Salford Malnutrition Taskforce Tony Ward Community Dietitian Salford Royal NHS Foundation Trust Salford CCG

Salford Malnutrition Taskforce A multi-agency steering group is working together to reduce the prevalence of preventable malnutrition and dehydration in Salford. Formed 5 years ago under the auspices of the national pilot in partnership with Age UK.

Disease Related Malnutrition (DRM) 10-14% of the 65+ population is at risk of malnutrition, 93% of those at risk of malnutrition are in the community. Dehydration in older adults is associated with hospitalization and higher health and care costs. DRM costs £29.5Billion in the UK.

Greater Manchester cost of sip feeds on FP10 Nov 2016-2017

Residents aged 65 years and over BMI of <20kg/m² in Salford

Task Force Achievements Raising Awareness Fridge magnets, posters, leaflets and Quizzes 2 awareness events Supermarket tours 1425 people reached Impact £300,000 saved in supplements Reduction in malnutrition related hospital admissions 50% increase in reporting underweight BMI Dash board created to malnutrition screening

Paperweight Armband, a simple, non-clinical tool to identify malnutrition and has promoted its use across the community in Salford. Signpost early identification of malnutrition, empowered non-clinical staff and volunteers to talk to older people about nutrition and raised awareness of how to eat well in later life Adapted from mid arm https://www.ageuk.org.uk/salford/about-us/improving-nutrition-and-hydration/the-paperweight-armband/

E-Learning Package An e-learning package Covering malnutrition and dysphagia. Designed initially for hospital staff, Adapted to make it accessible for community staff, Care home staff, volunteers and carers. http://paperweightarmband.org.uk/

Innovation Bids EAU (Emergency Admission unit) Project Kafoodle Speech and Language – Dysphagia Champions

I hope you all in enjoy the day Thank you

EAU Innovation Project Nutritional Action Plans and Discharge

Why did we set up the project? People are living longer The longer people live, the more at risk of malnutrition they are Weight loss is not a normal part of ageing Innovation project was set up to support these individuals and look at what type of individuals we were engaging with.

Care homes have the opportunity to support the message that weight loss is not a normal part of aging Care homes are a unique place to identify people who are at risk, put in a plan, support them and help them.

Nutritional Action plans When patients were discharged from hospital to any setting, appropriate nutritional action plans were sent out which were personalised to each patient Have you received these? We hope so! Where did you keep them and why do you keep them there?

Any Questions?

Kafoodle Innovation Project - Digitising Menus Revolutionising Nutrition in Health Care Tony Ward – Senior Dietitian Salford Royal NHS Foundation Trust

Salford CCG innovation bid: 1 year project Originally across 4 nursing homes Total 162 beds The problem: High referrals to dietetics High usage of nutritional supplements - £74114.06/year 2017 Hospital admissions from Care homes – total: 631 in 2018, average 53/month. CQC inadequate homes 2nd highest in UK The Bid

Driver diagram

Ensure appropriate prescribing of supplements. Project aims: To assess baseline data on nutritional status of care residences in 4 nursing homes. Reduce dietetic high ‘MUST’ referrals by >10% in 9 months in 4 care homes by optimising the menu. Ensure appropriate prescribing of supplements. Ensure the nutritional values of meals are appropriate and adequate, while increasing efficiency in documentation, budgeting and meal planning. The Project

All can have an impact on the quality of life of a resident The reality: Different consistencies (IDDSI) and allergens. Managing food wastage. Ensuring nutritionally complete. Adapting meals to maintain a healthy weight or controlling diabetes. Catering for different choices/culture difference/religious beliefs. Catering for dementia. Managing stock and incorrect deliveries. Managing budgets. All can have an impact on the quality of life of a resident The Reality

Safeguarding residents and the care homes Care home recipes were not documented Allergens were not clearly documented Nutritional content of meals was not recorded There was confusion over food fortification No consistency with allergens/nutrition/budget due to constantly changing recipes No official guidelines for consistencies for individualised recipes and no guidelines to check if correct (IDDSI) Over estimation of portions to ensure availability of choice is increasing wastage and cost Premade meals v homemade meal – choice, cost, adaptability Safeguarding

Recipes – are costed per portion and per batch. Kafoodle Kitchen All recipes will be recorded, analysed and costed - these can be printed off as a recipe card. Recipes – are costed per portion and per batch. Nutritional and allergen breakdown of the recipes. Instructions can be recorded on the recipes to ensure they are made to the correct consistencies. Provides a complete bank of recipes which can be organised by meal time for consistency. Guidance of constancies of meals Kafoodle Meal planning Build a meal plan that meets the nutritional requirements of all diners Lets you know if you are in budget. Alerts if a residents’ needs are not met. Develop and save seasonal meal cycles, or those for a special day (Christmas etc.) How can Kafoodle help?

The Kafoodle Home Screen

Manage Ingredients

Store recipes

Create recipe cards

Meal Plan

With the Kafoodle software care homes are able to: Improve the transparency of their nutrition and budgeting Meet CQC criteria reg 14 Meet food allergy legislation Save time and money Improve their service and reputation Kafoodle

ePMO – electronic Personalised Meal Ordering Record and monitor the intake of both food and beverages Save time Filter dishes by allergens, nutrition, medical condition or preference Track meals from order to delivery Set meal ordering times to as little as every half hour Record food temperature at various stages of production Refer to red, amber and green alerts Capture data and feedback for menu development Connect to live stock levels Residents can view images of the dishes they are selecting ePMO

Dietitians remote input Intake review Meal plans can be changed Speech and Language Therapy Change consistencies real time IDDSI The future

I will now take any questions? Thank you I will now take any questions?

Dysphagia Care Home Champions Innovation Susanna Cox – Speech and Language Therapist April 2019 Develop dysphagia care home champions. Project would run for 12 months to enable the champions to become established

Why? Changing population Studies have shown that up to 60% of residents in care homes will have difficulties eating and drinking Poor access to staff training and education affecting quality of management Consequence can be patients are fed with unsafe diet and fluids increasing risk of choking, aspiration pneumonia and possible admission to hospital Increased focus on safe swallowing from CQC Increasing population with more older people. Increased fraility and increase in people living with long term conditions. We are a small team in Salford and we want to work alongside care homes to skill up staff to manage dysphagia jointly. Eating and drinking are an important part of life, both physically and socially. Where swallowing is difficult, people may become isolated, under-nourished and frail.

Focus for Dysphagia Champions Introduction and establishment of IDDSI Establishment and confidence of supporting patients who are Risk Feeding Develop a risk assessment and support package for feeding residents with dysphagia In the UK, we need to be fully IDDSI compliant by April 2019! A risk feeding protocol has been developed within Salford (acute and community) providing a framework to support patients who choose to feed at risk of aspiration. Greater awareness of this protocol and the process for completing the protocol is needed within care homes. If completed correctly and care agencies are confident with using the protocol then this will lead to improved quality of life for patients, improved end of life care, supporting patients in decision making regarding risk feeding and reduced hospital admissions. 3. To develop a risk assessment and support package for care homes to use with families who choose to feed residents with dysphagia. A recent safeguarding incident highlighted that there is no such strategy in place and the risk of aspiration and choking is greater with this population. Families who feed their relatives who have dysphagia would benefit from support. This would reduce distress; empower families in caring for and supporting their loved ones, particularly towards end of life

The importance of safe eating and drinking is becoming more high profile and more of a priority than ever before. We are getting an increasing number of requests to attend Coroner’s Court for patients with swallowing problems who have choked and died, or had an aspiration pneumonia and died. These are some headlines from Coroner’s inquests around the world.

Case Study – Jane Olive Parker 1. What things can you identify that went wrong in this resident’s case? 2. What can we learn from this? We’re going to take a look at a local article from the Manchester Evening News about a lady in a care home and discuss it. Not an example from Salford, but it could just as easily be.

“She should have been on a special diet of soft and pureed food…” “she should have what was known as a 'stage three diet' - consisting only of semi-solid, soft or pureed food that could easily be digested” “…a decision was made not to assess her directly but rely on a previous care plan” “No new care plan was put in place and the transferred plan from Millbrook omitted any previous choking episodes, wrongly stating she could eat 'stage four foods” “Served in her bedroom rather than in the dining area, she chose chicken was left unsupervised to eat”

International Dysphagia Diet Standardisation Initiative IDDSI – What is it? International Dysphagia Diet Standardisation Initiative Most of you will have heard of IDDSI by now! We have gone round every care home in Salford explaining what IDDSI is and the changes it involves. The previous article highlights the need for a common language and more robust way of classifying dysphagia. A global initiative to improve the lives of over 590 million people worldwide living with dysphagia International initiative to provide safer descriptions of modified diet and fluids It is used for individuals with dysphagia of all ages, in all care settings, and for all cultures. The IDDSI framework consists of 8 levels (0-7). Levels are identified by text labels, numbers, and colour codes to improve safety and identification When a person’s swallowing has been assessed they will be given specific recommendations based on the IDDSI model.

Risk feeding protocol Poor awareness in care homes with risk feeding Seen as an easy option by care homes May use terminology inappropriately Protocol not communicated and resident given inappropriate foods/fluids Over reliance on SLT and inappropriate referrals to the service Advanced Care Planning may be missed Unnecessary hospital admissions Protocol successfully implemented in Salford (across acute and community settings) Framework to support people feeding at risk Alert on EPR in place Receive duplicate referrals for patients showing signs of difficulty swallowing but have protocol in place – needs greater understanding when appropriate to refer these patients back to the service Care homes want the protocol in place for example, if patient reports that not keen on soft diet e.g. patient was insisting on having ice cream so I did a risk assessment and she has been having ice cream (did not realise should have risk feeding discussions) Advanced Care Planning should be triggered when a risk feeding document is put into place – so, what should be done if patient develops chest infection/ pneumonia? Should the patient be admitted into hospital in this situation or treated within the care home? The champions training will cover how to assist / feed these patients as safely as possible, as well as looking at if the risk feeding document needs to be reviewed – for example if capacity changes or if someone develops new medical history that might impact on their swallowing.

Benefits if correctly implemented Supporting residents in decision making regarding risk feeding Improved Quality of Life for residents Reduce unnecessary hospital admissions Improved End of Life Care Reduced inappropriate referrals to speech and language therapy

Our proposal Identify 12 care homes based on residents with highest numbers prescribed thickener and highest referrers to SLT service Identify 2 senior members of staff for each care home to be dysphagia care homes champions Develop training package and resources Roll out to identified care homes and evaluate Training package will include the SLT spending time in the Care Home, providing the dysphagia champions with active learning tasks and competencies to achieve. It will cover learning about swallowing, assessment, appropriate referrals to SALT. We will look at menus and how meals comply with the IDDSI standards. Making thickened fluids, how to safely feed. We will also look at documentation – how recommendations are visible and communicated to all. How we are documenting in care plans and food and fluid charts. The homes with the highest numbers of residents on thickened fluids are Barton brook, Labernum Court, Arden Court, Pendleton Court, The Broughtons, The Fountains, Thornton Lodge, The Willows, Bluebell Court, Kenyon Lodge, Newlands, Walkden Manor, Cherry Trees, Broughton House, Abbeydale and The Beenstock. If you’re not on this list, it doesn’t mean you can’t take part!

Any Questions? Adult Community SALT team - Tel: 0161 206 2333 We take phone referrals / answer queries on the above number between 1-3.30pm every week day susanna.cox@srft.nhs.uk

Measuring success Baseline number of hospital admissions from care homes with risk feeding protocol in place and repeat at end of project Number of care homes identified and numbers of staff trained Qualitative measure of staff confidence in understanding and managing dysphagia and understanding of risk feeding protocol – completed at baseline and at end of project No of staff who have accessed Malnutrition and Swallowing Difficulties e-Learning

Measuring success All care homes will have written information and resources for relatives Evidence of paperwork and pathways in care plans –risk feeding, risk assessment for relatives feeding residents with dysphagia and discussions re advanced care planning Evidence of documentation in care plans/food and fluid charts with IDDSI descriptions for patients with dysphagia All care home staff are able to answer questions relevant to IDDSI descriptors and risk feeding when asked (through spot checks, questionnaires and interviews)

Maintaining success Resource pack available for additional individual care homes requiring training for dysphagia champions Community SLT team able to provide training to individual additional care homes within current staffing resources once project has finished Able to provide ongoing dysphagia champion link meetings on biannual basis to all trained champions for updates once project has finished