1.1 Malnutrition affects bodily functions, leading to health problems, complications after surgery, delayed recovery from illness, impaired ability to carry out activities of daily living, poor quality of life and wellbeing and even early death (Elia, M. 2015).

1.2 Nearly one third of all older people admitted to hospital are at risk of malnutrition and 50% of older people admitted to hospital from care homes were found to be at risk of malnutrition (Russell, C. A. and Elia, M. 2014).

1.3 Mealtimes not only provide patients with adequate nutrition but also provide an opportunity to support the enjoyment of eating and social interaction amongst patients. The role offered within the healing process cannot be underestimated.

1.4 Clinical areas often adopt different approaches to mealtimes; these can vary between wards and from day to day. Additionally, there are a number of environmental factors that may influence whether a patient eats or not.

1.5 Aspects of protected mealtimes such as requiring mealtime assistance, allowing more time to eat, appropriate positioning and timely mealtime assistance have been associated with increased energy and/or protein intakes (Palmer and Huxtable 2015, Young et al, 2016, Young et al, 2013).

1.6 The mealtime guideline (including protected mealtimes and coloured tray guidance) seeks to provide a framework for mealtimes, encouraging safe and effective ways of working, with the patient at the centre of the mealtime experience through appropriate levels to optimise oral intake.

1.7 NICE CG 32 (2017)) states that appropriate support should be provided for patients who are able to eat and drink but are unable to feed themselves. The British Dietetic Association (BDA) Nutrition and Hydration Digest 2023 (3^rd Edition) guidance defines ‘Nutritionally vulnerable’ as either those with normal nutritional requirements but poor appetite and/or unable to eat normal quantities at mealtimes or increased nutritional needs. It states, 'Help with eating and drinking is given to those people identified as vulnerable'. The Trust aims to improve the nutritional intake of patients by providing help and/or extra time to eat using specially designated meal trays indicating the level of assistance required.

1.8 The Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals.

All figures stated above use accepted British Association of Parenteral and Enteral Nutrition (BAPEN), National Institute for Clinical Excellence (NICE), World Health Organisation (WHO) definitions for malnutrition: “Body mass index (BMI) under 20 kg/m², loss of appetite and/or unexplained weight loss”.

These guidelines apply to all staff (including contractors) and volunteers that care for adult patients within Frimley Health Foundation Trust.

2.1 All staff (including contractors) and volunteers, must be aware of the guidelines, understand them and know how to access a copy from the Trust guidelines app or from the voluntary services team.

2.2 All heads of nursing and ward matrons/managers must have a good working knowledge of the guideline and procedure.

2.3 The coloured tray system should be used at all times.

2.4 All staff, therapists, radiographers, medical technicians and other healthcare workers must be aware of the guideline and where appropriate should comply with it.

3.1 Guideline: A formal document adopted by the Trust detailing governing principles or constraining action, setting out overall aims and objectives in a particular area.

3.2 Protected Mealtime:

Protected Mealtimes are periods of time where all non-urgent clinical activity stops on a hospital ward. During these times patients are able to eat without being interrupted and staff are available to offer assistance.

3.3 Red Tray:

A red tray at mealtimes identifies patients who have difficulty feeding independently and need one-to-one help or are at risk of aspiration and need close supervision by trained healthcare staff. The tray should not be removed when the meal is delivered.

3.4 Yellow/Blue Tray:

The use of a yellow tray (blue at Farnham Hospital) at mealtimes identifies patients who can eat independently but where there may be concerns around the patient’s nutritional status or there is a need for some assistance with cutting up food or opening packages. Patients with a yellow/blue tray may need additional time to finish their meal. The tray should not be removed when the meal is delivered.

3.5 Green/Black Tray:

A green (FPH)/black (WPH) tray will be used for patients who are independent with eating and drinking. At Farnham hospital, for patients who can eat independently, meals are put straight onto the table, not on trays.

4.1 To enable patients to eat their meals without unnecessary interruptions.

4.2 To improve the nutritional care of patients by supporting the consumption of food and enhancing the mealtime experience.

4.3 To support ward-based teams in the delivery of food at mealtimes.

4.4 To ensure that food and drinks are provided in an environment conducive to patients being able to consume their food (NHS England, 2019).

4.5 To ensure that staff and volunteers focus their attention on making the mealtime a success.

4.6 To ensure that mealtimes are a key social activity for patients.

4.7 To ensure that patients have an appropriate amount of time to eat their meals.

4.8 To ensure that health and safety is considered and prioritised at mealtimes with regards to appropriate hygiene precautions.

4.9 To ensure that mealtimes are as safe as possible by ensuring patients who can eat, and drink have appropriate food and fluids for their swallow needs, by monitoring patients for swallowing problems and by ensuring any patients who are nil by mouth are not given food or fluids. Patients should also be offered food and drink that meets their dietary needs in terms of allergies, intolerances and cultural needs and preferences.

4.10 To highlight the need to refer to appropriate healthcare professionals where necessary e.g. dietitian or speech and language therapist.

4.11 To ensure that the Trust continues to support National Standards including, but not exclusively, CQC standards on patient nutrition and hydration (CQC, 2023).

4.12 To improve the nutritional intake of patients by providing help and/or extra time to eat by using specially designated meal trays. This will easily identify those patients who need additional support at mealtimes.

The Guideline will provide staff employed by the Trust, its volunteers and its sub-contracted services a structured and organised process to follow to enable patients to eat and enjoy their meals in a therapeutic environment, where all aspects of nutritional support are undertaken, and health and safety is ensured.

5.1 A red tray at mealtimes identifies those patients who:

• have difficulty feeding independently and need one-to-one help.

• are at risk of aspiration and need close supervision by trained healthcare staff.

• nutritional intake of food and fluids is clearly documented on the electronic patient record system.

5.2 The use of yellow/blue trays at mealtimes identifies those patients who can eat independently but where:

• nutritional intake of food and fluids is clearly documented on the electronic patient record system.

• a texture modified diet is required for reasons other than dysphagia, for example those patients with dentition issues.

• concerns about their nutritional intake have been raised by family, carers or healthcare staff.

• there is a need for additional time to eat/need support cutting up food or opening packaging.

The tray colour required for each patient should be clearly documented on the electronic patient record system. This pathway forms part of the nutritional screening,

5.3 Meals on red or yellow/blue trays should not be offered to any other patients. A green (FPH) /black (WPH) tray will be used for patients who are independent with eating and drinking. At Farnham hospital, patients who are independent at mealtimes will have their meals served straight onto the table, not on trays.

5.4 Risk Management

• Under no circumstances should meals on red trays for named patients be offered to any other patient.

• Patients who are designated a red tray need assistance to feed.

• Some patients will require assistance to feed from a mobility or encouragement perspective and mealtime assistant volunteers are able to assist these patients.

• Some patients may require a red tray because they have swallowing difficulties. Volunteers must not feed any patients who have swallowing difficulties. Volunteers must always ask the nurse looking after the patient if the patient has swallowing difficulties. There may also be signage behind the back of the bed indicating if the patient requires modified consistency food or fluids (See Appendices 3 and 4) which indicates swallowing difficulties.

• Patients with swallowing difficulties must be monitored at all times.

• Non-compliance with these guidelines must be reported via the incident reporting system.

• Hand hygiene must be adhered to in order to reduce the risk of transferring organisms to patients and prevent healthcare associated infections.

6.1 Ward Manager/Nurse in Charge (NIC)

The ward manager or NIC will:

• facilitate Protected Mealtimes - times will vary from ward to ward. The NIC has the authority to reschedule ward activity ensuring minimal disruption to patients.

• ensure whenever possible, that sufficient staff are available at mealtimes and to arrange ward staff breaks either before or after patient mealtimes.

• be aware of any escalation guidelines with regards to getting additional help at mealtimes if required.

• ensure that sufficient staff are available to assist all patients identified as needing a red or yellow/blue tray.

• encourage relatives/carers/volunteers to provide assistance, to patients, if appropriate, to eat their meals and enhance the mealtime experience.

• ensure that each staff member has the appropriate training, skills and competencies to comply with these guidelines.

6.2 Ward Staff

• It is the responsibility of each staff member to ensure they have the appropriate training, skills and competencies to comply with these guidelines.

• A bell should be rung 15-20 mins prior to the meals arriving on the wards.

• All patients (if appropriate) should be helped to sit out for mealtimes or moved to a more suitable position for eating in their bed.

• Nursing staff should ensure that routine nursing care is not carried out during meal delivery or when patients are eating their meals.

• It is important for all staff to actively encourage and promote patient hand hygiene before eating any food. Ward staff should prepare patients before the meal service by providing hand hygiene and sitting the patient out if clinically appropriate.

• Ward staff will clear the bed space and table of unnecessary clutter and ensure the table is clean.

• Ward staff will provide assistance where needed with helping patients to eat, open packets, ensuring food is within reach and encouraging intake of food and drink.

• For those patients with swallowing problems, ward staff should ensure patients who can eat, and drink have appropriate food and fluids for their swallow needs according to Speech and Language Therapist recommendations.

• Where clinically possible, nursing staff will make food a priority during mealtimes so that all attention is on serving meals, helping and encouraging patients to eat.

• Following assessment of the patient’s nutritional intake and their ability to feed themselves, the registered nurse may recommend the use of a red/yellow/blue tray and / or particular menu.

• The need for a red or yellow/blue tray and menu type must be documented clearly on the electronic patient record system.

• Staff will provide the necessary assistance to any patient receiving their meal on a red/yellow/blue tray and report to the nurse in charge if this is not possible.

• Ward staff should identify the need for a red or yellow/blue tray by updating the electronic patient record system, clearly communicating this to the Ward Hosts who take the menu orders and updating, and records held on the ward. At Farnham Hospital the nurse looking after the patient should also be informed and this should also be written on the patient’s door with a marker pen.

• Ward Hosts must not remove the request for red or yellow/blue trays without checking with nursing staff.

• Nursing staff will document dietary intake as accurately as possible on the electronic patient record system.

• Ward staff will monitor patients for swallowing problems and refer to Speech and Language Therapy if required.

• Ward staff will ensure that patients who are nil by mouth are not given anything to eat or drink.

• Ward staff will adhere to rigorous hand hygiene practices in order to reduce the risk of transferring organisms to patients and prevent healthcare associated infections.

• It is the responsibility of all staff to comply with the 5 moments of hand hygiene. New_5_Moments_Poster

6.3 Volunteers

• Will only operate within the scope of their training.

• Must wear their lanyard card which makes it clear to staff on wards that they have passed the mealtime competency.

• Will notify a staff member if they have any concerns about the ability of any patient to swallow, or about their nutritional intake in general.

• Will inform the nurse or healthcare assistant looking after the patient, what they have had to eat or drink so that this can clearly be documented on the electronic patient record system.

• Will strive to ensure that mealtimes are a positive experience for patients, taking the time to support them in eating and engaging them in positive conversation as a part of the volunteers’ companionship responsibilities.

• Volunteers will adhere to rigorous hand hygiene practices in order to reduce the risk of transferring organisms to patients and prevent healthcare associated infections.

• It is the responsibility of all staff to comply with the World Health Organisation 5 moments of hand hygiene (WHO, ND).

6.4 Medical and Allied Health Professionals

• Should, where clinically possible, refrain from interrupting mealtimes, with the exception of Speech and Language therapists.

• Dietitians and Speech and Language Therapists may recommend the need for either a red/yellow/blue tray if, during their assessment of the patient, they find that the patient meets the criteria in 3.3 or 3.4.

• It is the responsibility of all staff to comply with the World Health Organisation 5 moments of hand hygiene (WHO, ND).

6.5 Catering Department

• Catering must run an efficient meal delivery service in order to ensure meals are delivered at the designated times.

• Catering staff or Ward Hosts will place the patient’s plates on the appropriate tray. A green/black tray will be used where no indication is made for either a red or yellow/blue tray.

• Ward hosts/hostesses will adhere to rigorous hand hygiene practices in order to reduce the risk of transferring organisms to patients and prevent healthcare associated infections.

• It is the responsibility of all staff to comply with the World Health Organisation 5 moments of hand hygiene (WHO, ND).

6.6 Oral Nutrition and Hydration Forum

The Oral Nutrition and Hydration Forum is partly responsible for implementing these guidelines, reviewing its compliance and effectiveness and reporting back to the Nutrition Steering Group as appropriate.

6.7 Visitors

• The patient and, where appropriate, their family/visitors will be made aware of the Protected Mealtimes Guideline as soon after admission to the ward as is reasonably possible. Visitors are asked to abide by the Ward Visiting Policies.

• A poster should be displayed on each ward detailing the specific mealtime for that ward. Visiting time within the Trust may vary from ward to ward depending on the nature of ward.

• The patient may wish to have company whilst they eat their meal. If this is the case, visitors should be encouraged to remain during the meal service. Visitors may bring their own lunch to the ward and eat it with the patient. The Trust encourages families to assist patients with eating if it is appropriate and safe to do so.

The following principles will be adopted by all areas when adhering to the Protected Mealtimes and coloured tray guidelines:

Key Points

• The principle of protected mealtimes and coloured trays needs to be embedded within the ward routine.

• Notices should be displayed on all participating wards making people aware that a protected mealtime is in action.

• A bell should be rung 15-20 mins prior to the meals arriving on the wards.

• All patients (if appropriate) should be helped to sit out for mealtimes or moved to a more suitable position for eating in their bed.

• The guideline must remain flexible to allow for individual patients clinical needs to be addressed, i.e., Doctors may interrupt a patient’s mealtime when clinically appropriate and patients can be admitted from ED and AMU, etc. Wards must ensure the needs of patients and the service are met.

• If a patient needs to have essential treatment off the ward and as a consequent misses a meal, depending on which site the patient is based on, food can be obtained in the following ways:

  • At Frimley Park Hospital: A C6 form can be downloaded from the Intranet. The form must be completed and sent or taken to the kitchen. Food choice would be dependent on the time of day and menu cycle.

  • At Wexham Park Hospital: A C6 form can be downloaded from the Intranet. The form must be completed and sent or taken to the kitchen. Food choice would be dependent on the time of day and menu cycle.

  • At Heatherwood Hospital food can be requested from the ward host/hostess between 7am-7pm.

  • At Farnham Hospital when patient gets back to the ward, they can request an omelette/sandwich or small frozen reheated meal. The kitchen is open from 7am-7pm. If the patient is leaving the hospital for a procedure, nursing staff can request a packed meal for them to take with them.

• All staff and volunteers involved in mealtimes must be made aware of the importance of monitoring a patient’s food intake where there is cause for concern and complete records on the electronic patient record system, as appropriate.

• The Standard Operating Procedure for Mealtimes should be adhered to.

• All patients should be offered hand hygiene prior to mealtimes.

1. The responsibility for dissemination of this guideline lies with Ward Managers, matrons and heads of nursing. The guideline will be published on the Trust Clinical Guidelines App. All staff will be made aware of the guideline. Individual departments will make sure that hard copies are available for staff who do not have computer access; however, it should be noted that the Clinical Guidelines App will have links to the current version.

2. All staff involved in providing food to patients must undergo appropriate training.

3. All volunteers involved in providing food to patients must undergo appropriate training.

4. The line manager/voluntary services manager is responsible for identifying the training needs of the individual to the practice development department so that training and governance can be undertaken.

5. The voluntary services manager must ensure that in induction of all new volunteers, new volunteers are informed that they cannot assist patients with eating and drinking until they have received appropriate training and been formally assessed as competent and they must not assist patients who have swallowing difficulties.

6. Volunteers recruited to assist with feeding must attend appropriate training delivered by the practice development team on feeding techniques and therapeutic diets in line with Trust Policies for staff in these areas.

7. Patients with swallowing difficulties must only be assisted by members of staff who have received specific training – volunteers must not assist patients with swallowing difficulties.

Key performance indicators relating to these guidelines:

1. Assessment of each patient’s needs by the registered nurse and documentation of recommended use of the yellow/blue or red tray.

2. Correct indication on the electronic patient record system and this must be communicated to ward hosts, to identify the requirement for a yellow/blue or red tray.

3. Indication by designated staff of the need for a yellow/blue or red tray on any appropriate records including the patient’s malnutrition risk assessment.

4. Provision of the necessary assistance by designated staff to any patient receiving their meal on a red tray, and report to the nurse in charge if this is not possible.

5. Adherence to the Protected Mealtime and Coloured Tray Guidelines for compliance, will be monitored by internal and external auditors.

6. PLACE (Patient Led Assessments of the Care Environment). These are assessments which put patient views at the centre of the assessment process and use information gleaned directly from patient assessors to report how well a hospital is performing in the areas assessed: privacy and dignity, cleanliness, food and general building maintenance. It focuses entirely on the care environment and does not cover clinical care provision or staff behaviours (CQC, 2017).

7. Voluntary Services will maintain a training record of all volunteers who have completed the mealtime competencies.

8. A record of training and competency for staff members should be held by the line manager in the relevant area.

• British Association of Parenteral and Enteral Nutrition (BAPEN). (ND) Introduction to malnutrition. Available from: https://www.bapen.org.uk/malnutrition/introduction-to-malnutrition/ [Accessed 16th October 2024]

• British Dietetic Association (BDA). (2023) The Nutrition and Hydration Digest. Improving Outcomes Though Food and Beverage Service. Available from: https://www.bda.uk.com/static/176907a2-f2d8-45bb-8213c581d3ccd7ba/06c5eecf-fa85-4472-948806c5165ed5d9/Nutrition-and-Hydration-Digest-3rd-edition.pdf [Accessed 29th August 2024]

• Care Quality Commission (CQC). (2023) Regulation 14: Meeting nutritional and hydration needs. Available from https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-14-meeting-nutritional-hydration-needs [Accessed August 2024]

• Elia, M. (2015) The cost of malnutrition in England and potential cost savings from nutritional interventions (short version). Available from: http://www.bapen.org.uk/pdfs/economic-report-short.pdf BAPEN and National institute for Health Research Southampton Biomedical Research Centre. [Accessed May 2018]

• NHS England. (ND) 10 key characteristics of ‘good nutrition and hydration care [internet] Available from: https://www.england.nhs.uk/commissioning/nut-hyd/10-key-characteristics [accessed June 2019]

• National Institute for Health and care Excellence. (2017) Nutrition Support in Adults: oral nutrition support, enteral tube feeding and parental nutrition. [CG 32]. Available from: https://www.nice.org.uk/Guidance/cg32 [Accessed May 2018].

• Palmer M, Huxtable S. (2015) Aspects of protected mealtimes are associated with improved mealtime energy and protein intakes in hospitalized adult patients on medical and surgical wards over 2 years. European Journal of Clinical Nutrition; 69, 961-965.

• Malnutrition Task Force. (2021) State of the nation 2021: older people and malnutrition in the UK today. Available from: https://www.malnutritiontaskforce.org.uk/sites/default/files/2021-10/State%20of%20the%20Nation%202020%20F%20revise.pdf [Accessed 16th October 2024]

• Young A, Mudge A, Banks M et al. (2013) Encouraging, assisting and time to EAT: Improved nutritional intake for older medical patients receiving Protected Mealtimes and/or additional nursing feeding assistance. Clinical Nutrition. 32 (4), 543,549.

• Young A, Allia A, Jolliffe L et al. (2016) Assisted or Protected Mealtimes? Exploring the impact of hospital mealtime practices on meal intake, Journal of Advanced Nursing 72 (7), 1616-1625.

• World Health Organisation (WHO). (2021) Five moments for hand hygiene. Available from: https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/infection-prevention-and-control/hand-hygiene/d_allmoments_a2_en.pdf [Accessed 16th October 2024]

• British Association of Parenteral and Enteral Nutrition (BAPEN). (1999) Hospital food as treatment. London: BAPEN.

• Council of European Alliance. (2009) Council of Europe Resolution: food and nutritional care in hospitals (10 key characteristics). Available from: https://www.bapen.org.uk/pdfs/coe_leaflet.pdf [Accessed: 16th October 2024]

• National Patient Safety Agency. (2007) Protected mealtimes review: findings and recommendations report. London: National Patient Safety.

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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