Nutrition and hydration policy (promoting good nutrition for patients, adults)

Contents

1 Policy summary

There is a requirement that people who use healthcare services have adequate nutrition and hydration to sustain life and good health and reduce the risks of malnutrition and dehydration while they receive care and treatment. The evidence demonstrates that:

• a substantial proportion of individuals cared for by healthcare professionals within community settings experience malnutrition (Russell and Elia, 2011) (Barker, et al., 2011)
• malnutrition is associated with poorer clinical outcomes and increased healthcare costs recovery from illness and surgery (Stratton, et al., 2003) (Guest, et al., 2011)(Elia, 2015)
• dehydration due to loss of water is associated with higher mortality, morbidity and disability in older people (Hooper, et al., 2014)
• older people are more at risk of dehydration due to loss of water (Hooper, et al., 2014). Patients admitted to hospitals from nursing homes are commonly dehydrated (Wolff, et al., 2015)

The CQC (Care Quality Commission, 2015) state:

• “people must have their nutritional needs assessed and food must be provided to meet those needs. This includes where people are prescribed nutritional supplements and, or parenteral nutrition. People’s preferences, religious and cultural backgrounds must be taken into account when providing food and drink”

NHS England ‘National Standards for Healthcare Food and Drink’ (NHS England, 2022) sets out eight standards that all NHS Organisations are required to meet.

In older people living at home issues surrounding fluid supply need to be addressed in order to promote optimal hydration and avoid dehydration.

This policy does not cover the corporate functions of food and drink which are covered in RDaSH food and drink plan.

Of the NHS England (2022) ‘National Standards for Healthcare Food and Drink’, the following are covered in this policy:

• organisations must have a designated board director responsible for food (nutrition and safety) and report on compliance with the healthcare food and drink standards at board level as a standing agenda item
• organisations must consider the level of input from a named food service dietitian to ensure choices are appropriate

This policy incorporates recommendations in the British Dietetic Association Nutrition and Hydration Digest and NHS England 10 Key Characteristics of ‘Good Nutrition and Hydration Care’.

2 Purpose

The purpose of this policy is to highlight the processes, requirements, roles and responsibilities concerning nutrition and hydration that enable all patients and clients under the care of RDaSH NHS Trust to receive nutrition and hydration in a form that is acceptable to them and meets their nutrition and hydration needs. It is intended to reinforce the importance of nutrition and hydration to the health of all patients, clients, visitors, and colleagues.

3 Scope

This policy concerns the nutritional and hydration needs of all adult patients under the care of RDaSH NHS Trust. It applies to all directly and indirectly employed colleagues within RDaSH NHS Trust and other persons working within the organisation.

For further information about responsibilities, accountabilities and duties of all employees, please see appendices A.

4 Quick guide and definitions

4.1 Quick guide

4.1.1 Personalised care

Colleagues should recognise how different backgrounds and cultures will impact on patients’ choice of food and drink and take steps to make appropriate choices available.

4.1.2 Health balanced diet

All patients should be encouraged and supported to follow a healthy balanced diet.

4.1.3 Malnutrition screening

Malnutrition screening should be undertaken for all inpatients and community patients. This is the first step in identifying individuals who may be at nutritional risk or potentially at risk, and who may benefit from appropriate nutritional intervention. An individual can be screened to determine their risk of malnutrition using the malnutrition universal screening tool (MUST).

4.1.4 Nutritional action planning

Once screened, colleagues are then required to implement the nutritional action plan or care plan relevant to their MUST score and other nutrition related care plans as needed. This is to support personalised care, improve clinical outcomes and quality of life. Regular reviews should also be undertaken to ensure care plans are still relevant and ensure timely and effective care.

4.1.5 Review and refer

Nutritional action plans must be reviewed within the agreed timescales and adjusted dependent of the patients needs and the MUST rescreen. Dependent on the outcome of the review a dietetic referral should be considered and completed where appropriate.

4.2 Definitions

5 Process and requirements

All patients or clients should be enabled to receive nutrition and hydration in a form that is acceptable to them, meets their nutritional and hydration needs and is safe.

5.1 General principles

5.1.1 Personalised care

Colleagues should recognise how different backgrounds and cultures will impact on patients’ choice of food and drink. Colleagues are responsible for obtaining the most up-to-date information about a person’s requirements and take steps to make appropriate choices available. Similarly, any known food allergies, intolerances, and sensitivities and, or other specialist dietary requirements should be recorded and care planned appropriately.

All nutritional care and treatment should be evidence based and consider the patients’ needs and preferences and give them the opportunity to make informed decisions about their care and treatment, in partnership with colleagues, carers and parents or relatives.

If someone does not have capacity to make decisions around their nutrition hydration, care and treatment, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act (MCA), please see the MCA Mental Capacity Act 2005 policy.

5.1.2 Dietary needs

Healthcare professionals should assess dietary needs and preferences on admission to inpatient units; ensure that any special requirements, including food choice, help with feeding and equipment are recorded and addressed; and identify risk factors associated with eating and drinking such as aspiration or choking. Patients should be referred to other healthcare professionals where appropriate.

Patients should be assisted to choose an appropriate diet to meet their needs (in terms of nutritional content, texture and any other requirements). This may involve using accessible information to enable a person to choose for themselves.

Patients should be offered food, fluids and medication that enable them to meet their nutritional and hydration needs and are appropriate for their medical condition and eating, drinking and swallowing ability.

Community colleagues should be aware of the timing of their interventions and mealtimes.

Inpatient mealtimes and the environment should be conducive to eating.

Food and drink should be available to patients 24 hours a day, 7 days a week during their inpatient stay. Patients should not have to seek colleagues permission to acquire food and drinks, but colleagues should work with patients to promote choices which are appropriate to their clinical needs in line with the Mental Capacity Act (2005) see the RDaSH MCA Mental Capacity Act (2005) policy.

Appropriate support to eat and drink should be offered (including modified eating and drinking aids, assistance to eat and drink and supervision or behaviour support in relation to identified choking risks).

Trust food safety policy should be followed when providing food and drink. Food and drinks should be served at a suitable temperature for safety and palatability.

Standard menus should provide a choice for patients from both nutritionally well and vulnerable groups. The daily nutrition standard is 1840 to 2772 kcal (energy) with those who are nutritionally well having a target of 56g protein (For females in the same age bracket the Reference Nutrient Intake (RNI) is 45g) and for those who are nutritionally vulnerable 79 to 92g protein (BDA, 2023). The upper end of the kcal target should be aimed for with nutritionally vulnerable patients.  Therefore to obtain a nutritionally balanced meal, meal nutrition targets (optional starter, main and dessert) are 500kcal (energy) and 15g (protein) for those nutritionally well and 800kcal (energy) and 27g protein for those nutritionally vulnerable. To ensure the daily menu is balanced it should include 5 servings of fruit and vegetables, 5 servings of potatoes, bread, rice, pasta and starchy carbohydrates, 3 servings of dairy and alternatives, 2 servings of beans, pulses, fish, eggs, meat and other proteins. Foods with a high fat or sugar content may be offered, but the emphasis will be different depending on individual needs.

The trust’s menus are reviewed annually by a food service dietitian who ensure the required standards are met.

5.2 Malnutrition screening

NICE (QS24) recommends all people who are screened for the risk of malnutrition have their screening results and nutrition support goals (if applicable) documented and communicated in writing within and between settings.

NICE (QS24) also recommends people receiving nutrition support are offered a review of the indications, route, risks, benefits and goals of nutrition support at planned intervals.

Malnutrition screening should be undertaken for all inpatients and community patients. This is the first step in identifying individuals who may be at nutritional risk or potentially at risk, and who may benefit from appropriate nutritional intervention.

Within 24 hours of admission onto an inpatient ward and within 24 hours of first contact for patients living in their own homes the MUST template should be completed. If a decision is made that completing all steps of the MUST is not appropriate, it is mandatory that the rationale for this is recorded on the MUST template on SystmOne.

Where colleagues are working into acute hospital settings the acute hospital’s MUST screening procedure will be completed by acute hospital colleagues. RDaSH colleagues should still complete the MUST template to evidence that “MUST considered and not completed”.

5.2.1 Malnutrition screening in people with palliative care needs

The nutritional management of palliative care patients has been divided into 3 stages. Early phase, late phase, and the last few days of life. For all palliative care patients, emphasis should always be on the enjoyment of foods and drinks and maximising the quality of life.

For patients with palliative care needs the following guidance should be followed:

5.2.1.1 Early phase palliative care

5.2.1.1.1 Definition

In early phase palliative care the patient is diagnosed with a terminal disease, but death is not imminent. Patients have years to live and may be undergoing palliative treatment to improve quality of life.

5.2.1.1.2 Nutritional assessment

Malnutrition screening and assessment in this patient group is a priority and appropriate early intervention could improve the patient’s response to treatment.

5.2.1.1.3 Community referrals and inpatient referrals

Patients should be screened using the MUST and advised to implement a ‘Food First’ nutritional action plan based on their calculated MUST score. On review if further weight loss is evident, the patient should be referred to the dietetic service.

5.2.1.2 Late phase palliative care

5.2.1.2.1 Definition

In late phase palliative care the patient’s condition is deteriorating and they may be experiencing pain, nausea and reduced appetite.

5.2.1.2.2 Nutritional assessment

The nutritional content of a meal is no longer of prime importance and the patient should be encouraged to eat and drink what they enjoy. The main aim is to maximise quality of life including comfort, symptom relief and enjoyment of food. The goal of nutritional intervention is not weight gain or reversal of malnutrition but quality of life.

5.2.1.2.3 Community and inpatient referrals

MUST screening or nutritional treatment in terms of ‘Food First’ and oral nutritional supplements is not recommended, the reason for not screening for malnutrition should be recorded in the patients records under “MUST considered and not completed”. The nutrition late-stage palliative care plan should be implemented if further guidance is required.

5.2.1.2.4 Nutrition and hydration recording

Clinical judgement should be used around decisions to record nutrition and hydration in late stage palliative care.

5.2.1.3 Last few days of life

5.2.1.3.1 Nutritional assessment

In the last few days of life the aim is to provide comfort and symptom relief.

5.2.1.3.2 Community and inpatient referrals

MUST screening or nutritional treatment in terms of ‘Food First’ and oral nutritional supplements is not recommended. The reason for not screening for malnutrition should be recorded in the patients records under “MUST considered and not completed”. Advise to offer mouth care and sips of fluids or mouthfuls of food as desired.

5.2.1.3.3 Nutrition and hydration recording

Clinical judgement should be used around decisions to record nutrition and hydration in the last few days of life.

Further information can be found on the RDaSH intranet:

• dietic service inpatients (staff access only) (opens in new window)
• dietic service community (staff access only) (opens in new window)

5.2.2 Equipment

All clinical teams or services are able to have access to the following:

• scales (weight measure), ensure scales (hoist, ramp or standing) follow the manufacturer’s instructions have been calibrated and conform to class III or higher
• tape measure for measuring mid-upper arm circumference
• stadiometer (height measure)

A proxy measure of weight may be used when the patient cannot be weighed using scales, as described in the full MUST (British Association of Enteral and Parenteral Nutrition, 2014). Where a proxy measure is used this must be recorded in the patients record on the MUST tool on SystmOne. A proxy measure of height should not be used, instead historical measures of height or patient or proxy recall should be used.

5.3 Nutritional action planning

5.3.1 Screening results and action planning

For patient’s whose MUST score is 0 (zero) a patient specific action plan is not required, a healthy balanced diet should be encouraged and lower calorie options where appropriate.’

For patients’ who MUST score is 1 or above, a patient specific action plan is required. The SystmOne MUST template enables clinical staff to generate this, following the principles below.

5.3.2 Food first approach

When MUST is completed and the outcome indicates a score of 1 or above, an individual nutritional action care plan should be generated and implemented. This action plan encourages a ‘Food First’ approach; this involves using every day food items to enrich the diet or fluid with energy and protein to increase the nutritional value of the food or drink eaten. This can include enriching meals, for example, with milk powder, eggs, butter, cream or cheese, encouraging energy dense snacks such as cheese and crackers, rice pudding and yoghurt, and nourishing fluids that contain nutrition, for example, milky drinks. It is recommended to avoid having drinks before meals to avoid feeling too full and avoiding low energy versions of drinks, for example, semi skimmed milk.

5.3.3 Oral nutritional supplements (ONS) prescribing

Oral Nutritional Supplements (ONS) are sterile liquids, semi-solids or powders, which provide macro and micronutrients. They are used in acute and community settings for individuals who are unable to meet their nutritional requirements through oral diet alone.

ONS should only be discussed and prescribed for inpatient and community adults if this has been assessed and requested by a Dietitian. As part of the assessment, dietitians consider Advisory Committee on Borderline Substances (ACBS) criteria, exhausting a ‘Food First’ and over the counter approach and working with patients and families on their medical and social circumstance. Rationale is provided upon request of prescription.

5.3.4 Nutrition via tube

Nutrition via tube will be considered by the multi-disciplinary team (MDT) for patients or clients who are malnourished or at risk of malnutrition and have inadequate or unsafe oral intake, and a functional, accessible gastrointestinal tract (National Institute for Clinical Excellence, 2006).

Patients with an enteral feeding tube in situ should be referred to the dietetic service on admission (inpatients). Patients with enteral feeding tube in place in acute hospital should be referred to the dietetic service as part of their discharge. Please see the enteral tube feeding adults policy.

5.3.5 Hydration

Good hydration is important for everyone. Drinking enough fluid is vital to maintain good health in the short and long term. Dehydration is linked to reduced alertness, concentration and constipation. It is also associated with urinary tract infections, kidney stones and chronic kidney disease.

Older adults, patients suffering with acute or chronic illness, cognitive decline, reduced mobility or those who require assistance are more at risk of dehydration.

Even mild dehydration adversely affects mental performance and increases feelings of tiredness. Common complications associated with dehydration also include low blood pressure, weakness, dizziness and increased risk of falls British Nutrition Foundation, dehydration in older people).

Drinks provide around 70 to 80% of our water needs. The remaining 20 to 30% comes from foods such as soup, stews, some fruits, and vegetables which contain a lot of water.

Recommended adequate intakes of water from drinks:

All fluids count except for alcohol over 4% alcohol by volume (ABV). Patients should be encouraged to drink from their preferred drinking vessel (where safe and appropriate to do so), their preferred choice of drink and at their preferred temperature.

Depending on the preferred type of drinking vessel, the amount of glasses or cups or mugs per day will vary depending on what the vessel holds. This needs to be documented in the patient’s plan of care to ensure their needs are met.

Hydration can be improved by encouraging wet foods, offering a standard amount with medications, offering fluids at routine events, for example, before therapy, during visits and having fluids readily available.

Ways to ensure a patient is drinking enough is biochemical monitoring, fluid balance charts, urine colour and reported sensation of thirst. Older adults can be at higher risk of dehydration if they are dependent on others for drinks, have dysphagia or are acutely unwell. Therefore, they may require further prompting, support or assistance to ensure they meet their hydration needs.

Any concerns with dehydration need to be escalated to the responsible clinician.

• BDA fluid water drinks webpage (opens in new window).
• BDA hydration in older adults webpage (opens in new window).

5.3.6 Plan of care

NICE (QS24) recommends that people who are malnourished or at risk of malnutrition have a management care plan that aims to meet their nutritional requirements. Planning, implementation, evaluation, and review of the nutritional action plan should be recorded in the electronic patient record. All colleagues will then be aware of the patient’s nutritional status and how nutrition support will be provided, if required.

Patients identified at risk of malnutrition (or obesity) and those with specific dietary needs should have an appropriate plan of care devised and implemented which may include referral to other healthcare agencies or workers.

Patients or clients identified as dehydrated or at risk of dehydration should have an appropriate plan of care devised and implemented which may include referral to other healthcare agencies or workers.

Nutrition and hydration may be significant factors in relation to risk of falls and tissue viability and relevant care plans should be cross-referenced.

Patients or clients with swallowing difficulties who are known to the speech and language therapy service must have a speech and language therapy eating and drinking care plan indicating how their dysphagia is managed. This care plan should be reviewed by a speech and language therapist if the patients or clients condition or needs change.

Patient or clients identified as at risk of choking should have a care plan that maintains an agreed level of risk and documentation detailing decision following multidisciplinary client and family consultation as appropriate.

It is the responsibility of all RDaSH colleagues to contact their manager if they are not able to support an eating and drinking care plan.

In in-patient units specific orders of dietary items and therapeutic or other diets should be given to the food service assistant 24 hours in advance wherever possible.

5.3.7 Nutrition and fluid recording

Diet and fluid charts are required for the following inpatients:

• patients with a MUST Score of 1 or above
• patients with a gastrostomy tube who also have oral diet and fluids
• patients with a pressure ulcer or at high risk of developing a pressure ulcer
• patients refusing to eat or drink (please see MUST template for strategies to manage food refusal)
• if highlighted within an individual’s personalised plan of care, for a cultural sensitivity, physical or mental health need or others as identified by the relevant clinician
• a copy of the personalised agreed plan of care should be offered to the patient or carer or family

As per section 5.2.1 clinical judgement should be used around decisions to record nutrition and hydration in the last few days of life.

Diet and fluids charts should be implemented, monitored, and reviewed by a relevant clinician and, or MDT on a weekly basis. They must have a rationale to be in place and be ceased if not providing any clinical purpose.

Diet and fluid charts can be completed via:

• performing an electronic care plan instruction (preferred)
• paper chart available on the RDaSH MUST tool, step 5

Any paper charts completed should be scanned onto SystmOne on a daily basis, under letters and communications as ‘SCANNED, food diary’.

Diet and fluid charts need to specify the type and amount of food or drink offered. The chart should also include the snacks and drinks as directed from the nutritional care plan if applicable.

The portion size and quantity of food or drink consumed needs to be stated clearly for example half, three-quarters, or all taken. Writing small diet or good amount taken is not adequate. The charts must also not be left blank, even if a patient has refused, the type and portion size must still be completed and ‘nil’ in quantity specified.

The focus and purpose of the documentation of fluid on the diet and fluid chart is also for fluids providing nutritional value, for example, orange juice, Coca-Cola, milkshakes, ensure, Fortisip.

5.3.8 Review and referral

Screening of nutritional status should be repeated weekly for patients or clients in inpatient units and regularly where indicated for patients or clients cared for in their own homes.

Following implementation of a nutritional action plan and upon MUST rescreen, if the patient was already a MUST score 1 or above and further weight loss has occurred on review, this would warrant referral to the dietetic service. Automatic referral to the dietetic service includes:

• if prescribed nutritional supplements on admission or not under a dietetic service in community
• grade 3 or 4 pressure ulcers

Inpatient services at Doncaster and Rotherham refer to Doncaster Dietetic Services. Inpatient services at North Lincolnshire to refer to Northern Lincolnshire and Goole NHS Foundation Trust.

Community services at Doncaster refer to Doncaster dietetic services. Community services at Rotherham refer to the Rotherham NHS Foundation Trust and North Lincolnshire refer to Northern Lincolnshire and Goole NHS Foundation Trust.

Patient or clients plan of care should be evaluated by monitoring their medical condition and food and fluid intake as appropriate. Following this the plan of care should be revised as required.

Referrals to the Dietetic team should be made through the MUST template on SystmOne. If this is not available a referral form and information can be found on the dietetic service page via the links below.

Further information can be found on the RDaSH intranet:

• dietic service inpatients (staff access only) (opens in new window)
• dietic service community (staff access only) (opens in new window)

5.4 Other considerations

5.4.1 Risk of choking and aspiration

Where patients have an increased risk of choking with or without a known dysphagia advice should be sought. For reference see RDaSH dysphagia management policy section 5.2.

5.4.2 Risk of re-feeding syndrome

Patients who are malnourished can be at risk of refeeding syndrome when oral intake increases. This can be life threatening and requires close management and monitoring by the medical team and dietitian.

Best practice suggests this should only be undertaken in an acute setting under medical supervision. It is unlikely and not recommended for admission of patients at risk of refeeding syndrome to be admitted to a non-acute ward setting or be managed in the community.

5.4.3 Mouth care

Supporting patients with regular mouth care is a fundamental part of care. Good mouth care contributes to good oral health. Oral health is an important part of general health and wellbeing.

It allows people to eat, speak and socialise without discomfort or embarrassment. Poor health and Hospitalisation is associated with a deterioration of oral health in patients. This has been linked to an increase in hospital-acquired infections (such as hospital-acquired pneumonia), poor nutritional uptake, longer hospital stays and increased care costs.

Mouth care responsibility is not just for nursing colleagues; it is also for other health care professionals including doctors, speech and language therapists, dietitians, occupational therapists, and pharmacists. Everyone should be aware of good oral health care.

Mouth care should be completed (inpatients) or encouraged (community) for all patient’s minimum twice daily using appropriate products and equipment deemed suitable for that person, however if a patient is nil by mouth, we recommended this is completed or encouraged at least 4 times per day when possible.

Mouth Care Matters has an abundance of resources available:

• Mouth Care Matters resources (opens in new window)

5.4.4 Dietary advice for wound care

Nutrition is an important part of recovery especially in the healing of traumatic injuries, surgical wounds, or pressure sores. These are more likely to heal quicker if a person is well nourished. Eating the right food groups and hydration will encourage the skin to heal alongside any medication.

It is important to eat a varied diet that is high in nutrients, specifically high in protein, vitamins and minerals. Please see booklet for further advice, dietary leaflet.

6 Training implications

6.1 MUST (universal malnutrition screening tool) training

6.1.1 Qualified nursing colleagues (band 5 and above) or other relevant colleague is identified by supervisor

• How often should this be undertaken: Every 3 years as a minimum. Repeated training as and when felt required by clinical colleagues  or management.
• Length of training: 1 to 2 hours.
• Delivery method: Virtual training via Microsoft Teams or self-directed learning via RDASH intranet or face to face.
• Training delivered by whom: Dietitians or dietetic assistants.
• Where are the records of attendance held: ESR (learning and development team).

Doncaster dietetic service currently provides training for malnutrition. For all other clinical areas outlined in this policy, all qualified nursing colleagues (band 5 and above) or other relevant colleague identified by supervisor that are responsibility for implementing the contents of this policy, will need to be familiar with its contents.

As a trust policy, all colleagues need to be aware of the key points that the policy covers. Colleagues can be made aware through:

• 1-to1 support and guidance from dietitians
• one to one meetings or supervision
• continuous professional development (CPD) sessions

7 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

7.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

7.1.1 How this will be met

Through personalised care planning, individual needs, preferences (and cultural and religion) requirements will be taken into account and give them the opportunity to make informed decisions about their care and treatment. Appropriate food choices should be available. Protected mealtimes allow patients the time to enjoy their meals, obtain assistance when required (supporting privacy, dignity and respect)

7.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

7.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005).

8 Links to any other associated documents

• Dysphagia management policy
• Enteral tube feeding adults policy
• Medical emergencies in eating disorders (MEED), guidance on recognition and management (CR233, May 2022), Royal College of Psychiatrists (opens in new window)

9 References

• Barker, L. A., Gout, B. S., and Crowe, T. C. (2011). Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system. International journal of environmental research and public health, 8(2), 514 to 527.
• British Medical Journal (BMJ) (2019). Best Practice Psychogenic Polydipsia.
• British Association of Parenteral and Enteral Nutrition (BAPEN) (2008) Malnutrition universal screening tool (MUST).
• British Dietetics Association (2023). The Nutrition and Hydration Digest.
• CQC (2015) Regulation 14: Meeting nutritional and hydration needs (opens in new window).
• Dehydration in older people, British Nutrition Foundation (accessed February 2024) (opens in new window).
• Elia, M. (2015). The cost of malnutrition in England and potential cost savings from nutritional interventions (full report). Malnutrition Action Group of BAPEN and National Institute for Health Research Southampton Biomedical Research Centre.
• Guest, J. F., Panca, M., Baeyens, J. P., de Man, F., Ljungqvist, O., Pichard, C., and Wilson, L. (2011). Health economic impact of managing patients following a community-based diagnosis of malnutrition in the UK. Clinical nutrition, 30(4), 422 to 429.
• Hooper, L, Bunn, D, Jimoh, F. O, and Fairweather-Tait, S. J. (2014). Water-loss dehydration and aging. Mechanisms of Ageing and Development, 136, 50 to 58.
• Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what it is, and how to prevent and treat it. BMJ. 28 June 2008.
• National Institute for Health and Clinical Excellence (2012) Nutrition support in adults, Quality standard (opens in new window).
• NHS England (2015) 10 key characteristics of ‘good nutrition and hydration care’ (opens in new window).
• NHS England (2022), National Standards for Healthcare Food and Drink (opens in new window).
• Patient Led Assessments of the Care Environment (PLACE), 2012, DOH place@ic.nhs.uk.
• Russell, C. A., and Elia, M. (2011). Nutrition Screening Survey in the UK and Republic of Ireland in 2010. A report by BAPEN, 6.
• Stratton, R. J., Green, C. J., and Elia, M. (2003). Disease-related malnutrition: an evidence-based approach to treatment.
• Thomas, D. R., Cote, T. R., Lawhorne, L., Levenson, S. A., Rubenstein, L. Z., Smith, D. A., and Council, D. (2008). Understanding clinical dehydration and its treatment. Journal of the American Medical Directors Association, 9(5), 292 to 301.
• Welch K (2010) Fluid balance. Learning Disability Practice; 13: 6, 33 to 38.
• Wolff, A., Stuckler, D., and McKee, M. (2015). Are patients admitted to hospitals from care homes dehydrated? A retrospective analysis of hypernatremia and in-hospital mortality. Journal of the Royal Society of Medicine, 108(7), 259 to 265.

10 Appendices

10.1 Appendix A Responsibilities, accountabilities and duties

10.1.1 Nominated board director for food and drink

Nominated board director for food and drink has responsibility to ensure that effective nutritional care systems are in place and that these are monitored, and report on compliance with the healthcare food and drink standards at board level.

10.1.2 Care group directors

• Implementation of all policies and procedures, which are in place to meet the needs of patients.
• Monitoring adherence to this and other related policies.
• Ensuring adequate resources and compliance with training.

10.1.3 Matrons or service managers or clinical leads

• Ensure colleagues are aware of and comply with the policy, through local induction, instruction, supervision and audit.
• Monitor compliance with this policy and take immediate action when non-compliance is identified.
• Ensure clinical colleagues attend regular training on the malnutrition universal screening tool (MUST) and nutritional action planning (NAP).
• Support clinical colleagues in seeking CPD or supervision for any other clinical areas as outlined in this policy.

10.1.4 All clinical colleagues including clinical support colleagues

• Undertake malnutrition screening of patients using MUST.
• Provide personalised and evidence-based nutritional care through the appropriate care plan template or liaison with the dietetic service if no appropriate care plan is available.
• Support patients to choose diet and fluid options appropriate for them, highlighted in their care plan.
• Implement and regularly review nutritional action plans for patients, including on discharge.
• Ensure appropriate, timely and complete documentation within the correct templates.
• Any allergies or special dietary needs are to be highlighted and communicated to the catering department and then liaison with the dietetic service should there be a consequential nutritional need.
• Liaise with other professionals for specialist assessment and, or therapeutic interventions as identified within the care plan, for example, dietitian, speech and language therapist, occupational therapist.
• Attend training regularly as recommended.
• Seek CPD or supervision for any other clinical areas as outlined in this policy.
• Provide accessible information about menus, the mealtime arrangements and ensure patients have protected mealtimes when in an inpatient setting.
• Where identified in a patient’s care plan, allow a patient’s carer to be present during mealtimes to encourage, assist and, or gain information relating to the patient’s eating and drinking needs.
• Determine the need for provision of specific dietary requirements.
• Liaise with catering colleagues, concerning dietary dysphagia recommendations, special diets, and snacks.
• Monitor foods brought in by carers or visitors and advise as necessary to follow the food safety procedures. Encouraged to bring in foods when appropriate.
• Provide and support with alternative catering options or choices where requested but assessed as appropriate by relevant colleagues, for example, self-catering.
• Provide feedback mechanisms, for example, ‘your opinion counts’ forms, patient forums.

10.1.5 Medical colleagues

Medical colleagues have a responsibility to work closely with clinical colleagues to:

• follow and encourage the relevant pathway for inpatients and community patients regarding MUST screening and nutritional action planning
• refer for specialist assessment and intervention as required

10.1.6 Dietitians

• Undertake comprehensive nutritional assessments of patients who are identified as being at risk of malnutrition following a referral from the managing service.
• Support and advise colleagues, patients and carers and provide necessary dietary information.
• Advise on oral and enteral nutrition support care and treatment.
• Assess and make recommendations when alternative feeding routes may need to be considered.
• Prescribe or advise medical colleagues on borderline substances such as enteral feeds and oral nutritional supplements.
• Provide education and training to colleagues.
• Produce resources for training purposes and patient education
• Ensure hospital menus conform to national guidance on nutritional standards and undertake recipe or menu analysis to any new options to interpret both the input of data and the results, whilst being aware of food regulations.

10.1.7 Speech and language therapists (SALT) or dysphagia trained practitioner

• When required, complete a comprehensive assessment of a patients eating, drinking and swallowing skills and advise clinical colleagues as necessary.
• Work collaboratively with dietitians in supporting patients who require input from both services.
• Please refer to the dysphagia management policy.

10.1.8 Occupational therapists

• Assessment and interventions to: manage risk, promote skills and abilities, maximise independence and to improve the mealtime experience.
• Provide or advise on equipment to support eating and drinking.
• Positioning and technique in relation to eating and drinking.
• Skills development (self-catering; preparing and cooking meals using fresh produce, shopping, reading labels etc.).
• Health promotion and supporting patients to make appropriate food choices, particularly where nutritional choices impact on physical conditions, for example, diabetes, obesity.

10.1.9 Catering colleagues

• High quality food is provided, to meet national standards, individual patient’s nutritional needs and significantly contributes to the patient’s wellbeing.
• Cater for patients with cultural and special dietary requirements which are suitably coded to enable patients to make an informed choice and assist ward colleagues who advise patients.
• The catering team provide allergen information on all menu items, and this can be found on the catering intranet site and the online menu ordering system, accessible by colleagues. Advice can be sought on ingredients in all dishes by contacting the catering department.
• Patient menus will be reviewed regularly by the Facilities Department, involving ward colleagues, patients or representatives, and dietitians.
•  Respond to patient or feedback to ensure needs led quality service.

10.1.10 Non-clinical support service assistants (domestic service colleagues)

• To refer to the patient diet board in the ward kitchen, which is completed by clinical colleagues, to understand the individual patient dietary requirements when placing meal orders and serving meals.
• Seek guidance from clinical colleagues when placing meal orders and serving meals around any special dietary requirements, including allergens.
• To enhance the patients, experience of mealtimes, for example, presentation of food, provision of appropriate cutlery, feeding utensils etc.
• To enhance the patient mealtime experience, protected mealtimes operates on all wards. This allows for a raised awareness of the importance of food and hydration. During this time, all clinical activity should cease to allow for patients to enjoy their meal.

10.2 Appendix B Monitoring arrangements

10.2.1 Audit of MUST and NAP pathway

• How: Clinical audit or Tendable.
• Who by: Ward manager or link champion.
• Reported to: Quality and safety sub-clinical leadership executive (CLE) group.
• Frequency: Annually.

10.2.2 Quality of Food

• How: Patient led assessment of the care environment (PLACE) inspections.
• Who by: Head of facilities.
• Reported to: Service managers or food and hydration forum.
• Frequency: Annually.

10.2.3 Patient feedback

• How: ‘your opinion counts’ forms.
• Who by: Patient Experience team.
• Reported to: Service managers or Organisational Learning team.
• Frequency: Monthly.

10.2.4 Compliance with this policy

• How: Via audit, IR1’s, patient feedback.
• Who by: Matrons or service managers or clinical leads.
• Reported to: Care groups.
• Frequency: As they arise.

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Document control

• Version: 9.
• Unique reference number: 398.
• Approved by: Clinical policy review and approval group.
• Date approved: 2 April 2024.
• Name of originator or author: Chief allied health professional.
• Name of responsible individual: Chief nurse.
• Date issued: 24 April 2024.
• Review date: 30 April 2027.
• Target audience: All adult inpatient and community services colleagues and catering colleagues.

Page last reviewed: November 20, 2024
Next review due: November 20, 2025

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