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

2. 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.

3. 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.

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

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

8. 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

9. 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

10. 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.

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

12. I hope you all in enjoy the day
Thank you

13. EAU Innovation Project
Nutritional Action Plans and Discharge

14. 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.

18. 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.

19. 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?

20. Any Questions?

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

22. 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 - £ /year 2017
Hospital admissions from Care homes – total: 631 in 2018, average 53/month.
CQC inadequate homes 2nd highest in UK
The Bid

23. Driver diagram

24. 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

25. 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

26. 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

27. 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?

28. The Kafoodle Home Screen

29. Manage Ingredients

30. Store recipes

31. Create recipe cards

32. Meal Plan

33. 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

34. 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

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

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

37. 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

38. 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.

39. 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

40. 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.

41. 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.

42. “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”

43. 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.

44. 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.

45. 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

46. 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!

47. Any Questions? Adult Community SALT team - Tel: 0161 206 2333
We take phone referrals / answer queries on the above number between pm every week day

48. 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

49. 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)

50. 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