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Prepared for the Auditor General for Scotland

Catering for patients

November 2003

2 Bye now, pay later follow-up

Auditor General for ScotlandThe Auditor General for Scotland is the Parliament’s watchdog forensuring propriety and value for money in the spending of public funds.

He is responsible for investigating whether public spending bodiesachieve the best possible value for money and adhere to the higheststandards of financial management.

He is independent and not subject to the control of any member of theScottish Executive or the Parliament.

The Auditor General is responsible for securing the audit of the ScottishExecutive and most other public sector bodies except local authoritiesand fire and police boards.

The following bodies fall within the remit of the Auditor General:

• departments of the Scottish Executive eg the Health Department• executive agencies eg the Prison Service, Historic Scotland• NHS boards and trusts• further education colleges• water authorities• NDPBs and others eg Scottish Enterprise.

AcknowledgementsAudit Scotland is grateful to those who acted as advisors to the study.The support of trusts, Island Health Boards and the State Hospital indevoting time and contributing to the study is gratefully acknowledged.

The study team was Angela Cullen and Catherine Vallely, under thegeneral direction of John Simmons.

Audit Scotland is a statutory body set up in April 2000under the Public Finance and Accountability (Scotland) Act2000. It provides services to the Auditor General forScotland and the Accounts Commission. Together theyensure that the Scottish Executive and public sector bodiesin Scotland are held to account for the proper, efficient andeffective use of public funds.

Main findingsPage 2

Part 1. IntroductionBackgroundPage 4

The studyPage 6

Part 2. NutritionMain findingsMenu planningIdentifying patients’ nutritional needsPage 7

Nutritionally analysed menusPage 8

RecommendationsPage 9

Part 3. Quality and patientsatisfactionMain findingsPresentation and delivery of mealsPage 10

Communication between wards andthe catering departmentPage 12

Patient satisfactionRecommendationsPage 15

Part 4. Costs of the catering serviceMain findingsTotal costs of the catering servicePatient catering servicesPage 16

Non-patient catering servicesPage 18


Contents1

Part 5. The catering serviceMain findingsManaging the catering servicePage 21

Food safety and hygienePage 23


Part 6. RecommendationsNutritionQuality and patient satisfaction Costs of the catering serviceThe catering servicePage 25

Appendix 1. Study advisory groupPage 27

Appendix 2. List of referencesPage 28


Main findings2

Nutritional care needs to be given a

higher priority by all staff (Part 2)

Around 70% of trusts have a validatedtool that allows them to screenpatients for risk of undernutrition.

Eighty-six per cent of trusts havenutritionally analysed menus.However, the extent of this analysisvaries with some menus being fullyanalysed whilst others have only asmall number of menu itemsanalysed for nutritional content.

One in four hospitals do not havestandard recipes. This makes thenutritional analysis of menus difficultand the measuring of the nutritionalintake of patients even morechallenging.

The majority of trusts undertake aformal menu planning process. Butvery few trusts fully comply with theprinciples of menu planning set out inpublished guidance.

Our findings show that around threein five catering specifications do notfully comply with the modelnutritional guidelines for cateringspecifications in the public sectorin Scotland.

The quality of the catering service is

satisfactory and patient satisfaction

is high (Part 3)

All long stay hospitals have at least athree week menu cycle in place inline with good practice.

Ninety-eight per cent of hospitalshave at least two main meal choiceson the menu at each mealtime butthere is limited choice for vegetarians,patients on therapeutic diets and forpatients with eating or swallowingdifficulties.

All hospitals have arrangements in placeto offer meals to minority ethnicpatients but not all ward staff are awareof these arrangements. This limits thechoice available to patients.

Only 43% of hospitals are operatinga system that allows patients toorder their meals no more than twomeals in advance.

We found that in half of hospitals,10% or more of patients said thatthey did not receive the meal thatthey ordered.

All hospitals have kitchens at wardlevel where snacks can be preparedfor patients and three-quarters ofhospitals are able to provide snacksoutwith meal times from thehospital kitchen.

Sixty-nine per cent of trusts carry outpatient satisfaction surveys. Patientsatisfaction with the catering serviceis high ranging from 74% to 100%and averaging around 92%. Theauditors’ survey of patient foodsupports these findings.

We found no relationship betweenpatient satisfaction levels and thecost of the service or the provider ofthe service.

Ward wastage needs to be reduced

(Part 4)

Ward wastage, or meals not actuallyserved to patients, is high in somehospitals ranging from under 1% toover 40% in the hospitals reviewed.

If a target of 10% was set forwastage from unserved meals,around three in five Scottish hospitalswould have to reduce their wardwastage levels and savings of up to£1.9 million could be made.

Fifty-six per cent of hospitals aremonitoring wastage levels regularly,but only 32% have set targets.

Spending on food and beverages for

patients varies significantly (Part 4)

A large proportion of cateringdepartments (42%) are basing thecatering service budget on historicalinformation.

Around 40% of hospitals have set adaily food allowance but less thanone in five hospitals are using this tocalculate the budget required for thecatering service.

There is a wide variation in costs.The majority of hospitals total netcatering costs range between £3.50and £7.50 per patient day. The costof patients’ food and beveragesranges from around £1.25 to over£3 per patient day. The variation incosts may be as a result of thequantity of ingredients used inproduction, poor portion control orlevels of food waste.

We found no relationship betweencost and production type or patientsatisfaction.

Non-patient catering is being

subsidised (Part 4)

Only one-third of hospitals reviewedwere able to split the costs of thecatering service between patient andnon-patient activities.

Three-quarters of hospitals aresubsidising the catering serviceprovided to staff and visitors. Mosthospitals are doing this unknowingly.The total cost of this subsidy is nearly£4.2 million per year or an averagehospital subsidy of around £110,000.

Conclusion

NHSScotland’s hospitals areproviding good quality cateringservices, which have high levels ofpatient satisfaction. In this report wehave identified a number ofweaknesses, and make somerecommendations that will have costimplications. However, we have alsoidentified a number of potential costsavings that may be used to offsetthe cost of implementing ourrecommendations.

Main findings 3

Background

1.1 The effective delivery of food andfluid and the provision of high qualitynutritional care are crucial for the wellbeing of patients

1. Hospital catering is

generally regarded as a non-clinicalservice within the NHS. As a result itis normally grouped with servicessuch as cleaning and portering. Thiscan lead to clinical staff believing thathospital food and the catering serviceare not their responsibility.

1.2 Recent studies have shown thatat least one person in three whoenters hospital has lost weight andone in ten has become seriouslymalnourished

2. In Scotland similar

research by the Clinical Resource andAudit Group (CRAG)

3has revealed

that one in five older people in long-term care establishments, includingNHS hospitals, are undernourished.High quality, nutritious food is notonly desirable but necessary for allpatients in hospital to maintain andaid recovery.

Putting hospital catering in context

1.3 Each year NHSScotland providesapproximately 28 million patientmeals costing around £55 million

4.

Since 2000 total spending onNHSScotland has increased by around8% each year. During the sameperiod spending on catering serviceshas been reducing slightly each year.On the whole, catering services arebecoming a smaller proportion ofoverall NHSScotland spending.

1.4 NHSScotland directly employsaround 3000 catering staff (2000whole time equivalents)

5. Private

contractors who provide cateringservices to NHSScotland’s hospitalsalso employ a number of cateringstaff.

1.5 For a catering service to beeffective it cannot be delivered solelyby catering staff. A catering servicethat meets the nutritional needs ofpatients also requires input fromother staff including domestic andportering staff, nurses, clinicians,dietitians and other allied healthprofessionals.

Service delivery

Service providers1.6 There were 116 cateringproduction units providing services to216 in-patient hospitals in 2001/02. Insome trusts, one or two large centralproduction units provide cateringservices for all hospitals in the trust.At the other extreme, all or mosthospitals in the trust have a kitchenwhere meals are prepared on-site.

1.7 Eighty per cent of cateringservice providers are in-house teams.Private contractors provide cateringservices to the other 20% ofhospitals, as a result of a PrivateFinance Initiative/Public PrivatePartnership deal or as a direct resultof market testing of the service.

Production methods1.8 There are four main productionmethods available, all of which werein operation in NHSScotland in2001/02 (Exhibit 1). Due to the smallnumbers involved cook-chill andcook-freeze production are reportedtogether in Exhibit 1.

Meal delivery service1.9 There are two ways in whichmeal services can be delivered towards and patients, bulk or plated(Exhibit 2).

Working with others

NHS Quality Improvement Scotland1.10 Standards on food, fluid andnutritional care were published inSeptember 2003. NHS QualityImprovement Scotland will assesstrusts compliance with thesestandards.

1.11 Audit Scotland and NHS QualityImprovement Scotland ensured theirwork was complementary to avoidduplication. Our study hasconcentrated on quality and patientsatisfaction, costs and the cateringservice and limited its review ofnutritional care as this is beingreviewed as part of the NHS QualityImprovement Scotland process. Ourreview was restricted to consideringthe following aspects of nutritionalcare as high level issues only:

• planning the menu to ensure itmeets patients’ needs

• identifying patients’ nutritionalneeds

• ensuring menus provide sufficientnutrients to satisfy patients’needs.

1.12 NHS Quality ImprovementScotland will carry out a detailedreview of nutritional care as part oftheir assessment process for thefood, fluid and nutritional carestandards. NHS Quality ImprovementScotland’s review will cover detailedareas of nutritional care such asscreening patients, staff training,assisting patients with feeding andmonitoring patients’ nutritional intake.

4

Part 1. Introduction

1. ‘Clinical standards for food, fluid and nutritional care in hospitals’, NHS Quality Improvement Scotland (2003).2. ‘Hospital food as treatment’, BAPEN (1999).3. ‘The nutrition of elderly people and nutritional aspects of their care in long-term care settings’, CRAG (2000).4. Scottish Health Services costs year ended 31 March 2002, Information & Statistics Division (ISD).5. Workforce Statistics as at 30 September 2002, ISD.

Cook-serve 83%With this meal production system,meals are generally prepared andcooked within the hospital kitchen fordistribution to the ward.

Cook-chill and cook-freeze 15%Food is prepared in advance and then heldin a chilled or frozen state and then reheatedat an appropriate time. Meals are producedby an in-house team or bought in froma commercial supplier.

Hybrid 2%A combination of the cook-serveand cook-chill/freeze methods.

Exhibit 1The percentage of hospitals using different production methods

Source: Audit Scotland

Part 1. Introduction

Plated 37%Meals are individually plated within the hospitalkitchen. They are then delivered in a trolley to thewards and served by a member of staff.

Hybrid 29%A mix of bulk and platedmeal services.

Bulk 34%A meal service where hot or cold food isportioned into large food containers whichare then put into heated/chilled bulk mealtrolleys and delivered to wards; meal servicestaff then plate up the patients’ individualmeals according to their personal choice.

Exhibit 2The percentage of hospitals using different methods of meal delivery service


5

6

Departmental Implementation Group1.13 The Scottish Executive HealthDepartment set up an advisory groupin winter 2001 drawn largely fromthe NHS and representatives ofpatients’ organisations. This groupsupported the implementation of thestandards on food, fluid andnutritional care and will produce areport soon providing advice to theNHS on the provision of nutritionalcare in hospitals. We understand thatthe Department will consider theneed for additional guidance toNHSScotland on food, fluid andnutritional care in winter 2003 inlight of that report and ourrecommendations.

The study

1.14 This is a report by AuditScotland on behalf of the AuditorGeneral for Scotland. This is the firstreview of hospital catering by AuditScotland and is based on 2001/02data. The findings andrecommendations set out in thisreport will be followed up by AuditScotland on behalf of the AuditorGeneral for Scotland in due course.Trusts have received reports settingout local findings andrecommendations.

1.15 We reviewed 26 NHS bodiesincluding trusts, island NHS boardsand the State Hospital (for ease ofreference the term ‘trusts’ will beused throughout this report) and 41hospital sites.

1.16 Hospital sites were selected forreview if they were a reasonable sizeand had on-site catering facilities. Themajority of hospitals selected have75 or more staffed beds. A fewsmaller hospitals were also selectedfor review. The selection of allhospital sites was agreed betweentrusts and their local auditors prior tothe review commencing. Hospitalsites reviewed cover all types ofproduction and service delivery. Thehospitals selected include acute,

maternity, teaching, psychiatric,learning disabilities, community andother long stay hospitals and providea reasonable geographical spreadthroughout the country. Overall, the41 hospitals reviewed representnearly 50% of the total staffed bedsin NHSScotland in 2001/02.

1.17 This report provides a summaryof the main issues arising from thereview, detailed findings on nutrition,quality and patient satisfaction, costsand the catering service and makes anumber of recommendations.

Main findings

The majority of trusts plan theirmenus but very few fully complywith the recognised principles ofmenu planning.

Around one in five of trusts do nothave a tool to screen patients forrisk of undernutrition.

86% of hospital menus have beenanalysed for nutritional contentbut the extent of this analysisvaries considerably.

Around one in five hospitals donot have standard recipes inplace.

Three in five cateringspecifications do not fully complywith the model nutritionalguidelines for cateringspecifications in the public sectorin Scotland.

Part 2. Nutrition

2.1 In this chapter we look at thenutritional care of patients in terms of:

• planning the menu to ensure itmeets patients’ needs

• identifying patients’ nutritionalneeds

• ensuring menus provide sufficientnutrients to satisfy patients’ needs.

Menu planning

2.2 Menus should be planned toensure that they meet patients’needs and are nutritionally sound.A wide range of professionals withintrusts hold the appropriateknowledge and information to dothis properly. Planning the menushould, therefore, be carried out by agroup of people who bring their ownexpert knowledge to the process.The group should include, as aminimum, a catering manager,dietitian, nurse and a clinician.

2.3 In the past decade a number ofpublications

6 7 8 9have set out the

principles of menu planningspecifically for the NHS and olderpeople. We found that the majority oftrusts undertake a formal menuplanning process. However, trusts’compliance with the principlesoutlined in these documents varies.The majority of trusts reported thatthey generally adopt the recognisedprinciples whilst a few trusts do notcomply at all.

Identifying patients’ nutritional

needs

2.4 In recent years publishedresearch has raised concerns aboutthe prevalence of malnutrition amonghospital patients. Up to 40% ofadults admitted to hospital were atleast mildly undernourished onadmission or became malnourishedduring their stay in hospital

10.

Part 2. NutritionHow is the nutritional care of patients addressed?

6. ‘The health of the nation – Nutrition guidelines for hospital catering’, Department of Health (1995).7. ‘Hospital catering: Delivering a quality service’, NHS Executive (1996).8. ‘Eating well for older people’, The Caroline Walker Trust (1995).9. ‘Nursing Homes Scotland Core Standards’, Scottish Executive (MEL (1999) 54).10. ‘Incidence and recognition of malnutrition in hospital’, McWhirter JP, Pennington CR (1994).

7

2.5 Nutritional screening of allpatients should be an integral part ofclinical practice. Nutritional screeningis a simple and rapid process thatidentifies the characteristicsassociated with malnutrition

11. If risk

of undernutrition is detected patientsshould be referred to a dietitian.Patients may also need to bereferred to other allied healthprofessionals such as a speech andlanguage therapist. Staff trained inthe use of a validated nutritionalscreening tool should undertakescreening.

2.6 Around 70% of trusts have avalidated nutritional screening tool inplace. A further 10% of trusts arescreening patients for risk ofundernutrition, but are using ascreening tool that has not beenvalidated for the patient group. Thismeans that nearly 20% of trusts donot have an effective nutritionalscreening tool at all. We identified

some good practice in this area andCase study 1 provides details of anexample.

Nutritionally analysed menus

2.7 Menus should be analysed fornutritional content to ensure thatpatients are provided with nutritionallysound meals. This analysis may bedone in three stages: an analysis ofthe nutritional value of each menuitem, comparison of these valuesagainst the recommended minimumnutritional content, and an analysis ofthe entire menu to ensure that it isnutritionally balanced. Eighty-six percent of trusts have nutritionallyanalysed menus, but the extent of thisanalysis varies considerably. Forexample, in some trusts the first twostages may be complete but themenu may not have been assessedfor nutritional balance. In other truststhe first stage may not yet becomplete with only a few menu itemsanalysed for nutritional value.

2.8 Once a menu has been analysedfor nutritional content the preparationof meals needs to be standardised.This ensures that the sameingredients are used and cookingmethod applied each time the mealis prepared. Otherwise the nutritionalcontent of the same meal could varyfrom one day to another. Standardrecipes are fundamental to the wholeprocess of providing nutritionallyanalysed food to patients. Nearly fourin five hospitals have standardrecipes in place. The Department ofHealth’s Better Hospital Foodwebsite

12offers a large range of

standard recipes, all of which havebeen nutritionally analysed.

2.9 The Scottish Diet Action Plan13

recommended that cateringspecifications should comply with themodel nutritional guidelines forcatering specifications in the publicsector in Scotland. Our findings showthat around three in five catering

Ayrshire and Arran Primary Care NHS Trust routinely undertakes nutritional care assessments for olderpeople.

Ayrshire and Arran PCT has developed a nutritional screening tool to identify elderly patients who were alreadyundernourished or those at risk of becoming undernourished in hospital. On admission all patients receive nutritionalscreening, which is completed by qualified nursing staff. Evaluation within the trust has proven the tool to be reliableand valid*. To support the tool, the trust has devised a training pack that includes guidelines for completion of thenutrition screening tool and a suggested care pathway.

*Mackintosh M A and Hankey C R (2001) Reliability of a Nutrition Screening Tool for use in elderly day hospitals.Journal of Human Nutrition and Dietetics. 14 129-136.

Case study 1Good practice example


8

11. ‘Nutrition – assessment and referral in the care of adults in hospital’, Best practice statement, Nursing & Midwifery Practice Development Unit (2002).12. www.betterhospitalfood.com13. ‘Eating for health – A diet action plan for Scotland’, Scottish Office (1996).

Part 2. Nutrition

specifications do not fully complywith the model nutritional guidelines.

2.10 The DepartmentalImplementation Group hasconsidered issuing national nutritionand catering specifications. Wewould recommend this as goodpractice, with benefit for all cateringservice providers and patients.

Recommendations

Menu planning

• Trusts should plan their menus inline with the recognised principlesof menu planning.

• All trusts should set up a group toplan the menu, ensuring that allavailable knowledge andexperience within the trust areused where appropriate.

Identifying patients’ nutritional needs

• Trusts should ensure that patientsare screened on admission for riskof undernutrition.

• Trusts should use a validatednutritional screening tool toscreen patients and staff shouldbe trained in how to use this tool.

Nutritionally analysed menus

• All menus should be nutritionallyanalysed. To avoid duplication ofeffort and maximise the use oflimited dietetic resources thiscould be done as part of thenational database of standardrecipes recommended below.

• All catering production unitsshould use standard recipes.The cost associated with thesestandard recipes should becalculated and maintained.The Scottish Executive HealthDepartment should considerdeveloping a national database ofstandard recipes for NHSScotland.This database could be held on

NHSScotland’s website (ScottishHealth On the Web) to allow easyaccess.

• Trusts should ensure that cateringspecifications comply with themodel nutritional guidelines forcatering specifications in thepublic sector in Scotland.

• The DepartmentalImplementation Group shoulddevelop or commission nationalcatering and nutritionspecifications for NHSScotland.

9

Main findings

Patient satisfaction levels are high.

We found no relationship betweenpatient satisfaction and the cost orprovider of the service.

All long stay hospitals have at leasta three week menu cycle in linewith good practice.

Most hospitals offer a sufficientchoice of meals to patients eatingeveryday meals but the choice forvegetarians and special diets islimited.

All hospitals have arrangements inplace to offer meals to minorityethnic patients but not all staff areaware of these arrangements.

More than half of patients areordering their meals more thantwo meals in advance.

In half of hospitals more than 10%of patients reported that they didnot receive the meal they hadordered.

Every hospital has ward levelkitchens where snacks can beprepared for patients.

Around 70% of trusts undertakepatient satisfaction surveys.

3.1 In this chapter we look at thequality of the catering service andpatients’ perceptions in terms of:

• the presentation and delivery ofpatient meals

• communication between wardsand the catering department

• patient satisfaction.

Presentation and delivery of meals

The menu cycle

3.2 Menu planning includes setting amenu cycle. This involves planningthe menu to provide three meals aday with no item repeated within aspecific time period. The length ofmenu cycle varies among hospitals.A shorter length of menu cycle issufficient in acute hospitals wherethe average length of stay forpatients is around four days. In long

stay hospitals, however, this can be amajor problem when patients arefaced with the same menu choiceson a regular basis, and may increasetheir risk of becoming malnourished.The CRAG report recommended thatat least a three week menu cycleshould be in operation for long stayelderly patients.

3.3 All long stay hospitals have atleast a three week menu cycle inplace in line with good practice.Three-quarters of acute hospitals arealso operating at least a three weekmenu cycle. The remaining acutehospitals are operating a two weekmenu cycle. This is likely to besufficient for the majority of acutehospitals. However, those acutehospitals with long stay wards orbeds should ensure that they areoperating a three week menu cycle,at least for these patients.

Patient choice

3.4 Menus should contain a sufficientrange of meals to meet the dietaryneeds and preferences of all patientgroups including patients who:

• are children

Part 3. Quality and patient satisfactionWhat affects the quality of the catering service and how do patients perceive it?

10

• are vegetarian or vegan

• are from minority ethnic groups

• require the texture of food to beadapted because they haveproblems eating or swallowing

• require therapeutic meals due toa medical condition such asdiabetes.

3.5 Ninety-eight per cent of hospitalshave at least two main meal choiceson the menu at each mealtime.Many hospitals offer alternatives tomain meals such as salads andsandwiches, aimed at patients whodo not want to eat two large mealseach day. Some other good practicewas identified in extending thechoice available to patients. Forexample, some hospitals offer up tosix choices for lunch and eveningmeal. A specific example of goodpractice is outlined at Case study 2.

3.6 But there is a limited choice forvegetarians, patients on therapeuticdiets and for patients with eating orswallowing difficulties. In somecases, only one choice was available

from the menu for these types ofdiets, and in some hospitals thesemeals were not available from themenu but had to be requested bypatients and ward staff. For example,one in ten hospitals do not offer avegetarian option from the menuevery day.

3.7 All hospitals have arrangementsin place to offer meals to minorityethnic patients. In a few wardsvisited staff were not aware of thesearrangements potentially limiting thechoice available to patients. Thereview also identified some areas ofgood practice where separate ethnicmenus were available at ward level.Case study 3 highlights one of theseareas of good practice.

3.8 Menus should, whereverpossible, give patients enoughinformation to choose their ownmeal. This may be done throughproviding a description of dishes onthe menu and offering differentportion sizes. Menus should also becoded to show which meals aresuitable for vegetarians, therapeuticdiets and patients with swallowing oreating difficulties.

Dumfries & Galloway Acute and Maternity Hospitals Unit has developed a hotel list to provide patients with analternative to meals on the menu.

If a patient does not find anything on the menu that appeals to them, they can write on the menu card what theywould like to eat. This may be a lighter meal such as scrambled eggs or a more substantial meal such as scampi orsteak. The catering department will try to meet this request wherever possible whilst ensuring that the facility is notabused. In circumstances where the catering department cannot provide the patient’s preferred meal they willspeak to the patient and discuss alternatives that can be provided. This practice helps maintain patients’ nutritionalintake and increases patient satisfaction.



Part 3. Quality and patient satisfaction

3.9 Nearly all menus provide anaccurate description of dishes thatare easily understood by patients andthe majority provide a range ofportion sizes. We also identified that83% of menus are coded for specialdietary needs, allowing patients tochoose a meal that is suitablefor them.

3.10 Where patients may havecommunication difficulties it is goodpractice to have menus available inlanguages other than English, orpicture menus. These menus ensurethe meal service is accessible to allpatients and can help patients maketheir choice. Our review alsohighlighted some good practice inthis area and an example is outlinedin Case study 3.

11

Ordering and delivery of patient

meals

3.11 Patients should choose theirmeal as close to the actual meal timeas possible. This can raise patientsatisfaction and avoid unnecessarywastage as a result of patientshaving been discharged, transferredor receiving treatment during mealtimes. The Patients’ Charterrecommends that patients shouldorder their meals no more than twomeals in advance of the mealtime.In any normal day this would meanpatients ordering their lunch andevening meal at breakfast time.

3.12 We found that only 43% ofhospitals are operating a system thatallows patients to order their mealsno more than two meals in advance.Exhibit 3 shows the timescales forordering patient meals in 2001/02.From Exhibit 3 it can be seen that17% of hospitals indicated that theywere operating an ‘other’ system ofmeal ordering. In some of thesehospitals when the meal is ordereddepends on the patient group. Forexample, acute patients order theirmeals forty eight hours in advancewhilst care of the elderly patient meals

are ordered one week in advance.

3.13 As part of a patient satisfactionsurvey we asked patients if they hadreceived the meal that they ordered.We found that in half of hospitalssurveyed, 10% or more of patientssaid they did not receive the mealthat they ordered (Exhibit 4).

Out of hours services

3.14 Most hospitals operate fixedmeal times. Meals and refreshmentsshould be available to patientsoutwith these fixed meal times. Thismay be necessary for patients whohave missed a meal or because thetime between the evening meal andbreakfast can be long. The standardson food, fluid and nutritional carestate that a substantial snack shouldbe provided where the time betweenevening meal and breakfast isfourteen hours or more.

3.15 All hospitals have kitchens atward level where snacks can beprepared for patients and three-quarters of hospitals are able toprovide snacks outwith meal timesfrom hospital kitchens. Our reviewidentified good practice in providing

out of hours catering and an exampleis detailed at Case study 4 overleaf.

Communication between wards and

the catering department

3.16 Good communication betweenwards and the catering department isvital to the provision of a qualitypatient meal service. It is essentialthat all staff involved in the cateringservice (from production, throughdelivery, to helping patients to eat)work together as a team. Theyshould communicate with each otherto ensure that patients receive thebest quality of service possible. Goodcommunication between wards andthe catering department can result in:

• higher patient satisfaction levels

• patients actually receiving themeal they ordered

• fewer meals being ordered andwasted

• problems being dealt with efficiently

• potential problems beingidentified early and addressed.

Lanarkshire Acute Hospitals NHS Trust and Lanarkshire Primary Care NHS Trust have special menus for minorityethnic groups and patients with communication difficulties.

Lanarkshire Acute Hospitals NHS Trust

Wishaw General Hospital has a multicultural menu for patients. The menu, devised by Serco, is available in Hindi, Arabic,Cantonese, Urdu, and Punjabi. Requests for religious or minority ethnic meals from this menu are made to the PatientMeals Service Coordinator in the catering department. All of the menu choices are numbered to allow patients to indicate tothe coordinator which option they would like. This practice enables non-English speaking patients to select meals that aresuitable for their religious beliefs or traditions.

Lanarkshire Primary Care NHS Trust

The trust has taken significant action to improve the quality of service for patients with sensory impairment. All cateringmanagers are currently completing a sign language course to enable them to communicate better with hearing impairedpatients. In addition, pictorial menus have been piloted. For patients with visual impairments, menus on audiotape will beintroduced. All of these measures will allow patients with sensory impairments to have more control over their menuchoice, and enable them to communicate their preferences or comments on the catering service more effectively.

Case study 3Good practice examples


12

Percentage

other

1 week in advance

48 hours in advance

24 hours in advance

2 meals in advance

1 meal in advance

Immediately prior to meal

0 5 10 15 20 25 30

Exhibit 3Advance ordering of patient meals


Perc

enta

ge

Hospitals

0

10

20

30

40

50

60

70

80

90

100

Exhibit 4Percentage of patients who said they received the meal they ordered


Part 3. Quality and patient satisfaction 13

Highland Primary Care NHS Trust has developed its out of hours catering by introducing a late admissions tray atCaithness General Hospital.

Patients admitted to Caithness General Hospital after the patient meals have been ordered from the kitchen are suppliedwith a ‘late admission tray’. This tray consists of soup, sandwich, and yoghurt. This out of hours service ensures that allpatients receive a nutritionally sound meal.



14

Grampian University Hospitals NHS Trust has improved communication between wards and the cateringdepartment by introducing a twinning system.

The trust has recently introduced a system whereby each cook or assistant cook is twinned with a ward. This providesward-based staff with a familiar point of contact within the catering department whom they can approach with any queriesor complaints. This development should also lead to catering staff having an increased sense of responsibility towards theirparticular ward. Overall the aims are to help improve communication and the working relationship between ward andkitchen staff and ensure a better quality service for patients.



Perc

enta

ge

Hospitals

0

10

20

30

40

50

60

70

80

90

100

Exhibit 5Percentage of patients scoring the catering service as satisfactory or above


3.17 We identified some goodpractice where wards and thecatering department werecommunicating effectively. Anexample of good practice ishighlighted at Case study 5.

Patient satisfaction

3.18 Patients are encouraged to eatand drink when they are in hospitalsto aid their recovery and avoidmalnourishment. It is thereforeessential that trusts seek patients’views about their needs and whetherthese are being met by the hospitalcatering service.

3.19 All trusts obtain patients’ viewson the catering service. Sixty-nine percent of trusts carry out patientsatisfaction surveys. The frequencyof surveys varies considerably withsome trusts carrying out monthlysurveys whilst others have carriedout only one survey in two years. Forpatient satisfaction surveys to be ofany benefit to catering departmentsand patients they need to be carriedout on a frequent basis. We foundthat the 31% of trusts which do notundertake surveys obtain patients’views through other methods suchas comment cards, informing staff orthe formal complaints procedure.These forms of collecting patients’views place the responsibility formaking comments with the patientrather than the trust actively askingfor their views. We recommend thatall trusts carry out patient satisfactionsurveys at least quarterly.

3.20 The results of our patientsatisfaction survey are shown inExhibit 5. Patient satisfaction levelsare generally high ranging from 74%to 100% with an average satisfactionlevel of 92%.

3.21 Auditors also carried out anindependent survey on the quality ofpatient meals in each hospital.Auditors ordered a sample of meals,across four to six wards over a few

Part 3. Quality and patient satisfaction

meal times. Meals were then scoredagainst the following seven criteria:taste, texture, aroma, temperature,appearance, the correct item beingreceived and portion size. Any surveyof this type is likely to be subjective,but the results – ranging from 81%to 99% – support the high satisfactionscores from the patient survey.Lower scores tended to be becausethe incorrect item had been receivedor food temperatures wereinappropriate.

3.22 Trusts should monitor thequality of the catering service on aregular basis. Many trusts do theirown internal monitoring wheresurveys similar to that outlined above(para 3.21) are used. All of the privatecontractors undertake their ownregular monitoring of the cateringservice. Around half of trusts usepatient groups or the local healthcouncil to obtain the views ofpatients and give an independentview on the quality of the service.

3.23 We found no relationshipbetween patient satisfaction levelsand the cost of the service or theprovider of the service.

Recommendations

Presentation and delivery of meals

• Acute trusts with long stay bedsshould ensure that they have athree week menu cycle, at leastfor these patients.

• Menus should be reviewed toensure they offer sufficientchoice to all patient groups.Where it is consideredappropriate, separate menus maybe developed for ethnic mealsand other special diets.

• Trusts should remind all their staffof the procedures for offering,ordering and delivering meals andin particular meals for patientswho require a special diet.

• All menus should be dietarycoded to help patients make aninformed choice.

• All catering services should aim tohave patients ordering their mealsas close to the meal time aspossible and no more than twomeals in advance.

• All catering services should aim toprovide all patients with the mealthey ordered.

Communication between wards and

the catering department

• Trusts should encouragecommunication between wardstaff and the catering department.

Patient satisfaction

• Trusts should ensure that theyobtain patients’ views on thecatering service through theintroduction of regular (at leastquarterly) patient satisfactionsurveys.

• Trusts should monitor the qualityof the catering service throughinternal quality assurance surveysand/or using patient and usergroups to obtain the viewsof patients.

15

16

Main findings

Costs of the catering service varysignificantly with the majority ofhospitals net cost per patient dayranging between £3.50 and £7.50and food and beverages cost perpatient day ranging from £1.25 toover £3.00.

Two-thirds of hospitals cannot splitthe costs of patient catering fromthe costs of staff and visitors (non-patient) catering.

Over 60% of hospitals wastemore than 10% of food deliveredto wards. Reducing ward wastageto 10% in all hospitals could saveup to £1.9 million forNHSScotland.

Three-quarters of hospitals aresubsidising non-patient cateringservices. Most are doing thisunknowingly as they cannot splittheir costs. The annual cost ofsubsidising non-patient catering isaround £4.2 million. The averagesubsidy per hospital is £110,000.

We found no relationshipbetween cost and production typeor patient satisfaction.

4.1 This chapter looks at the cost ofthe catering service at three levels:

• total costs of the catering service

• patient catering services

• non-patient catering services.

The figures used in this part of thereport are those calculated byauditors.

4.2 The private contractors providingcatering services to eight of thehospital sites reviewed did notsupply us with any cost informationfor commercial confidentiality

reasons. Trusts should make everyeffort to include a clause in contractswith private service providers thatallows the disclosure of sufficientfinancial information for managementdecision making. Some of the in-house catering providers were alsounable to provide us with suitablecost information. The exhibits in thispart of the report only include thosehospitals where cost information wasobtained.

Total costs of the catering service

Budget setting

4.3 Budgets are set for the cateringservice as a whole taking the patientservice and meals provided to staffand visitors (non-patient catering)together. This allows any incomegenerated from non-patient cateringto be used to reduce the overall costof the catering service.

4.4 The largest proportion of cateringdepartments (42%) base theircatering service budget on historicalinformation. Other cateringdepartments are basing their budgetson target patient cost per patientweek (32%), daily food allowance(18%) and contract price (8%).

4.5 Using historical information tobudget generally means increasingthe cost element each year for inflation.Budgeting on this basis simply takesaccount of pay rises and increases inthe cost of food and beverages. Itdoes not take account of variation inthe number of meals produced orother changes such as revisions tothe menu. Income generation targetsare likely to be increased each yearto offset these increased costs andmay be set even higher to reducethe overall catering budget.

Total gross cost of the catering

service

4.6 Expenditure on the catering

Part 4. Costs of the catering serviceWhat is the cost of hospital catering services?

service includes the costs of foodand beverages, staffing, otherindirect costs such as cleaningmaterials and a proportion of trustoverheads. Exhibit 6 shows thebreakdown of total gross costs bythese four components. Food andbeverages and staff account for justover 90% of total gross cost.

Net costs per patient day

4.7 There is a wide variation in netcost

14per patient day, with the

average cost being £5.50. Themajority of hospitals range between£3.50 and £7.50. Some of thisvariation will be due to the level ofincome generated from non-patientcatering services and the hospitals’pricing policies. We found norelationship between cost andproduction type or patient satisfaction.

Patient catering services

Costs of the patient catering service

4.8 Only one-third of hospitals thatwe reviewed were able to split thecosts of the catering servicebetween patient and non-patientactivities. This highlights a lack ofcontrol over the costs of the cateringservice. For example, if a daily foodallowance were set the majority ofhospitals would be unable tocalculate whether they were meetingthis allowance. Around 40% ofhospitals have set a daily foodallowance but they do not appear tobe using this properly. For example,only around half of hospitals areusing this to calculate the budgetrequired for the catering service.

4.9 We identified that the cost ofpatients’ food and beverages variessignificantly ranging from around£1.25 to over £3.00 per patient day(Exhibit 7). Variations in food andbeverage costs do not necessarilymean better or worse ingredients.The vast majority of ingredients are

14. Net costs are the total costs of the catering service (including non-patient catering) less any income generated from catering.

Food and beverages 42%All food and beverages includingward provisions.

Other indirect costs and overheads 8%Indirect costs – the cost of other itemsused by the catering department, suchas crockery and cutlery.Overheads – the cost of other servicessupporting the catering department,such as finance.

Staffing 50%The cost of all staff involved inpreparing and cooking meals(excludes transport and servingcosts).

Exhibit 6Components of total gross cost


0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

£

Hospitals

Exhibit 7Cost of patients’ food and beverages per patient day


Part 4. Costs of the catering service 17

18

purchased through national contractsand so costs vary only marginally.The variation in costs may be as aresult of the quantity of ingredientsused in production, poor portioncontrol or food waste. This reporthighlighted earlier that standardrecipes are not in place in everyhospital and are not used consistently.

Food wastage

Monitoring wastage levels4.10 The levels of food wastage canaffect the cost of a catering service.Food waste may occur at any or all ofthe following stages: production,unserved meals at ward level, uneatenfood left on patients’ plates and foodwasted in the staff dining room.

4.11 Monitoring wastage enablescatering departments to determinehow accurately they are planningproduction. The best controls overfood waste are when wastagelevels are regularly monitored,wastage targets are set and wastagelevels and values measured againstthese targets. Fifty-six per cent ofhospitals are monitoring wastagelevels regularly, but only 32% haveset targets.

Ward wastage4.12 As part of the review we carriedout a survey of wastage at a sampleof wards over a range of meal times.We looked at the number of unservedmeals left at each ward after allpatient meals had been served. Thesurvey was restricted to unservedmeals due to the practical difficultiesin measuring waste left on platesafter patients have finished eating.

4.13 Wastage rates range from 1%to 44%, but these vary depending onthe type of meal service (Exhibit 8).

4.14 Hospitals using a bulk meal

service tend to have higher wastagelevels than those using a plated mealservice. Higher wastage levels are aninherent risk of using a bulk mealservice, as meals are issued to wardsin trays of a set size. For example, atray may hold twelve portions butonly ten portions are required forpatients, leaving two portions (or 17%)unserved. Some catering departmentshave addressed this problem byusing different sizes of trays.

4.15 Plated meal services have thelowest wastage rates, with anaverage of 10%. The lower quartilelevel for all hospitals is even less at7%. Our results show that three infive hospitals surveyed have wardwastage rates over 10% and only afew operating bulk or hybrid mealdelivery achieved wastage rates ofless than 7%.

4.16 It is very difficult to eliminatewastage from unserved meals, and itis likely that doing so could adverselyaffect quality. We recommend thathospitals should adopt a target of10% wastage from unserved meals.This is equivalent to the averagewastage rate for plated mealsservices. Hospitals operating a bulkmeals service can achieve this targetby adopting some different practices.They can collect information on themeals selected by patients, whichwill allow more accurate prediction ofthe uptake of particular dishes. Theycan also use different size trayswhen portioning meals for deliveryto wards.

4.17 The annual cost to NHSScotlandof wastage from unserved meals isaround £4.2 million. If all hospitalsreduced their wastage to 10%NHSScotland could save up to£1.9 million. This is equivalent to anextra 25 pence on food andbeverages for each patient each day.

We have identified some goodpractice, which has resulted in lowwastage rates, and an example isoutlined at Case study 6.

Non-patient catering services

4.18 Most hospitals provide non-patient catering services to staff andvisitors in the dining room, vendingmachines and hospitality for meetingsand events. Some hospitals haveextended this service by operatingshops and cafes and providingcatering for external functions andparties, and some provide meals tonon-NHS bodies such as local carehomes and police stations.

4.19 The income from non-patientservices is generally used to offsetthe cost of the catering service. Ourreview found that 84% of cateringdepartments have set incomegeneration targets; this allowscatering managers to manage theirbudgets effectively.

4.20 Income from non-patientservices should at least cover thecosts of non-patient catering, andwhere possible contribute to the costof the patient service. The exceptionto this would be where a trust has aclear, written policy on subsidisingstaff meals. In such a circumstance,a target level of subsidy should beset and monitored. It is normal tohave a pricing policy for staff and aseparate policy for visitors (charginghigher prices).

4.21 All hospitals have pricing policies inplace, but in the main, hospitals arefollowing a pricing policy that wasoriginally set in 1978

15. This pricing

policy states that staff prices should beset at provisions cost plus 50% plusVAT. The pricing policy advised in thiscircular is unlikely to recover all of thecosts associated with providing a non-patient catering service.

15. NHS Circular 1978 (GEN) 6.

0

5

10

15

20

25

30

35

40

45

Perc

enta

ge

Hospitals

Bulk Hybrid Plated

Exhibit 8Percentage of unserved meals wasted on wards

Source: Audit Scotland(See Exhibit 2 for a definition of meal delivery services)

Part 4. Costs of the catering service

Grampian University Hospitals NHS Trust and Highland Primary Care NHS Trust have developed procedures tohelp reduce levels of ward wastage.

Grampian University Hospitals NHS Trust

Patients in the trust receive menu cards at breakfast time to complete for lunch and evening meal and the following day’sbreakfast. Ward staff collect the menu cards and forward them to the catering department which uses them for planningproduction levels. The menu cards are put into pigeonholes within the catering department and prior to each mealtime theward reception staff update them. Meals ordered for patients who have since been discharged are removed and orders fornew patients are inserted. This ensures that all patients receive a meal of their choice and food wastage is kept to aminimum.

Highland Primary Care NHS Trust

Ward and catering staff at Caithness General Hospital operate a straightforward but effective system that keeps cateringstaff as up to date as possible with the number of meals required for the day. A white board on each ward details all plannedadmissions and discharges for the day. Nursing staff note on the board the actual times of each admission or discharge andthe time at which the kitchen were informed. This aids communication between the wards and catering department andreduces the amount of unserved meals at ward level.

Case study 6Good practice examples


19

20

4.22 The income generated fromnon-patient catering rarely covers thecosts of the service. Around threequarters of hospitals are subsidisingtheir non-patient catering servicesand most are doing this unknowingly.Exhibit 9 shows the level ofcontribution or subsidy achieved in2001/02 for the hospitals reviewed.This ranges from an annualcontribution of £118,000 to a subsidyof £266,000.

4.23 The average hospital subsidy isaround £110,000 per annum. Thecost of this level of subsidy forNHSScotland is approximately£4.2 million per year.

Recommendations

• Trusts should ensure that theyhave appropriate financialinformation on the cateringservice to allow informeddecision making.

• All catering departments shouldhave systems in place whichallow them to accurately calculatethe costs of providing patient andnon-patient catering.

• Trusts should base their cateringbudgets on the most recent,relevant and accurate informationavailable.

• Trusts should consider setting adaily food and beveragesallowance for patients.

• All hospitals should aim to reducethe level of ward wastage(unserved meals) to 10%.

• Trusts should set pricing policiesand income generation targetsthat aim to at least break-even onnon-patient catering activities orhave a clear, written policy on thelevel and costs of subsidisation.

• The Scottish Executive HealthDepartment should withdrawcircular NHS 1978 (GEN) 6 andreplace it with guidance whichstates that non-patient cateringactivities should at least break-even.

Exhibit 9Contribution/subsidy level of non-patient catering services


£

Hospitals

-300,000

-200,000

-100,000

0

100,000

200,000

Part 5. The catering service

Main findings

There is a lack of strategicdirection for catering services.

Investment in computerisedsystems could improve controlover the catering service.

Some catering services aresuffering from recruitment andretention problems.

Some food handling staff are notappropriately trained in food safetyand hygiene.

5.1 This chapter looks at:

• management of the catering service

• food safety and hygiene.

Managing the catering service

Strategic direction

5.2 Many trusts are currentlyundergoing major service changesdue to retraction programmes in longstay hospitals and acute servicesreviews. In such circumstances trustmanagement should consider theimplications of those changes on allservices including the cateringservice. Their decision on the futureprovision of the catering serviceshould be set out in a formalstrategy document.

5.3 Only 15% of trusts have a formalcatering strategy. However, sometrusts have made recent strategicdecisions that have not yet beendocumented or formally approved.

5.4 The Diet Action Plan for Scotlandset out the requirement for food andhealth policies to include:

• a policy statement recognising

Part 5. The catering serviceHow are hospital catering services managed?

dietary problems with referenceto the Scottish dietary targets andany locally developed targets andinitiatives

• patients’ nutritional requirements

• staff meals

• nutritional education

• health promotion.

5.5 Around 90% of trusts have foodand health policies although some ofthese do not meet all of therequirements set out in the DietAction Plan.

Recruitment and retention of staff

5.6 The NHSScotland StaffGovernance Standard

16states that

sickness absence, staff turnover andstaff vacancy rates should bemonitored by trusts and the keyfactors affecting turnover should beknown eg, pay-related, careerdevelopment opportunities oremployee morale and motivation.To meet these requirements trustsshould have introduced measuressuch as back to work interviewsfollowing sick leave and exitinterviews.

5.7 Sickness absence rates for thehospitals reviewed are shown inExhibit 10. These range from 2.4%to 17.5%, with an average of 6.95%.Exhibit 10 also shows that city-basedhospitals appear to have a biggerproblem with sickness absence thanhospitals located in urban or ruralareas. Sickness absence in cityhospitals is averaging 8.79%, whichis above the average for all hospitals.

16. NHSScotland Staff Governance Standard (2002).

21

Exhibit 10Sickness absence rates for 2001/02


Dumfries and Galloway Acute and Maternity Hospitals Unit has introduced an incentive system to reduce sicknessabsence in the catering department.

The unit operates a scheme where catering staff are awarded a bonus dependent on the department’s performanceagainst the prior year’s budget. The bonus is also linked to sickness absence. Each individual’s bonus entitlement iscalculated using a ‘sliding scale’ depending on how many days sickness absence they have had. This systemincreases staff motivation and helps reduce the level of sickness absence.



22Perc

enta

ge

Hospitals

0

2

4

6

8

10

12

14

16

18

Average sicknessabsence = 6.95%

city rural urban

0

5

10

15

20

25

30

35

Perc

enta

ge

Hospitals

city rural urban

Average vacancyrate = 12.5%

Exhibit 11Staff vacancy rates for 2001/02

Part 5. The catering service

5.8 High levels of sickness absencemay be due to the nature of the workand the relative low pay of cateringstaff. We have identified some goodpractice in targeting sicknessabsence and an example is given inCase study 7.

5.9 Another factor that may affectthe ability of the catering departmentto meet demand and provide mealsof a consistent quality is a largeturnover of staff or high vacancy rate.Exhibit 11 shows that vacancy ratesfor the hospitals included in the studyvaried between 0% and 32% with anaverage vacancy rate of 12.5%. Ourreview identifies that vacancy ratesare higher in hospitals based in rurallocations. High staff vacancy andturnover rates may be due to the payrates offered by local competitors,the nature of the work and thelocation of the hospital.

5.10 The new pay deal for ancillaryworkers will help to address some ofthese problems but staff turnover

and vacancy rates should continue tobe monitored.

Computerised catering systems

5.11 Catering departments shouldplan their workloads and control therelated costs, quality and nutritionalcontent of meals provided.Computerised catering systemsprovide more accurate productionplanning and control over thecatering department as a whole.

5.12 Over half of hospital cateringdepartments have computerisedcatering systems in place. The extentto which these systems are usedvaries considerably. For example,some catering departments aresimply using these systems to storestandard recipes. Others are makingbetter use of their computerisedsystems by using them to controlstock levels, order goods, recordsales in the dining room throughelectronic point of sale, print menucards and carry out patientsatisfaction surveys.

Food safety and hygiene

5.13 The provision of safe andnutritious food in hospitals forpatients and staff is a majorundertaking. This is achieved byhaving a combination of goodmanagement, staff trained in safehygiene practices and catering skills,and appropriate quality controls.

Policies and procedures

5.14 The Scottish Infection Manual17

sets out the roles and responsibilitiesof NHSScotland bodies in relation toinfection control. It also includesspecific guidance relating to theprovision of safe food and cateringservices in hospitals.

5.15 Every hospital reviewed has afood safety control system in place.These systems ensure that food isprepared and served in accordancewith recognised food safetyprocedures and legislation

18.

5.16 As part of our survey on foodquality temperature failures were

17. Scottish Infection Manual, The Scottish Office (1998).18. Food Safety Act 1990, Food Safety (General Food Hygiene) Regulations 1995 and The Food Safety (Temperature Control) Regulations 1995.


23

24

identified at the point of servingmeals to patients. This may be dueto the location of the ward in relationto the kitchen or the use ofparticularly old equipment totransport or reheat food. Whateverthe reason this is an unacceptablefood safety risk and action should betaken to deal with this keyweakness.

5.17 Some hospitals have developedlocal policies for using microwaves atward level and patients and theirvisitors bringing food in to hospitals.These are particularly useful inavoiding some of the risksassociated with ward level catering.

Appropriately trained staff

5.18 Everyone who handles,prepares, processes and distributesfood should have an understandingof the principles of food hygiene andgood food handling practices. Thisincludes all staff that handle patients’food such as nurses, domestic staffand ward hostesses as well ascatering staff.

5.19 Over 90% of hospital cateringdepartments have a training policyand the majority support this with atraining plan. All catering staff havebeen trained in food safety andhygiene matters prior tocommencing production and servingduties and we found examples ofgood practice in this area. Forexample, where catering staff havenot yet been appropriately trainedthey carry out other non-foodhandling duties.

5.20 We reviewed a sample of wardbased staffs’ qualifications andtraining. This highlighted a number ofward based staff that are servingmeals to patients but have notreceived the appropriate training infood safety and hygiene.

Recommendations

Managing the catering service

• All trusts should have a food andhealth policy in line with the DietAction Plan for Scotland.

• Trusts should ensure that a clearstrategy has been approved forthe future provision of cateringservices where other services arebeing reconfigured.

• All trusts should ensure the staffgovernance standard forNHSScotland employees iscomplied with for all staff.

• Staff vacancy and turnover ratesare high in some areas. Wherethis is the case trusts should takeaction to address these issues.

• Trusts should monitor staffvacancy and turnover rates on aregular basis.

Food safety and hygiene

• Trusts should ensure that all foodhandling staff including wardbased staff are appropriatelytrained in food safety and hygiene.

• Where temperature failures havebeen identified as local issues fortrusts they should take specificaction to ensure that food isalways served to patients at thecorrect temperature.

Part 6. Recommendations

Nutrition

• Trusts should plan their menus inline with the recognisedprinciples of menu planning.

• All trusts should set up a group toplan the menu, ensuring that allavailable knowledge andexperience within the trust areused where appropriate.

• Trusts should ensure that patientsare screened on admission forrisk of undernutrition.

• Trusts should use a validatednutritional screening tool toscreen patients and staff shouldbe trained in how to use this tool.

• All menus should be nutritionallyanalysed. To avoid duplication ofeffort and maximise the use oflimited dietetic resources thiscould be done as part of thenational database of standardrecipes recommended below.

• All catering production unitsshould use standard recipes.The cost associated with thesestandard recipes should becalculated and maintained.The Scottish Executive HealthDepartment should considerdeveloping a national databaseof standard recipes forNHSScotland. This databasecould be held on NHSScotland’swebsite (Scottish Health On theWeb) to allow easy access.

• Trusts should ensure that cateringspecifications comply with themodel nutritional guidelines forcatering specifications in thepublic sector in Scotland.

• The DepartmentalImplementation Group shoulddevelop or commission nationalcatering and nutritionspecifications for NHSScotland.

Part 6. RecommendationsA summary of the recommendations made in this report

Quality and patient satisfaction

• Acute trusts with long stay bedsshould ensure that they have athree week menu cycle, at leastfor these patients.

• Menus should be reviewed toensure that they offer sufficientchoice to all patient groups.Where it is consideredappropriate, separate menus maybe developed for ethnic mealsand other special diets.

• Trusts should remind all of theirstaff of the procedures foroffering, ordering and deliveringmeals and in particular meals forpatients who require a specialdiet.

• All menus should be dietarycoded to help patients make aninformed choice.

• All catering services should aim tohave patients ordering their mealsas close to the mealtime aspossible and no more than twomeals in advance.

• All catering services should aim toprovide all patients with the mealthey ordered.

• Trusts should encouragecommunication between wardstaff and the catering department.

• Trusts should ensure that theyobtain patients’ views on thecatering service through theintroduction of regular (at leastquarterly) patient satisfactionsurveys.

• Trusts should monitor the qualityof the catering service throughinternal quality assurance surveysand/or using patient and usergroups to obtain the views ofpatients.

Costs of the catering service

• Trusts should ensure that theyhave appropriate financialinformation on the cateringservice to allow informeddecision making.

• All catering departments shouldhave systems in place, whichallow them to accurately calculatethe costs of providing patient andnon-patient catering.

• Trusts should base their cateringbudgets on the most recent,relevant and accurate informationavailable.

• Trusts should consider setting adaily food and beveragesallowance for patients.

• All hospitals should aim to reducethe level of ward wastage(unserved meals) to 10%.

• Trusts should set pricing policiesand income generation targetsthat aim to at least break-even onnon-patient catering activities orhave a clear stated policy on thelevel and costs of subsidisation.

• The Scottish Executive HealthDepartment should withdrawcircular NHS 1978 (GEN) 6 andreplace it with guidance whichstates that non-patient cateringactivities should at least break-even.

The catering service

• All trusts should have a food andhealth policy in line with the DietAction Plan for Scotland.

• Trusts should ensure that a clearstrategy has been approved forthe future provision of cateringservices where other services arebeing reconfigured.

25

26

• All trusts should ensure the staffgovernance standard forNHSScotland employees iscomplied with for all staff.

• Staff vacancy and turnover ratesare high in some areas. Wherethis is the case trusts should takeaction to address these issues.

• Trusts should monitor staffvacancy and turnover rates on aregular basis.

• Trusts should ensure that all foodhandling staff, including wardbased staff, are appropriatelytrained in food safety andhygiene.

• Where temperature failures havebeen identified as local issues fortrusts they should take specificaction to ensure that food isalways served to patients at thecorrect temperature.

Appendix 1. Study advisory group

Members sat on the group in apersonal capacity

Mr Scott Carmichael

Head of Performance Management– North Boards,Scottish Executive HealthDepartment

Mrs Marjory Chirnside

Catering Manager, West LothianHealthcare NHS Trust

Dr Bill Creaney

Consultant Psychiatrist, Psychiatry ofOld Age, Ayrshire and Arran PCT

Ms Ellen Davidson

Management Accountant, ForthValley Acute Hospitals NHS Trust

Mrs Isabella Dickie

Hotel Services Manager, Ayrshireand Arran PCT and Chair,Hospitals Caterers Association(West of Scotland)

Mrs Anne Hanley

Review Manager, NHS QualityImprovement Scotland

Mr Sean Hunter

Catering Manager, Royal Infirmary ofEdinburgh and Chair,Hospitals Caterers Association(East of Scotland)

Mrs Cathy McGillivray

Director of Nursing, Argyll and ClydeAcute Hospitals NHS Trust

Mr Brian Main

Support Services Manager, TaysideUniversity Hospitals NHS Trust

Mr Eddie Monks

Lay representative, Argyll and ClydeHealth Council

Mr Harry Norton

Finance Manager, GrampianUniversity Hospitals NHS Trust

Appendix 1. Study advisory group

Mrs Ann Paterson

Head of Nursing, Continuing Careand Psychiatry for the Elderly,Renfrewshire and Inverclyde PCT

Mr George Reid

Trustwide Catering Manager,Grampian PCT

Mr Douglas Seago

Director of Operations, HighlandAcute Hospitals NHS Trust

Ms Marjory Thomson

Professional Adviser – Nutrition,Care Commission

27

28

Appendix 2. List of references

1 ‘Clinical standards for food, fluidand nutritional care in hospitals’,NHS Quality ImprovementScotland (2003)

2 ‘Hospital food as treatment’,British Association for Parenteraland Enteral Nutrition (1999)

3 ‘The nutrition of elderly peopleand nutritional aspects of theircare in long-term care settings’,Clinical Resource and Audit Group(2000)

4 Scottish Health Services costsyear ended 31 March 2002,Information & Statistics Division(ISD)

5 Workforce Statistics as at 30September 2002, ISD

6 ‘The health of the nation –Nutrition guidelines for hospitalcatering’, Department of Health(1995)

7 ‘Hospital catering: Delivering aquality service’, NHS Executive(1996)

8 ‘Eating well for older people’, TheCaroline Walker Trust (1995)

9 Nursing Homes Scotland CoreStandards, Scottish Executive(MEL (1999) 54)

10 ‘Incidence and recognition ofmalnutrition in hospital’,McWhirter JP, Pennington CR(1994)

11 ‘Nutrition – assessment andreferral in the care of adults inhospital’, Best practice statement,Nursing & Midwifery PracticeDevelopment Unit (2002)

12 Better Hospital Food website,http://www.betterhospitalfood.com

13 ‘Eating for health: A diet actionplan for Scotland’, The ScottishOffice (1992)

14 Circular NHS 1978 (GEN) 6

15 NHSScotland Staff GovernanceStandard (2002)

16 Scottish Infection Manual, TheScottish Office (1998)

17 Food Safety Act 1990, FoodSafety (General Food Hygiene)Regulations 1995 and The FoodSafety (Temperature Control)Regulations 1995.


Catering for patients

Audit Scotland110 George StreetEdinburgh EH2 4LH

Telephone0131 477 1234Fax0131 477 4567

www.audit-scotland.gov.uk ISBN 0 904651 17 8 AGS/2003/10

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