The Chief Executive of NHS Ayrshire & Arran and the Chief Officers of the Health and Social Care Partnerships (HSCPs) have ultimate accountability for health and care within the organisation and are thereby accountable for food, fluid and nutritional care.

The Nurse Director, has delegated responsibility for the development, implementation and evaluation of a Food, Fluid and Nutritional Care policy and strategic action plan to the Area Nutritional Steering Group (ANSG). The ANSG with AHP Director as chair, assists the Nurse Director in discharging the role of coordinating related activities on food, fluid and nutritional care across hospital and community settings.

Managers accountable for catering services are responsible for the delivery of a safe, effective and person centred food and beverage service. They will monitor the catering service and make improvements as necessary, ensuring that staff and systems are compliant with food safety legislation. They lead on the implementation, monitoring including:

• Controlling the catering budget and utilizing the NHS Scotland National Procurement contracts for food, beverages and snacks.
• Use a catering management system for recording service user menu choices, use of standard recipes and ingredient control.
• Developing recipes and menus taking into consideration dietetic advice and any required texture modification of food, individuals’ age, culture religion and medical condition.
• Preparing food to approved standards.
• Supporting the delivery of food to wards.
• Maintaining and supervising food hygiene at all times, ensuring compliance with Environmental Health requirements.
• Controlling cost and monitoring waste and customer satisfaction.
• Auditing and developing service delivery.

Leading Allied Health Professionals across Ayrshire and Arran is the Director of AHPs and three AHP Managers based with the Partnerships. The Director of AHPs currently chairs the ANSG meetings.

It is the responsibility of these staff to support and lead AHPs services in the delivery of food, fluid and nutritional care.

The majority of this AHP role will be in relation to Dietetic and Speech and Language services. However other AHPs should be aware of best practice in relation to food, fluid and nutritional care and any implications for day to day health and care practices.

There are three Dietetic and Speech and Language Service Managers based in the North, South and East HSCPs who lead acute and community teams. These managers are integral in leading on food, fluid and nutritional care within each locality area.

Dietitians are the only qualified health professional that assess, diagnose and treat diet and nutrition at an individual and population level. The dietitian will take a lead role in relation to diet and nutrition management plan for individuals, oral and enteral parenteral nutrition for individuals identified as having a therapeutic need and discuss the nature of the intervention with other members of the team. Dietitians also advise on nutritional adequacy of menus, therapeutic adaptations and snacks. They also have a key role in promoting health through promotion of healthy food choices at a population based level.

Dietitians will:

• Undertake a full nutrition assessment upon receipt of a referral for a service user identified at risk of malnutrition through organisational nutritional risk scoring and/or an identified therapeutic need e.g. gluten free diet.
• Recommend a therapeutic dietary care plan/regimen which optimises a service user’s nutritional status and/or alleviates their symptoms. Examples are texture modified diets, energy dense diets / foods, nutritional fortification/supplementation, enteral or parenteral nutrition.
• Communicate recommendations to staff, family and carers who are supporting the service user in both hospital and community settings.
• Contribute to/provide/develop training and resources for all staff who provide nutritional care.
• Are a key member of the hospital based Nutrition Support Team

Speech and Language Therapists (SLTs) have a key role in the identification and management of dysphagia and work closely with other professionals delivering care to patients.

The SLT takes a lead role in the development of a management plan in relation to dysphagia and will discuss the nature of the intervention with the individual (where possible), the multidisciplinary team, carers and the family.

The SLT will:

• Carry out a full clinical bedside swallowing assessment (multiple assessments may be required over time) to allow accurate diagnosis and safe management of the dysphagia. This assessment takes into account the service users cognitive abilities, individual preferences circumstances.
• Recommend a video-fluoroscopic evaluation of swallowing when further information on the anatomy or physiology of the swallow is required to supplement clinical decision-making.
• Document in Electronic Patient Record or SLT paper notes the results of assessment, supervision requirements and the dysphagia management plan.
• Communicate recommendations on the dysphagia management plan to the individual, to the staff, and to carers. Recommendations may include texture modification of diet, consistency modification of fluids, posture, bolus size, pacing and presentation of food/drink and coping strategies. Onward referral may then take place support further assessment around nutritional adequacy and appropriate provision of food and drinks i.e. the Dietitian.
• Contribute to/provide/develop training and resources for all the staff who provide nutritional care.
• Review and reassess the individual with dysphagia as required to ensure intervention continues to be appropriate and valid.
• Provide swallowing rehabilitation where appropriate.
• Liaise with other members of the multi-disciplinary team to ensure the individuals postural, supervision and equipment needs are met.

Medical staff play a co-coordinating role between nutritional and othermedical and surgical treatments. This includes:

• Acknowledging the importance of the involvement of all doctors in food, fluid and nutritional care.
• Developing, fostering and encouraging an awareness of the benefits of appropriate nutritional and hydration management and treatment, before, during and after hospital admission.
• Considering the individual’s mental and physical ability to eat, the integrity of gastrointestinal function including motility, digestion and absorption, the metabolism and excretory function in the context of a diagnosis.
• Prescribing treatment, taking into consideration drug nutrient interactions, surgical needs etc.
• Taking note of nutritional care plan associated with individuals risk score, monitoring nutritional status using clinical information available e.g. weight/BMI, biochemistry, haematology and microbiology results in liaison with the MDT.
• Deciding, in liaison with the multi-disciplinary team, on the optimal approach to each individual’s nutritional and hydration needs and ensuring informed consent.
• Liaising with individual and individual’s relatives e.g. providing a major source of information in respect of all aspects of treatment including food, fluid and nutritional care.
• Leading on ethical decision making in conjunction with the multi-disciplinary team, taking into consideration family and/or carers’ views including interpretation of advance directives.
• Consider food, fluid and nutritional care in plans for discharge and follow up.
• Consider food, fluid and nutritional care information when liaising with GP and primary care and community services colleagues.

The role and remit of the pharmacist is to:

• Provide advice to any enquires in relation to potential food and medication interactions.
• Provide guidance regarding temporarily suspending percutaneous endoscopic gastrostomy (PEG) or nasogastric (NG) feeding to avoid drug interactions.
• Provide advice on alternative preparations or crushing tablets to aid covert administration (if food is involved in the administration process).
• Provide advice on whether or not liquid medications can be thickened or if alternative preparations or routes should be sought.

Senior Charge Nurse / Midwives and Team Leaders have responsibility for the delivery of safe, effective and person centered service user care, and will ensure that all nursing and care staff are compliant with the Food, Fluid and Nutritional Care policy. They will ensure that all nursing / care staff (as appropriate) are competent in the assessment, planning, implementation and evaluation food, fluid and nutritional care and in the provision of appropriate food and drink (where appropriate) to their service user / client group(s). This includes:

• Ensure staff are appropriately inducted, educated and trained around food fluid and nutritional care practices including the inclusion of the MUST Learn-Pro, Food hygiene modules, artificial feeding pump, Dysphagia learn-Pro training in PDPs on an initial and ongoing basis, as appropriate.
• Maintaining an ongoing commitment to delivering optimal food, fluid and nutritional care.
• Support the allocation of a mealtime coordinator within the ward(s) they manage.
• Ensuring there is continuous evaluation and improvement in place in relation to nutritional care from data gathered from results of the ward based measures for food, fluid and nutritional care.
• Ensuring there is a system for service users, relatives, visitors to comment on all aspects of food, fluid and nutritional care.
• Maximizing use of available facilities and options to achieve enjoyable, psychosocially beneficial, nutritionally effective meals and food intake.
• Ensuring systems are in place and co-coordinating a protected mealtime policy at ward level.
• Ensuring system is in place for people to receive nutritional supplements, be assisted where necessary to take these, and for the supplements to be accurately recorded. Discharge supplies provided for home as required.

The role and remit of the Registered/Unregistered Nurse/Midwife/Care staff is to ensure their practice complies with the Food, Fluid and Nutritional Care policy by:

• Providing safe, effective and person centred food, fluid and nutritional care.
• Supporting the Senior Charge Nurse/Midwife/Team Leader and Nutrition Link Nurse/Midwife in the undertaking of nutrition measures using agreed tools and change / improvement methodologies to allow for improvements in food, fluid and nutritional care, including:
  • Helping service users with food and drink choices.
  • Helping people with eating and drinking as appropriate.
  • Monitoring and/or keeping records of food and fluid intake when necessary.
  • Being alert to unsafe feeding and drinking practice.
  • Being alert to any unsafe weighing and measuring equipment and reporting this.
  • Compliance with specialist eating and drinking requirements e.g. dysphagia management.
  • Providing competent safe delivery and monitoring of artificial nutritional support (as appropriate).
  • Delivering enteral and parenteral nutrition competently, closely following standard operating procedures, protocols and guidance, if appropriately trained and educated to do so within their scope of practice.
  • Monitoring enteral and parenteral nutrition including fluid balance, blood/urine glucose, diabetic monitoring charts, and microbiology, if appropriately trained and educated to do so.
  • Undertaking all necessary FFN training for their role, including the MUST, Dysphagia and food hygiene, Fluid Balance Learn-pro modules and pump training within their scope of practice and competency.

The Nutrition Support Team (NST) brings together the expertise of a doctor, nurse, dietitian and pharmacist who have specialist skills in relation to the provision and management of complex artificial nutritional support. Ward based dietitians remain the first point of contact where nutritional concerns exist. The NST supports the general dietetic and nursing teams by providing specialist nutrition nursing, dietetic and pharmacist input and medical liaison, in order to optimise metabolic care of some of the complex people in the hospital, employing the parenteral route when necessary.

For further information on the NST please see the Nutritional Care pages on AthenA.

The NNP coordinates the recommendations of the Nutrition Support Team with regard to general nursing care and specifically:

• Develops and supports the implementation of local artificial nutrition guidelines in relation to nursing practice.
• Provides advanced technical nursing skills and knowledge in relation to artificial nutritional support techniques, e.g. passing nasogastric tubes, changing gastrostomy tubes, care of PEG sites and care of intravenous lines.
• Delivers specific training and supervision of practical nursing care in relation to the above skills for all ward nurse / midwives, medical staff, students, people and carers, as appropriate.
• Contributes to complex nutritional education for all healthcare staff.
• Liaison with other departments, hospital and community staff, including specialist units and other nutrition nurse/midwife practitioners to foster effective relationships, share good practice and continually develop artificial nutritional care locally.
• Liaison with community nurse / midwifes, dietitians, people and carers to co-ordinate the follow-up and continued monitoring of discharged people to continue with complex nutrition at home from a nursing perspective.
• Clinical assessment of service user with regards to artificial nutritional care, including review of reported biochemistry.
• Liaison with other members of the NST and participation in weekly team meetings to discuss complex nutritional issues.
• Provide an advisory role to other healthcare professionals responsible for the nutritional management of people on nursing aspects of nutritional care.
• Advises on and assists in the procurement of equipment.
• Acts as the people advocate with regards to nutritional care including home parenteral feeding.
• Participates in and often leads relevant audit projects e.g. central line sepsis rates.

The role and remit of the Nutrition and Hydration Champion in addition to that of the registered nurse / midwife is to:

• Promote their role and position, in order that all, people, relatives and carers, are aware of whom they are on a ward.
• Keep up to date with the role and ensure that all nursing staff understand and follow the Food, Fluid and Nutritional Care policy.
• In agreement with the Senior Charge Nurse/midwife, undertake food, fluid and nutritional care measures or delegate this responsibility to another member of the nursing team with guidance on how to undertake the task.
• Undertake or support other nursing staff to complete Plan-Do-Study-Act (PDSA) cycles in order that there is continuous food, fluid and nutritional care improvement within the ward area.
• Work closely with the Senior Charge Nurse/midwife to identify and ensure that all nursing staff attend food, fluid and nutritional care training relevant to their role.

The mealtime coordinator is a key requirement of any mealtime process and ensures a mealtime service is delivered effectively and safely. The role ensures all necessary safety and quality arrangements are in place before, during and after meals. The role will:

• Support co-operation between catering/facilities staff and multi-disciplinary team to improve patients mealtime experience.
• Have a thorough understanding of role and responsibilities.
• Clear understanding of mealtime processes and National Nutrition and Hydration polices/guidance.
• Co-ordinate mealtimes, delegating patient assistance as required, escalating any issues with staff numbers to safely assist patients during mealtime.
• Have full overview of patients nutritional/hydration needs, cascading information with other staff to ensure safe mealtime delivery.
• Can identify modified diet levels, can undertake correct testing techniques and cascade information to other staff.
• Escalate any nutrition/hydration concerns, reporting as required on Datix.

All other service / clinical managers will identify where and how their services and practices may impact on the successful delivery of food, fluid and nutritional care, and ensure that processes and staff are compliant with the Food, Fluid and Nutritional Care policy.

All staff must understand their responsibility for food, fluid and nutritional care, and ensure that they are compliant with the Food, Fluid and Nutritional Care policy, access necessary nutrition training and implement associated protocols, procedures and guidelines.

For a variety of reasons, some individuals may require assistance with eating and drinking. To complement the nursing team, volunteers may be recruited as ward mealtime volunteers. Duties may include opening packages, preparation of area, prior to meals, assisting patients in handwashing prior to meal, assisting patient in selecting menu choice. These volunteers receive training that is delivered by healthcare staff. Once placed on a ward, the volunteers also receive on-going support and supervision from the nursing team and their NHS named contact.