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Clinical nutrition steering groups, as multi-disciplinary teams within LHBs, work collaboratively in order to meet nutritional care standards and ensure that the design and delivery of nutrition to patients is of sufficient standard to meet their care needs.

Part of this process has been the development of localised LHB specifications for food service, which set out the expectations of those involved in catering and food service, their respective roles and responsibilities, and to whom they are

accountable. Whilst ward sisters and charge nurses have ultimate operational and professional responsibility for ensuring each patient’s nutritional needs are met, this is delegated to registered nurses, supported by healthcare assistants, on the ward.

164 Catering managers have clear lines of responsibility within facilities and operational management and collectively these groups are responsible to the Boards through patient experience and safety committees, headed by the respective nurse

directors. The respective internal nursing, dietetic and food quality audit results are brought together through this structural pathway.

These hierarchical and divisional structures are supported by LHB and NHS wide networks with local and national groups for nurses (at various levels of responsibility and experience), dietitians, caterers and facilities managers. Collaboration also takes place between catering managers, dietitians and procurement through the ‘All Wales’ Foodstuffs Commodities Advisory Group (CAG) which is embedded in the sourcing and contracting processes of the NWSSP-PS.

The two LHBs considered in detail within this study demonstrate different internal structures for catering and food service, in each case taking a different approach to improving patient experience. Both have major acute hospitals supported by community based hospitals, and care collectively for just under one third of the population of Wales, including some of the most deprived areas of the UK.

The respective LHBs have retained their separate catering technologies and food service models, in each case replicating their respective food service models in their newly constructed hospital premises.

5.3.1.1 LHB Z

LHB Z adopts a conventional catering model, with either plated or bulk trolley service to the wards from central kitchens within the respective hospitals. Some smaller hospitals do, however, use a cook freeze and regeneration system. Meals are either plated in the kitchen and served by housekeeping staff, or plated from the trolley by catering or housekeeping staff and served to patients by nurses. The drawback of this approach is that the conventional system requires patients to complete their menus the evening before so that the kitchen can have the order early the next morning, deemed to be a contributory factor in over-catered waste.

Menus rotate over a 14 day cycle and are changed seasonally or when food prices exceed the available daily allowance

This LHB has a particularly good reputation for sound business management of catering operations, the WAO (2011) recommending that other LHBs consider them as best practice. There is a dedicated business team led by a catering manager and supported by a lead dietitian, food safety adviser and administrative assistance. The business manager provides a direct and dedicated strategic link between

165 procurement and catering. Computerised catering management systems have been put in place to enable the catering manager to set and continuously manage the catering budget through a patient daily meal allowance. The system also enables prompt identification, at ward level, of excessive over-ordered or over-catered waste, meals returned to the kitchen being recorded by catering staff. The dedicated link dietitian is present on Food Interest Groups (FIGs) at each locality, where staff involved in nutrition are brought together to collectively deal with any issues arising specific to that location. Within this LHB there are formal structural and operational links between key actors in procurement, catering, dietetics and nursing.

Criticisms from within the LHB have been that the effectiveness of these local groups is dependent upon the active involvement of senior nurses, but the increasing awareness of nutrition has, in some locations, broadened their

membership beyond nurse-dietetics-catering. The purpose of these groups is to enable communication but also to facilitate multi-disciplinary and mutual learning, a process also enabled by disciplinary based networks within the LHB.

Although praised for its financial management in the 2010 individual WAO report, the LHB was criticised for the levels of waste, poor performance in terms of meal ordering, and lack of robust approach to the nutritional assessment of recipes. Its financial management of non-patient catering operations has been praised, but this has been attributed locally to the unique level of demand in one hospital that is unlikely to transfer elsewhere. The patient and non-patient catering are, however, accounted for as separate catering operations, a system only in operation in this and one other LHB.

The new hospitals within this LHB have been designed to retain the existing models for the hospitals being replaced, with conventional centrally cooked meals. The design of the kitchen and restaurant facilities in one of the new hospitals has come under a lot of criticism, attributed by several informants within and external to the LHB, to a failure to take account of the requirements specified by the facilities and catering staff in the design process. Repeated requests for additional space to accommodate a conventional catering service were rejected on the grounds that this was not available within the overall design footprint. The catering equipment supplied was not in accordance with the type and models specified by the in house caterers. A change ‘control request’ was considered by the Project Board but rejected on the grounds of cost. As a result substantial expenditure has

subsequently been incurred in replacing much of the equipment that failed in the early days of operation. The restaurant was subsequently extended, but it has also

166 been necessary to construct an additional deep freeze building in the grounds external to the catering department. Another new hospital within the LHB did experience similar difficulties but it was possible to make the changes, which included replacing specified equipment and the kitchen flooring, before the building opened.

The strategic plan for future catering services will assess the option of changing to a regeneration model in any new-build hospitals, although the particular meal

production technology has not been defined.

Food service models in the new hospitals reflect existing local arrangements, although there have been some significant innovations at ward level which has improved both efficiency and patient experience. Following an example from a different hospital within the LHB, communicated through the FIG, the ward structure has been changed, initially on one, but now two, wards within this hospital. A

nursing assistant has been re-assigned as a ward hostess, whose role is to look after the patient environment, a large part of which relates to food.

Although there is a formal job specification, the role has evolved as opportunities to improve aspects of patient care have become apparent. There are many nutrition related activities which form part of the housekeeper’s responsibilities. He/she will take meal orders direct from patients on the preceding day, discussing options and ensuring appropriate choices are made. Those beds which are due to become vacant also are identified on the bed plan and the collective order that is sent to the kitchen. The orders are then checked the following day, and amendments

communicated to the kitchen. Despite the need for previous day ordering with this catering technology, the potential for waste is thereby minimised. The managerial role of the head chef is significant within this system, as he/she is in contact with the respective wards on a daily basis in connection with patient, rather than catering needs.

Meal service has been redesigned on this ward, and further changes are being discussed between the hostess and the ward sister/charge nurse. The hostess prepares the trolley with trays, identifying those who need assistance by use of red trays. Nursing staff are allocated patients by room, and working as pairs they will collect the trays, ensures that food served by the ward housekeeper from the trolley is as ordered by the patient, taking into account portion sizes, and deliver the food to the patient. The plated main courses are covered to retain heat, and those patients who need assistance eating are helped once all patients have received

167 their food. Prior to the change, the trolley was moved along the ward during service, but the changes that have been brought about mean that the nursing staff, rather than the food trolley, is mobile to maintain optimum temperature and quality; meal service time has halved, so that patients receive their meals as quickly as possible.

The ward sister, in collaboration with the hostess, is considering trying further changes to the order of meal service to try to optimise the quality, in particular the temperature, of the main courses at the bedside. Deemed a huge success, the LHB is promoting this ‘model’ as good practice across the LHB. Although successful, implementation is at the discretion of the ward sister/charge nurse. The nursing assistant was not a newly created role, and the lack of staff capacity on other wards is seen as a barrier to universal adoption by practitioners.

LHB Z has also been working for some time on standardising recipes across their catering sites to ensure quality, as consistency in nutritional content and

organoleptic qualities, and efficiency through simplification and standardisation with a consequential reduction in transaction and administrative costs.

The LHB has used and continues to develop the role of volunteers, who assist with mealtimes in hospitals catering, particularly for elderly patients. Although limited to preparing the patient and their surroundings for mealtimes, the role is being developed and training provided to enable volunteers to provide more direct assistance with feeding.

5.3.1.2 LHB X

LHB X, on the other hand, has taken the strategic decision to standardise the catering and food service operations across the LHB and uses a central production unit to supply cook-freeze main meals to each of their hospitals for regeneration at ward level. Orders are taken an hour or two before lunchtime service by ward based catering staff, and meals are served to patients by nursing staff. Provisions other than the frozen meals are delivered direct to hospitals.

This standardisation of the meal production and service models across LHB X included significant capital expenditure to build new ward based regeneration kitchens in an existing hospital as well as expanding the capacity of the existing central production facility (CPU). The rationale behind the standardisation of patient catering and food service across the LHB was that that particular catering and food service model provides the best patient experience, through consistency,

organoleptic quality and mealtime experience, but also that it was more efficient, enabled economies of scale and ensured the highest standards of quality

168 management. Critical to its success is the fact that meals can be ordered the same day, with catering staff being able to build relationships with patients due to their continual presence on the ward. This was reported by a key informant as having a very positive effect on the morale of catering staff as well as having had a dramatic effect in reducing waste. The existing bulk cook-freeze model was also amended so that meals are available in smaller two-portion size trays, overcoming previous problems with over-catered for waste in the bulk delivery system.

Financial management of catering operations has followed need, with the use of nutritionally assessed recipes dictating cost. There has been a recent introduction of a seasonal menu, providing a wider range of options than in other LHBs, but with fewer menu changes. The strategic management of catering expenditure also follows a different model to LHB Z, and to date annual budgets have followed the previous year’s expenditure, the underlying rationale that efficient processes ensure that quality can be met at minimum cost.

Although the restructuring within the LHB was largely based upon the best practice catering model in one of the major hospitals, it also provided an opportunity to adopt more strategic and commercial approach to catering operations within and beyond the LHB. This involved the otherwise redundant kitchen and chefs being used to develop new nutritionally assessed recipes, with a view to then using the catering facility on a commercial basis to supply other LHBs and public sector bodies. This development work has been extended to the supply chain, the catering services manager working in collaboration with a Welsh SME to establish whether their product can be provided to the correct nutritional standards, organoleptic qualities such as taste, sight and smell, portion size and quantity for the NHS and whether the cost can be reduced, for instance by altering the packaging. The creative use of the ability for LHBs to purchase off contract is thereby enabling supply chain

innovation.

The use of volunteers within this LHB has been developed and directed towards assessing performance, with volunteers spending time talking to patients to get feedback as part of the FOC audit. Responses given to the volunteers are reported to have demonstrated slightly lower levels of patient satisfaction than those given to nursing staff, and have been viewed as a more realistic and helpful basis from which to work on improving the patient experience.

Future plans, currently under trial, are to introduce a professional style laminated and printed seasonal menu, which has fewer changes, but more choice. The menu

169 cards will be available permanently at the bedside so that patients can think about food choices in advance, but also to enable patients, relatives and carers to engage with nutritional care through the food choices on offer.

5.3.1.3 Improving Patient Experience within LHBs

Despite differing internal structures, both LHBs have demonstrated innovations that are considered to have driven improvements in demand efficiency through

addressing the quality of the food service, catering operations and patient experience in a holistic manner.

Experiences of these two LHBs have had a significant influence on the model being recommended as best practice through the ‘All Wales’ Catering Group. The

benefits of the model food service being recommended were cited by an informant as “good communication with nurses; we can sort out minor problems straight away.

If there’s a problem then we produce action plans, so there is no misconception of who is either at fault or has something to do as corrective action.”

In addition to these two case studies, examples of innovations shared as part of the WAO Good Practice Exchange demonstrate how specific needs are being dealt with within care, reflecting dignity and respect for differentiated needs. The introduction of a milkshake round in Cardiff and Vale LHB is one good example which also demonstrates the 1000 Lives methodology in practice. A local audit of a ward with predominantly elderly patients revealed that they were at particular risk of

malnutrition and consuming 70%-80% of their nutritional requirements. Although 70% of the patients required nutritional support through oral supplements, only 40%

were consumed. A pilot was undertaken to replace the fortified drinks with

milkshakes, increasing the uptake from 32% to 60%. Following further refinement, which included addressing technical issues relating to nutrition, promoting

awareness and collaborating on how to integrate the round into ward schedules, the scheme was tested further. 70% of the patients offered the milkshake took it in place of the alternative fortified supplement, and 64% finished the whole drink.

Further adapted to include a biscuit, the development team were able to show that patients were receiving up to 20% more calorific intake. The success of the

implementation on one ward was shared with two other elderly wards within the LHB (C&V, 2011).

From catering practice, the development of a texture modified menu for patients who require puree meals in Cwm Taf LHB was extended across the LHB in 2011.

The need was identified as traditionally puree meals were perceived to be of poor

170 nutritional quality and unpalatable appearance. The meals are freshly prepared by chefs, frozen and delivered to hospital sites. Patients have a choice of three meals a day and to assist with communication can choose from pictorial menus. The meals are presented in a form that is as close as possible to a standard hospital meal rather than as a response to special needs. The range of items for the menu continues to be expanded (CTLHB, 2011).

In addition to different models of food service and meal production technologies, menus and recipes within LHBs were not always co-ordinated, nor nutritionally assessed. An informant in one LHB remarked that when they looked at

standardising and assessing their recipes, they found 23 different recipes were being used for porridge, each with their own ‘special’ ingredient. Standardisation and nutritional assessment therefore reduced the number of ingredients, and enabled co-ordination with the central procurement contracts.