Studies have shown that up to 40% of patients admitted to hospital are malnourished and can become further malnourished during their hospital stay¹. The provision of good quality food, fluid and nutritional care should therefore be considered an integral part of the therapeutic care provided in hospital.

It is important that everyone involved in the hospital food chain is aware of their role and how this impacts on meeting patients’ nutritional needs. Ward staff have a key role to play in promoting and maintaining high standards of nutritional care through managing mealtimes and enhancing the mealtime environment².

This guideline combines two previously separate guidance documents namely ‘Guideline for the Provision and Management of Patient Meals in NHS Ayrshire & Arran’ and ‘Operational Catering Services Guideline – Patient Services’. It is designed to support all staff directly involved in the ordering / preparation / distribution / and delivery of patient meals.

An aide-memoir / summary of the guideline is available at appendix 1.

All dishes and menus have been analysed for nutritional content and have been approved by a registered Dietitian as meeting the preferences and nutritional requirements of the majority of patients.

Patients will be offered a choice of healthy, well balanced meals in line with the NHS Scotland National Nutritional Catering Specification ‘Food in hospitals’ 2016.

2.1 Patient menu

A ‘3 week’ (21 day) menu cycle is employed to include breakfast, lunch and evening meal, and mid-morning, afternoon and evening snacks as appropriate.

All patients’ menus are issued for completion no earlier than one meal in advance.

The standard adult menu is offered to all in-patients from which (unless assessed by a Dietitian and advised to follow a therapeutic diet), patients can choose two courses at each mealtime.

2.2 Special menu days

Various special menus are held throughout the year to further enhance the standard of service provision. Patients are offered special menus on the following feast days;

• Christmas Day
• New Years Day
• Burns Night
• Valentine’s Day
• Easter Sunday
• Mothers Day
• Father’s Day
• St. Andrew’s Day
• Hallowe’en.

Therapeutic dietary provision continues to be catered for on these menus.

2.3 Children's menu

Children on the Paediatric Ward should be encouraged to make their menu choices from the standard menu.

If there is not an acceptable choice within the standard menu for an individual child the ‘Children’s Menu’ is available. This offers a range of ‘child friendly’ options with familiar children’s meals and if chosen, should be written onto their menu card.

It is important that the age of the child is clearly marked on the menu card in order that the cutlery choice, food consistency etc is suitable for each individual child.

2.4 Therapeutic diets

The provision of ‘Therapeutic Diets’ relates to specific dietary adaptations in dealing with the treatment of a disease state e.g. Texture Modified Diets, low total fat to promote lipid lowering; low sugar/ healthy eating diets to promote good blood glucose control in Diabetes; Gluten Free diets in the treatment of ‘Coeliac Disease’ or ‘Dermatitis Herpetiformis’.

Some specific therapeutic diets are coded against each item on the menu card.
Other non-coded therapeutic diets are also provided at every meal.

Patients should be referred to the Dietitian to ensure that the correct dietary modifications are provided. Further guidance on the provision of therapeutic diets and dysphasia is available from the Dietetic and Speech and Language Departments respectively. Guidance documents are also available on the Athena Nutritional Care and Clinical Guidelines pages of AthenA.

2.5 Maternity

The maternity unit has its own in-patient dining room and in-patients will choose their meal requirement at the time of service from an assisted service point.

Prior to each meal service the catering department telephones each maternity ward to ascertain the number of patients. Ward staff must advise the catering department of any patient with special dietary needs.

For longer term patients the standard patient menu cards can be available.

2.6 Renal Unit

Patients within the Renal Unit may attend for dialysis on either a Monday, Wednesday, Friday cycle or Tuesday, Thursday, Saturday cycle. A 3-week soup and sandwich menu has been designed to specifically meet the needs of the patients on this unit. The menu cycle has been checked by the renal dietitians to ensure that there will always be a choice suitable for every patient regardless of restriction they may be on. Whilst a patient is attending the unit they choose their sandwiches at the point of service.

2.7 Short Stay Units and Wards

Due to the nature and quick turnaround of patients in these areas, assorted breakfasts, soup and sandwich lunch and assorted evening meals are offered. Ward/unit staff must advise the catering department of any patient with special dietary needs. Patients who remain in these areas longer term are free to request a choice from the full menu.

2.8 Emergency Department/Endoscopy/Day Surgery

These departments can obtain sandwiches on request by telephoning the catering department. Other catering requests can be accommodated e.g. Day Surgery requiring assorted evening meals.

2.9 Cultural/ethnic and/or religious requirements

To ensure that all food and fluid meets the dietary requirements of the individual the local procedures are in place to provide patients with a choice of meals to meet their cultural, ethnic and religious requirements.

The Catering Department can provide meals for cultural/ ethnic or religious reasons. A stock of Halal meals is held locally and Kosher meals can be obtained when required.

Such meals will be regenerated and served to the patient in the original packaging to comply with their individual beliefs.

Each ward has been issued with a guide entitled ‘Food Rules of Religions’ to help promote awareness and provide advice regarding religious dietary beliefs (appendix 2).

2.10 Food allergies

Information for food allergy sufferers is printed clearly on the reverse side of the patient menu cards. This information includes who to contact for advice regarding ingredients/ dish composition where this is required.

Patient menu items containing nuts will have the relevant nut incorporated into the dish name e.g. Vegetable and walnut risotto.

In addition to comply with Statutory Regulations each menu has been checked against 14 allergens. This information is available to all wards on Athena - Nutritional Care.

2.11 Ward provisions

Bread and milk is routinely provided to wards, if wards require additional supplies then contact the Catering Department.

Additional items such as biscuits, diluting juice, sauces etc are available for wards to order via a requisition form available on Athena Nutritional Care. Give sufficient time from requisition to delivery.

2.12 Snack provision

Snacks are available by various routes, for example, from menu card, from dietetic referral, ward provisions. Snacks that arrive on trolleys with identified names and mealtimes must be given to those patients at the specified times.

2.13 Out of hours food availability

Acute admission wards have ward provisions, sandwiches etc. available for new admissions between 9.00pm and 7.00am.

Community hospitals hold a limited range of food items at ward level.

2.14 Vegetarian and vegan

A vegetarian option is available at each meal. Suitable starters and main courses are coded (v). All puddings are suitable for vegetarians. Vegan meal choices are available by contacting the Catering Department as soon as possible after admission.

2.15 Portion sizes

Patients will be offered a standard portion or the choice of a small portion or a large portion, which should be indicated on the menu card.

Exact serving times will vary across sites depending on ward areas and may be subject to variation in specific circumstances. Approximate serving times are listed below.

4.1 Distribution and return of menu cards

The procedures in place for the distribution and return of patient menu cards must be adhered to in order to ensure that, as far as possible, patients get the meal of their choice and food waste is kept to a minimum (Please see appendix 3 for a copy of this flowchart).

• Menu cards for each meal will be distributed, from the Catering Department.
• The menu card should be completed by the patient, with assistance from ward staff only if required.
• Ward staff must ensure that the patients name and ward/room number are written on the menu card, red dot (for any patient who requires assistance and meal is delivered on a red tray).
• It is the overall responsibility of the qualified nurse/midwife to check that patient menus are reviewed to ensure appropriate choices have been made and that ‘special diets’ have been correctly identified as per ward guide ‘How to Complete a Menu Card’. Appendix four gives guidance on ‘how to complete a menu card.
• This task can be delegated to other appropriately trained members of the ward team.
• A Red Tray system is available for patients who require assistance – mark menu card with a red dot.
• The menu cards for the following meal should be returned to the catering department either by a staff member or on the return meal trolley.

4.2 Meal distribution

Patient meals are prepared and plated from the main kitchens at specific hospital sites and then distributed in ambient food trolleys by hand and/or vans to other hospital sites/ward areas by Clinical Support Services staff, depending on the type of service undertaken on-site. The system is designed to operate without delay, with ward staff being informed that the meal trolley has been delivered to their clinical area before Clinical Support Services staff leave.

Any cold, items not being consumed straight away e.g. sandwiches, cold milk drinks, must be placed in the refrigerator immediately.

Random temperature checks of the meals arriving on the wards will be carried out by senior members of the catering department and recorded as per the Food Safety Assurance Manual.

4.3 Ward activity prior to meal service

Protected Mealtimes operate throughout the organisation. This encompass aspects of what should occur prior to meal service (including preparing the patients for meals; discussions with mealtime co-ordinator etc) and the principles that all non-essential clinical and non clinical ward activity e.g. blood tests, investigations, cleaning etc, are stopped and not carried out during the mealtime period (further information on protected mealtimes can be found on the Athena Nutritional Care page).

4.4 Meal service

A plated meal service system is in place as standard for patient meals in all hospitals across NHS Ayrshire & Arran.

Meal service will start as soon as the meal trolley has been delivered to the ward.

Overall responsibility for meal service lies with the nurse/midwife in charge of the ward however any member of the ward team can assist with meal distribution. A team approach is required in order to monitor meal service and ensure that;

• The correct meals are received by the ward.
• The patient receives the meal that they have chosen, through cross reference with the menu card.
• The meal is attractively presented.
• There has been no spillage during transfer.
• The meal that the patient has chosen is still suitable for their needs.
• Meals should be served one course at a time.
• Patients are given adequate time to eat, drink and enjoy their meal. Mealtimes should be regarded as protected time for patients to enjoy their meal, and should not be rushed or interrupted unless absolutely necessary.
• Staff make themselves available to assist and support patients as required.
• Patient’s intake of food and fluid is monitored (see section 8.5).
• Protected mealtimes.
• Mealtime Coordinator is managing the service.
• Patients are provided with the equipment/utensils that they require for eating and drinking e.g. feeding beakers, special cutlery etc. to meet their individual needs, prior to the meal service.

It is vital that meals are placed within easy reach of the patient. Assistance with feeding will be identified and offered, where required, while the food is still at the appropriate temperature.

In order to ensure that each course is kept at the correct temperature, lids should not be removed, until the previous course has been eaten.

If there are problems relating to incorrect meals, temperature, presentation or spillage during transfer the Catering Department should be informed immediately by telephone (appendix 5 – Catering Department Contact List).

4.5 Documentation of nutritional intake

Patient’s intake of food and fluid should be recorded and monitored on the appropriate record charts which form part of the patients nursing record. It is the responsibility of nursing staff to ensure all relevant information regarding the consumption of food and fluid is recorded, including reasons for refusal of food and fluids.

Nursing staff should take action if it is suspected a patient’s intake of food or fluid is inadequate. Patients with persistent poor dietary intake affecting nutritional status should be referred to the Dietetic Department for a full nutritional assessment.

N.B. All items consumed throughout the day e.g. between meal snacks, oral nutritional supplements, recommended by the Dietitian, and other drinks should also be documented on the appropriate recording sheets.

4.6 Return of the meal trolley

When all patients have finished eating, ward staff will collect the meal plates/trays and return them to the trolley. During this process ward staff must ensure;

• All non-contaminated food waste is returned to the Catering Department for disposal via the appropriate methods.
  N.B: Hot meals for patients who are unable to eat them at the time of service should NOT be kept back on the ward to be reheated, and must be returned to the kitchen.
• No patient property (including dentures), surgical implements, dressings, sharps or patient drugs are left on the plate/meal tray.
• The plate/meal tray is not contaminated with any bodily fluids. Contaminated food waste i.e. food waste which has been contaminated by blood, urine, vomit, faeces or sputum must be treated as clinical waste. Crockery or cutlery becoming contaminated must be suitably sanitised before it is returned to the Catering Department.
• Any special crockery or cutlery is retained and washed at ward level (see section 9.4).

The meal trolleys will be collected by the Clinical Support Services staff and returned to the Catering Department.

4.7 Extra meals/replacement meals

Requests for extra or replacement meals should be made as timeously as possible during mealtimes, by telephoning the main kitchen.

4.8 Process for ordering missed meals

If a patient has missed a meal, and requires a replacement meal outwith normal mealtimes, the nurse should telephone the Catering Department.

Ward staff within the acute hospitals and Hotel Services staff in community hospitals will usually collect/deliver any extra meals required, as per local agreement.

5.1 Food safety

Food Safety is governed by Food Hygiene Regulations which requires a Food Safety Assurance system to be in place. For ward staff to be aware of their responsibilities a aide memoir is available (appendix 6).

5.2 Bringing food into hospital

NHS Ayrshire & Arran require to provide traceability in complying with temperature control, therefore, the Food Safety Assurance Manual and Health & Safety guideline ‘Food Safety’ states that patients and/or relatives/carers must not be encouraged to bring food into hospital. This is due to elements within the Food Hygiene Regulations.

Any food known to be brought into the hospital for an individual patient must be documented in their nursing notes, thereby ensuring an audit trail.

In reality, it is known that patients and/or relatives will through free choice, bring food into the ward. While this may be the case, staff must not actively assist in the sourcing; distribution or re-heating/chilling and/or freezing of any food stuffs brought onto the ward by patients or relatives/visitors. Staff should record timorously in the patients notes on observation of any food consumed. Nursing staff should advise patients/relatives of the dangers of the risk of cross-contamination which may affect the patient’s clinical condition.

Low risk food items can be brought into patients e.g. ambient products that are wrapped, date coded and ingredients listed. High risk foods can only be provided by the Catering Department.

6.1 Accompaniments/condiments

Accompaniments will be available across the sites and available as per local delivery method. Particular condiments are available for wards to obtain through the ward requisitions.

6.2 Procedures for "wash up" at ward level

Where specialist crockery and/or cutlery are washed at ward level it must be washed using a bactericidal detergent in the ward pantry/kitchen. Dishwasher temperature controls must be documented and in accordance with Food Safety Assurance System.

6.3 Use of ward microwaves

Under the Food Safety Assurance System patients food must not be reheated at ward level, as records must comply with The Food Hygiene (Scotland) Regulations 2006. The catering department has the responsibility for food temperature control across the organisation and maintains the appropriate records and documentation for Environmental Health Officers inspections.

Some specific areas within the community hospitals allow patient self – catering as part of the treatment of care e.g. Learning Disability. In these circumstances, the ‘Self catering Policy’ must be adhered to.

Microwaves within wards are there only for the use of staff in the preparation of their own personal foodstuffs.

Employees are reminded that they may have patients/carers who require communication in an alternative format e.g. other languages or signing. Additionally, some patients/carers may have difficulties with written material. At all times, communication and material should be in the patient’s/carer’s preferred format. This may also apply to patients with learning difficulties.

In some circumstances there may be religious and/or cultural issues which may impact on food/meal choices. Paragraph 4.9 provides information on what provision is made for patients who need a meal to meet their cultural or religious requirements.

Some patients may have a physical disability or impairment that makes it difficult for them to eat/feed themselves. Paragraph 6.4 provides information on what will be done to accommodate this.

Patients’ sexual orientation may or may not be relevant to the implementation of this guideline, however, non-sexuality specific language should be used when asking patients about their sexual history. Where sexual orientation may be relevant, tailored advice and information may be given.

This guideline has been impact assessed using the NHS Ayrshire and Arran Equality Impact Assessment Tool Kit. No additional equality & diversity issues were identified.

Related documents

For additional information (including relevant legislative requirements and / or other guidance documents) please seek advice from the Occupational Health and Safety and/or Catering Department.

References

1. McWhirter, JP, Pennington, CR., (1994), Incidence and Recognition of Malnutrition in Hospital, BMJ 308: 945-948.
2. Nursing and Midwifery Practice Development Unit, Nutrition: Assessment and Referral in the Care of Adults in Hospital, Best Practice Statement.

Bibliography

NHS HIS Clinical Standards (2014) Food, Fluid and Nutritional Care in Hospitals. Available from: https://www.healthcareimprovementscotland.org/our_work/standards_and_guidelines/stnds/nutritional_care_standards.aspx

This appendix is also available as a PDF.

Ordering Process

• Individual menu cards are provided for patient meals and will be delivered on the top of each meal trolley, one meal in advance.
• Menu cards should be completed appropriately. Assistance should be given to patients who require help to complete an individual menu card.
• Menu cards should be returned to the Catering Department, either by a staff member or on the return meal trolley.

Therapeutic diets

Patients who require a therapeutic diet should be referred to the Dietetic Department. For patients who require a coded therapeutic diet mark at the bottom of the menu card.

Food allergies

If you require information about a particular menu item, please check Allergen Manual (Athena – Nutritional Care page) or contact the Catering Department.

Meal times

Process for ordering "missed meals"

Should a patient require a meal out with normal mealtimes, due to clinical reasons, nursing staff should contact the Catering Department.

Out of hours

Please refer to the local arrangement within each hospital.

Ward provisions

Requisitions forms are available on Athena – Nutritional Care page.

Patients/relatives bringing food into hospital

Please refer to other guidance.

Use of microwaves

Microwaves must not be used to reheat patient meals.

Food rules of religions

Process for ordering and receipt of patient meals

This flowchart is also available as a PDF.

How to complete a menu card

This appendix is also available as a PDF.

Policy

It is NHS Ayrshire & Arran policy to ensure that the highest standards of food safety are maintained at all times.

There is a legal obligation on all staff involved in food service that they do not compromise food safety through poor personal hygiene.

Ward staff must take all necessary steps to avoid cross contamination of food.

Food service to patients must commence as soon as the food trolley is delivered to the ward to ensure that legal food temperatures are met:

• Hot food above 63°c.
• Cold food must be stored below 5°c.

Always remember - food poisoning can kill!