Good nutrition and hydration are a priority in supporting people’s health and wellbeing and ultimately our patients and service user’s rehabilitation and recovery. We embrace a culture where everyone works together to improve the nutritional outcomes for our patients and service users in environments where our food is high quality, is part of our patients and service users care and is an important part of everyone’s day. Meals that look good, taste good and are nutritious are key to good health and together in an organisation where food and drink are everyone’s business, we can achieve our ambition of delivering the highest level of nutritional and safe care possible.

We have developed a Trust Nutrition & Hydration Strategy and policy, which are overseen and monitored by our Nutrition and Hydration Steering Group. You can view the policy on the policies and procedures section of YourSpace.

Merseycare NHS Foundation Trust is committed to promoting optimal nutrition and hydration for our patients across community, mental health and secure divisions. This may include advice on malnutrition screening to identify those at risk of malnutrition and the treatment of disease related malnutrition through food first/food fortification, oral nutritional supplementation or enteral feeding. We work closely with the wider MDT including District Nurses, GPs, Specialist Nurses, Speech and Language Therapists and Nutrition and medical teams to advocate the nutrition and hydration needs of our patients. We cover a wide range of settings from inpatient mental health and secure units, community outpatients and patients living in care homes, residential homes, ICRAS and reablement hubs, Longmoor House and in-reach to patients in respite or day centres. 

National obesity rates continue to rise and we are passionate about promoting healthy lifestyles amongst our staff and visitors. 

Our inpatient catering services and catering outlets aim to offer healthy food in a context of informed choice, while maintaining awareness of sustainability and environmental issues. 

What Is Dysphagia?

Dysphagia is the term used to describe difficulties that may occur with an individuals eating, drinking or swallowing. Dysphagia affects both adults and children and usually occurs as a result of another health condition. Conditions that are associated with Dysphagia include:

  • Neurological disorders, including stroke, Brain Injury, Parkinson’s disease, dementia, Muscular Dystrophy, Moto Neuron Disease etc
  • Respiratory conditions, including COPD, asthma
  • Learning Disability or developmental and acquired disorders e.g. Cerebral Palsy, Autism, Down Syndrome, Cleft Lip and palate
  • Cancers, including Oesophageal, Head and Neck etc.
  • Disorders of the immune system
  • Gastroesophageal disorders, including reflux

Watch our animation around dysphagia 

Implications of Dysphagia

Eating, drinking and swallowing difficulties have potentially life-threatening consequences and can greatly affect the quality of life of the individual with Dysphagia and those around them. Some identified implications and consequences of Dysphagia include:

  • Choking
  • Malnutrition
  • Dehydration
  • Fatality
  • Inability to take medications
  • Aspiration or developing a respiratory condition
  • Reduced Quality of Life and social implications
  • Anxiety and/or embarrassment around eating, drinking and swallowing

What are the signs of Dysphagia?

Early identification and management of Dysphagia can reduce hospital admissions,  fatality but also improve quality of life and mental health wellbeing.

Common Signs and Symptoms of Dysphagia include:

  • Coughing or choking while eating or drinking or up to 30 minutes post meal or drink
  • Bringing food back up (regurgitation)
  • Changes to voice quality around eating and/or drinking
  • A sensation that food is stuck in your throat 
  • Drooling of saliva  
  • Change in breathing rate while eating or drinking

The individual may also show changes to their general health including:

  • Recurrent chest infections
  • Pneumonia
  • Weight loss and/or reduced appetite
  • Dehydration and/or UTI’s

What you can do to help

  • If you are supporting a service user who is having difficulties with eating, drinking and swallowing, or you have concerns, please contact your Division’s speech and language therapy services (see list) Referrals are accepted based on the individual service's eligibility criteria however will also be able to offer advice.

How can we help you?

Our Team of speech and language therapists support individuals with Dysphagia by providing assessment, diagnosis and management of swallowing difficulties. We aim to improve the quality of life for patients and where possible improve function and independence within the community.

Speech and language therapists main roles whilst working within Dysphagia may include:

  • Promoting safety through Diet or Fluid Modifications in line with the IDDSI framework (see below)
  • Providing exercises or techniques to minimise risks with eating and drinking and aim to improve swallow function
  • Highlighting the need for further assessment
  • Working alongside the MDT as identified which may include GP’s, Nurses, Physiotherapists, Dietitians, Occupational therapists etc.
  • Supporting the individuals or their carers with expressing preferences or beliefs around their eating, drinking and swallowing needs

The Clinical Skills Team also provides training and/or guidance to our workforce who are supporting individuals who are at increased risk of Dysphagia. For more information please visit the Clinical Skills Team webpage.  

 
View our dysphagia page

‘MUST’: The ‘Malnutrition Universal Screening Tool’

‘MUST’ is a five-step screening tool to identify adults, who are malnourished, at risk of malnutrition (undernutrition), or obese. It also includes management guidelines which can be used to develop a care plan. It is for use in hospitals, community and other care settings and can be used by all care workers.

‘MUST’ - five-step screening tool

Step 1 Measure height and weight to get a BMI score. This chart can be used to calculate BMI . If unable to obtain height and weight, use the alternative procedures shown below.

Step 2 Note percentage unplanned weight loss. Please find weight loss charts to help with this calculation. 

Step 3 Establish acute disease effect and score. If a patient is acutely ill and there has been or is likely to be no nutritional intake for more than 5 days this would give a score of 2.

Step 4 Add scores from steps 1, 2 and 3 together to obtain overall risk of malnutrition.

Step 5 Use management guidelines and/or local policy to develop care plan.

Alternative measurement for weight: Mid upper arm circumference (MUAC).

  • If MUAC is < 23.5 cm, BMI is likely to be <20kg/m2
  • If MUAC is > 32.0 cm, BMI is likely to be >30 kg/m2

Alternative measurement for height: Ulna Length.

Guides on how to take the measurements can be seen here

Guidelines for Managing Malnutrition and Oral Nutritional Supplements in Inpatients can be found here which includes First Line Nutritional Advice

ALL resources for MUST can be found on the BAPEN website: www.bapen.org.uk.

Community Dietitians:

Please see Community Nutrition Support Policy 181 for guidance on MUST and referral criteria. This is available on yourpace  https://merseycare.nhs.uk/download_file/15179/0

The community dietitians request the malnutrition universal screening tool score is used as part of their referral criteria, although as oulined in the policy above there are certain patient groups that will be reviewed regardless of their MUST score based on their clinical condition. 

MUST compliance is monitored and all patients with a MUST of 2 or more require a referral to the Dietitian. 

Mental Health Care Division Dietitians:

All new admissions are to be screened within 72 hours of admission the MUST score will be repeated weekly through the admission. All patients will require a Nutritional care plan in line with MUST score.

Please follow the guidelines for referral to Dietitian.

MUST training, food fortification and first line weight management is delivered monthly, please contact your dietitian for dates

Choking

Choking is the term used to describe when someone experiences difficulty or an inability to breath due to an obstruction of the airway. It also referred to as Foreign Body Airway Obstruction (FBAO).

Anyone can experience choking and some of the main causes of Choking include:

  • Mechanical Causes

Including when we are not eating carefully or swallowing non food objects.

  • Neurological

Includes neurological conditions including, Stroke, Parkinson’s disease, Brain Injury or Trauma, Cancer etc.

  • Musculoskeletal

Weakness or changes to the structure of our muscles, bones and joints which can affect our posture and movements, for example- sitting up right or eating.

 

Symptoms of Choking

Choking symptoms may vary from person and may even be silent, however below are a list of common accompanying symptoms of choking:

  • Breathlessness or inability to breathe
  • Coughing
  • Appearing to be in discomfort or pain
  • Gagging
  • Dizziness
  • Unable to speak
  • Eyes watering or nose running
  • Unconsciousness
  • Changes to the person colour
  • Feeling something stuck at the back of your throat

Foreign body airway obstruction (Resuscitation Council UK Guidelines 2021)

  • Suspect choking if someone is suddenly unable to speak or talk, particularly if eating.
  • Encourage the person to cough.
  • If the cough becomes ineffective, give up to 5 back blows:
    • Lean the person forward.
    • Apply blows between the shoulder blades using the heel of one hand.
  • If back blows are ineffective, give up to 5 abdominal thrusts:
    • Stand behind the person and put both your arms around the upper part of their abdomen.
    • Lean the person forwards.
    • Clench your fist and place it between the umbilicus (navel) and the ribcage.
    • Grasp your fist with the other hand and pull sharply inwards and upwards.
  • If choking has not been relieved after 5 abdominal thrusts, continue alternating 5 back blows with 5 abdominal thrusts until it is relieved, or the person becomes unresponsive.
  • If you observe any of the following signs: The person becomes unresponsive, their legs are buckling or they are unable to hold their weight, start CPR.

Community Division

Please see community Dietetics webpages for service information, signposting information, inclusion and exclusion criteria and contact details for our Dietetic teams across Liverpool, Sefton and Mid Mersey.  

Liverpool Community Dietitians: https://www.merseycare.nhs.uk/dietetics-liverpool 

Sefton Community Dietitians: https://www.merseycare.nhs.uk/our-services/sefton/community-dietitians

Mid Mersey Community Dietitians: https://www.merseycare.nhs.uk/our-services/knowsley/community-dietitians

We also have a Community Nutrition Support Policy 181 available from yourspace link: https://yourspace.merseycare.nhs.uk/download_file/15179/0

This policy gives an overview of the management of malnutrition in community division and the relevant clinical evidence and guidance. 

Malnutrition Universal Screening Tool (MUST) training is available to staff on electronic staff record.  

Mental Health Care Division

Dietitians provide support for inpatient wards of Liverpool and Sefton. We accept referrals for a range of nutritional problems MUST 2+, food and fluid refusal, Unintentional weight loss – please be aware that some of our patients have unintentional weight loss due to deterioration in mental health but may have a BMI above healthy range these patients still require referral to dietitian.

In line with NICE Guidelines, we encourage food first approach and use oral nutritional supplements or artificial feeding where indicated.

We also accept referrals for other nutritional problems that are not identified by the MUST tool for example weight management, diabetes, bowels, Pressure areas this list is not exhaustive. Please contact your Dietitian for advice

Secure Services

Development of weight management pathway within the secure services.

Dietetics and the Health and Fitness team have developed an 8 week Nutrition and Fitness education programme in collaboration ‘FITTER’ with patients and service users in secure services.

Implementation of the NHS accredited FITTER programme which is monitored by NHS QISMET and feeds into a national agenda relating to nutrition and hydration. This is coproduced and delivered with patients and service users.

Dietetics also achieved NHS accreditation for the new 6-week Structured Diabetes Education Programme developed by Dietetics and Chronic Disease Nurses. Training and evaluation is being disseminated to multi-disciplinary teams to support delivery of these rolling programmes.

Community Dietetics

Community Dietitians are not commissioned to provide a specialist weight management advice service.  Weight management service provision varies across places. In Liverpool, Tier 1 and 2 Weight Management Services are commissioned by Liverpool Council by Liv Life Liverpool (https://livelifeliverpool.org) Tier 3 Specialist Weight Management Services are provided by Liverpool Obesity Support Service (LOSS) for those with a Liverpool GP and certain referral criteria must be met. There is a weight management service Healthy Knowsley for those with a Knowsley GP, more information here: https://www.merseycare.nhs.uk/our-services/knowsley/healthy-knowsley-service 

In Sefton, weight management advice is via Active Lifestyles Sefton: https://activelifestyles-sefton.co.uk

Dietitians will see those with overweight and obesity for other reasons other than weight management if they meet our inclusion criteria. 

 

 

Catering information

Catering Team

Food is provided by your local catering team. They are here to help with all your catering and food needs

Ashworth/Rowan View/Aspen Wood  Catering manager Dragana Jovanoska Dragana.jovanoska@merseycare.co.uk

Hollins Park/Brooker centre/Peasley court/Knowsley Resource centre Catering manager Paddy Costello Paddy.Costello@merseycare.co.uk

Liverpool Catering manager Martin Currell martin.currell@merseycare.co.uk

Clockview Facilities manager Kelly Manning Kelly.manning@merseycare.co.uk

Broadoak/Windsor House/Hope centre Ulrike Sharpe Ulrike.sharpe@merseycare.nhs.uk

Rathbone Facilities site manager Helen Coyne helen.coyne@merseycare.co.uk

Hartley Facilities site manager Angel Campbell Angela.Campbell@merseycare.nhs.uk 

Leigh Moss/Wavertree bungalow/Heys court Jan Nunn jan.nunn@merseycare.co.uk

Emma Hyland Catering Dietitian emma.hyland@merseycare.co.uk

Menus

Our menus have been developed with patients, caterers, dietitians, speech therapists and ward staff. The menus have been designed to meet the different needs of patients across the trust, providing healthy eating, higher protein/energy, vegetarian, and softer choices. Specialist menus including finger food, vegan and dysphagia menus are available. These can be ordered via the special diets request form.

To support patients in making healthy eating choices the amount of energy, protein, carbohydrate, fat,  sugar, salt, and portions of fruit/vegetables of the meals is available for patients.

Full allergen information of the menus is also available on the ward. If a patient has any allergens, please let catering know via the special diets request form.

Copies of menus are in development and will be published here once completed for the following areas: Whalley, Rowan view, Ashworth, Liverpool, Hollins Park

Further information on making the most of your menu can be found here

Meal observations

Regular meal observations are carried out  jointly by catering, dietitians or speech therapists and nursing staff called the power of three. These have increased collaboration between catering, dietitians, speech therapy and staff on the wards. It has also informed good practise and menu changes If you are interested in conducting a meal observation, please contact Emma Hyland catering dietitian emma.hyland@merseycare.nhs.uk and she will arrange this with you and your local catering team.

Please find copy of the audit here.

The catering dietitian along with catering also conducts regular meal audits which look at all aspects of food service and food safety.

Volunteers also regularly visit the wards and taste the food provided to give regular patient feedback regarding catering.

Patient feedback

There are regular catering meetings which catering, and ward staff attend. Catering staff and the catering dietitian will come to any community meetings to discuss food and catering with the patients. Please contact the catering dietitian Emma Hyland emma.hyland@merseycare.nhs.uk or your local catering manager.

Patient’s receiving food that they enjoy and is suitable for there needs is vital to help the catering services develop and make improvements. Patients can complete a patient satisfaction survey which can be returned to you local catering manager. Please click here for copy of the patient satisfaction survey.

Sustainability

Catering has an important role to play in the trust’s sustainability agenda. One of the ways this can be done is by reducing food waste. You can help by ensuring your orders are correct and not over-ordering food. Regular waste audits are conducted by catering staff.

Guidelines for food service

Staff on the wards or facilities management assistants may serve the food to patients depending to the site.  Please click to find some guidelines for a safe and efficient food service.

Food Hygiene

All staff serving food should have completed their on-line food hygiene training. If not, please discuss with your ward manager.

Training

Please find some presentation on various topics including special diets e.g. renal diets.

Special Diet Pathway