Public Accounts Committee

PAC(4)-06-11 – Paper 3


Wales Audit Office report on Hospital Catering & Nutrition




1. The Welsh Government welcomes the Auditor General’s report on Hospital Catering and Patient Nutrition. It is committed to addressing the issues identified by the report to improve services and patient experience.

2. This paper provides the Committee with an overview of the work that has been undertaken to improve hospital catering and patient nutrition. It also outlines current and future developments. The Welsh Government recognises that although catering arrangements and nutritional care provided to patients in Welsh hospitals have improved, good practice needs to be uniformly implemented so that all patients’ nutritional needs are met.

3. Responsibility for delivering the Auditor General’s recommendations is shared between the Welsh Government, the Local Health Boards and Velindre NHS Trust.



4. In November 2007, the then Minister for Health and Social Services established the Empowering Ward Sister/Charge Nurse Task and Finish Group.  The report which followed, Free to Lead Free to Care (WAG 2008), made 35 recommendations. These included the development of an All Wales Fundamentals of Care Audit Tool, the development of an All Wales Nutrition Care Pathway and the development of an All Wales Food Record Chart.


5. In 2009 the All Wales Nutrition Care Pathway was introduced across all wards in every hospital in Wales.  The Care Pathway assists nurses in the decision making process associated with the nutritional screening of every patient on admission and the nutritional care required throughout their hospital stay.  It is supported by the new All Wales Food Record Chart and the revised Daily and Weekly Intake and Output Charts, with accompanying posters giving pictorial illustrations of various portion sizes. These charts and posters enable the accurate, standardised recording of patients food and drink intake across NHS Wales, supporting the identification, monitoring and treatment of nutritionally at risk patients.


6. These developments were underpinned by a Nutrition Awareness Campaign for staff delivered by RCN Wales which aimed to raise the importance of food and hydration to the same level as that given to medication.


7. In 2010 revised Healthcare Standards for Wales, ‘Doing Well Doing Better: Standards for Health Services in Wales’, were published. The new standard for hospital food, Standard 14, and the accompanying guidance strengthened the requirements for meeting patients’ nutritional needs and the importance of implementing the All Wales Nutrition Care Pathway.


8. Since 2002 the NHS Wales Shared Services Partnership – Facilities Services (NHS-SSP-FS), formerly Welsh Health Estates, has maintained a database of performance information based on annual Local Health Board and Trust returns. This includes information on hospital catering services as well as other issues such as cleaning.  This database is referred to as the Estates and Facilities Performance Management System (EFPMS). In relation to catering EFPMS can assist health bodies to improve performance in areas such as food wastage and catering costs. It also provides the Welsh Government with a better understanding of NHS performance including the provision of hospital catering.  


Auditor General’s Findings


9.  The Auditor General’s report concludes that catering arrangements and nutritional care have generally improved since the Audit Commission in Wales study in 2002, and that patient satisfaction remains high. However, it also concludes that more still needs to be done to ensure recognised good practice is more widely implemented, particularly in relation to nutritional screening and care planning, and to ensure that food waste is minimised. The report raises four broad issues in relation to the provision of hospital catering and patient nutrition:


i. Patients are typically screened for nutritional problems but the quality of nutritional screening can be improved (WAO report pages 21-27).


ii. Most hospitals provide an appropriate choice of meals and patients are generally satisfied with the food they receive, but the nutritional assessment of menus and patients’ mealtime experiences need to improve (WAO report pages 28-35).


iii. A clearer management focus on the costs of catering services is needed to better understand the variations that exist across NHS organisations and to reduce food wastage, which remains unacceptably high on many wards (WAO report pages 36-46).


iv. More work is needed to develop clearer national and local planning frameworks for planning and delivering catering services, and ensuring that these are informed by the views of patients (WAO report pages 47-52).


Ensuring patients nutritional needs are met

Progress on WAO recommendations 1a, 1b, 1c, 1d, 1e, 2a, 2b, 3a, 3b, 3c


10. To ensure that all ward staff understand how to fully implement the All Wales Nutrition Care Pathway and complete the All Wales Food Record Chart, an E-learning package was introduced in September 2011.  The full implementation of the All Wales Nutrition Care Pathway will address many of the issues raised in the audit report. The Care Pathway requires all patients to be nutritionally screened on admission. The screening will identify all patients who have nutritional problems, or who are at risk of developing them, and activate an appropriate care plan, evaluation and monitoring process. All ward based staff are required to complete the e-learning training package in the next 12 months and new staff will have to complete it within 12 months of appointment.


11. In 2011 the Free to Lead Free to Care - Post Implementation Group was established to undertake specific projects that support improvements in patient care. This includes addressing issues identified in Fundamentals of Care Audits and national reports such as the Older People’s Commissioner for Wales report ‘Dignified Care?’ (2011). A working group has been established to review and standardise nursing documentation across Wales, thus ensuring a consistent approach to nutritional screening and care planning.


12. The implementation of the All Wales Nutrition Care Pathway and the compliance with the training requirement is monitored through the Fundamentals of Care Audit Tool. Since 2009 NHS organisations are required to undertake a full audit of all their hospital wards/departments on an annual basis and submit the results to the Chief Nursing Officer/Nurse Director for Wales. The electronic system underpinning the audit tool can analyse and generate reports from the data entered at ward level. It also enables each ward to develop action plans to address identified issues causing concern as well as building on areas of good practice.  The 2010 All Wales Fundamentals of Care audit showed that since 2009 all Health Boards/Trusts have improved their overall score for the Eating and Drinking standard, from both the operational and user perspective. For example Cardiff and the Vale have improved on their operational score in 2009 of 75% to 90.8% in 2010 and their user perspective score from 79.1% to 91.7% respectively.


13. Five of the eight NHS bodies specifically report that their local Wales Audit Office reports are being used as a key driver for improvements in nutrition and catering.  All NHS bodies state that they follow the Care Pathway and that patient care planning is based on the outcome of nutritional screening. They are addressing any issues with poor compliance to the Care Pathway. Each Health Board/Trust has appointed a co-ordinator to lead, monitor and feedback on the implementation of the e-learning training on the Care Pathway, ensuring that all ward based staff receive the training within 12 months.


14. Building on the All Wales Care Pathway, All Wales Nutrition and Catering Standards for Food and Fluid Provision for Hospital Inpatients were introduced in October 2011 and are being phased in for all hospitals. They set nutrient and food based standards for meals, snacks and fluid. A group of dietitians and caterers has been established to develop a national database of nutritionally analysed menus and recipes that comply with the Standards.


Improving Patients’ mealtime experience

Progress on WAO recommendations 3a, 3b, 3c


15. All NHS bodies have, or are in the process of, reviewing menus and arrangements for ordering and serving food to ensure that they provide appropriate choices for patients’ dietary and cultural needs and meet the new All Wales Nutrition and Catering Standards for Food and Fluid Provision for Hospital Inpatients. All NHS bodies also report reviewing practices at ward level, to make sure that staff prepare the ward environment so that it encourages patients to eat and that patients are helped to get ready for their meals, including being able to wash their hands before the meal is served. The majority have utilised patient feedback to inform changes in practice and have identified a specific member of the ward team to actively promote and implement new practices.


16. All NHS bodies indicate that the majority of wards operate protected mealtime policy.  They flagged complacency as an issue and it is recognised that there is still work to do with wider, non nursing, disciplines in order to make protected mealtimes the norm. For example working with doctors to discourage non urgent clinical activity during mealtimes.


Controlling the cost of catering service

Progress on WAO recommendations 4a, 4b, 5a, 5b, 5c, 6a, 6b, 6c, 6d, 7a, 7b


17. Work is underway, in partnership with Aneurin Bevan Local Health Board, to develop a model for costing patient and non-patient catering services to enable meaningful comparison of hospital catering costs across Wales. This will be complete by end of December 2011 and will build on the good practice model already developed by the Board, which currently identifies costs for patient and non-patient catering services. At the same time NHS-SSP-FS are liaising with Local Health Boards and Velindre NHS Trust to obtain detailed information on costing models they currently use to inform the EFPMS data.


18. Over half of the NHS bodies are implementing computerised catering information systems and the others are currently reviewing their practices. All NHS bodies report that a large percentage of products are purchased through all Wales NHS Shared Services Partnership-Procurement Services, formerly Welsh Health Supplies contracts. The majority of NHS bodies have some standardised costed recipes in place but not all of them have established daily food and beverage allowances for patients. All NHS bodies recognise the need to address this and plan to do so as they adapt menus to comply with the new All Wales Nutrition and Catering Standards for Food and Fluid Provision for Hospital Inpatients.  This will be supported by the central development of a database of recipes and menus. All NHS Bodies have begun to address the recommendations relating to non patient catering services and the costing model will support this work.


19. The Audit report recommends the setting of targets for food wastage. The Welsh Government is currently working with Defra, Scottish Government, Northern Ireland and the Government sponsored body WRAP (Waste and Resources Action Programme) to develop a voluntary agreement for the Hospitality Sector, including hospital catering, which includes a waste reduction target. Most NHS Bodies report that they are identifying the reasons for wastage, and that they are using this information to reduce waste. Most organisations note an improvement in the development of collective responsibility for controlling waste with action taken at local level. 


Effective service planning and monitoring

Progress on WAO recommendations 8a, 8b, 8c, 9a, 9b, 9c, 10a, 10b, 11a, 11b, 11c


20. A ‘Hospital Nutrition and Catering Framework’ website has been developed to bring together all the policy guidance that covers hospital catering and patient nutrition. It is part of ‘Health in Wales’, the organisational portal of NHS Wales, formally Health of Wales Information System (HOWIS).  The ‘Framework’ website will shortly be made available on every ward in every hospital via the recently introduced All Wales Nursing Information Zone.


21. All NHS bodies report having, or developing, local structures and multi disciplinary teams to ensure up to date plans and procedures are in place for implementing national policy requirements. Executive leads at Director level have been identified within each NHS body and all Boards are informed about catering and nutrition issues by an annual report, as a minimum.


22. All NHS bodies identify nutritionally at risk patients by nutritional screening. Further work needs to be carried out to ensure that this information is shared and used to determine the likely impact on catering and nutrition services.  Compliance with the use of a nutritional screening tool is collected as part of the Fundamentals of Care Audit which is undertaken on every ward throughout Wales.


23. Six of the eight NHS bodies reported undertaking patient satisfaction surveys on catering services and all are engaging patients via a range of mechanisms to identify issues, share findings with ward staff and caterers, and to ultimately improve their catering and nutrition services.


24. This year, as in previous years, NHS-SSP-FS worked with NHS bodies to ensure they understood the data definitions and to improve the robustness of the data submitted. Data for the 2010-2011 EFPMS has been received with reports due for publication in December 2011. The EFPMS data used in the preparation of the reports will be available from the NHS-SSP-FS website. All NHS bodies report using the EFPMS data to some degree.


25. This year, following publication, a feedback session is planned with all NHS bodies to establish how the EFPMS might become a more effective benchmarking tool in raising standards and improving the quality and efficiency of services to patients. NHS-SSP-FS are also collaborating with nursing colleagues in the Welsh Government to ensure coordination between the data collected via the EFPMS system and that collected as part of the Fundamentals of Care audits. This is considered essential to the provision of information on local implementation of national policy objectives.



26. The Welsh Government is committed to improving hospital catering and patient nutrition.  This paper has highlighted a range of action that has already been taken prior to the publication of the Wales Audit Office report as well as significant new developments such as the new All Wales Nutrition and Catering Standards for Food and Fluid Provision for Hospital Inpatients which set nutrient and food based standards for meals, snacks and fluid.

27. Through the use of the Fundamentals of Care Audit Tool, wards across Wales can identify areas of practice and patient experience which need improvement.  This includes the patient’s experience of eating and drinking whilst in hospital.  The 2011 All Wales Fundamentals of Care audit has just commenced and it is anticipated that NHS bodies will continue to make further improvements in this area.

28. The Wales Audit Office report's findings and its recommendations will inform further action.

David Sissling

Director General Health, Social Services and Children
October 2011