Nutrition - enhancing nutritional care

We will share good practice in nutritional care in this section of the resource.

• Care Quality Commission
• Enhancing nutritional care
• High Impact Actions: Keeping nourished, getting better
• Improving nutrition...improving care
• Nutritional care in hospitals
• FoNS projects
• Other case studies. 

Some of the resources on this page are in PDF format - see how to access PDF files.

Care Quality Commission case studies

• CQC works with NHS hospital to meet government nutrition standards. Ensuring people have enough food and drink is one of the government standards that all hospitals must meet by law. This case study focuses on the CQC’s work with an NHS hospital which they found was not meeting government standards on nutrition. During an unannounced inspection of the hospital they found patients were not getting the support they needed to stay hydrated.

Enhancing nutritional care case studies

The RCN's Nutrition Now campaign set out to help all members of the multi-disciplinary team better understand the importance of good nutritional care, their role in providing it and how they can improve the care provided in their own settings by collaborating with colleagues.

The Enhancing Nutritional Care booklet (2008, revised 2010) (PDF 840KB) describes seven organisations that have participated in the Nutrition Now campaign. They each highlight the importance of working together and the positive impact that multi-disciplinary working has on patient/client experience.

• Berkshire Healthcare NHS Foundation Trust - implementing the "Malnutrition Universal Screening Tool" (MUST) in a mental health setting.
• County Durham and Darlington PCT - developing and implementing a nutrition intake monitoring tool in the community hospital setting.
• County Durham and Darlington PCT - improving patient choice of food.
• West Hertfordshire Hospitals NHS Trust - ensuring appropriate resources are available to provide safe quality nutritional care.
• West Suffolk NHS Trust - developing key performance indicators for nutrition.
• Stockport NHS Foundation Trust - promoting breastfeeding.
• Walsall Hospitals NHS Trust - making nutritional training and development a priority. 

High impact actions: nutrition case studies

Keeping nourished, getting better is one of the eight High Impact Actions unveiled by the Chief Nursing Officer for England Dame Christine Beasley in 2009. Four good practice examples (written and video) provide details of what was done and ‘how they did it’ in order to make a real difference to nutritional care. 

• Salford Community Health (PDF 1.2MB) - Salford’s community nutritional support dieticians worked across the health economy to ensure the appropriate use of supplements by implementing a nutrition screening policy and ensuring a consistent dietetic approach across acute and community services.
• Lancashire Teaching Hospital (PDF 1.44 MB) - Staff at Lancashire Teaching Hospitals NHS Foundation Trust have cut the use of total parenteral nutrition (TPN) and improved care for this vulnerable group of patients, through a specialist nutritional nursing service and daily ward round. 
• NHS County Durham and Darlington Primary Care Trust (1023.57 KB) - Staff working in Durham’s community hospitals have dramatically reduced the amount of supplements being used – and thrown away – by developing a food fortification programme that, along with other changes, enables staff to ensure their patients are well-nourished.
• Hereford Hospitals NHS Trust (1.52 MB) - Hereford Hospitals NHS Trust developed a scoring tool to monitor fluid balance, to speed up interventions and improve mealtimes, introducing volunteer helpers who ensure those who need help eating get it.

Improving nutrition...improving care programme

Held as part of the implementation of the NHSScotland Improving Nutritional Care Programme and to mark the publication of the Improving Nutrition...Improving Care interim report, the conference brought together more than 150 practitioners from the NHS and care homes, colleagues from academia and members of the public. The event report Improving nutrition...improving care (2011) celebrates work undertaken through the Improving Nutritional Care programme, and includes examples of good practice from around the country.

• Ayrshire & Arran - standardised white boards are used in ward kitchens so that all relevant information is captured, for example if patients are on staged diets or fluids, have supplements or a red tray. The relevant professional (nurse, speech and language therapist or dietician) updates the boards regularly.
• Forth Valley - the board has incorporated a MUST risk category into its electronically generated discharge letters through its eWARD alert, a system to electronically document the patient’s journey from arrival to discharge. This supports the clinical team by providing an episode history through a shared record.
• National Waiting Times Centre - a meal voucher system is used to allow longer-term patients to go to the hospital restaurant for their meal with family or friends. The aim of the vouchers, which are redeemed at the restaurant till, is to encourage patients to be more independent.
• Greater Glasgow and Clyde - on admission, patients receive leaflets about food and health in hospital. These include advice for visitors about what food they can bring in and how to store it along with space for patients to give written feedback to the catering department.
• The State Hospital - staff use colour-coded menus to help patients with food choices and are developing BMI and weight change charts.
• Western Isles - wards are sharing information gleaned from the clinical quality indicators (CQI) and making small improvements, for example, by ensuring patients’ likes and dislikes are entered in their nutritional profiles. 

Nutritional care in hospitals

This Scottish resource aims to support all staff involved in nutritional care in hospitals, ensuring that they have the knowledge, skills and capabilities to optimise nutritional care as part of the patient experience. View: Nutritional care in hospitals. The Learning in nutrition toolkit, developed by NHS Education for Scotland as part of the ‘Nutritional care in hospitals’ online learning programme, includes case study activities which present issues reflecting gaps in knowledge or skills that may adversely affect nutritional care of patients.

FoNS projects

The FoNS Centre for Nursing Innovation works with nurses and healthcare teams to develop and share innovative ways of improving practice; enabling them to provide care that is high quality; evidence based and meets the needs of patients. FoNS has examples showing how clinically based nurses have led innovations in their workplace.

• What’s Food Got to do With It? The Dewsbury Link Nurse Project (2005) -  This project aimed to put the responsibility for ensuring that patients eat and drink firmly back with the qualified nurse, and to reinforce that nutrition is seen as having “a lot to do with it” when promoting the recovery of health.
• Working in partnership with patients and families on a dementia assessment unit (2011) - This report describes a project in a Health and Social Care Trust in Northern Ireland in which, as part of a series of improvements in response to feedback from relatives and carers  an action plan and range of improvement developments were  implemented in particular to make care more patient-centred. This included improving the mealtime experience through the provision of more visual cues and prompts to help people with dementia recognise that it is a mealtime and to minimise distractions protected mealtimes was introduced.
• Improving the health choices for older people: implementing patient-focused mealtime practice (2005) - The dissemination series contains reports about projects which have aimed to reflect improvements in care and changes in practice that are responsive to patient care. This project aimed to improve the experience of mealtimes in a discharge unit for older people resulting in greater choice for patients and the active involvement of all staff in mealtimes.
• Embedding excellent nutritional care practices in a large acute hospital ward (2012) - The project used a three stage process which involved: audits to review nutritional care; engaging staff via time out sessions, claims concerns and issues and process mapping; follow-up audits to establish changes in practice. “Improvements in practice were demonstrated. These included improved screening practices using the MUST tool, improved documentation of nutritional care, and a greater level of involvement of both registered and non registered nurses in the mealtime care of patients”. 

Other case studies

• Nurses place nutrition at the centre of care, Basildon and Thurrock University Hospitals - Nutrition Nurse Specialists Anita Beukes and Andrea Cartwright launched Nutrition Mission aimed at encouraging everyone in the Trust to sign up to the Mission and play their part in delivering excellent nutritional care,  including a re-launch of protected mealtimes across all wards.
• Tiptree Box Toolkit – the ‘Tiptree Box’ activity table (originally piloted in 2006 by Carrie Tyler and Helen Langthorne at Colchester) was chosen by NHS East of England, the strategic health authority, as one of its ‘Top Ten High Impact Actions’ for nurses and midwives. The toolkit is for use in acute hospital wards as therapeutic intervention with patients suffering from confusion. It has been shown to reduce falls, anxiety and dehydration. View: Regional success for dementia therapy created in Colchester.   
• Ward nutrition assistants, Derby Hospitals NHS Trust - a role dedicated to improving the nutritional care of older people at Derby Hospitals NHS Foundation Trust won the ‘Personalisation of Care’ category at the inaugural Patient Experience Network (PEN) national awards. The new role of ‘ward nutrition assistant’ was created – someone who could dedicate time to help encourage older people to feed and drink. 
• Guardian: A recipe to tackle malnutrition among the elderly (Food First project). This article published by the Guardian on 2 October 2012 describes the Food First project led by two registered dietitians based at Bedfordshire primary care trust which is now part of the South Essex Partnership Trust (SEPT). The aim of the project is to support residential care homes in providing a high standard of dietary intake for residents, particularly those at risk of malnutrition, in order to reduce the use of oral nutritional supplements and inappropriate prescribing of these. Menus have been redesigned to improve nutritional content and this has also enabled residents to enjoy their food more. The project provides training to all staff in local care homes and also involves regular inspection of care homes’ food standards.
  A set of leaflets developed by the project are available on the BAPEN website and may be used with acknowledgement, but should not be modified or used without acknowledgement – see Food First Project leaflets.