Prescribing, policies & pathways
The integrated care board (ICB) is the local NHS organisation that ensures that health services work well together to improve health and wellbeing. The ICB have put together clinical and prescribing information including decisions, guidance, pathways and policies to healthcare workers within Hertfordshire.
Please ensure you use this website to stay up to date with the latest information and guidance. Prescribing, Policies and Pathways (hweclinicalguidance.nhs.uk)
You can view specific Nutrition documents here https://www.hweclinicalguidance.nhs.uk/all-clinical-areas-documents/nutrition-hydration for Primary Care, Care homes, relatives, and friends.
Documents include:
- Guides on Oral nutritional supplement (ONS), including thickeners and thickened guidance for Primary Care, Care homes, relatives and friends.
- Malnutrition
- Dysphagia
- Coeliac disease
- Vitamin insufficiency and vitamin deficiency
- Eating and drinking at end of life
- Eating well and eating well for for small appetites
- Guidance on food fortification and homemade supplements
- Managing nutrition
- Position statements on the use of ONS, prescribed nutritional products, end of life and dessert style ONS.
Nutrition in Care Homes
The following guidance is relevant to residents in any type of catered accommodation.
| Document name | Document description | Document link |
| Care Home Managing Malnutrition pathway | Care Home Malnutrition Management Pathway is designed specifically for care home staff. It sets out the nutritional management required for each level of malnutrition risk identified using MUST. It also links to all the ICB food-based resources below and details the process for care homes to follow if they think they might need to refer residents to a Dietitian. HWE Dieticians created a video to explain the pathway. Click here to view | Click here |
| Relative and friends leaflet – treating malnutrition | Relatives and friends’ information is a resource designed to support relatives and friends of people living in a care home setting to understand why ONS are not routinely used in care homes, and how food is used to meet peoples’ nutritional needs instead. | Click here |
Food in Care Homes
A food-based approach to managing malnutrition is focussed on intake of a ‘nutrient dense’ diet. Nutrient dense foods contain a wide range of nutrients including energy, protein, vitamins and minerals and may also contain fibre.
It is important for people who have or are at risk of malnutrition to be encouraged and enabled to eat foods from a variety of different food groups every day including:
• Starchy carbohydrates such as bread, pasta, rice, cereals or potatoes
• Protein such as meat, fish, eggs, nuts, beans/lentils, Quorn, soya
• Milk and milk containing foods such as yogurt, fromage frais or cheese
• Fruit and vegetables
• Fluid
As we age our requirements for fat or sugar do not increase therefore recommending an increase in intake of foods primarily containing these ingredients is unlikely to support good health. We are likely to need more protein and we still need the same amount of micronutrients (vitamins and minerals) as we did when we were younger. However, people who have or are at risk of malnutrition often have a small appetite and can find it more difficult to eat enough to meet these needs which is why advising a nutrient dense diet is so important. Vitamin and mineral intake can be supplemented by provision of a purchased one-a-day multivitamin and mineral supplement, but this should not be thought of as an alternative to a nutrient dense diet.
| Document name | Document description | Document name |
| Eating well – Homemade supplements | Homemade supplements is designed for patients at high risk of malnutrition according to MUST and intended to be provided together with either ‘Eating well for small appetites’ or ‘Fortifying Food for Care Homes’. The homemade milkshake recipe is nutritionally almost identical to prescribed milkshake type ONS. | Click here |
| Fortifying Food for Care Homes | Fortifying food is a brief, practical guide for Care Home cooks/chefs on how to fortify food for residents at medium or high risk of malnutrition according to MUST. It guides cooks/chefs to use nutrient dense fortifiers, and to use an adequate amount of each fortifier so that this enables intake of an additional 500 calories per day. | Click here |
| Creating a fortified diet: recipe book for caterers | Catering for people who are at risk of malnutrition or who are malnourished is a big part of food provision in care homes. The attached information and guidance may be slightly different to what you have learned before. It should help you to think a little differently about how food can best support nutritional needs for those with or at risk of malnutrition. | Click here |
| National Care Home Digest – food based standards for care home caterers | The BDA’s Nutrition and Hydration Digest is a fundamental resource, providing expert knowledge and support for all involved in the provision of food and drink services in healthcare. | Click here |
ONS in Care Homes
Hertfordshire and West Essex ICS does not support use of prescribed ONS for care home residents. Food-based interventions (which contain a similar range of nutrients) should be provided for residents by care homes instead. The only exceptions to this are if ONS is given via a feeding tube or resident requires thickened ONS due to diagnosed dysphagia requiring use of a thickener plus identified malnutrition.
| Document name | Document description | Document link |
| ONS in Care Homes position statement | ONS in Care Homes – Position statement provides a clear message for all care homes and healthcare professionals that homemade supplements should be routinely provided by care homes for the vast majority of residents identified as at high risk of malnutrition. Homemade supplements are nutritionally almost identical to ONS, as easy to make as a powdered ONS and more palatable. | Click here |
| Thickeners and thickening ONS | Thickeners and thickening ONS is a quick reference regarding thickener prescribing (which may be required for people with diagnosed dysphagia to reduce risk of aspiration). Resource ThickenUp Clear continues to be the first-choice thickener in Hertfordshire and Nutilis Clear is the first-choice thickener in West Essex. For those who also have malnutrition, pre-thickened ONS is likely to be more reliable than thickening standard ONS. | Click here |
| Dessert Style Oral Nutritional Supplements (ONS):Position statement | Dessert Style Oral Nutritional Supplements – Position Statement makes it clear for prescribers and others that ONS dessert type products are not appropriate for prescription due to their consistency (not in line with IDDSI), and lack of cost effectiveness (lower in nutrition and higher in price compared to comparable size liquid ONS). | Click here |
Nutrition for domiciliary care
The following guidance is relevant to people in their own homes or residing in supported living where they cook their own meals.
Food in domiciliary care
A food-based approach to managing malnutrition is focussed on intake of a ‘nutrient dense’ diet. Nutrient dense foods contain a wide range of nutrients including energy, protein, vitamins and minerals and may also contain fibre.
It is important for people who have or are at risk of malnutrition to be encouraged and enabled to eat foods from a variety of different food groups every day including:
• Starchy carbohydrates such as bread, pasta, rice, cereals or potatoes
• Protein such as meat, fish, eggs, nuts, beans/lentils, Quorn, soya
• Milk and milk containing foods such as yogurt, fromage frais or cheese
• Fruit and vegetables
• Fluid
As we age our requirements for fat or sugar do not increase therefore recommending an increase in intake of foods primarily containing these ingredients is unlikely to support good health. We are likely to need more protein and we still need the same amount of micronutrients (vitamins and minerals) as we did when we were younger. However, people who have or are at risk of malnutrition often have a small appetite and can find it more difficult to eat enough to meet these needs which is why advising a nutrient dense diet is so important. Vitamin and mineral intake can be supplemented by provision of a purchased one-a-day multivitamin and mineral supplement, but this should not be thought of as an alternative to a nutrient dense diet.
| Document name | Document description | Document link |
| Eating well for small appetites | Eating well for small appetites provides information on dietary changes that can be made to support individuals to meet their nutritional requirements using food. It includes hints and tips on suitable snacks and drinks, as well as guidance on fortifying food. | Click here |
| Eating well – Quick guide | Eating well – Quick guide is a short version of the above leaflet. It demonstrates how an additional 500 calories from nutrient dense foods can be consumed simply by making 3 or 4 small dietary changes each day. | Click here |
| Eating well – Homemade supplements | Homemade supplements is designed for patients at high risk of malnutrition according to MUST and intended to be provided together with either ‘Eating well for small appetites’ or ‘Fortifying Food for Care Homes’. The homemade milkshake recipe is nutritionally almost identical to prescribed milkshake type ONS. | Click here |
| Creating a fortified diet recipe book | This is a resource to support food fortification for those caring for people who have been identified as at risk of malnutrition, or who are malnourished. It is likely to be particularly useful for those working in, or supporting care homes for older adults, but could also be used to support people living in their own homes. | Click here |
ONS in domiciliary care
| Document name | Document description | Document link |
| Adult ONS in Primary Care | This is the main guidance for all GPs and other healthcare professionals (including dietitians) to follow & all other food-based resources can be accessed from this document. Malnutrition should be identified using the Malnutrition Universal Screening Tool (MUST) before treatment is commenced (medium or high risk = malnourished). Treatment of malnutrition should start with a food-based approach to management. | Click here |
| Thickeners and thickening ONS | Thickeners and thickening ONS is a quick reference regarding thickener prescribing (which may be required for people with diagnosed dysphagia to reduce risk of aspiration). Resource ThickenUp Clear continues to be the first-choice thickener in Hertfordshire and Nutilis Clear is the first-choice thickener in West Essex. For those who also have malnutrition, pre-thickened ONS is likely to be more reliable than thickening standard ONS. | Click here |
| Dessert Style Oral Nutritional Supplements (ONS):Position statement | Dessert Style Oral Nutritional Supplements – Position Statement makes it clear for prescribers and others that ONS dessert type products are not appropriate for prescription due to their consistency (not in line with IDDSI), and lack of cost effectiveness (lower in nutrition and higher in price compared to comparable size liquid ONS). | Click here |
Dementia & nutrition
| Document name | Document link |
| Eating and Drinking Well with Dementia: A Guide for Care Staff | Click here |
| Eating and Drinking Well with Dementia: A Guide for Family Carers and Friends | Click here |
| Eating and Drinking well: supporting people living with dementia | Click here |
Healthy eating in older adults – “Eating, drinking and ageing well”
Healthy eating messages for the general population are not always appropriate for older people, due to additional factors which influence health and eating with ageing.
Over 65s, for example, need a diet containing more protein, calcium, folate and vitamin B12. They may not be as able to identify thirst as they used to as well, so highlighting the need to drink enough, and that all fluids count for older people is important.
Nutrition & Learning Disabilities
| Resource name | Resource link |
|---|---|
| Healthy Bones leaflet for service users | Click here |
| Carers Guide to Helping People With Learning Disabilities Tackle Obesity | Click here |
Pressure Injuries & Nutrition
Pressure injuries (previously known as pressure ulcers, pressure sores and bedsores) are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin. Pressure injuries often develop where bones are close to the skin such as on the lower back/spine, hips, heels and elbows.
Pressure injury can occur for a number of reasons and poor food and fluid intake may be one of those reasons.
This fact sheet focuses on how food and fluid choices may be able to help with both prevention and treatment.
Hydration
Good hydration (drinking enough fluid) is important for all of us for lots of reasons, including preventing dehydration.
Older adults can be at higher risk of becoming dehydrated and may need to remember to drink regularly throughout the day.
- This fact sheet contains information about hydration for older adults (over 65 years).
- This fact sheet contains general advice about hydration for children and adults (under 65 years).
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