Guidelines for oral nutrition support - East Cheshire NHS Trust

Guidelines forOral Nutrition Supportin Adult InpatientsCNSG 003 East Cheshire NHS Trust Guidelines for Oral Nutrition Support in Adults Page 1 of 17

Policy Title:ExecutiveSummary:Supersedes:Description ofAmendment(s):Guidelines for Oral Nutrition Support in Adult InpatientsTo provide evidence-based guidance for the use of food fortificationand oral nutritional supplements for adult inpatients under the careof East Cheshire NHS Trust.New GuidelinesNew GuidelinesThis policy will impact on:All staff caring for adult patients under the care of East Cheshire NHS Trust (ECT).Financial Implications:Appropriate, timely and cost-effective oral nutritional support should improve nutritional careand reduce costs and risks associated with sub-optimal patient nutrition.Policy Area: Trust Wide Document Reference: CNSG003Version Number: 1 Effective Date: 1 st July 2011Issued By:Kath Senior, ExecutiveDirector of Nursing,Performance & QualityReview Date: 1 st July 2013Authors:Amanda Hamilton(Specialist Dietitian)Impact AssessmentDate:1 st July 2013APPROVAL RECORDConsultation:Approved by Director:Received for information:Committees / GroupDateClinical Nutrition Steering Group 31 st March 2011 &14 th June 2011Matrons and Departments of: 2009-2010 Nutrition and Dietetics Pharmacy Catering & Supplies Speech & Language TherapyMedicines Management Group April/May 2011Kath SeniorTrust Quality Strategy GroupCNSG 003 East Cheshire NHS Trust Guidelines for Oral Nutrition Support in Adults Page 2 of 17

CONTENTSPAGES1.0 INTRODUCTION 42.0 AIMS 43.0 ORGANISATIONAL RESPONSIBILITIES 53.1 Medical Staff3.2 Dietitians3.3 Matrons and Ward Managers3.4 Ward Pharmacists3.5 Catering & Supplies Departments3.6 Speech & Language Therapists4.0 SNACKS AND “OUT OF HOURS” MEAL PROVISION 65.0 FOOD FORTIFICATION 66.0 PRESCRIBABLE ORAL NUTRITIONAL SUPPLEMENTS 6-77.0 PROCEDURE FOR PATIENTS REQUIRING PRESCRIBABLE ORALNUTRITIONAL SUPPLEMENTS ON DISCHARGE FROM HOSPITAL 78.0 REFERENCES & RELATED DOCUMENTS 89.0 APPENDICES 9-121 Procedure for Ordering Prescribable Oral NutritionSupplements and Enteral Feeds for Adult Wards2 Oral Nutritional Supplements used for Inpatients at ECT3 How to Store & Use Oral Nutritional Supplements10.0 EQUALITY & HUMAN RIGHTS IMPACT ASSESSMENT FORM 13-17CNSG 003 East Cheshire NHS Trust Guidelines for Oral Nutrition Support in Adults Page 3 of 17

1.0 INTRODUCTIONAll clinical staff at East Cheshire NHS Trust (ECT) have a crucial role to play in achievingand maintaining good nutritional care.Malnutrition (under-nutrition) can adversely affect every system in the body. Many patientscoming into hospital are able to drink normally and manage a normal diet during theirhospital stay. Patients identified as “at high” risk of malnutrition, with a MUST (MalnutritionUniversal Screening Tool) score of 2 or above, will require nutrition support to help to meettheir nutritional requirements. Randomised controlled studies and meta-analyses suggestthat nutrition support of undernourished individuals can reduce mortality, complications afterillness, length of hospital stay, re-admission rates to hospital and costs of care, and alsoimprove well being. 1,2,3Nutrition support can be provided by the following: Food fortification and use of snacks Use of oral nutritional supplements, some of which are prescribable Enteral tube feeding Parenteral nutritionFood is the simplest form of nutritional intervention and should always be used first.Oral nutrition support (food fortification, snacks, supplements) is the first-line “treatment” forthose at risk of malnutrition and should always be considered before enteral tube feeding orparenteral nutrition.2.0 AIMSThe aim is to provide evidence-based guidance for the use of food fortification and oralnutritional supplements for adult inpatients under the care of health care professionalsworking in ECT.3.0 ORGANISATIONAL RESPONSIBILITIESThe Executive Director of Nursing, who is a member of the Trust Board, has overallresponsibility for the provision of nutrition within ECT. The Clinical Nutrition Steering Group(CNSG) is responsible for the oversight of all aspects of nutrition within ECT and is currentlyaccountable to the Quality Strategy Steering Group, which is in turn accountable to the TrustBoard via the Safety and Quality Standards Committee (SQS). For further informationregarding the role and responsibility of the CNSG in the provision of nutrition, refer to theEast Cheshire NHS Trust Nutrition Policy for in-patients (CNSG001).All clinical service team managers are responsible for ensuring compliance with thisguidance within their unit/team and that staff are competent and attend appropriate training.Certain professional groups and departments have specific responsibilities.CNSG 003 East Cheshire NHS Trust Guidelines for Oral Nutrition Support in Adults Page 4 of 17

3.1 Medical Staff are responsible for: Encouraging an awareness of the benefits of appropriate nutritional managementand treatment before, during and after hospital admission. Considering oral nutritional supplements as part of the appropriate nutritionalmanagement to prevent or treat malnutrition.Ensuring that oral nutritional supplements are correctly prescribed and monitored aspart of the patient’s nutritional care plans during admission and on discharge.3.2 Dietitians are responsible for:Assessing each patient’s nutritional requirements and making any recommendationsfor use of oral nutritional supplements as part of his/her nutritional care plan.Writing any recommended prescribable oral nutrition supplements on inpatient drugcharts, according to the procedure agreed with the Medicines Management Group.Requesting that the patient’s general practitioner prescribes any recommended oralnutritional supplements for patients discharged into the community, as part of theiron-going nutritional care plan, with guidance as to time span and review frequency.Ensuring appropriate nutritional, anthropometric and clinical monitoring of the patientin hospital and in the community if required. Delivering education and training programmes for staff relating to the use of oralnutritional supplements in patient care.3.3 Matrons and Ward Managers are responsible for ensuring that: Patients are screened for the risk of malnutrition using the Malnutrition UniversalScreening Tool (MUST) on admission and weekly thereafter.Nursing staff refer patients identified at risk of malnutrition (MUST score of 2 or more)to the Department of Nutrition and Dietetics.Ordering, stock control and storage of oral nutritional supplements is satisfactory.Ward staff are appropriately trained in the use of oral nutritional supplements.Prescribable oral nutrition supplements are correctly given.3.4 Ward Pharmacists are responsible for:Ensuring that prescribable oral nutritional supplements are correctly prescribed andthat any drug/nutrient interactions are identified.3.5 The Catering and Supplies Departments are responsible forProviding menus with a variety of choices at each mealtime, to include High Energy.Providing appropriate high calorie snacks.Using oral nutritional supplements to fortify meals as directed by the Department ofNutrition and Dietetics.Co-ordinating the ordering and supply of oral nutritional supplements from contractedsuppliers and/or wholesalers in a cost-effective and timely manner.3.6 Speech & Language Therapists are responsible for:Providing guidance to ward staff regarding thickening of oral nutritional supplementsto the recommended consistency for patients who have swallowing problems.CNSG 003 East Cheshire NHS Trust Guidelines for Oral Nutrition Support in Adults Page 5 of 17

4.0 SNACKS AND “OUT OF HOURS” MEAL PROVISIONThe NHS Plan (DoH, 2000) was devised to improve patients’ access to good quality foodand to improve its provision and presentation at ward level.The Catering Department is open from 0700 to 1800 daily. However, outside these hours,a snack box is available (accessible via the porters) for patients who have missed meals.Snacks are available at ward level and include milky drinks, biscuits, toast and Build-Up(non-prescribable supplement). Other snacks are at the discretion of the ward manager.Patients at high risk of malnutrition who are under the care of the Nutrition and DieteticsDepartment will receive snacks between meals, including appropriate snacks for patients ontherapeutic diets (e.g. gluten-free, texture-modified).5.0 FOOD FORTIFICATIONFood fortification is a key part of oral nutrition support and is done by enriching existingmenu items acceptable to patients to improve the nutritional profile. Fortification can bedone using food products such as butter, cream, milk powder and with prescribableborderline substances (see section 5.0). Items suitable for fortification include orange juice,porridge, soup, milk puddings, yoghurt, texture-modified meals and mashed potato.Patients requiring food fortification are identified by ward dietitians during nutritionalassessment and the requirement for a fortified “supplemented” diet is recorded at ward leveland in the Catering Department.The menus of patients requiring a supplemented diet are identified and amended by thedietetic assistant or designated person checking the menus, who highlights the items chosenfor fortification and collates the figures for the Catering Department.The diet chef fortifies the number of items required using standard recipes calculated by theDietetics Department.The highlighted menus are visible on the service belt and the supplemented items preparedare placed on the tray for the named patient for transport to the wards.6.0 PRESCRIBABLE ORAL NUTRITIONAL SUPPLEMENTSIn certain conditions some foods have characteristics of drugs and the Advisory Committeeon Borderline Substances (ACBS) advises as to the circumstances in which suchsubstances may be regarded as drugs. More details are given in section A7 of the BritishNational Formulary. Prescribable products used at ECT to fortify food are on the ACBS list.Prescribable oral nutritional supplements are ordered, stored and managed by wards atMacclesfield, Congleton & Knutsford hospitals. Each ward should have a designatedindividual responsible for this task, who should liaise with the Supplies and DieteticsDepartments. The procedure for ordering feed and supplements is outlined in Appendix 1.Certain borderline substances are also ordered by the Catering Department from theSupplies Department and from the collated figures wards can be recharged for the productsused at the end of each month.CNSG 003 East Cheshire NHS Trust Guidelines for Oral Nutrition Support in Adults Page 6 of 17

The range of nutritional supplements that are stocked at ECT is listed in Appendix 2. Someare nutritionally complete and can be used as a sole source of nutrition, while others areused to supplement an inadequate oral intake. It is essential that the patient’s total intake isa balance of protein, energy, fibre, electrolytes and vitamins and minerals (NICE guidanceCG032) 4 and this should always be considered when supplements are prescribed.The use of oral nutritional supplements should be restricted to those patients who are unableto meet their nutritional requirements despite the use of high calorie & protein foods and foodfortification. 4 Supplements can be used inappropriately leading to clinical risk and also highlevels of wastage with cost implications,Nutritional supplements should be given under the direction and supervision of a doctor ordietitian, who will write the appropriate product and dosage on the drug chart.If a patient is admitted on supplements not stocked by ECT, the Dietetics Department shouldbe contacted for advice about appropriate alternatives or obtaining the supplement.Supplements should not be given unless accurately written on the drug chart and signed forby a trained member of staff.Oral nutritional supplements should be thickened to the recommended consistency asadvised by the Speech & Language Therapy Department for those patients that areidentified as having swallowing problems.Unopened supplements should be stored in a cool dry place between 5 ºC and 25ºC. Onceopened, supplements should be stored according to the guidance outlined in Appendix 3.7.0 PROCEDURE FOR PATIENTS REQUIRING PRESCRIBABLE ORALNUTRITIONAL SUPPLEMENTS ON DISCHARGE FROM HOSPITALOn discharge, patients should be given 7 days supply of the oral nutritional supplements thatthey require, from ward stock. Oral nutritional supplements should not be listed specificallyas medications for discharge on the Electronic Discharge Notification Form (EDNF), butshould be included as “ward supplies”. If the patient is assessed as not requiring oralnutritional supplements on discharge, the dietitian will write “Not for TTO’s” in the instructionbox on the drug chart.While inpatients will be started on oral nutritional supplements supplied by the company thatholds the ECT contract for them, these supplements should be reviewed before discharge toensure that nutrition support in the community is provided in the most cost-effective way.Where appropriate, the ward dietitian should give samples of oral nutritional supplementsthat are more cost-effective for use in the community to the patient, who will be able to trialthese samples on discharge. If well tolerated, further supplies of these supplements canthen be requested from his/her general practitioner on prescription after discharge.For all patients who require prescribable oral nutritional supplements as part of their ongoingnutritional care plan after discharge, the dietitian will request a prescription from his/hergeneral practitioner using a standard prescription request letter. This will provide informationregarding the supplement(s) required and patient follow up plan.CNSG 003 East Cheshire NHS Trust Guidelines for Oral Nutrition Support in Adults Page 7 of 17

Patients in the community are followed up by the acute unit dietitians at the MacclesfieldDGH outpatient department or by general practice dietitians. No community dietetic serviceis currently provided in Eastern Cheshire for patients who are housebound or living inresidential care establishments, but in 2008 the dietetic service developed an algorithm fortheir nutritional management for care establishment staff and general practitioners to follow.Additionally, in collaboration with the Medicines Management Team, the dietetic service:has developed, and regularly reviews, guidance on prescribing oral nutritionalsupplements for general practitioners; and has contributed to the traffic light formulary and script switch to support ongoingcost-effective prescribing of oral nutritional supplements in the community.8.0 REFERENCES1. Edington J, Kon P, Martyn CN. Prevalence of malnutrition after major surgery.Journal of Human Nutrition and Dietetics 1997; 10: 111-116.2. Green C. Existence, causes and consequences of disease related malnutrition in thehospital and the community and clinical and financial benefits of nutritionalintervention. Clinical Nutrition 1999; 18 (Supplement 2): 3-28.3. Stratton RJ, Green CJ, Elia M Disease-related malnutrition. An evidence basedapproach to treatment. Oxford: CABI Publishing (CAB International), 2003.4. National lnstitute for Health and Clinical Excellence (NICE). CG032: Nutrition Supportin Adults, 2006.CNSG 003 East Cheshire NHS Trust Guidelines for Oral Nutrition Support in Adults Page 8 of 17

9.0 APPENDICESAppendix 1Procedure for Ordering Prescribable Oral Nutrition Supplements and EnteralFeeds for Adult Wards at Macclesfield, Knutsford and Congleton Hospitalsa) AIMTo ensure that all staff are aware of how to order enteral feeds, giving sets and prescribablenutritional supplements and that there are adequate stocks for all patients.b) ORDERING PROCEDURECurrently enteral feeding products are obtained through the Supplies Department (notPharmacy). There are 2 order forms:(i)(ii)Abbott Requisition Form – this is used to order products from Abbott, who hold thecontract, including feeding equipment such as giving sets and feed reservoirs.Non-Abbott Requisition Form – this is used to order all other specialised feeds andONSP. The more common items are listed on the form. No other products can beordered unless requested by the Dietetics Department.The Blank Requisition Forms are to be kept in a file marked FEED AND SUPPLEMENTORDERING.The stock levels should be checked weekly and orders placed if needed by 1200 midday onTuesdays. This is done by faxing the requisition to Supplies (fax number 3091).Patients discharged on prescribable oral nutrition supplements or enteral feeds will need totake seven days supply from ward stock.c) CHECKING ORDERSWhen products are received onto the ward refer to the order form to check that the order iscorrect e.g. all the products ordered have arrived and the correct giving sets have been sent.“Build Up” is non-prescribable and is obtained from NHS Logistics.CNSG 003 East Cheshire NHS Trust Guidelines for Oral Nutrition Support in Adults Page 9 of 17

Appendix 2Oral Nutritional Supplements used for Inpatients at ECTEnsure Plus Milkshake Style Prescribable Milkshake style – best served chilled Various flavours – vanilla/strawberry most popular Nutritionally complete – in 5 bottles Each bottle contains 330 Kcals and 14g protein Can be thickened with care Similar products include Fortisip, Fresubin Energy drinkAbbottEnsure Plus Yoghurt Style Prescribable Yoghurt style – best served chilled – No pro-biotic action Flavours include strawberry swirl and pineapple twist Nutritionally complete – in 5 bottles Similar products include FortifreshAbbottEnsure Plus Juce (Formerly Enlive Plus) Prescribable Fruit juice style – best served chilled Various flavours – lemon & lime are most popular Fat free NOT nutritionally complete Each bottle contains 330 Kcals and 11g protein Very difficult to thicken Similar products include Fortijuce, Provide ExtraAbbottEnsure Plus Créme Prescribable Pudding style supplement Four flavours Nutritionally complete Each pot gives 171 Kcals and 7 g protein ‘Custard ’consistency Similar products include Forticreme CompleteAbbottEnsure Plus With Fibre (Formerly Enrich Plus) Prescribable Ensure Plus with added fibre Each bottle gives 5g fibre, 305 Kcals and 12.5g protein Slightly thicker than Ensure Plus Similar products include Fortisip Multifibre, Fresubin Energy FibreAbbottEnsure Twocal• Prescribable• Each carton given 400 Kcalories and 17g protein• Nutritionally complete in two cartons• Slightly thicker than Ensure PlusAbbottCNSG 003 East Cheshire NHS Trust Guidelines for Oral Nutrition Support in Adults Page 10 of 17

Appendix 3How to Store & Use Oral Nutritional SupplementsUnopened supplements should be stored in a cool (5-25 o C) dry place. Some, e.g.Ensure Plus and Ensure Plus Juce, are more palatable if served chilled from the Wardfridge.Always check the 'best before' date before using.Once opened items should be labelled with the patient’s name. The following guidelinesshould be followed:Product Label required Once opened usewithinAdditionalinformationCalogen Date 14 days Must be stored inward drugs fridgeEnsure Plus Date and time 4 hoursEnsure PlusFibreEnsure PlusJuceEnsure PlusCremeDate and timeDate and timeDate and time4 hours4 hours4 hoursEnsure Twocal Date and time 4 hoursNepro Date and time 4 hoursMaxijul Powder Date 1 monthProcal Date 1 month for TubSingle use for SachetScandishake/EnshakeBuild-UpDate and timeWhen made up: 4 hours at roomtemperature24 hours in fridgeStore in ward foodfridge in coveredjug/beakerOpened sachet: 2 daysOpened sachet incool, dry place.Thickener andthickeneddrinksDate and timeWhen made up: 4 hours at roomtemperatureFor supplements not listed please refer to manufacturer's information or dietetic instruction.CNSG 003 East Cheshire NHS Trust Guidelines for Oral Nutrition Support in Adults Page 12 of 17

10.0 EQUALITY & HUMAN RIGHTS IMPACT ASSESSMENT FORMPart 1 – AIMS AND IMPLEMENTATION OF THE POLICY1.1 What is being assessed? Name of the policy, procedure, strategy or servicespecification (from now on referred to as ‘DOCUMENT’):Guidelines for Oral Nutrition Support in Adult Inpatients, CNSG0031.2 Details of person responsible for completing the assessment: Name: Dr. David Alan OLEESKY Job title: Consultant Chemical Pathologist and Chairman of CNSG until 31/3/2011 Team: Clinical Nutrition Steering Group (CNSG)1.3 What is the main purpose or aims of the document?(This is usually the first paragraph of what you are writing – cut and paste it here. Alsoinclude details of legislation, guidance, regulations etc which have shaped or informed thedocument)The document’s aim is to provide evidence-based guidance for the use of food fortificationand oral nutritional supplements for adult inpatients under the care of health careprofessionals working in ECT.1.4 Who is this document intended for?Who will need to do something differently because of this document? Who will be affected bywhat this document covers? All staff or just a team? All patients or just those who use aparticular service? Any other group?Clinical and catering staff involved in the care of adult patients who are considered for orbeing given food fortification and/or oral nutritional supplements. The particular clinical staffgroups concerned are medical practitioners, nurses and dietitians.1.5 How will the document be put into practice and who will be responsible for it?(Who defined the document? Who implements the document? Does this document cover aparticular team/Unit or does it link to another team, agency or contractor? If external partiesare involved then what are the measures in place to ensure that they comply with the Trust’sEquality and Diversity Policy?)The document is issued under the aegis of the CNSG, which is currently accountable directlyto the Trust Executive Management Team. The CNSG has overall responsibility forimplementation of the policy, but this is done via the medical/surgical divisions and clinicalteams working within them. Other departments involved include dietetics and catering.CNSG 003 East Cheshire NHS Trust Guidelines for Oral Nutrition Support in Adults Page 13 of 17

Part 2 – CONSIDERATION OF DATA AND RESEARCHTo conduct the assessment you will need information about service users, and the staff thatprovide the service. This section is to help you identify the sort of information that will beneeded to help you assess whether there may be barriers to different groups who areaffected by this document.2.1 Give details of RELEVANT quantitative and qualitative data or informationavailable that gives you an understanding of who will be affected by this document(include information where appropriate from other teams/units, census, patient or staffmonitoring etc.) Please note that in some cases data may not exist or be available and youmay therefore have to undertake additional research. Look on the Trust website/Intranet atthe local ‘Cohesia’ Report, which gives you more up to date data for the local area than thecensus. For information about Trust patient activity, contact the Information Department onext 1186.70% of referrals made to Nutrition and Dietetics are for nutrition support for patents at highrisk of malnutrition as identified by the Malnutrition Universal Screening Tool (MUST).2.2 Profile of users or beneficiariesWhat have you found out using this information? Are there any key groups of people who willbe affected, or who have been over/under represented?The majority of the patients requiring oral nutrition support are aged over 65 years. Theproportion of the population aged over 65 years is higher in Eastern Cheshire than the UK asa whole, so proportionately more individuals in this area may require oral nutrition support.2.3 Relevant consultationHaving identified key groups, how have you made sure that the document will affect them inthe way that you intend? Have you spoken to staff groups, charities, national organisationsetc?Consultation has been undertaken with representatives of the key groups involved inimplementation of the document.2.4 Evidence of complaints relating to this document on grounds of discrimination(Is there any evidence of complaints either from patients or staff (grievance) relating to thedocument or its effects on different groups?)None.2.5 Does the information gathered from 2.1, 2.2, 2.3 and 2.4 indicate any negativeimpact as a result of this document?No.CNSG 003 East Cheshire NHS Trust Guidelines for Oral Nutrition Support in Adults Page 14 of 17

Part 3 – ASSESSMENT OF IMPACTNow that you have looked at the purpose, etc. of the document (part 1) and looked at thedata and research you have (part 2), this section asks you to assess the impact of thedocument on each of the strands listed below.RACE – testing of disproportional and adverse impacta. How are racial groups reflected in the numbers of people affected by thisdocument? No difference from the general population.b. From the evidence available does the document affect, or have the potential toaffect, racial groups differently? Noc. If yes, do any of the differences amount to barriers, negative impact or unlawfuldiscrimination? Reason/evidence/comment. Not applicable.GENDER (INCLUDING TRANSGENDER) – testing of disproportional & adverse impacta. How are different gender groups reflected in the numbers of people affected by thisdocument? No difference from the general population.b. From the evidence available does the document affect, or have the potential toaffect, different gender groups differently? Noc. If yes, do any of the differences amount to barriers, negative impact or unlawfuldiscrimination? Reason/evidence/comment. Not applicable.DISABILITY – testing of disproportional and adverse impacta. How are disabled people reflected in the numbers of people affected by thisdocument? Disabled individuals may have more difficulty feeding themselves and aretherefore more likely to require food fortification and/or oral nutritional supplements.b. From the evidence available does the document affect, or have the potential toaffect, disabled people differently? Noc. If yes, do any of the differences amount to barriers, negative impact or unlawfuldiscrimination? Reason/evidence/ comment. Not applicable.AGE – testing of disproportional and adverse impacta. How are different age groups reflected in the numbers of people affected by thisdocument? Older patients are more likely to have malnutrition and require supplements.b. From the evidence available does the document affect, or have the potential toaffect, age groups differently? Noc. If yes, do any of the differences amount to barriers, negative impact or unlawfuldiscrimination? Reason/evidence/comment. Not applicable.CNSG 003 East Cheshire NHS Trust Guidelines for Oral Nutrition Support in Adults Page 15 of 17

CHILDREN - testing of disproportional and adverse impacta. Is there a direct or indirect impact upon children? Nob. If yes please describe the nature and level of the impact (consideration to be givento all children; children in a specific group or area, or individual children. As well asconsideration of impact now or in the future; competing / conflicting impact betweendifferent groups of children and young people. Not applicable.c. If no please describe why there is considered to be no impact / significant impact onchildren: The document does not apply to children.LESBIAN, GAY, BISEXUAL – testing of disproportional and adverse impacta. How are people with different sexual orientations reflected in the numbers of peopleaffected by this document? No difference from the general population.b. From the evidence available does the document affect, or have the potential toaffect, LESBIAN, GAY AND BISEXUAL people differently? Noc. If yes, do any of the differences amount to barriers, negative impact or unlawfuldiscrimination? Reason/evidence/comment. Not applicable.RELIGION/BELIEF – testing of disproportional and adverse impacta. How are people with different RELIGIONS OR BELIEFS reflected in the numbers ofpeople affected by this document? No difference from the general population.b. From the evidence available does the document affect, or have the potential toaffect, RELIGIOUS/BELIEF groups differently? Adherents of certain religions may bereluctant to take foods or oral nutritional supplements that do not comply with their beliefs.c. If yes, do any of the differences amount to barriers, negative impact or unlawfuldiscrimination? Reason/evidence/comment. No; staff need to be aware of the compositionof oral nutrition supplements regarding their acceptability from a religious perspective.CARERS – testing of disproportional and adverse impacta. How are people with caring responsibilities reflected in the numbers of peopleaffected by this document? No difference from the general population.b. From the evidence available does the document affect, or have the potential toaffect carers people differently? Noc. If yes, do any of the differences amount to barriers, negative impact or unlawfuldiscrimination? Reason/evidence/comment. Not applicable.OTHER – Additional groups that may experience impacts - testing of disproportionaland adverse impact:There are no other additional groups that may be adversely affected by this document.CNSG 003 East Cheshire NHS Trust Guidelines for Oral Nutrition Support in Adults Page 16 of 17

Part 4 - CONSULTATION WITH EQUALITY AND DIVERSITY LEADAt this point, you should forward the template to the Trust’s Equality and DiversityLead and arrange a meeting or telephone call. You will be asked a number of finalquestions based on your responses to date.(For service issues contact Lyn Bailey – 3981, for HR contact Ruth Knighton – 3042)You can record the results of that conversation here:E-mail approval from Lyn Bailey (PPI manager) sent 06 June 2011 at 09:31.Part 5 - CONCLUSIONS AND RECOMMENDATIONS5.1 Summary of changes implementedVERY briefly, list changes made as a consequence of conducting this assessment.None.5.2 Is there anything which you think may have an adverse impact but which youhave not been able to address in writing your document?No.5.3 Have you identified any work which you will need to do in the future to ensurethat the document has no adverse impact? List all actions (large and small) that havebeen identified during the assessment and include a named person and date for completion.Action Name Lead Date to be AchievedNone5.4 When will the document be reviewed?(Include dates for completion and officer(s) responsible.)March 2013, by Amanda Hamilton (Specialist Dietitian) in conjunction with the ClinicalNutrition Steering Group.Date completed: 13 th June 2011Signed by (Manager):David OleeskyCNSG 003 East Cheshire NHS Trust Guidelines for Oral Nutrition Support in Adults Page 17 of 17