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Hospital food standards report

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Department of Health .

on 3 November 2015

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Transcript of Hospital food standards report

Introduction by Dianne Jeffrey
Click play to watch

The 10 characteristics of good nutritional care
Case study

Royal Liverpool University Hospital demonstrating compliance with Nutrition Alliance 10 Key characteristics

The Royal Liverpool takes a multi-disciplinary approach to patient nutrition and hydration one aspect of which is in the form of a Patient Meal Experience Group. The groups remit covers every aspect of nutrition from trying to influence the content of nurse training at university, to drawing up and overseeing implementation of protocols for both nursing staff and catering staff in relation to expectations before, during and after mealtimes, to the involvement of therapists in assessing needs such as requirements for feeding aids, and the development of a multi-disciplinary content ward food and nutrition manual to name but a few of the Groups areas of focus over the last 2-3 years. The Group also receives summaries of feedback directly from patients and work done as a result of this feedback.

For example feedback from hematology patients at the Trust identified a level of dissatisfaction. When investigated further it was specifically related to the fact that, due to the nature of the illness and medication that patients were on, they did not always feel like eating at the routine mealtimes. Through the routine gathering of patient feedback it was recognised that not every group of patients can be accommodated by the routine meals times. The ward, the catering department, Trust Catering lead and the patients came up with a call order style meal offer which allowed patients who did not feel like eating at routine mealtimes to request and receive food when they felt like it.

The key to the success of this flexible approach was the engagement of all disciplines - teamwork. Patients responded positively and were much happier. Nursing staff reported that patient satisfaction has improved. The hospital is applying the approach of different offers for different patient groups more widely with trials in gerontology and surgical wards. This demonstrates that working within the constraints of a clinical environment, processes can be developed to benefit patients allowing them to be accommodated outside of the standard system and also that by working jointly the clinical and catering teams can make a difference.
Nutrition and Hydration Digest

A detailed toolkit which helps hospitals deliver nutritional meals to meet patient requirements

The Nutrition and Hydration Digest
The Nutrition and Hydration Digest
Case study

Leeds Teaching Hospitals NHS Trust demonstrating compliance with the British Dietetic Association Nutrition and Hydration Digest.

As one of the largest NHS Trust’s in the UK, Leeds Teaching Hospitals NHS Trust (LTHT) has the responsibility of feeding around 2,000 patients a day at five different sites across the city. The Trust has put nutrition along with quality and patient satisfaction as the priority for all decision making about products and patient menu planning. The Trust has used the outline guidance provided by the Nutrition & Hydration Digest to develop minimum nutritional targets for all products to meet before they can be considered for inclusion on the patient menus.
The evaluation process has put Nutrition as a top priority. All products are first assessed by the facilities dietician against the Trust’s nutritional targets, and if they achieve the minimum standards they are put forward to taste and quality testing panels, which consist of patient representatives and various staff groups. If a product does not meet the minimum nutritional targets, it does not go forward for taste testing as it is considered to be unsuitable for our patient menus. These changes have been implemented without increasing in the food costs of the patient catering service.

A review of the patient menu provided on the Older Adult wards has resulted in the provision of smaller portions of nutritious items (providing a minimum nutritional content) at lunchtime along with easier to eat / finger food items. This lunchtime meal has been supplemented as part of the nutritional planning of the menu with an afternoon tea service, providing each ward with a locally baked fresh cake (on a covered cake stand) to be served with afternoon tea. The cakes and portion sizes have been chosen so that they provide a higher energy snack, as defined in the Nutrition & Hydration Digest. Promotional posters of the afternoon tea and the menus are available on the wards to promote this service.

Malnutrition Universal Screening Tool or Equivalent

MUST – a validated nutrition 5 step screening tool for identifying adults at risk of malnutrition

Malnutrition Universal Screening Tool or Equivalent 'MUST'
Malnutrition Universal Screening Tool or Equivalent 'MUST'
Case study

Poole Hospital NHS Foundation Trust demonstrating compliance with the Malnutrition Universal Screening Tool (MUST)

Debbie Thompson, Nutrition Nurse Specialist, was appointed in May 2011. Understanding the cost implications of under nutrition, the benefits of screening and the impact of managing and preventing under nutrition (BAPEN), Debbie was tasked with improving the Trusts MUST/nutrition screening. An initial audit, in June 2011, demonstrated a poor compliance (24% of patients screened with 24 hours of admission) a consistent and tireless approach has meant Debbie has turned this around and the latest audit showed a considerable improvement with 96% of patients being MUST screened (90% within 24 hours of admission)

Prior to Debbie taking up post, the MUST document had been manipulated to include 3 pre-MUST questions, permitting a MUST exclusion criteria. Three negative answers negated the need for patients to require a full MUST screen. Audit established that patients meeting the exclusion criteria often resulted in potentially undernourished patients being missed. Pre MUST questions were deemed inappropriate for patients presenting in an acute hospital setting and these were removed from the MUST documentation 6 months later, the new guidelines introduced required all patients to be screened.

To monitor, evaluate and give feedback Debbie undertook 6 monthly audits supporting individual ward leads in developing action plans to improve compliance. It is now standard practice that all nursing staff receive MUST education on Induction and all staff have access to monthly MUST drop in session. MUST is taught as part of the ANT’s (Agents for Nutrition and Tissue viability) study days, with 4 intakes per year. (A MUST game, ‘In Pursuit of MUST’ developed by Debbie is used with the ANT nurses as a light hearted way to ‘get the message across’) There is an emphasis on ANT nurses supporting and encouraging colleagues with MUST screening. ANT nurses are involved in auditing their own ward areas, their input this supports action planning and cascading information.

It was recognised that ‘Bank Nursing staff’, who often makeup a large percentage of staff on the ward, were frequently missing out on essential training such as MUST. This has now been addressed and Bank staff have an ongoing programme of education which includes MUST on a monthly basis. Regular updates to the MUST document has meant it is more user friendly and meet our needs.

In the last 9 months, MUST has been monitored by each ward lead, on a monthly basis as part of our ‘Wednesday Ward Watch’,(WWW) in which data for the PST ( Patient Safety Thermometer) is collected along with data for many other audits that are needed to monitor CCG requirements and our Trust standards. Our compliance target is 90%.Wards not achieving this standard for two consecutive months are targeted for specific support / training until compliance has improved. These education sessions are supported by Dietetic assistants. The WWW helps keep the profile of MUST and importance of nutrition screening high on the agenda.

Debbie is currently working with Outpatient departments to ensure screening occurs for all patients on their first visit, and thereafter if there are any concerns. She is looking at developing a tool for patients to self screen – with signposting of ‘what to do next and where to get additional help’.
Nutrition Education and MUST is part of our National e-learning education via the intranet. All nursing auxiliaries new in post are expected to complete this e-learning within 6 months of starting in the Trust.
Healthier and More Sustainable Catering
- Nutrition Principles

Nutrition principles for staff and visitor catering to enable the provision of healthier and more sustainable choices

Healthier and More Sustainable Catering
- Nutrition Principles
Healthier and More Sustainable Catering - Nutrition Principles
Case study

Bolton Hospital NHS Foundation Trust demonstrating compliance with Healthier and more sustainable catering guidance – nutrition principles (Public Health England)

Hospitals generally strive to make their food and drink healthier. Against a background of increasing obesity and diet related disease, hospitals have both a duty of care and a solid business case to improve their nutritional environments. Snack foods can be a significant source of income for hospitals but these foods are increasingly being identified as contributing to poor health. Evidence suggests health education is not working and environments need to change to support healthier choices.

A Hospital trust may cater for many thousands of people each week and can be a major source of daily food consumption for staff. With regard to patients, we try to incorporate nutrition as a part of the treatment a hospital provides, as it can significantly improve health outcomes for many. Changing a hospital environment to remove unhealthy foods is difficult but not impossible. Singular hospitals making changes to their food and drink environments will not be as effective as groups of hospitals doing so. Hospitals can be proactive and fulfil an important public health duty by promoting good food and restricting the availability of bad food or they may be increasingly chastised or even penalised if they do not modify their nutrition environments to promote good health.

At the Royal Bolton Hospital the first stage of modifications involved reducing the availability of some products identified as being both unhealthy but also widely consumed. Most high sugar drinks were removed leaving only sugar drinks in small portion sizes of no more than 330ml. Most drinks available are now light (low sugar) or diet (no sugar) options. We removed the highest fat content crisps and requested only the light options remained of no more than 120 calories but ideally at 100 calories & pack sizes no larger than 30g. We limited chocolate bars to 60g to remove the increasingly larger chocolate bar offers. Large boxes of biscuits were also removed. These changes were made in vending machines, cafes and restaurant and Royal Voluntary Service (RVS) shops and trolleys.

A new deli bar was installed that allowed the making of sandwiches with fresher food and more salads. A new salad bar was installed for those who liked a wider range of salad foods. A weekly visit to several locations within the hospital from a fruit & veg van selling at market prices ensures we make purchasing healthy foods easier and a weekly fruit and veg stall at the main entrance ensured all hospital users saw we were promoting healthy foods and increased access to purchasing it. Whilst the changes have caused some consternation at times there have been few formal complaints and people have got used to what is on offer. More changes are planned to further reduce the availability of unhealthy food products and increase access to healthier ones where possible.

Government Buying Standards for Food and Catering Services

Food GBS is a set of criteria covering three main areas of sustainable procurement:

a. Food procured to a higher sustainable standards

b. Foods procured and served to a higher nutritional standard

c. Catering operation to a higher sustainable standards

Government Buying Standards for Food and Catering Services
Government Buying Standards for Food and Catering Services
Case study

Hull and East Yorkshire Hospitals NHS Trust demonstrating compliance with Government Buying Standards for Food and Catering Services

Hull and East Yorkshire Hospitals NHS Trust are compliant with Government Buying Standards for Food and Catering Services (Food GBS) for patients, staff and visitors. The inpatient delivered meal system two weekly menu cycle exceeds the requirements of the standards in many areas. They have also developed a range of ‘healthier’ calorie counted main course and dessert items in line with the Food GBS. The trust met Food GBS within cost by effective menu engineering. For nutritionally vulnerable patients the trust has developed a wide range of energy dense meals cooked on site in diet bays.
A new ‘healthier’ range is available throughout all the café bars and restaurants, which are also fully compliant with Food GBS, offering a wide range of healthier menu items that include ‘seasonal’ vegetable choices, reduced fat salad dressings, low salt and fewer saturated fats. The trust has developed a range of fact sheets entitled ‘Balanced Diet’ to assist our staff and visitors to make the right choices. In addition to the fact sheets and calorie counted meals the trust is planning to run a series of cooking demonstrations incorporating delicious recipes from seasonal foods to highlight the simplicity of cooking healthier balanced meals. Step-by-step recipe cards will be made available to customers to assist them in developing their cooking skills.

Patient Nutrition & Hydration
Appropriate nutrition and hydration can help recovery as well as supporting psychological well-being and quality of life

The last nine yards from the entrance of the ward to the patients bedside can make all the difference to the meal experience for better or worse.

Presentation - Clinical and catering staff should work together to deliver nutritious, balanced and well presented meals

Service - Protected mealtimes should be respected and meal service efficient in order to provide the best possible patient experience
Assistance - The best food and drink will not contribute to clinical care if not consumed by the patient; therefore appropriate help should be provided

On-site kitchens enable:

Food prepared using some fresh, seasonal, locally sourced ingredients
Benefits to local area: economic, social and environmental
Employment for skilled catering staff

Delivered meals enable:

Consistent compliance with food and nutrition standards
Wide choice including special and cultural diets
Controlled costs

Both on-site kitchens and delivered meal systems can provide:

Nutritious and high quality food
Provenance and sustainability
Flexibility and choice
Ethical procurement
Benefits to the environment
Affordable food

If all food standards were implemented there is the potential of a £2.5 million saving a year across the NHS.  There is also the potential for £1.5m in health benefits

The 10 Key characteristics of good nutritional care
10 Key characteristics of good nutritional care in hospitals
A set of principles for good nutritional care which can help in developing a food and drink strategy. Covering protected mealtimes, multi-disciplinary teams, patient screening, staff skills, and involving patients

1. 1O Key Characteristics of Good Nutritional Care, NHS England

2. Nutrition & Hydration Digest, the British Dietetic Association

3. Malnutrition Universal Screening Tool or equivalent, BAPEN

4. Healthier and More Sustainable Catering - Nutrition Principles (for staff and visitor catering), Public Health England

5. Government Buying Standards for Food and Catering Services, Defra
Local Commissioning for Quality and Innovation (CQUIN)

294 - Hospital Food CQUIN exemplar


NHS hospitals are required to comply with five food standards
Case study: Food and Drink Strategy

Glen Burley the Chief Executive at South Warwickshire NHS Trust
Healthier Eating Across Hospitals
Sustainable Food and Catering Services
Click play to watch
Watch Marie Batey from NHS England and chair of the expert reference group on patient nutritional care
Click play to watch
NHS Hospital Food
Watch Professor Susan Jebb from the University of Oxford and chair of the expert reference group on Healthier Eating
Click play to watch
Watch Maya de Souza from Defra and chair of expert reference group for Sustainable Food and Catering Services
Click play to watch
Help to Eat
Care Planning
Meal Timings
On-site Shops
Plate Waste
Animal Welfare
For SME's
Hospital Food and Drink Strategy
Nutritious Food for Patients
Healthier Food for Staff and Visitors
Sustainable Food for All
The findings of the Hospital Food Standards Panel are highlighted in the NHS Standards Contract 2015/16

Cost Benefit Analysis
Local Commissioning for Quality and Innovation (CQUIN)

309 - To improve the provision of healthier food and beverage options for staff and visitors

Both staff and visitors need food services that encourage them to make healthier lifestyle choices. If the NHS is to properly promote health as well as deal with ill-health, then it must look to the food and drink it provides.
Staff need healthier, nutritious food to support them in delivering optimal care
For many staff, the food they eat at work makes up a substantial part of their daily diet and a healthier intake can make a real difference

The aim is to improve food and drink across the NHS, so that everyone who eats there has a healthier food experience*, and so that everyone involved in its production is properly valued
Hospital Food and Drink Strategy
*By a healthier food experience we mean that patients, staff and visitors are offered a selection of food and drink that meets their daily nutritional needs and reduces the risk of later ill-health

For most people this would equate to the 'eatwell plate'. Some people may need more energy rich food and drink and others less.

All need to 'eat for good health.'

From Source to Consumption...
At least 1.25% of a provider's total contract out turn is available for local CQUIN schemes, agreed between commissioner and provider. The number and content of local CQUIN schemes are entirely for local agreement.
Recognised tools and schemes which can support improvement and reward excellence in some cases...
The Plan for Public Procurement of Food and catering Services - Balanced Scorecard

- Out of Home calorie labelling (Pledge F1)

- Calorie Reduction (Pledge F4)

- Salt reduction including 2017 targets (Pledges F5, F9 and F10)

- Health at Work (Pledge H4)
The Soil Association's Food for life Catering Mark

Responsibility Deal Pledges
Check out the toolkit used to create a food and drink strategy
Hospital Food Chain

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