have changed so that they are lighter for patients to use and see. All wards use the National Fluid Balance Charts to record patient fluid intake and output. Coloured lids are used on water jugs to visually identify those patients whose fluid intake needs to be encouraged and carefully monitored. Regular beverage rounds are supported by both Nursing staff and hotel services, in compliance with national standards. Fresh drinking water is available in all staff dining areas which enables easy accessibility for staff to maintain their hydration levels. Water dispensing units are also available in patient areas to enable visitors to maintain their hydration whilst on the wards. Risks: The 1000 Lives Improvement initiative to improve Acute Kidney Injury tends to be acute-care focussed, this could lead to a risk of Community Hospital non engagement and a failure to address AKI in primary and community care. Next Steps: Undertake an audit of compliance with Fluid Balance Charts Explore the options for addressing Acute Kidney Injury in Primary Care & Community.

Catering Key deliverables: Eliminate inconsistencies in catering service quality, strengthen cost control and bench marking and ensure total costs for patients catering does not exceed the planned budget, without a detrimental effect on quality. Introduce computerised catering information systems to support cost controls, enhance patient experience through the use of bedside ordering technology, and improve patient safety through patient specific menus. Ensure set pricing and income generation targets aim to ensure non-patient catering services at least break even. Monitor income and expenditure of non-patient catering services to ensure the financial performance is as expected and that unacceptable deficits are not incurred. What we have done: Improved the menu design, structure and planning with consideration given to texture, modified meals and special dietary requirements, the provision of snacks and enriched foods, allergens and food intolerances. Eliminated inconsistencies in the catering service without a detrimental effect on quality. Maintained safe working environments achieving 4 or 5* EHO food hygiene ratings. Increased opportunities for patients, visitors and staff to consume healthier food and drink options. We have nutritionally assessed recipes and products providing assurances that national standards are met. Menu planning is centralised and standardised There is better information on food allergens. We have better understanding of the correct portion size for given nutrient content. Nutritional quality is specified as part of contracts for provisions.

Catering Menu planning and catering operational systems are a key enabler to the delivery of patients nutritional care with focused investment required to achieve the best outcomes for patients. If patients do not enjoy the food provided a high standard of nutritional care cannot follow. For this reason the Powys Teaching Health Board includes patient feedback from questionnaires and patient representatives in menu planning. It is this feedback that has influenced an increase in frequency of traditional Roast Dinners on the menu. Despite having adopted a standardised approach to menus, the use of recipes, portion control, robust waste monitoring systems, staff restaurant charging and the procurement of ingredients, we continue to see some fluctuations in the average spend on patient s food per patient day. Without a computerised catering system these variations are difficult to quantify. The overall average cost per patient day for food is 4.50, which is above average for NHS Wales but PTHB does have a high proportion of patients who are dependant on texturemodified foods, and this increases costs. An All Wales approach has commenced to identify a single computerised catering system, which each health board, subject to individual capital funding approval, can purchase to meet their specific needs. Health Boards are keen to have a system that is patient focused and future proofed. The aim of the system is to enable bedside ordering, registering of patients dietary needs/allergen risks, through to stock control, production planning, live restaurant point of sale and performance reporting. It will also link the system to procurement for maintaining product information and ordering replenishments, facilitating increased operating efficiencies. An in-patient menu showcase was undertaken in October 2017 involving stakeholders, including patient representatives, with examples of items from the new patient menus. Risks: Accounting and processes cannot provide the same level of control as that offered by a computerised catering system, the risk for which is no funding to secure the system. Next Steps: Approve and introduce a computerised catering information system to support cost control and improve patient experience. Engage more closely with Directorates to ensure staff recognise the opportunity of promoting health and wellbeing for patients, the public and themselves. Explore how PTHB introduces health eating options for staff and visitors using the canteen facilities.

Patient Experience Key deliverables: Introduce a Mealtime Co-ordinator role to all wards. Provide further adaptations including specialised cutlery and hi-low tables to compliment hi-low beds. Enhance mealtime support to ensure patients have the most appropriate level of assistance and encouragement to eat and drink. Ensure patient views on the quality of food and catering are captured at least annually. What we have done: A business case for specialised cutlery and crockery has been developed and funding is being sourced. Protected Mealtimes implementation has ensured a focus on patient experience. Patient views are captured through the 360 degree auditing process as well as the annual survey. Unfortunately the mealtime coordinator role has not been introduced as yet. Patient experience is further enhanced by the use of the red tray and the butterfly schemes for those patients who require additional assistance, which are a visual but subtle & dignified reminder that a patient requires support. Next Steps: Introduce the Mealtime Coordinator role across the Health Board. Secure funding for adapted cutlery and crockery. Ensure an annual survey of patient experience to include nutrition and hydration.