Protected Mealtimes - Guideline For

Publication: 26/03/2013  
Next review: 28/07/2025  
Clinical Guideline
CURRENT 
ID: 3280 
Supported by: LTHT Nutrition and Hydration Care Steering Group
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2022  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline For Mealtimes (Protected and Assisted)

Summary of Guideline

The Leeds Teaching Hospitals NHS Trust is committed to providing high quality nutritional care to patients in its hospitals and recognises that mealtimes are an essential part of the delivery of safe and effective nutritional care which can improve health outcomes as well as the patient experience. The purpose of this Mealtime Guideline is to support the provision of optimal nutritional care and treatment for patients by ensuring that mealtimes are protected from unnecessary and avoidable interruptions, by providing an environment conducive to eating and by ensuring staff provide patients with support and assistance to eat and drink. The Mealtime Guideline provides a framework for mealtimes (and the time shortly before and after it) that places the patient, and their nutritional care, at the centre of the mealtime experience. 

This Mealtime Guideline protects mealtimes from unnecessary and avoidable interruptions. Wherever possible non-essential clinical and non-clinical activity (e.g. ward rounds, MDT meetings, drug rounds - unless drug required to be taken with meals, cleaning, therapy, ward staff breaks) should cease at mealtimes to provide an environment conducive to eating and ensure that the nutrition and hydration care of patients is not compromised. It is recognised that certain essential clinical tests may need to take place, on occasion, during mealtime and this will be a clinical decision. The mealtime guideline should never prevent emergency or critical care from taking place i.e., care that could not be reasonably delayed due to risks of harm to the patient. For patients who are nil by mouth, X-rays or tests etc. may take place over mealtimes as this will not impact on their nutritional intake.

Mealtime periods (including a short time prior to meals to prepare patients and staff and post meals to assess food intake etc):
Adult services:

  1. Breakfast: Time can vary between wards generally 07:30 - 08:30
  2. Lunchtime: 12:15 - 1:15 pm 
  3. Evening Meal: 5:15 - 6:15 pm

Children’s services:

  1. Breakfast: Time can vary between wards generally 07:30 - 08:30
  2. Lunchtime: 12:15 - 1:15 pm 
  3. Evening Meal: 4:45 - 5:45 pm

Signs (Appendix 1) displayed outside and/or inside the ward will be used to inform staff and relatives of the mealtime period.
During each mealtime, the following measures should be in place on the ward to reduce patient interruptions and enable ward staff to prioritise nutritional care:

  1. Patients, and their eating area, are prepared adequately before the meal takes place. All patients should be seated in a comfortable position for eating (as far as possible), ideally in a chair, unless this is clinically contraindicated. They should be encouraged and/or assisted to undertake hand hygiene and to use the toilet (if required) before their meal.
  2. A named nursing mealtime co-ordinator should be identified at the beginning of each shift. They should link with the housekeeping team and oversee the delivery of mealtime nutritional care (including the identification of other ward staff roles for the mealtime) for the ward or clinical area. They should also ensure patients receive the appropriate food and drink according to their dietary needs, texture modification etc. A recognisable element such as an armband or badge would be useful to recognise this role.
  3. A red tray will be used to identify patients ‘at risk’ of malnutrition.  Ward staff will make food and fluid a priority for these patients during mealtimes by encouraging and assisting with eating, monitoring how much food is eaten by patients and completing food record charts.
  4. Relatives, carers and visitors are made aware of the benefits of the ward’s protected and assisted mealtimes approach and should be welcomed to encourage or assist their friend or family member where appropriate.
  5. Food and drink is placed within easy reach of the patient, and patients are provided with prompting, encouragement or assistance to eat and drink, appropriate to their needs.
  6. Interruptions e.g., ward rounds, drug rounds, assessments and/or interventions by healthcare staff, cleaning, documentation and therapy will only occur (during mealtimes) when clinically appropriate.
  7. Departments out-with the ward will avoid ringing wards during mealtimes where possible.

Aims

  1. To promote an environment and culture that recognises the central importance of mealtimes in providing a nutritious diet for our patients, as an integral part of their care and treatment
  2. To provide consistent individualised high-quality care in provision of nutrition at mealtimes for patients of Leeds Teaching Hospitals NHS Trust
  3. To improve the “mealtime experience” for patients by enabling them to eat their meals without non-urgent interruption in an environment conducive to eating

Objectives

  1. To focus ward housekeeping and ward teams on the service and provision of food and drink for patients
  2. To create a quiet and relaxed atmosphere in which patients are given time and support to enjoy meals
  3. To limit ward activity, both clinical and non-clinical (e.g., ward rounds, diagnostic tests and observations, patient ward moves) to those that are ‘essential’ to undertake during the mealtime periods
  4. To ensure patient mealtimes are free from avoidable and unnecessary interruptions
  5. To ensure patients are adequately prepared for and supported during mealtimes
  6. To recognise and support the social aspects of eating
  7. To provide an environment that is welcoming, clean and tidy for eating.
  8. To improve the nutrition and hydration care of patients by supporting them at mealtimes with the consumption of food and drink

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Background

The National Survey of Malnutrition and Nutritional Care in Adults (2021) reported that 38% (of the hospitals surveyed) of adult patients admitted to hospitals in the UK are at risk of malnutrition, (BAPEN, 2021). For many their hospital admission exacerbates the condition with many patients ‘at risk’ of malnutrition and dehydration during their stay (BAPEN 2018).  If an individual is unable to achieve an adequate nutritional intake and becomes malnourished, they are more susceptible to disease. This can cause further deterioration, impairing their recovery.

In the acute hospital setting a number of factors (e.g., disease-related malnutrition, side-effects of treatment, missed meals, nil by mouth for procedures) contribute to patients decreased nutritional intake, and subsequent malnutrition risk which in turn is linked with reduced quality of life, poorer health outcomes (e.g. increased infections, poor wound healing, mortality) and length of hospital stay (BAPEN 2018, BDA 2019, Department of Health and Social Care 2020). In addition, certain groups of patients, in particular children and older adults, have specific dietary and/or eating/feeding preferences or requirements, that need to be met as part of their nutritional care to prevent malnutrition and to aid recovery. 
The ward environment, presentation of food and the timing and content of meals are important elements in encouraging patients to eat well. The importance of mealtimes needs to be emphasised and ward-based staff given the opportunity to focus on the nutritional care needs of patients at mealtimes. Positive and encouraging behaviour when handling and serving food provides invaluable support which is instrumental in persuading many unwell and anxious people to eat. This important input from food service staff should be complemented by the same positive attitude to the food and beverage services from nursing and other clinical staff (BDA, 2019).
In 2021 the Malnutrition Task Force for Eating and Drinking in Later Life stated ‘Of those who needed help with eating, more than one in three (38%) reported that they only sometimes received help with eating from staff or did not receive enough help from staff’ again highlighting the importance of freeing up staff at mealtimes, allowing assistance to patients as needed.
The Protected Mealtimes Initiative (PMI) was an initiative of the National Better Hospital Food Programme, supported by NHS Estates, Hospital Caterers Association and Royal College of Nursing (the latter two providing a policy template in 2004). It is now well documented and integral to best practice guidelines and standards (CQC 2021, NHS England accessed 2022, Department of Health and Social Care 2020) and has expanded to include the importance of assisting patients with their meals.
In 2020 the Report of the Independent Review of NHS Hospital Food stated:
 ‘What good looks like: At mealtimes, all ward activity is focused on the meal service with extra assistance where required to support physical, social and medical barriers, while retaining dignity in eating, for example, dental issues, swallowing problems, dexterity, physical difficulties, such as opening packaging or using cutlery, the time it takes to eat, confusion’.

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 Management

  1. In order to maximise the benefits to patients of the mealtime experience, ward staff are required to prepare themselves, the environment and their patients during the 15 - 30 minutes prior to the service of food
  2. Patients should be able to eat their food in a relaxed environment, at their own pace and rest afterwards. Thus, during the mealtime period all nonessential ward-based activities (where clinically appropriate) should stop.
  3. Ward-housekeeping and ward teams will serve food and give assistance and support to patients, respectively.
  4. Patient's clinical needs are a priority and protected and assisted mealtimes will not prevent treatments, procedures or transfers from being carried out where deemed a clinical priority
  5. Where there are unavoidable interruptions to patient mealtimes such as scheduled investigations these will be anticipated, and alternative meal/food arrangements made to ensure that the nutrition and hydration care of the patient is not compromised.
  6. Where a patient misses a meal due to unforeseen circumstances, the nursing team will ensure an alternative is provided. A ‘Missed Meal Menu’ is available for this purpose Patient Catering, Menus (leedsth.nhs.uk)
  7. If, under exceptional circumstances, a meal is not provided then this will be documented in the patient’s record.
  8. Staff from departments out with the ward should avoid ringing the ward at mealtimes where possible
  9. Senior Sisters/Charge Nurses are responsible for implementing the protected mealtimes guidelines in their clinical areas and should adopt the following principles/standards in all clinical areas where patients receive food:
    1. A nursing ‘mealtime coordinator’ will be allocated at the start of each shift
    2. 15 - 30 minutes prior to meal service time the coordinator will allocate roles (to support the below) to the ward team
    3. Ward staff will encourage, and where required, assist patients to undertake hand hygiene prior to the service of food
    4. Ward staff will check, where required, that dentures are in place and the patient’s mouth is in the optimum condition in order to eat http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=4435
    5. Ward staff will provide patients with assistance to use the toilet, where required prior to the service of food
    6. Bed tables and eating areas will be cleared (prior to the service of food) of items not conducive to mealtimes e.g., urine bottles and used dressings
    7. Each table will be clean and suitably prepared prior to the service of food and beverages, with appropriate cutlery, crockery and condiments
    8. Consideration will be given to where patients (including provision and encouragement for communal eating) sit to eat their meals, supporting the social aspects of mealtimes whilst respecting the preferences, religious or cultural views of the individual
    9. Patients will be made comfortable prior to the service of meals and will be in an appropriate position ideally in a chair, for eating where possible.
    10. Patients requiring assistance (prompting, encouragement, feeding) with eating will be identified by the nursing team prior to the service of meals. 
    11. Appropriate feeding aids e.g. rimmed plates, adapted cutlery handles, dementia friendly crockery etc will be provided, if required, to support independence as far as possible
    12. Clear signage will be used to inform staff and visitors of the mealtime periods
    13. Food will be served within a comfortable reach
    14. Drinks will be available, within easy reach and in the appropriate drinking vessel e.g., dementia friendly beaker
    15. Assistance, such as removing packaging or with eating and drinking, will be provided to patients, as required
    16. Patients, their relatives, carers and visitors will be made aware of the benefits of the wards protected mealtimes approach and asked not to make telephone enquiries during the mealtime period. They should be referred to the LTHT internet site for further information about visiting during protected mealtimes. http://www.leedsth.nhs.uk/patients-visitors/patient-and-visitor-information/visiting-times/ The presence of carers or family members at mealtimes should reflect the principles of Johns Campaign http://www.goldstandardsframework.org.uk/john-s-campaign-dementia and be negotiated in individual conversations in the best interests of the patient.
    17. Interruptions to mealtimes e.g., from ward rounds, drug rounds, cleaning, documentation and therapy will only occur (during mealtimes) when urgent/clinically unavoidable
    18. Staff directly involved with patients at mealtimes will avoid answering the telephone at mealtimes. 
    19. In line with the LTHT Guideline for the Oral Nutritional Support of Adults (2019), a red tray will be used to identify those patients ‘at risk’ of malnutrition. Ward staff will make food and fluid a priority for these patients during mealtimes by encouraging and assisting with meals, monitoring how much food is eaten by patients and completing food record charts.
    20. Collaborative working and clear communication, specifically handover of dietary requirements and concerns, between catering/facilities staff and ward teams should be embedded and evident.

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Resources

Ward posters and further information can be found here:
Adult Oral Nutritional Support (Including Ward Information & Resources for Protected Mealtimes) - Leeds Teaching Hospitals NHS Trust (leedsth.nhs.uk)

Provenance

Record: 3280
Objective:
Clinical condition:

All

Target patient group: All Inpatients (Adults and Paediatrics)
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Allied Health Professionals
Adapted from:

Evidence base

References and Evidence levels:
BAPEN (2014) Nutrition Screening Surveys in Hospitals in England, 2007 - 2011

BAPEN (2018) Managing malnutrition to improve lives and save money

British Dietetic Association (2019) The Nutrition and Hydration Digest: improving outcomes through food and beverage services.

Hospital Caterers Association and Royal College of Nursing (2004) Sample Protected Mealtimes Policy.

Care Quality Commission (26.11.21) “Regulation 14: Meeting nutritional and hydration needs,” [Online]. Available: https://www.cqc.org.uk/guidance-providers/regulations-enforcement/ regulation-14-meeting-nutritional-hydration-needs.

NHS England (Accessed April 2022) [ Online] ’10 Key Characteristics of good nutrition and hydration care’ https://www.england.nhs.uk/commissioning/nut-hyd/10-key-characteristics/

Department of Health and Social Care (2020) Report of the Independent review of NHS hospital food

Malnutrition Task Force (2021) State of the Nation 2021

The Leeds Teaching Hospitals NHS Trust (2019) Food and Drink Strategy 2019 - 2021

The Leeds Teaching Hospitals NHS Trust, (2022) Guidelines for the Oral Nutritional Support of Adults.
http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=1391

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 2.0

Related information

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Appendix 1

(available at: Mealtimes at LTHT — LTH Web (leedsth.nhs.uk)

Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.