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Improving Nutritional Care A joint Action Plan from the Department of Health and Nutrition Summit stakeholders Nutrition Summit stakeholder group Working in partnership with the Department of Health DH INformatIoN reaDer BoX Policy HR/Workforce Management Planning Clinical Estates Commissioning IM & T Finance Social Care/Partnership Working Document purpose Policy roCr reference Gateway reference 8813 title author Publication date target audience Circulation list Description Cross-reference Superseded documents action required timing Contact details for recipient’s use Improving Nutritional Care: A joint Action Plan from the Department of Health and Nutrition Summit stakeholders Jointly produced by the Department of Health and the Nutrition Summit stakeholder group October 2007 PCT CEs, NHS Trust CEs, SHA CEs, Care Trust CEs, Foundation Trust CEs, Medical Directors, Directors of PH, Directors of Nursing, Local Authority CEs, Directors of Adult SSs, Allied Health Professionals, GPs Communications leads, voluntary organisations/ NDPBs The Nutrition Action Plan outlines how nutritional care and hydration can be improved and suggests five key priority areas through which managers and staff working in health and social care can address this.
N/A N/A N/A N/A Rachel Swallow Social Care Directorate Room 8E30 Quarry House Quarry Hill Leeds LS2 7UE www.dh.gov.uk/publications Contents ministerial foreword executive summary Introduction: the importance of nutrition Progress ongoing challenges Key priority areas for tackling nutrition action Plan Governance arrangements Suggestions for how you could tackle issues around nutrition and hydration Conclusion membership of the Nutrition Summit stakeholder group 2 3 5 7 19 21 25 32 33 37 38 1 ministerial foreword Ivan Lewis mP, Parliamentary Under Secretary of State for Care Services I very much welcome the publication of this Nutrition Action Plan, which is the result of a successful collaboration between the Department of Health and members of the Nutrition Summit stakeholder group.
This is the first time that the organisations involved in the Nutrition Summit stakeholder group have worked with the Department of Health to produce a joint plan of action for how collectively we can address nutritional care within hospitals, care homes and the community – whether that is through the provision of ample and nourishing food, help with eating, modified diets or specialist tube feeding.
By bringing all these organisations together in this way, I hope we will be able to achieve much more than any organisation could achieve alone.

Good nutrition and hydration and enjoyable mealtimes can dramatically improve the health and well-being of older people.
It is unacceptable that in some institutions there is an absence of good quality, attractive and nutritious food for older people and a failure to provide support at mealtimes for those who need it – that constitutes a lack of respect for people’s dignity.

Mealtimes should be considered a priority in terms of importance and dedication of staff time, and systems within organisations should reflect this.
This Action Plan describes the main methods by which malnutrition can be tackled by health and social care organisations through the five key priorities for action outlined in the document.
Collectively, we will tackle issues including: better awareness about the importance of nutrition and hydration and their link to good health; improving access to training and qualifications on nutrition for front-line staff; ensuring guidance is clearer in future, clarifying nutritional standards and strengthening the inspection process.
I hope that this joint Action Plan will help to raise awareness, bring about changes in local practices and lead to an improvement in both the importance and delivery of nutritional care and hydration.

Ultimately, it demonstrates the Department of Health’s aim that nutrition should be viewed as equally important as a person receiving their medication.
Ivan Lewis MP Parliamentary Under Secretary of State for Care Services 2 executive summary Having enough to eat and drink is one of the most basic human needs.

And yet we know from the Department of Health’s Dignity in Care campaign, recent media articles, research reports and official complaints that some vulnerable people are not having this fundamental need met.
The very people who are being cared for by health and social care services are at times not getting the right nutritional care to support them to eat and drink.

A lot of work has been undertaken in the past to address this issue and a plethora of guidance, tools and information exists, yet still some health and social care organisations do not always give nutritional care sufficient priority.
the need for a Nutrition action Plan To address this issue thoroughly, the Department of Health has joined forces with a wide range of stakeholders – all committed to tackling this problem.

Pooling their expertise and knowledge, the Department of Health together with the other Nutrition Summit organisations (listed at ‘Membership of the Nutrition Summit stakeholder group’ on page 38) have agreed a range of options and recommendations for how, collectively, they and government will tackle the agenda.
This joint Department of Health/stakeholder Action Plan is the result.

It sets out the five key priorities for action, which were agreed by the Nutrition Summit stakeholders: 1.

To raise awareness of the link between nutrition and good health and that malnutrition can be prevented.

2.

To ensure that accessible guidance is available across all sectors and that the most relevant guidance is appropriate and user-friendly.

3.
3.

To encourage nutritional screening for all people using health and social care services, paying particular attention to those groups that are known to be vulnerable.

4.

To encourage provision and access to relevant training for front-line staff and managers on the importance of nutrition for good health and nutritional care.

5.

To clarify standards and strengthen inspection and regulation.
By producing this Action Plan, the Department of Health and the Nutrition Summit stakeholders aim to ensure that health and social care staff and managers are clear what government and nutrition experts believe are the solutions to the problems of access to good nutrition and addressing poor nutritional care.

In addition, the plan ensures that health and social care staff and managers are well informed, equipped and supported to provide good nutrition and effective nutritional care.
We want to make sure that senior managers and trust board members, local authorities, NHS and social care managers, other staff, people who use health and care services and their carers know what good nutritional care looks like and how it is best organised, and are aware that health and social care services will be held to account by the relevant regulatory bodies where they fail to provide that care.

3 A range of actions have been agreed to support each of the five key priorities for action.
These are described in further detail later in the document, but particular highlights of new developments include: • support and promotion of the Council of Europe Alliance (UK)’s 10 key characteristics of good nutritional care in hospitals (www.bda.uk.com) – a landmark document that creates a common understanding of what good nutritional care looks like in hospital settings • a purpose-designed online training session on nutritional care and assistance with eating that will be available to all NHS and social care staff from May 2008 • commitment from the Nursing and Midwifery Council (NMC) that Essential Skills Clusters that include nutrition principles will be required to be assessed in practice as part of student nurse training from September 2008 • the largest study ever undertaken on malnutrition on admission to hospital and care homes across the whole of the UK – conducted by the British association for Parenteral and enteral Nutrition (BaPeN) • BAPEN has developed a web-based information resource, Organisation of food and nutrition support in hospitals, which will help those tasked with overseeing nutritional care in ensuring that the appropriate infrastructure, processes and resources are in place • development by the Department of Health and the Social Care Institute for Excellence of a range of good practice on nutritional care as part of the Dignity in Care online practice guide.
4 Introduction: the importance of nutrition Good nutritional care, adequate hydration and enjoyable mealtimes can dramatically improve the general health and well-being of older people, as well as increasing their resistance to disease and their recovery from any illness, trauma or surgery.
The importance of dignity at mealtimes to people who use health and social care services is evidenced in a number of recent studies, including PRIAE/Help the Aged, 2001,1 which found that food, nutrition and mealtimes are a high priority for older people and the top priority for older people from black and ethnic minority groups.
1 Dignity on the ward: Towards dignity: Acting on the lessons from hospital experiences of black and minority ethnic older people – a report from the Policy Research Institute on Ageing and Ethnicity for the Dignity on the Ward Campaign, Policy Research Institute on Ageing and Ethnicity (PRIAE)/Help the Aged, 2001 Meals and mealtimes affect the quality of life of older people and are indeed ‘the highlight of the day’ for many people in residential care.2 A small study into care homes also found that, for residents, food is a definer of the quality of a home.3 Nutritional interventions in malnourished hospital patients can reduce complications, lengths of stay and mortality.4 Together with the associated key facts, these findings demonstrate the crucial importance of nutritional care, whether delivered through food, help with eating, modified diets, supplements or specialist tube feeding.
2 Highlight of the day?
: Improving meals for older people in care homes, Commission for Social Care Inspection (CSCI), 2006 3 PG Professional and the English Community Care Association, 2006 4 Nutrition support for adults: Oral nutrition support, enteral tube feeding and parenteral nutrition, Clinical Guideline 32, National Institute for Health and Clinical Excellence (NICE), 2006 5 Key facts • Malnutrition affects over 10% of older people (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 expended 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; Age Concern, 2006).
• Malnutrition is currently under-recognised and therefore under-treated (The ‘MUST’ report, BAPEN, 2003).

• Malnutrition can be treated effectively (The ‘MUST’ report, BAPEN, 2003).

6 Progress A lot of work has already been done to address the five key priorities for action and, collectively, the Department of Health and Nutrition Summit stakeholders have made significant advances in improving nutritional care in the NHS and social care.
Useful links to further information and the milestones achieved so far are provided throughout this section.

7 Key priority for action 1 to raise awareness of the link between nutrition and good health and that malnutrition can be prevented.

1.

The Council of Europe Alliance (UK), a wide range of stakeholders, has developed 10 key characteristics of good nutritional care in hospitals, which should help create a common understanding of what good nutritional care in hospital looks like.
The Council of Europe Alliance (UK) will develop the 10 key characteristics to make them more suitable for following in a social care environment.

It will also ensure that they refer to the importance of good hydration.

Copies of posters displaying the 10 key characteristics can be downloaded from www.bda.uk.com.

Managers are encouraged to make use of this easily replicable document to promote good nutritional care.
The document can be used to assess whether services are meeting the nutritional care needs of service users.

10 Key Characteristics of Good Nutritional Care in Hospitals 9 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.

9 All patients have a care plan which identifies their nutritional care needs and how they are to be met.
9 The hospital includes specific guidance on food services and nutritional care in its Clinical Governance arrangements.

9 Patients are involved in the planning and monitoring arrangements for food service provision.

9 The ward implements Protected Mealtimes to provide an environment conducive to patients enjoying and being able to eat their food.

9 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.

9 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.

9 The hospital has a policy for food service and nutritional care which is patient centred and performance managed in line with home country governance frameworks.

9 Food service and nutritional care is delivered to the patient safely.
9 The hospital supports a multi-disciplinary approach to nutritional care and values the contribution of all staff groups working in partnership with patients and users.

8 2.
8 2.

A number of recent campaigns have also highlighted the importance of receiving nutritious food and help with eating and drinking: • age Concern’s Hungry to be Heard campaign, launched in 2006, highlights the extent of malnutrition of older people in hospitals and sets out seven steps to ending malnutrition in hospital based on data provided by BAPEN.

Through the campaign, staff and the public are encouraged to raise this as an issue with their local NHS trusts.
Patients and their carers can access information and advice on how to protect themselves and their loved ones, including leaflets and posters.

• The Royal College of Nursing (RCN) has signalled its commitment to addressing this issue through its Nutrition Now campaign, which aims to help nurses at all levels improve the nutrition and hydration of patients.

“The RCN campaign Nutrition Now aims to improve the standards of nutritional care given to patients in hospitals and the community.
Nurses are, of course, responsible for ensuring that patients and clients eat the right food at the right time with the right supervision and assistance.

But nurses cannot raise standards by themselves.


Our campaign recognises that high-quality nutritional care can only be delivered in partnership with other professional groups and with a commitment from the highest level in an organisation.” Geraldine Cunningham, RCN Institute • The Hospital Caterers Association (HCA) also highlighted this as an important issue through its 2007 National Service excellence Day.
Staff throughout the country were provided with practice advice and tips on how to make a difference.

3.

BAPEN has provided the research and evidence base to demonstrate the link between under-nutrition and ill health.

This is provided in the ‘mUSt’ report (BAPEN, 2003) and the cost of disease-related malnutrition (BAPEN, 2006).

4.
4.

NICE has examined the evidence base relating to oral, enteral and parenteral nutrition support and has issued authoritative guidelines (NICE, 2006)5 on why, when and in whom nutrition support should be considered as well as on what should be provided and how that might be given.1 5.

The New Dynamics of Ageing programme is running a five-day think tank in January 2008 (known as a ‘sandpit’) to discuss the topic of nutrition for older people.
The aim of the event is to generate research proposals that might lead to £2 million worth of funding to explore issues around nutrition.

It gives participants from a wide range of backgrounds an opportunity to discuss the current problems around nutrition.

The Department of Health will be engaging in this process and hopes to learn from the outputs of the event and the subsequent research that may follow.
More information about the work can be found at www.epsrc.ac.uk/CallsforProposals/ NutritionSandpitCall.htm.

5 Nutrition support for adults: Oral nutrition support, enteral tube feeding and parenteral nutrition, Clinical Guideline 32, NICE, 2006 9 Key priority for action 2 to ensure that accessible guidance is available across all sectors and that the most relevant guidance is appropriate and user-friendly.

Some key guidance and checklists for hospitals and care settings are listed below.
Please note that this list is not exhaustive and does not represent an endorsement of these documents over other sets of guidance.

It acts as a summary of the major pieces of guidance that have recently been published.

Further sets of guidance (not listed here) can be found on the Nutrition Summit stakeholders’ websites.
title of guidance author Description In August 2007, SCIE and the Department of Health collated key guidance, case studies and good practice examples on nutritional care and hydration in a ‘specific mealtimes’ section of the Dignity in Care online practice guide.

In October 2006, the FSA issued nutrient and food-based guidance for UK institutions.

The advice for care homes includes guidance on appropriate nutrient and food intakes and allergy and food hygiene tips.
There are also example menu plans to help caterers for care homes follow the guidance, with a technical report showing how the menus follow FSA advice.

The guidance is available to download from www.food.gov.uk/ healthiereating/nutritioncommunity/care.

The primary source of guidance on nutritional care in social care settings is the NACC.

The three documents cited are those issued most recently.
Dignity in Care online practice guide Social Care Institute for Excellence (SCIE) and the Department of Health FSA nutrient and food based guidelines for UK institutions Food Standards Agency (FSA) National association of Care Catering (NaCC) Food served to older people in residential care Menu planning and special diets in care homes (2006/07) The national minimum care standards for care catering: Care homes for older people (2005) A recommended standard for community meals (2005) 10 title of guidance author Description Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition, Clinical Guideline 32 Hungry to be heard Is an older person you care about malnourished?
NICE Clinical guidance to help identify patients who are malnourished or at risk of malnutrition.

Age Concern The Hungry to be heard report sets out seven steps hospitals can follow to end malnutrition and can be downloaded from www.ageconcern.org.uk/ageConcern/ hungry2bheard.asp.

Is an older person you care about malnourished?

is a leaflet providing advice on how to spot signs of malnutrition in older people and what to do if you are concerned.
Guidance In addition, Age Concern has teamed up with the RCN to develop a free resource pack for hospitals to help promote good nutrition, enable more people to assist at mealtimes, and encourage patient involvement and feedback.

The pack includes: • • • • • Helping an older patient to eat helping and encouraging an older patient to eat well in hospital leaflet: tips for Hungry to help?
becoming a mealtime volunteer in hospitals leaflet: information on Don’t go hungry in hospital older patients on eating well in hospital leaflet: advice for Nutrition on admission card to ward staff of an older person’s usual diet, appetite and food preferences : a quick snapshot : to capture the mealtimes questionnaire experiences of older people and their relatives/ carers, and give them the opportunity to shape and improve service delivery.

Free packs are available from htbh@ace.org.uk.


11 title of guidance author Description 10 key characteristics of good nutritional care in hospitals Council of Europe Alliance (UK) Ten principles of providing nutritional care in hospitals are distilled onto one page, for displaying as a poster on a wall or using as a reference document.

Copies of the document can be found on the British Dietetic Association’s (BDA’s) website at www.bda.uk.com.
Department of Health The benchmarks include attention to nutritional assessment, the environment, presentation of food and appropriate assistance.

Water UK Water UK is the primary source of guidance to encourage better awareness about the health impacts of poor hydration.

The Hydration best practice toolkit for care homes has been developed to assist care managers, care caterers and other service providers to bring the benefits of improved water consumption to older people using care services.
The Hydration best practice toolkit for hospitals and healthcare is an online resource developed through partnership working with nurses, patient groups and key stakeholders, including Water UK.

It provides practical advice for healthcare staff on how to minimise the risk and potential harm that poor hydration can cause, and offers solutions to improve the provision of water to hospital patients.

The campaign provides a range of advice on providing assistance with eating, aimed at nursing staff.
To allow interested parties to access the information the RCN is providing to nurses and other health professionals, the guidance RCN principles for nutrition and hydration is available on the RCN campaign website at www.rcn.org.uk/nutritionnow.

NHS essence of Care benchmarks for food and nutrition Wise up on water!
medical evidence fact sheets and hydration awareness posters Hydration best practice toolkit for care homes Hydration best practice toolkit for hospitals and healthcare Nutrition Now campaign RCN 12 title of guidance author Description BAPEN Organisation of food and nutritional support in hospitals (2007) BAPEN has recently published its up-to-date web-based information resource.
This was developed in order to help trusts respond to and implement guidance from NICE promoting screening (Nutrition support for adults).

It helps hospitals and primary care trusts (PCTs) develop their infrastructure to deliver improved food and nutrition support services.

The new module provides structured self-directed training support that underpins the Council of Europe Alliance (UK)’s newly launched 10 key characteristics of good nutritional care in hospitals and this Nutrition Action Plan.
The module is freely available to access on the BAPEN website at www.bapen.org.uk.

It is best viewed and used interactively online due to the hotlinks in place.

However, paper copies can be made available upon request via the website.

13 Key priority for action 3 to encourage nutritional screening for all people using health and social care services, paying particular attention to those groups that are known to be vulnerable.

1.
1.

The NICE guidance Nutrition support for adults recommends that: • “All hospital inpatients on admission and all outpatients at their first clinic appointment should be screened.

Screening should be repeated weekly for inpatients and when there is clinical concern for outpatients.
People in care homes should be screened on admission and when there is clinical concern.” • “Nutrition support should be considered in people at risk of malnutrition who, as defined by any of the following: – have eaten little or nothing for more than five days and/or are likely to eat little or nothing for the next five days or longer – have a poor absorptive capacity, and/or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism.” 2.
BAPEN held a Nutrition Screening Week during September 2007 to raise the profile of screening, collect valid and current data on malnutrition on admission to hospital and care, and provide information on implementation.

The RCN, BDA, National Patient Safety Agency (NPSA), NACC and Department of Health all played active roles in supporting BAPEN’s screening initiative.
For the first time, this information on the prevalence of malnutrition – collated from over 600 hospitals and care homes – provided three important things: • the largest study ever undertaken on malnutrition on admission to hospital and care homes across the whole of the UK • consistent, reliable and comparable data – all reporters used the same criteria, based on BAPEN’s ‘mUSt’ (malnutrition Universal Screening tool) • a clear indication of the extent of malnutrition where it starts – out in the community.
BAPEN’s Nutrition Screening Week will provide clear data for the hospital and care sectors on the scale of the problem, how their organisations and infrastructures will need to change to respond appropriately, and the access to professionals and physical resources required to address malnutrition and its underlying causes effectively.

14 “Screening is a first step to reassuring us as patients, as well as our families and carers, that our nutrition needs are being addressed.
BAPEN led the way by developing the ‘MUST’ screening tool.” Justine Bayes, a member of the Patients on Intravenous and Nasogastric Nutrition Therapy patient network for adults and children and a member of BAPEN “Screening patients in hospital, the community, primary care and residents in care for risk of malnutrition with ‘MUST’ provides us with the information on which we base appropriate nutritional care and treatment plans – whether that is through help with eating, adjusted diet or special nutritional support.
It also alerts us to those individuals whose nutrition needs to be monitored most carefully.” Vera Todorovic, Consultant Dietitian in Clinical Nutrition, Doncaster and Bassetlaw Hospitals NHS Foundation Trust 15 Key priority for action 4 to encourage provision and access to relevant training for front-line staff and managers on the importance of nutrition for good health and nutritional care.

1.
1.

Skills for Care has produced a Knowledge set for nutrition and well-being, which outlines key learning outcomes for staff working in adult social care who are involved in nutrition.

The key learning outcomes provide minimum standardised outcomes that employers can use, either to produce their own in-house learning or learning packages or as a benchmark when buying in learning provision or learning packages.

2.
2.

A number of organisations are currently developing or delivering training in nutrition, clinical nutrition and healthy eating.

For example, BaPeN has developed a web-based information resource, Organisation of food and nutritional support in hospitals, for those tasked with ensuring that the appropriate infrastructure and resources are in place.
BAPEN is also in discussion with Doctors.net.uk (www.doctors.net.uk/) to develop interactive and self-directed modules on nutritional care for doctors at all levels.

Organisation of food and nutritional support in hospitals is freely available to access on the BAPEN website at www.bapen.org.uk.
It is designed to aid hospital trusts to develop the infrastructure and resources required to deliver best patient nutritional care and treatment across all departments, all patients and involving all staff teams (medical, nursing, pharmaceutical and catering).
The resource builds on previously published work and guidance from BAPEN, the Royal College of Physicians, RCN, Council of Europe Alliance (UK), BDA, NICE and the Department of Health to encourage trusts to take an ‘aspirational’ approach to planning the comprehensive delivery of nutritional support services to all patients.

It underpins the Council of Europe Alliance (UK)’s newly launched 10 key characteristics of good nutritional care in hospitals and the content of this Nutrition Action Plan.
16 Designed by a multi-disciplinary team from BAPEN, the resource will help trusts develop: • a clear understanding of the roles and responsibilities of all involved in delivering nutritional care for all patients in all departments • a nutrition steering group/nutrition support team to spearhead change • a change of culture that embeds nutritional care – from screening to feeding – into routine practice • an individual patient-centred approach to nutritional care • a sustainable resource for established and new staff.
“It is no good having screening for malnutrition without the system and resources in place to back it up and ensure that nutrition care plans can be delivered to meet each patient’s needs – whether that’s with food or special feeding through tubes.

Hospital trusts need to think about the infrastructure, resources and training required to achieve this.
BAPEN’s new web-based resource, Organisation of food and nutritional support in hospitals, is designed to do just that.” Professor Jeremy Powell-Tuck, Consultant Gastroenterologist, Barts and The London NHS Trust 3.

An inter-agency round table group (co-chaired by NACC and the Royal Institute of Public Health), consisting of several of the Nutrition Summit stakeholders, has already met to raise issues around training and inform the Department of Health about its suggestions.

4.
4.

Falling out of the Council of Europe Alliance (UK)’s work on the 10 key characteristics of good nutritional care in hospitals, work is under way on NNEdPro (the Need for Nutrition Education Project).

This will survey nutrition knowledge, attitudes and practices, before and after a nutrition education intervention, in undergraduate medical students across the UK.

Essentially the project will look at what education is needed on the undergraduate medical curriculum around nutrition.
The Nutrition Action Plan Delivery Board hopes to learn from the outcomes of this work.
“The service where I work provides a high standard of individual care, tailored to the needs of the individual… Service users choose their own meals… The staff help them to lead full and active lives at home and in the community.” Anonymous member of staff in NHS/social care completing the Dignity in Care online public survey, Department of Health, October 2006 17 Key priority for action 5 to clarify standards and strengthen inspection and regulation.

1.
1.

The health and social care regulators, the Healthcare Commission and CSCI, have signalled their commitment by giving greater priority to issues around dignity and assistance with eating in their inspections.

2.

The Healthcare Commission has sent a strong message to NHS trusts that poor quality nutritional care must not be tolerated through its recent review of how trusts are meeting core standards around dignity and nutrition.
The report following that review, Caring for dignity: a national report on dignity in care for older people while in hospital, was published on 27 September 2007 and includes key findings, best practice from trusts that excelled and a number of recommendations for trusts, strategic health authorities (SHAs), PCTs, policy makers and voluntary organisations.

In the report, the Healthcare Commission also makes a series of commitments for actions it will take itself.

3.
3.

The inspection guides used by inspectors for assessments undertaken in 2006/07 have been revised by the Healthcare Commission in the light of new criteria on the core standards on food and nutritional care.

CSCI also has guidance for inspectors, Clinical trigger: The management of nutritional care for older people in care homes, published in June 2006, which includes the need for a nutritional assessment to be carried out and reflects best practice as advised by nutritional groups.

4.
4.

The Patient Environment Action Team inspection process is reviewed annually by the NPSA and special attention this year has been given to the section on nutritional care, in conjunction with the Healthcare Commission.

This aligns the content more closely with Department of Health core standards and therefore makes it more useful for trusts in demonstrating compliance.
18 ongoing challenges Living well in later life (2006) identified that many older people are missing meals on hospital wards due to a lack of assistance with eating and drinking, meals not being suitable or clinical activity taking place during mealtimes.

It also found that people with dementia were not receiving adequate or sensitive help with eating.
Age Concern recently published Hungry to be heard (2006), a compelling report into malnourished older people in hospital that strongly argues for a change in culture and practice.

It recommends seven steps that hospitals should take to end the malnourishment of older people.

Following the introduction of the Better Hospital food Programme in 2001, hospital food is better now than at any time since measurement began.
However, insufficient attention to the importance of nutritional care, meals and mealtimes remains evident in a number of NHS and social care organisations.

Assistance with eating and dignity at mealtimes were common issues raised in the Department of Health online Dignity in Care survey (2006) and the ministerial listening events held in 2006 with older people and their carers.
“When my father went into hospital, I witnessed food and drinks being left on trolleys for people who were unable to eat and drink unaided.

I always went in at mealtimes to make sure my father got something to eat.” Anonymous service user completing the Dignity in Care online public survey, Department of Health, October 2006 19 According to the report by CSCI, Highlight of the day?
: Improving meals for older people in care homes (March 2006), most care homes were meeting the core standards for providing nutritious food but many care homes were not.

This evidence, taken alongside complaints data and anecdotal feedback, suggests that despite a raft of recent initiatives and investment, unacceptable poor practice around food and mealtimes and delivery of appropriate nutritional care still exists in some NHS and social care services.
The most recent Healthcare Commission Inpatient Survey (2006) found that of those patients who needed help to eat their meals, fewer said they always received it (58%, down from 62% in 2005).

The survey showed a rise in the proportion of patients who needed help from staff to eat their meals saying they did not get enough help, increasing from 18% in 2005 to 20% in 2006.
The recent Healthcare Commission report on privacy and dignity in NHS trusts, Caring for dignity, found that of the 23 trusts sampled: • not all of them had clear policies relating to dignity and nutrition.

Many trusts claimed that these were embedded in other policies • implementation of policies and practices tended to be fragmented and was left to individual wards, which caused variations • not all trust boards received and considered regular reports on dignity and nutrition issues.
The issue is also significant within social care.

Comic Relief and the Department of Health jointly published a report into the abuse and neglect of older people called UK study of abuse and neglect of older people: Prevalence survey report (June 2007).

The study was based on a survey of around 2,000 people aged 66 and over who live in their own homes (including sheltered housing).
It found that of those who reported being neglected, 85% had not received help with a day-to-day activity (such as shopping, housework or meal preparation), and 41% had not received help with personal care (such as getting in and out of bed, washing, using the toilet, dressing and eating).

In each case, there was an expectation that this help was going to be provided, and the person was unable to carry out the activity without assistance.
20 Key priority areas for tackling nutrition To address these ongoing challenges and to develop workable solutions, the Department of Health took the unprecedented step of bringing together a wide range of interested stakeholders at the first Nutrition Summit in March 2007.

At a subsequent Summit in July 2007, stakeholders suggested a range of options and recommendations for how, collectively, they and government could tackle this agenda.

Five key priorities for action were established.


It is important to note that, while the backdrop to the Action Plan has been to consider the nutritional needs of older people, these five priorities apply to all adults, particularly vulnerable adults and those with physical and learning disabilities.

raising awareness Nutrition Summit stakeholders agreed that education and raising the profile of nutrition and its impact on people’s health are key to preventing malnutrition occurring in the first place.
Therefore, raising awareness of this link is crucial to addressing nutritional care and hydration issues.

More needs to be done to raise awareness among managers, staff and the public of the impact poor nutritional care can have on general health and well-being and the difference good nutritional care can make.

This is especially true in a community setting.


If the nutritional status of someone in the community is poor, then they are more likely to need to move into institutional care, where they may subsequently have poorer health outcomes.
21 We therefore need to ensure that staff and managers at all levels of an organisation that provides services for or interacts with older people understand the link between good nutritional care and assistance with eating and promoting good health and well-being, and see this as a fundamental aspect of good care.

Together, we must as a priority: Raise awareness of the link between nutrition and good health and that malnutrition can be prevented.
the right guidance Next, we need to look at the quality and availability of appropriate guidance.

A plethora of guidance, case studies and best practice already exists to support local organisations and their staff to deliver good nutritional care.

The sheer volume and complexity of this guidance is, in part, contributing to organisations and staff being confused about which guidance is the most appropriate for them and the people they care for.
Much of the existing guidance is too long, too complex or in the wrong format.

Consequently, people have difficulty translating it into practice.

While it seems to cover all sectors, available guidance may be lacking simple, easy-to-read material for people providing care in a community setting, such as domiciliary care staff, people employed through direct payments and family carers.

It is widely recognised that protected mealtimes allow patients to have an uninterrupted mealtime environment.
However, as the recent Healthcare Commission report, Caring for dignity, highlights, local policies around protected mealtimes are not being implemented uniformly and lack commitment at board level in some trusts.

Where they have been implemented, not all groups of staff have been adhering to the policies.

The Healthcare Commission believes that it is important that all groups of staff, including medical practitioners, adhere to initiatives such as protected mealtimes.
There is a requirement for all managers and staff to be able to find and easily use up-to- date, core guidance and information that will help them ensure that the people they care for are not malnourished or dehydrated.

Together, we must as a priority: Ensure that accessible guidance is available across all sectors and that the most relevant guidance is appropriate and user-friendly.
Screening for all Nutritional screening is key to identifying those at risk of malnutrition and monitoring the progress of people who have been identified as malnourished.

Although screening is beginning to be implemented in hospitals and care homes, it is not used in all cases, particularly where care is being provided in community settings, such as sheltered housing and domiciliary care services.
The Single Assessment Process (SAP) – or its replacement, the Common Assessment Framework (CAF) – which is frequently undertaken with older people using health and social care services, includes an assessment question on nutrition.

Where any issues are raised around nutrition as part of SAP/CAF, this should lead to a more in-depth nutritional assessment.
All the three main accredited SAP/ CAF toolkits prompt assessors to consider an older person’s ability to eat and drink, their diet, weight loss/gain and their ability to prepare a meal.

In 2005, half of all local authorities in England deployed an accredited SAP/CAF tool.

That proportion is likely to be higher now, with the remainder of local authorities using very similar locally developed tools.
Given this, the vast majority of older people at risk of malnutrition who are in contact with health and care services should be identified using the SAP/CAF process.

22 Despite the information about nutritional assessments being included in the SAP/CAF and the use of nutritional screening in many care settings, we know that people are still being left without enough to eat and drink or appropriate nutritional care.
There is a need to gain a greater understanding of the prevalence of malnutrition in the NHS and social care and what the contributing factors are.

Further information is also needed on what actions are currently being taken after screening or the needs assessment, where people have been identified as being at risk of malnutrition, including sharing of information and specialist interventions as well as more in-depth nutritional assessments.
Together, we must as a priority: Encourage nutritional screening for all people using health and social care services, paying particular attention to those groups that are known to be vulnerable.

more relevant training A well trained and equipped workforce is key to ensuring that nutritional screening and other interventions are properly implemented and that vulnerable people receive appropriate nutritional care and the practical assistance they need at mealtimes.
It is important that staff working in health and social care can recognise the signs of malnutrition and poor hydration; this should ideally be a part of any training on nutritional care.

Currently, there is no mandatory requirement for care home staff, staff working in people’s own homes, catering staff in care homes or hospital-based care professionals to complete a training module or qualification in nutritional care and/or assistance with eating.
However, Common Induction Standards and General Social Care Council codes have an expectation that all staff are competent in the work they are required to undertake.

Existing training provision in this area is patchy and organisations are not clear about what training they should commission or from where.

Expert nutrition organisations need to have a greater role in evaluating and determining the training of staff and professionals.
Professional bodies should influence curriculum development in nutrition training for health professionals.

We need front-line staff and managers in all care settings, including those preparing and serving food and those providing assistance with eating, to have the knowledge and skills required to deliver good nutritional care.
Together, we must as a priority: Encourage provision and access to relevant training for front-line staff and managers on the importance of nutrition for good health and nutritional care.

maintaining standards Core standards already exist for nutrition and mealtimes in health and social care services.

They are not enforceable by law but are important requirements to help providers, inspectors and people who use services judge the standard of service.
These represent an attempt to ensure that everyone understands what is expected so that services can be measured against the same standards.

The current relevant national standards are: • the Department of Health’s National minimum Standards for Care Services, which set a minimum level of care, service and facilities that should be provided by those that operate residential homes, domiciliary care and nurses agencies and adult placement schemes.
CSCI takes these into account when inspecting services 23 • the Department of Health’s Standards for Better Health, which include 24 core standards that all NHS healthcare providers in England must achieve, as well as 13 developmental standards that they should be working towards achieving.

Core standards C15a and 15b directly relate to nutrition and assistance with eating.

The majority of Nutrition Summit stakeholders considered that references to nutrition in the existing standards are sufficient.
Most see the issue as being about variations in how these standards are being interpreted and measured.

Some thought that existing standards need to be more enforceable, with supporting guidance issued to help make the standards clearer and easier to understand.

Others suggested that existing standards are too vague and should be made more explicit.

People being supported in the community through domiciliary care services were seen as the least protected by existing standards.
Together, we must as a priority: Clarify standards and strengthen inspection and regulation.
“As a student nurse it was often routine for patients’ meals to be left on a table at the bottom of their bed when they were clearly incapable of reaching them or eating independently.” Anonymous member of staff in NHS/social care completing the Dignity in Care online public survey, Department of Health, October 2006 24 action Plan Building on the progress already made, the Nutrition Summit stakeholders have made several commitments to take action, either individually or collectively, to address the five key priorities for action over the coming year.
25 1. to further raise awareness of the link between nutrition and good health and that malnutrition can be prevented, the Nutrition Summit stakeholders have agreed on the following action Plan commitments: 1.

All Summit stakeholders will support and widely promote the Council of Europe Alliance (UK)’s 10 key characteristics of good nutritional care in hospitals, creating a common understanding of what good nutritional care looks like in hospital settings and how it should be organised.
Copies of the document can be found on the BDA’s website at www.bda.uk.com.

2.

The Council of Europe Alliance (UK) will develop the 10 key characteristics to make them more suitable for following in a social care environment.

They will also ensure that they refer to the importance of good hydration.

3.
3.

All Summit organisations will use their own communications mechanisms, including conferences, events, newsletters and guidance, to ensure that the key messages, best practice and information endorsed by the Summit members reach the widest possible health and social care audiences.

4.
4.

The NACC and English Community Care Association are working with Water UK, the Water for Health Alliance and selected water companies to understand the benefits and challenges that care homes have experienced since introducing their recently published Hydration best practice toolkit for care homes, and as a result of this will produce advice and case studies to encourage other homes to promote good hydration and drinking water.
“[The Council of Europe Alliance (UK)’s 10 key characteristics of good nutritional care in hospitals provides] a clear description of what good nutritional care looks like, important for providers and regulators alike.” Rick Wilson, BDA and Chair of the Council of Europe Alliance (UK) Group 26 2. to further ensure that accessible guidance is available across all sectors and that the most relevant guidance is appropriate and user-friendly, the Nutrition Summit stakeholders have agreed on the following action Plan commitments: 1.
All Summit organisations will ensure that any guidance they issue in future is made simpler and easier to read and co-ordinated with guidance produced by other stakeholders.

2.

The RCN, NPSA, Water UK, HCA, NHS Supply Chain and Patients Association are all working together to publicise their recently launched Hydration best practice toolkit for hospitals and healthcare.
Based on the concept used to build the care homes hydration kit, this initiative will raise awareness of the benefits of drinking water to patient care, before more specific guidance is developed.

This will include advice on purchasing hydration equipment, facilitating patients in drinking, and promoting the role of nurses in accurately completing fluid charts.

The toolkit was launched on 24 September 2007.

3.


The United Kingdom Homecare Association will work with the NACC to publish guidance to all members, with a provisional title of ‘Homecare and nutrition’, in early 2008.

The guidance will cover food hygiene issues and nutrition within the home and will be clearly written and easy to read.

4.
4.

Age Concern has teamed up with the RCN to develop a free resource pack for hospitals and patients to help promote good nutrition, enable more people to assist at mealtimes, and encourage patient involvement and feedback.

It includes useful leaflets for ward staff and service users.

See the information in the table on page 11 for more details.
27 3. to further encourage nutritional screening for all people using health and social care services, the Nutrition Summit stakeholders have agreed on the following action Plan commitments: 1.

The Department of Health and the Nutrition Summit stakeholder group will communicate the importance of NHS and social care organisations implementing nutritional screening for all.

2.

The health and social care regulators will look for evidence of nutritional screening in their assessments of local services.

3.
3.

BAPEN aims to repeat the Nutrition Screening Week on an annual basis and, given appropriate funding, will expand the initiative to cover GP surgeries, sheltered housing and other settings.

BAPEN will also work with the Department of Health and the Nutrition Summit stakeholders to effectively address malnutrition in the community through what they learn about the prevalence of malnutrition as part of their Screening Week.
BAPEN will also continue its work in promoting best practice in the implementation of screening through its ‘shared learning’ initiative linked with NICE.

4.

BAPEN, the NACC and ERoSH (the Sheltered Housing Consortium), together with the City of Westminster, Richmond Housing Partnership, the Accent Group and Harrogate Neighbours, are developing a nutritional screening tool to pilot within sheltered housing schemes and plan to extend this work to cover domiciliary care services.
The pilot starts in October 2007 with results expected to be presented in late spring 2008.

5.

The Department of Health will take forward research to identify the prevalence of nutrition-related neglect and abuse in hospitals and care homes.

This work will follow on from a feasibility study already commissioned by the Department of Health to explore extending Comic Relief research on the prevalence of abuse and neglect in people’s homes to cover care homes and hospital settings.

6.
6.

As part of the CAF proposals, the Department of Health will be reaffirming its commitment to SAP/CAF and encouraging multi-dimensional assessments of need for all adults.

Proposals for the development of integrated e-care records include a field relating to eating/drinking and nutrition.
“Screening for malnutrition on admission to hospital and other care settings makes medical, nursing and care professionals think about nutrition as an integral part of routine clinical care – and ensures that we act on what we find.
The ‘MUST’ has been a catalyst in getting screening for malnutrition established in practice.” Professor Marinos Elia, Chair of BAPEN, Southampton General Hospital 28 4. to further encourage provision and access to relevant training for front-line staff and managers on the importance of nutrition for good health and nutritional care, the Nutrition Summit stakeholders have agreed on the following action Plan commitments: 1.
The Nutrition Action Plan Delivery Board will advise on any gaps in current training provision and take steps to encourage training providers to fill those gaps.

2.

All Nutrition Summit stakeholders will promote key nutritional training to their members.

3.

The NPSA has contributed to the development of the NMC’s Essential Skills Clusters (ESCs) that from September 2008 will require nutrition principles to be taught and assessed in practice as part of the pre-registration nursing programme.
The NMC will monitor the use of ESCs through its ongoing quality assessment arrangements.

4.

The NHS Core Learning Unit will run an online training session on nutritional care and assistance with eating from May 2008.

The session will last no longer than two hours and will be available to all health and social care staff.

5.
5.

The Sector Skills Councils (including Skills for Health, Skills for Care and Development (UK) and Skills for Care (England)), in collaboration with the FSA, will undertake a qualifications strategy review to explore the nutritional care learning and qualifications needs for the adult health and social care workforce.

They will consult a range of stakeholders about the necessary improvements to the current National Occupational Standards for the workforce in respect of catering and nutritional feeding.
The FSA, the NACC, employers, people who use the services and carers will all be involved.

6.

Help the Aged with the National Care Forum and BUPA have developed an evidence-based programme on improving the quality of life for care home residents.

Visit www.myhomelife.org.uk for a review of the literature, educational materials and shared space to promote best practice on all aspects of life in care homes.
29 5. to further clarify standards and strengthen inspection and regulation, the Nutrition Summit stakeholders have agreed on the following action Plan commitments: 1.

Skills for Care will work with CSCI to develop training for its inspectors around awareness of what good nutritional care looks like in practice.

Outputs from this work will be delivered to inspectors within CSCI’s overall training programme.

2.
2.

The Healthcare Commission will continue to assess the performance of NHS organisations through the annual health check process against the core standards relevant to Dignity in Care – these include core standards C15a and 15b on nutrition.

They will also advise SHAs to carry on working with trusts at a local level to facilitate improvement in services for older people.

3.
3.

The Healthcare Commission will also improve and enhance the use of surveillance- based risk assessment as a model to identify poor performing trusts.

These trusts will be followed up for further scrutiny and notification if and where concerns are identified.

4.

In addition, the Healthcare Commission has announced in its report Caring for dignity that trusts may receive unannounced visits to check up on their performance against Dignity in Care.
They are encouraging patients, their carers and representative bodies such as Age Concern to tell the Commission when they have any concerns.

The Healthcare Commission has also reviewed its inspection guides used by inspectors for assessments in the light of new criteria in the core standards on food and nutritional care.

Copies of the report are available at www.healthcarecommission.org.uk/nationalfindings/publications.cfm.

5.
5.

CSCI has produced guidance for inspectors, Clinical trigger: The management of nutritional care for older people in care homes (published in June 2006), which includes the need for a nutritional screening to be carried out and reflects best practice as advised by nutritional groups.

Within its Inspecting for Better Lives policy, CSCI will undertake risk-based and proportionate inspections of regulated services.
Inspections focus on good outcomes for people using services, and the Commission is introducing new inspection tools to measure these, including short observational frameworks for people with dementia and the use of people who have used services as ‘experts by experience’ to help inspectors to form judgements.

6.

CSCI will use its Annual Quality Assurance Assessment (AQAA) to ask all providers to confirm that they carry out nutritional screening for people at risk of malnutrition.
Where evidence raises concern about nutrition and malnutrition, it will ensure that this is fully explored during the next inspection of the service.

7.

CSCI will track through the AQAA the assessment of individual person-centred plans to make sure that, where required, nutritional screening has taken place.

30 8.

Services will be assessed on whether people have nutritious and attractive meals and snacks, at a time and place to suit them.
CSCI is introducing published quality ratings (0–3 stars) for all registered services from January 2008.

These will provide the public with access to clear information about the quality provided in each service.

9.

The Department of Health expects nutrition to be an important element in the criteria that the new Health and Adult Social Care Regulator will use to assess health and social care services.

10.
10.

Help the Aged and the Department of Health are working with stakeholders to develop a set of dignity metrics that will include metrics around support at mealtimes.

These metrics will help organisations and the public to see how their local services fare on support at mealtimes.
31 Governance arrangements Progress against the plan will be monitored over the coming year by a Nutrition Action Plan Delivery Board, which will consist of some of the Nutrition Summit stakeholders and will be accountable to the Minister for Care Services.

A progress report on actions within the plan and the impact of those actions will be published by the Nutrition Action Plan Delivery Board in summer 2008.
Gordon Lishman, Director General of Age Concern, will be the Chair of the Nutrition Action Plan Delivery Board and will be responsible for organising the membership of the group, ensuring that stakeholders are accountable to the Board and monitoring progress against implementing the actions named in this Action Plan.

The success of the Action Plan will be assessed by the Nutrition Action Plan Delivery Board.
Examples of the kinds of measures the Board may look at include such things as: • more positive assessments of performance being observed via inspection assessments and findings from any themed reviews undertaken by the Healthcare Commission and CSCI • greater satisfaction being reported through patient and service user surveys • reductions in complaints relating to meals and mealtimes • fewer cases of malnutrition within health and social care settings • monitoring malnutrition in the community.
32 Suggestions for how you could tackle issues around nutrition and hydration The joint Action Plan sets out the five key priorities for action and the numerous commitments made by the Nutrition Summit stakeholder group to tackle this issue.

Local health and social care organisations, including providers and commissioners of services, also have a key role to play.

Here are some suggestions for how you can help tackle nutrition and hydration within your organisation.
Strategic health authorities • Work with local NHS trusts to ensure that any plans are implemented and the necessary improvements take place where concerns are identified around nutritional care, either through Healthcare Commission inspections or through complaints processes.

• Seek and act on feedback from service users on nutritional issues and their experiences of mealtimes while in hospital and use this to inform declarations of compliance with standards.
• Refer NHS trusts to ‘shared learning’ examples available on the BAPEN and NICE websites.

regional government offices • Make malnutrition in the community a public health priority, pay attention to factors affecting malnutrition (such as poverty, access to food, isolation, illness and loneliness among older people) and encourage local investment in low-level universal services, such as ‘meals on wheels’, to help tackle malnutrition in the wider community.
33 • Consider developing a local evidence base • Consider whether you can share information on what can be done to successfully address malnutrition within the community.

Health and social care commissioners • Include specific outcomes and measures around nutritional care in commissioning arrangements with local health and social care providers.
• Make use of existing information available through inspectorates and complaints processes to monitor local provider performance on nutritional care and take strong and swift action where commissioned services provide poor nutritional care.

• Seek and act on feedback from service users on nutritional issues and their experiences of mealtimes while in hospital and use this to inform declarations of compliance with standards.
• Healthcare commissioners should ensure that there is access to dietitians for all people, including those in care homes.

• Take forward local analysis to assess the impact of poor nutritional care in the NHS and social care settings, which leads to higher dependency needs and increased costs later on.

Local authorities • Champion good nutritional care at a local authority level and promote training and guidance to social workers, local care homes and domiciliary care agencies.
• Seek and act on feedback from service users on nutritional issues and quality of meals provided in a care home or domiciliary care setting.

about the nutritional requirements and preferences of those people in receipt of council-led meals (eg ‘meals on wheels’) with the acute sector.
This will ensure that individuals’ needs and preferences are taken into account by staff caring for them in a hospital setting, should an individual be admitted to hospital who had previously been receiving meals from the local authority.

elected members • Undertake quality checks of food provided in care homes and the community and use the influence of elected members to address areas of concern.

• Volunteer to be the ‘nutrition champion’ for your organisation.
• Try to interest the local Overview and Scrutiny Committee in doing a review of nutritional care in your area.

NHS trusts (including foundation trusts) • Make use of nutritional screening tools (eg BAPEN’s ‘MUST’ tool) to assess service users’ nutritional needs, their overall state of health and what they might require in terms of nutrition support, whether that is assistance with eating and drinking, modified diets, supplements or tube feeding.
NICE guidelines should be followed (Nutrition support for adults, February 2006), which state that all people should be screened on admission to hospital as an inpatient and for all outpatients at their first appointment.

There should be repeat screening where there is clinical concern.

34 • Consider signing up to the Council of Europe Alliance (UK)’s 10 key characteristics of good nutritional care in hospitals (www.bda.uk.com/www.bapen.org.uk).
• Ensure that appropriate structures are in place to deliver nutritional care.

Trusts might wish to consider organising this via a nutrition steering group and/or a nutrition support team.

• Champion nutritional care at board level.

The board should ensure that it has access to regular up-to-date information on nutritional care within the trust, including the views of service users and complaints relating to that care.
• Set aside training time for staff to complete the NHS core learning module on nutritional care and assistance with eating.

• Use the information, guidance, toolkits and best practice in the ‘mealtimes’ section of the Dignity in Care online practice guide.

• Seek and act on feedback from service users on nutritional issues and their experiences of mealtimes while in hospital and use this to inform declarations of compliance with standards.
• Review discharge procedures to ensure that whatever accommodation an older person is returning to (eg own home or sheltered housing) appropriate arrangements are in place to ensure continuity of nutritional care.

• Work with voluntary sector organisations and community care services to consider how you can provide additional assistance with eating to those who need it, for instance by using trained volunteers to help at mealtimes.
Care home and domiciliary care providers • Undertake nutritional screening for all older people at risk of malnutrition receiving care services or living in supported housing, in line with NICE guidelines (Nutrition support for adults, February 2006).

The guidelines state that all people should be screened on admission to a care home with screening repeated regularly where there is concern.

• Implement appropriate nutrition care plans following screening.
• Prioritise training for staff in nutritional care and assistance with eating.

• Use the information, guidance, toolkits and best practice in the ‘mealtimes’ section of the Dignity in Care online practice guide.

• Sign up to Help the Aged’s and the National Care Forum’s my Home Life programme to promote quality of life in care homes.

• Seek and act on feedback from service users on nutritional issues and their experiences of mealtimes while in a care home or domiciliary care setting.
• Work with voluntary sector organisations and community care services to consider how you can provide additional assistance with eating to those who need it, for instance by using trained volunteers to help at mealtimes.
Primary care • GPs, district nurses and others in the primary care team should undertake nutritional screening for older people in line with the NICE guidelines (Nutrition support for adults, February 2006), which state that all people should be screened on registering with a GP’s surgery and if there is clinical concern.

35 • Make training on nutrition available for • Encourage patients, service users and carers the PCT’s own staff and their independent contractors.
This training could raise awareness of malnutrition within the community and the importance of practitioners looking for this when seeing service users in the community.

with valid concerns around nutritional care to raise the issue with relevant staff immediately in order for the problem to be addressed.

If that course of action is not satisfactory, encourage the service user to formally complain to the care provider.
• Work with voluntary sector organisations and community care services to consider how you can help hospitals to provide additional assistance with eating by helping them to commission trained volunteers to help at mealtimes.

Housing providers (ie registered social landlords, housing associations, sheltered housing providers, etc) • Management and onsite staff should undertake training on nutrition to raise awareness of malnutrition and its potential impact on residents.
• Explore ways of cascading that information to residents and their carers and families to raise awareness and prevent malnutrition.

• Work with multi-disciplinary experts, such as BAPEN, to develop appropriate pathways for referrals for residents who are malnourished or at risk of malnutrition.
Patient and service user representative organisations • Work with hospitals, care homes and other relevant organisations to help them to gain feedback from service users about the quality of their food and the assistance with eating that is provided.

• Promote Age Concern’s Hungry to be heard leaflets to patients and carers.
• Work with voluntary sector organisations, hospitals, care homes and community care services to consider how you can provide additional assistance with eating to those who need it, for instance by using trained volunteers to help at mealtimes.

Voluntary sector organisations • Work with hospitals, care homes and community care services to consider how you can secure or provide additional assistance with eating to those who need it, for instance by using trained volunteers to help at mealtimes.
• Signpost service users to where they can go for advice on issues around malnutrition.

• Highlight the risks of malnutrition.

Maximise opportunities to inform people about nutrition through such activities as luncheon clubs or social events provided by the voluntary sector.
36 Conclusion This Action Plan marks a step change in our approach to ensuring good nutrition and nutritional care, adequate hydration and enjoyable mealtimes, which in turn can dramatically improve the health and well-being of people, particularly older or vulnerable people.

For the first time, it unites the energies and expertise of a broad range of expert stakeholders in a common pursuit – to improve the standard of nutritional care throughout the NHS and social care.
Many valuable working relationships have already been formed on cross-cutting issues and these are sure to be further developed and enhanced as the Action Plan’s recommendations are put into practice.

With a clearer vision for how we will address issues of nutritional care and hydration through this Action Plan, we look forward to the first progress report from the Nutrition Action Plan Delivery Board in summer 2008.
37 membership of the Nutrition Summit stakeholder group The first Nutrition Summit was convened by the Department of Health in March 2007 and brought together, for the first time, a wide range of stakeholders committed to improving nutritional care in the NHS and social care.

The group has a distinguished membership: Stakeholder organisation Description Association of Directors of Adult Social Services An organisation representing all the directors of adult social services in England.
for more information, visit the website at: www.adss.org.uk 38 for more information, visit the website at: www.ageconcern.org.uk www.bma.org.uk www.bapen.org.uk Stakeholder organisation Description Age Concern British Medical Association British Association for Parenteral and Enteral Nutrition (BAPEN) The UK’s largest charity working with and for older people.

In England, Age Concern is a federation of over 400 charities working together to promote the well-being of all older people.
Age Concern’s work ranges from providing vital local services to influencing public opinion and government.

Every day Age Concern is in touch with thousands of older people from all kinds of backgrounds, enabling them to make more of life.

A body representing doctors from all branches of medicine all over the UK.
An organisation providing a wealth of clinical and management advice, publications, good practice, resources and newsletters on the organisation and delivery of nutritional care and treatment, including specialist tube feeding in hospital, care and community settings.

Responsible for producing the ‘MUST’ screening tool available to download from their website.

British Dietetic Association (BDA) The professional association for dietitians.
Caroline Walker Trust (CWT) Commission for Social Care Inspection (CSCI) A charitable trust named after the work of a distinguished nutritionist.

The work of the CWT is particularly targeted towards vulnerable groups and people who need special help.

They produce nutritional and practical guidelines for both young and old.

A regulatory body that inspects and reports on care services and councils to improve social care and stamp out bad practice.
www.bda.uk.com www.cwt.org.uk www.csci.org.uk 39 Stakeholder organisation Description Council of Europe Alliance (UK) A UK-wide stakeholder group of non-government and government organisations brought together to take forward the Council of Europe’s Resolution (ResAP 2003(3)).
Recommendations include: • • • implementation of national recommendations on food and nutritional care in hospitals promotion of implementation in both the public and private sectors ensuring the widest possible dissemination of the recommendations.

English Community Care Association (ECCA) A registered charity and leading representative body for independent care homes.
for more information, visit the website at: The Council of Europe does not have its own website but the outputs from the council can be seen through the partner organisations: • • • • • The Hospital Caterers Association The Royal College of Nursing The British Dietetic Association The National Patient Safety Agency The British Medical Association www.ecca.org.uk ECCA works on behalf of small, medium and large providers to promote high standards of health and social care in the independent sector and create an environment in which care homes can deliver high-quality care.
An independent government department set up by an Act of Parliament in 2000 to protect the public’s health and consumer interests in relation to food.

Its vision is to ensure safe food and healthy eating for all.

The health watchdog for England.

It checks that healthcare services meet the required standards in safety, cleanliness, waiting times and many other areas.
www.food.gov.uk www.healthcare commission.org.uk Food Standards Agency (FSA) Healthcare Commission 40 for more information, visit the website at: www.helptheaged.org.uk www.hospitalcaterers.org www.lga.gov.uk Stakeholder organisation Description Help the Aged Hospital Caterers Association (HCA) Local Government Association An international charity fighting to free disadvantaged older people from poverty, isolation and neglect.
It researches the needs of older people in the UK and overseas and campaigns for changes in policy.

It also provides community services and publishes information for the elderly on finance and how to stay healthy, as well as guidance on choosing a care home.

An association representing the needs of caterers within hospitals.
The aims and objectives of the HCA are: • • • the promotion and improvement of the standards of catering in hospitals and healthcare establishments in Great Britain, Northern Ireland and elsewhere the education and training of people in healthcare catering services the provision and improvement of the professional interests and status of those engaged in healthcare catering services.

The Local Government Association promotes the interests of English and Welsh local authorities.
It exists to promote better local government.

It works with and for its member authorities to realise a shared vision of local government that enables local people to shape a distinctive and better future for their locality and its communities.
41 for more information, visit the website at: www.thenacc.co.uk www.nnng.org www.npsa.nhs.uk email: clpu@sysha.nhs.uk Stakeholder organisation Description The NACC promotes high standards of catering within the care sector, providing a forum for debate among individuals, professionals (eg caterers, social work staff, dietitians), companies and organisations of all kinds involved in catering for the care sector.
The NACC will commission research into matters relating to catering for the care sector and will develop and publish guidelines, policy papers and authoritative statements on all aspects of catering for the care sector.

Care sector catering may take place in residential homes for children, for the elderly or for people with disabilities.
It may be meals served to groups in day care or other centres, such as luncheon clubs, or it may involve delivering or cooking individual, fresh or frozen meals to people in their own homes.

A national charitable organisation for nurses and other allied healthcare professionals, whose focus is on nutrition-support education and promoting evidence-based clinical practices, to assist the delivery of excellent care to patients.

The NPSA is part of the NHS.


It was established in 2001 with a mandate to identify issues relating to patient safety.

It aims to put patient safety at the top of the NHS agenda through encouraging greater transparency and accountability for the provision of safer healthcare in all care settings.

The NHS CLU was set up after the NHS University was dissolved.
The unit runs higher education blended learning programmes aimed at non-clinical employees from health and social care, or other related public and private sectors.
National Association of Care Catering (NACC) National Nurses Nutrition Group National Patient Safety Agency (NPSA) NHS Core Learning Unit (NHS CLU) 42 Stakeholder organisation Description National Institute for Health and Clinical Excellence (NICE) Patients Association People First Royal Institute of Public Health Royal College of Nursing (RCN) Skills for Care Skills for Health The independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.
An advice service and collective voice for patients.

It is independent of the government and medical profession.

An advocacy group run by and representing people with learning disabilities.

An independent body with the aims of protecting and promoting public health through education, training and policy development.

The RCN represents nurses and nursing, promotes excellence in practice and shapes health policies.
A member of the Sector Skills Council for the social care sector, representing England only.

Skills for Care works in consultation with carers, employers and service users.

It aims to modernise adult social care in England.

It (along with Skills for Health, People First and other bodies) belongs to the Sector Skills Councils group, which sets the minimum competencies of staff working in the relevant sectors.

The Sector Skills Council for the UK health sector.
Skills for Health aims to help the whole health sector develop solutions that deliver a skilled and flexible UK workforce in order to improve health and healthcare.
for more information, visit the website at: www.nice.org.uk www.patients- association.org.uk www.peoplefirst.org.uk www.riph.org.uk www.rcn.org.uk www.skillsforcareand development.org.uk www.skillsforhealth.org.uk 43 Stakeholder organisation Description Sustain United Kingdom Homecare Association Water UK The alliance for better food and farming, with a focus on sustainable development and health when procuring food.
In 2005, the NACC and Sustain embarked on a project to explore the opportunities for sustainable food procurement in care catering.

They produced a joint briefing paper entitled ‘Sustainable food in care catering’, which can be found on the Sustain website.

The paper gives a brief explanation of what is meant by sustainable food, outlines the key obstacles and opportunities, and points readers to sources of more information and useful case studies.
The national professional association and representative association for organisations that provide care, including nursing care, to people in their own homes.

The industry association that represents all UK water and wastewater service suppliers at national and European level.

for more information, visit the website at: www.sustainweb.org www.ukhca.co.uk www.water.org.uk 44 © Crown copyright 2007 Produced by COI for the Department of Health 283925 1p 80 October 07 www.dh.gov.uk/publications