It is recognised that there are always opportunities through shared learning of audit information and reviewing current practice to make improvements to the standard and quality of nursing records. As a result a number of improvement initiative are being taken forward:
· The Health and Care Standards Operational documentation audit will be used as part of the nursing documentation audit programme, which looks at the whole holistic nursing assessment and care planning, of which contributing factors to nutrition and hydration e.g. communication needs, are reviewed. This information will be recorded on the Health and Care Monitoring system, which will allow for reports and improvement planning to be undertaken, further strengthening the assurance of the standards of nursing documentation.
· To ensure a consistent approach is applied across all inpatient areas, a Standard Operating Procedures for Inpatient Nutrition, Catering and Hydration is being developed, this will include the minimum standard with regards to the nursing documentation and assessment ensuring patient’s nutritional needs are met.
· A Sister’s Forum is held on a monthly basis, this is the forum where Nutrition and Hydration is discussed with audits results and themes shared for learning to take place.
2. What information do you collate and analyse on patients’ nutritional status to support service planning and to monitor patient outcomes?
Powys is unique as the inpatient demographics are fairly static with the majority of inpatients being +65 presenting with comorbidity health needs. The rich source of data to support service planning comes from the multi professionals (Nursing, Dietetics and SALTs) who work directly with the patients, families, carers and staff on a daily basis. The information that is shared by these professionals supports the menu planning process (menu design, food tasting sessions and ensuring the correct protein and calories) and the training and education of staff.
Powys doesn’t have a rich cultural diversity in terms of population so there is little need for specialist diets however these are available at short notice as required through our suppliers.
As part of the 360 process, information is collected about the number of patients who are on the red tray system and the number of patients who need assistance with feeding, which gives an indication of nutritional dependency of the patients on the ward at the time of the audit, supporting information provided by the multi professional team.
The nurses will review patient food charts and use feedback from patients and carers, to support identifying if a patient seems to like a certain food. This information is shared with catering staff and supports informing service planning.
The implementation of a computerised catering system, will be enable business intelligence to identify patient’s food preferences to support service planning and minimising waste.
It is standard practice in Powys Teaching Health Board that patients (with support as required from the nursing staff/ family/carers) order from a cyclic 14 day menu. This ensures patient choice is promoted.
3. What action are you taking to ensure that food and fluid intake is recorded appropriately, particularly for those patients at risk?
The Ward Sister is the key person to ensure that food and fluid intake is recorded appropriately to include those patient’s at risk. This action is part of the routine leadership rounds which take place throughout the day. Any anomalies identified will be noted by the Ward Sister or Nurse in Charge and followed up.
The 360 audit process also reviews compliance with the completion of food charts and the counter signing by a registered nurse. The Core Care Plans support and prompt nurses to ensure/ consider using food and fluid charts, these are held at the bottom of the patient bed, ensuring easy access for reviewing and updating.
4. What is the level of compliance with the e-learning training package on the nutritional care pathway in your health board?
The current compliance with the e – learning training package is 25%.
If you have yet to achieve full compliance, what steps are you taking to improve it? Do you anticipate being able to achieve 100% compliance, and if not, what are the barriers?
Whilst Welsh Government have indicated that the E-Learning is compulsory, PTHB has not identified it as an area of priority in terms of securing 100% compliance, as approved by the Workforce and Organisational Development Committee. This is because we have reviewed compliance across all Mandatory and Statutory training requirements and have taken a prioritised, risk-based approach. If there was poor compliance to nutritional risk assessment, high levels of complaints &/or poor 360 audit results then we would be prioritising the training. However this is not the case in Powys.
5. What is the level of compliance with nutritional screening across hospitals within your health board?
PTHB average 94%
What are you doing to improve/sustain compliance with nutritional screening?
Through the Health and Care Standards Monitoring Tool, the wards undertake a monthly audit, using the All Wales Nutrition Metric indicator. Local auditing criteria has recently been applied to ensure that all staff are auditing using the same methodology/ standards to strengthen our assurance. Therefore as part of this indicator the completion of the MUST assessment and admission documentation with 24 hours, the appropriate implementation of a Core Care Plan along with evidence of evaluation is assessed. If any one of the previous mention elements are not meeting the minimum standard agreed then this is recorded as an incomplete assessment, with improvement/ learning taken forward.
The Health and Care Standards Operational documentation audit will be used as part of the nursing documentation audit programme, which looks at the whole holistic nursing assessment and care planning, of which contributing factor to nutrition and hydration e.g. communication needs are reviewed. This information will be recorded on the Health and Care Monitoring system, which will allow for reports and improvement planning to be undertaken, further strengthening the assurance of the standards of nursing documentation.
360 spot checks are being undertaken across PTHB to review compliance with nutritional screening in the specified timeframes. Unannounced visits are planned to review compliance with ‘protected mealtimes’ and to ascertain patients views of the food provided.
6. Is there a named individual for ensuring compliance with nutritional screening is improved and sustained across the hospitals?
The Executive Lead for Nutrition and Hydration is the Director of Nursing. The Assistant Director of Nursing is co chair of the “Nutrition, Hydration and Catering Oversight Group“ and is an active member of the 360 team as well as participating in the unannounced visits.
7. What difference has the all-Wales menu framework made to food in your hospitals?
The Framework has supported the HB in a range of ways to improve our delivery of catering services in compliance of the All Wales Nutrition and Catering Standards for Food and Fluid Provision for Hospital Inpatients. Meeting the standards starts with the NHS Wales agreement to procure our food provisions in a consistent manner through NHS Wales’s contracts. That is, building into the contracts the agreed ingredients and products we need and their specification to ensure that the practicalities of service delivery can be met in terms of cost, availability, sustainability and of course nutritional suitability. This work was headed by shared services procurement with close liaison of the procurement dietician who is playing an essential role in its success.
Secondly the framework has led on the standardisation of recipes and cooking methods, nutritional analysis of menu items and a range of snacks. This work continues on a rolling basis as additional menus are added or amended within its portfolio.
There is, in our view, a final piece of the jigsaw missing and that is an NHS Wales joint catering computer system. There is the opportunity to link our national procurement services to a national catering computer system to give us a global account of catering cost performance. Currently HBs are implementing their own systems, duplicating administration in maintaining up to date stock details.
8. How have you used the national patient survey findings to improve catering and nutrition services in your health board? What other ways do you gather patient’s views on hospital food?
The national patient surveys have been helpful not only to allow us to benchmark against patient’s views in other health boards but also to inform us on areas for our own improvement.
In addition we have a rolling program of formal 360 Nutrition, Hydration and Catering Audits which includes a patient satisfaction survey. We have also more recently commenced unannounced mealtime observations that considers the effectiveness of protected mealtimes, the operational delivery arrangements, food wastage and quality. These observation sessions are useful to receive real time feedback from patients on that particular mealtime experience which we use to refine and improve the service. It also serves to maintain the staffs focus, particularly on the requirements of service delivery outside normal working hours.
9. What actions have been taken to improve catering services in response to patients’ views?
Aside from using feedback to refine our protected mealtime arrangements we use patient’s comments and menu “take up” data to identify preferences for inclusion in the menu. We understand the importance of matching the patient’s menu preferences to increase the likelihood of them consuming the food we provide. This helps not only to provide the protein and calories our patient groups needs but also helps to minimise waste. The preference amongst Powys patients are very traditional dishes such as roast meats, casseroles, pies and fish in sauces and our flexible “hybrid” menu system allows us to meet this requirement.
When we develop new menus we include patient representatives at the tasting sessions to help select the items that will appear on the menu.
10. How do you promote good hydration on all your wards?
Hydration is supported through the multidisciplinary team. Water jugs are replaced 3 times a day by the Hotel Services staff and refilled in between as necessary by nursing staff. Beverages are offered throughout the day on 7 or 8 occasions and additional patient requests can be provided 24 hours a day.
Awareness raising of the importance of hydration in patient’s wellbeing and recovery are evident in the nursing conference, sisters meetings and during the “Water Keeps You Well” campaign.
11. What information is provided to patients about catering and nutrition services when admitted to hospital?
Patients and relatives are provided with an “Eating Well In Hospital, what you should expect” leaflet published by the Wales Audit Office.
12. How do you ensure protected mealtimes are adhered to within your hospitals?
This is the role of the Ward Sister/Charge Nurse or the Nurse in Charge to ensure that mealtimes are protected. We encourage family member attendance to assist at mealtimes, promoting mealtimes as a social activity. Some patients respond more positively to family members supporting them at mealtimes.
Unannounced visits also take place to assess compliance. A multi professional approach provides an opportunity to ensure that ‘Protected Mealtimes’ are being adhered to.
Patient Status at a Glance Boards is a mechanism whereby symbols are used to identify patient’s nutritional status, Red Trays are also used to identify those patients requiring assistance during mealtimes. The multidisciplinary team are made fully aware of the requirements of all patients at the beginning of each shift.
We are currently standardising the protected meal signage across the health board and protected meal times philosophy is being reinforced through the development of the SOP.
The health board has signed up to John campaign, which will actively encourage relative/careers to support mealtime experience for the patient
13. How do you ensure patients are provided with timely support to prepare for mealtimes and prompt help with eating?
The Ward Sister or Nurse in Charge of the shift is responsible for ensuring patients are provided with timely support to prepare for mealtimes and prompt help with eating.
All patients are encouraged to prepare for mealtimes, i.e. visiting the bath room, staff are also expected to provide all patients with an opportunity to wash their hands prior to mealtimes. This practice is captured in the SOP to provide all staff with the role and responsibilities in respect of mealtimes in the ward environment.
14. How do you measure food waste that is, the number of unserved meals at ward level, and are you confident that this is an accurate reflection?
We believe that the EFPMS “untouched meal” methodology for monitoring food waste only tells a small part of the food waste story and does not fully inform on the causation of the waste.
PTHB have designed a different methodology and tool that takes into consideration:
· The number of menu items ordered
· The number of portions prepared by the kitchen
· The number of portions sent to the ward from the kitchen
· The number of portions prepared but not sent or not utilised in the staff canteen.
· Unserved portions on the ward trolley
· Plate waste in portions
From the example below it can be clearly seen where the waste is generated whether due to inaccurate ordering, over production or incorrect portion size being offered, I.E. low levels remaining on ward trolley but high plate waste. The PTHB tool shows our own in-house % waste score as well as the EFPMS % for national reporting purposes.
15. What action are you taking to reduce food waste from unserved meals?
The size of Powys’ Community Hospitals allows for very close working relationships between staff groups allows us to communicate any emerging problems quickly. Where the causation is unclear or there is a need to demonstrate the cause, our food waste audit can assist. Having identified the cause we can then change practices to mitigate the problem. Local teams are aware of the need to minimise food waste and that it is everyone’s responsibility to assist with reducing waste and ensuring value.
16. What information does your board receive on hospital catering and patient nutrition and how frequently? Do you have a named individual at board level with responsibility for catering? If not, how does the Board receive assurances on the efficiency and effectiveness of catering services?
The “Nutrition, Hydration and Catering Oversight Group“ reports to the Patient Experience, Quality and Safety Committee (which is a sub-committee of the Board), providing highlight reports as per the business cycle and an Annual Report which will be presented to the Board.
Whilst final accountability for all aspects of healthcare nutrition, hydration and catering lies with the Chief Executive and the Board, the Director of Nursing, is the designated executive board member responsible for nutrition and hydration and the Director of Primary Care, Community & Mental Health is responsible for Catering.
17. What feedback do you receive from patients on a regular basis about catering services and the mealtime experience?
The most frequent feed back from patients is verbally during their mealtime experience where they are very quick to offer their views. Our patients are mostly very happy with the meal service but when there is some concern expressed from a patient we have the flexibility to put things right immediately.
Feed back is also regularly received by visiting staff to the ward on other business when it is common practices to talk to the patients about their experiences. Again this is within our gift being such small hospital sites.
Furthermore part of our 360 Nutrition, Hydration and Catering audits carried out on a rolling basis do include a comprehensive patient satisfaction questionnaire.
The health board undertakes on an annual basis the Health and Care Standards Patient experience audit, which include questions relating to nutrition and hydration.
The health board has recently approved a patient experience strategy and developed an implementation plan to accompany this strategy.
18. What actions are being taken to ensure non-patient catering services break even?
Given the comparatively small numbers of staff in PTHB, our demand for staff catering is low. Non-patient catering services in PTHB are provided therefore from the same kitchen, utilising the same staff as patient catering services. The catering provided for staff is based around that day’s patient menu to minimise the staff resources required. The total staff utilised would be needed in any case, even if we were not catering for staff, so staff catering is seen as a by-product of patient catering. We do not have separate kitchens or stand alone restaurants for staff, so provisions for both are expended from the same budget line. To ensure that non-patient catering services are breaking even in terms of provisions spend attributed to it, we inflate the cost price of meals by 75%. This process also allows us to deduce by looking at staff meals income how much was spent on staff meals and then the remainder will be seen as the cost for patient’s meals. This remainder divided by patient days activity provides us with patient provisions cost per day.
Whilst this costing model is simple and fully transparent it is based on a number of assumptions and it is unlikely that other HBs use the same model, so benchmarking could be seen as flawed. As eluded to earlier in our response to question 7, it would be helpful if an NHS Wales joint catering computer system were procured to ensure a full and consistent approach to catering cost control and performance reporting across all HBs.