Better HospitalFoodCateringServices forChildren andYoung Adults

Better HospitalFoodCateringServices forChildren andYoung Adults

With the biggest building programme inthe NHS underway, designing healthcarefacilities that positively enhance thepatients’ experience and treatment iscentral to our policy. This meansaddressing such issues as privacy anddignity, communication, entertainment,nutrition, cleanliness, comfort, controland the supply of information. To meetthe standards expected by today’s – andtomorrow’s – patients, we need to ensurethat the design of hospitals and healthcarefacilities embodies sound principles fromthe outset.

This title forms part of a new series ofpublications by NHS Estates. Intended tostimulate and inspire all those involved indesigning, procuring, developing andmaintaining healthcare buildings, we hopethey will encourage new and inventiveways to improve environments for patientsand staff alike. They contain best practicecase studies, advice and guidance on howbest to implement and manageprogrammes for change in both newbuildings and areas for refurbishment.

4

Foreword

The NHS Plan identifies that ‘health at the very beginning of life is the foundationfor health throughout life’.

The food that children and young adults eat while in hospital plays a key part intheir treatment and recovery; it forms an important part of the child’s relationshipwith its hospital carers and can also provide social opportunities that are importantfor a child’s development.

It follows that good food and good food services for children and young adults arevital. The Children’s National Service Framework puts children and their families atthe centre of their care, and calls for Trusts to design services to meet children’sneeds: for food, this means making available the right food, at the right time, in anenvironment which will encourage the patient to eat.

I know that this book will be a valuable resource and will assist Trusts in providingchildren with first-class nutritional care by focusing on the special needs ofchildren and young adults in food and food service.

Al Aynsley-Green

National Clinical DirectorChildrens Services

Contents

ForewordAl Aynsley-GreenNational Clinical Director for Children

1 Introduction 7

Kate Harrod-Wild, 7Chair, Paediatric Group,British Dietetic Association

Neil Watson-Jones 8

Chair, Hospital Caterers Association

2 Scope of this book 9

3 Background 11

4 Nutrition in children 13

5 The Better Hospital Foodprogramme 15

(a) Catering Services for Children 15

(b) Long-stay patients and those 17with special dietary needs

(c) The Mealtime Framework 17

(i) Introduction 17

(ii) General principles 17

(iii) Breakfast 19

(iv) Mid-morning 20

(v) Mid-day meal 20

(vi) Mid-afternoon 21

(vii) Evening meal 21

(viii) Mid-evening 22

(d) 24-Hour Services 22

(e) Choice of eating environment 22

(f) Crockery, cutlery and tableware 23

(g) Menus and ordering 23

(h) Patient Satisfaction Surveys 24

6 Appendix 1: 25

Children and Adolescents’ CateringServices Assessment and ProgressMonitoring Toolkit

7 Appendix 2: 29

Members of the group

NOTE: All references to children in thisbook should be taken to include youngadults unless otherwise stated. 6

Kate Harrod-Wild

Chair, Paediatric Group of the BritishDietetic Association

The role of nutrition in health and diseasehas never been so well recognised. Childrenare particularly vulnerable to poor nutrition,because of their extra requirements forgrowth. Additionally, children’s appetitescan be much more adversely affected bychanges in food and environment than isthe case for adults. It is extremelyencouraging to see caterers and dietitiansworking together to improve food provisionfor children and young people. It is to behoped that chief executives will put foodand nutrition high on their agendas andprovide the funding to ensure that theserecommendations can be put into practice.This report gives a framework for bestpractice, which – if implemented – willhopefully do much to improve food provisionto meet children’s nutritional – andemotional – needs in the years to come.

Neil Watson-Jones

Chairman, Hospital CaterersAssociation

NHS catering provides approximately300 million meals a year and Children andYoung Adults form a significant proportionof this requirement.

Whereas those hospitals predominatelyspecialising in the care of this group ofpatients will understand the specific needsand requirements of Children, Young Adultsand their parents and family, that maybe notbe the case when this group of patientsare a small part of a much larger acutehospital setting.

The provision of an excellent cateringservice is dependent on a multi –disciplinary approach and requires anunderstanding of the patient’s requirements.This guide provides the key points to lookfor, makes recommendations on bestpractice and contains a comprehensiveaudit tool to assist hospitals in thedevelopment of a service that is secondto none.

The Hospital Caterers Association is fullysupportive of this guide, its aims andobjectives and see it as an invaluabledocument in aiding the development of ameal service designed specifically aroundneeds of Children & Young Adults. It hasbeen produced by a group of individualswith experience and specific workingknowledge of hospitalised children andI commend it to all those involved in thecare of Children & Young Adults.

7

Introduction1

8

The aim of this report is to assist hospitalsin designing appropriate catering servicesfor children and young adults, so that thebest possible nutritional outcomes canbe achieved including an awareness ofhealthy eating.

This book is intended for the benefit ofthose children and young adults in the agerange 12 months to 16 years. It has beencompiled by an ad-hoc working groupdrawing on the expertise and experience ofcatering managers, paediatric dietitians,nursing staff and activity organisers. Itrecognises the diverse needs of children inhospital ranging from undernourishment tochildren for whom a normal diet based onprinciples of healthy eating is appropriate.

It reflects the requirements of the NationalService Framework – Child Health. It alsoembodies the recommendations of theCouncil of Europe report from theCommittee of Experts on Nutrition, FoodSafety and Consumer Health Ad-Hoc Group– Nutrition Programmes in Hospitals, titledFood and Nutritional Care in Hospitals: Howto Prevent Undernutrition.

This document does not set mandatorytargets. Rather it sets out what could beconsidered a ‘Gold Standard’ in theprovision of catering services to childrenand adolescents. Hospitals are encouragedto consider the recommendations containedin the report and respond appropriately.

This report is intended for cateringmanagers and their staff, and additionallyall those who are involved in the provisionof care to children and adolescents. Thisincludes the following, although the list isnot exhaustive:

• Trust Chief Executives, Directors ofFinance, Directors of Nursing andBoards;

• Medical staff, particularlypaediatricians;

• Nursing staff;

• Dietitians;

• Ward housekeepers;

• Hospital education service providers;

• Play/activity specialists;

• Children, their families and friends.

At Appendix 1 is an assessment tool whichenables hospitals to undertake an initialassessment of the catering services theyprovide to children and young adults. Thiswill provide a benchmark against whichimprovements can be measured. The aimof all hospitals should be to make year onyear improvements in line with therequirements of the NHS Plan.

9

Scope of this book2

10

12

The Better Hospital Food programme wasannounced in the NHS Plan, published inJuly 2000. The NHS Plan recognised thatthe quality of hospital food varied greatlyacross the NHS, and that food was notalways served at times or in a manner thatencouraged patients to eat and enjoy theirmeals. The Plan recognised that thisresulted in too much food being wasted andthe failure of patients to benefit from thenutrition available.

The NHS increasingly recognises that thepractice of promoting good nutritionamongst hospital patients leads to otherbenefits, particularly providing anopportunity to develop healthy eating habits.Food is an important part of our lives: notonly does it sustain life, but it provides anopportunity for social interaction and can bea ‘high point’ in the day. In hospital,however, food plays an additional role:nutrition is a crucial element in the patient’streatment, and has an impact on recovery.

Cultural needs

The report has been written in genericterms since the key issues are relevantto all children regardless of their ethnicorigin or religious background.

However, hospitals should be aware thatchildren may have specific dietary needsarising from cultural or religious observancesand catering services must be sensitive toand take account of these.

To assist hospitals in this, it isrecommended that hospitals obtaina copy of the SHAP Calendar of ReligiousFestivals from:The SHAP Working Party,PO Box 38580,London SW1P 3XF(price at date of publication of thisreport £4.90).

11

Background3

14

As with adult patients, ‘ordinary’ foodshould always be the first choice ofnutritional support. If this proves insufficient,then the energy density of ordinary foodshould be optimised. Alternative forms offeeding should only be considered whererequired energy intake cannot be achievedthrough these routes.

For a child, a hospital stay represents asignificant break with routine. While this isgenerally acknowledged to be disruptive forthe child, such a break may also providegood opportunities to introduce new ideasand habits. A hospital may be a goodenvironment in which to introduce a childto health promotion messages, backed upby good eating habits encouraged by thehospital menu, and to begin to dispel anyinappropriate food myths.

The media, and TV in particular, play asignificant role in shaping the kinds of foodsthat children wish to eat. When designingcatering services for children, it is importantto be aware of not only current themes,campaigns and promotions, but alsooverarching strategies in the advertising ofchildren’s food, and to reflect these as faras possible and practical in the menus andtypes of food offered to children.

Nutritional screening

Hospitalised children are at nutritional risk,but the screening of paediatric patients atrisk is relatively easy to perform.

There are no validated nutritional screeningtools for children in the UK. However,accurate measurement of height and weighton admission and subsequent plotting ontogrowth charts will identify children who arenutritionally at risk. Weekly measurementof weight and three-monthly heightmeasurement would be a minimum aimin order to monitor adequate nutrition andhence growth. Keeping a record of a child’sintake of food and drink will easily identifya poor eater, and indicate the desirabilityof closer monitoring of the adequacy ofthe diet.

Recommendation:

All hospitals should have in place nutritionalscreening tools which at least ensure:

• measurement of weight and heighton admission;

• weekly measurement of weight andthree-monthly height measurement;

• accurate records of children’s intakeof food and drink;

• identification of children whose intakeis a cause for concern.

• identification of children at riskof developing obesity

In children, undernutrition and overnutritioncan have early and serious consequences.Excess energy intake coupled with reducedphysical activity can increase the risk ofdeveloping obesity, while undernutrition canlead to slowing of growth, increasedsusceptibility to infections, impairedneurodevelopment and increased length ofhospital stay. Additionally, children cannotsurvive starvation as long as adults becausethey have lesser energy stores relative totheir higher rate of energy expenditure.

The objective must therefore be to ensurethat children are able to eat sufficient foodto meet their nutritional requirements assoon as possible after admission, andparticularly following surgical procedures orduring treatment, since it is at these timesthey are most vulnerable.

In the popular axiom of dietitians, thenutritional value of food not eaten is nil.The importance of this cannot beunderestimated. Patients need to betempted to eat, and this is just as true ofchildren as of any other patient group.The attempt to impose a ‘healthy’ diet upona sick child can be futile and even counter-productive, for if such an impositionleads to insufficient food being eaten,prolonged ill-health can result. Rather thereport seeks to set out a strategy to ensurethat hospitalised children take in sufficient

and appropriate food to meet theirnutritional needs. However, it must berecognised that there may be some childrenfor whom a diet based on the principlesof healthy eating may be appropriate,particularly if they are overweight and atrisk of developing obesity. For such childrentheir hospital stay can be an opportunity todevelop an awareness of and experiencehealthy eating.

In very simple terms, this means:

Focus on energy

• the child should preferably decidewhat they want to eat;

• meet the Estimated AverageRequirement (EAR) for energy byincreasing energy density andfrequency of meals;

• round-the-clock availability of favouritefoods;

• avoidance of unfamiliar or ‘strange’foods.

Diminished focus on protein

• the recommended protein requirement(Reference Nutrient Intake or RNI) isnearly always met when the energyrequirement is achieved;

• avoid high (>20% energy from protein)intake as this might reduce appetite.

13

Nutrition in children4

16

Allied to this are the benefits to be obtainedfrom providing the opportunity for childrento eat with their parents and/or siblings. Insome cases the provision of food to these,or indeed to members of staff where thiswill encourage the child to eat, is to berecommended. Many hospitals alreadyhave an active policy of providing foodto non-patients where this has a positiveeffect on the child’s consumption, andsuch food provision can be looked uponas ‘therapeutic meals’.

Recommendation:

All hospitals should preparea pre-admission leaflet that:

• sets out clearly the hospital’s policyon provision of catering services tochildren and details the cateringservices available to them;

• sets out clearly the extent to which,and the manner in which, parents andothers are encouraged to contributeto ensuring children receive adequateand appropriate nutrition. This shouldinclude the circumstances in whichfood will be provided by the hospitalto parents and/or siblings where adviceis that this is appropriate and will be ofbenefit to the child’s nutritional status.

All hospitals should also preparea post-discharge leaflet that:

• provides appropriate advice abouteating to ensure that nutritional statusis not unnecessarily compromised bythe effects of treatment or surgery.

• Provides advice on healthy eating. Theopportunity should be taken to ensurethat parents/family/friends are aware ofthe potential to compromise the child’snutritional intake through the provisionof inappropriate snacks outside normalmealtimes.

Catering services for children

The following sections set out a range ofrecommendations regarding the provisionof catering services to children. The overallaim should be to provide a service that isflexible, responsive and caters for all thechild’s nutritional needs.

The view of the Working Group, and itssubsequent advice, is that for youngerchildren there is little to be gained fromthe availability of specially designed dishes.The emphasis for younger children shouldbe for the provision of popular, familiarfoods. Older children, however, may findthese designed dishes of greater attraction.The recommendation is that hospitals donot need to include Leading Chef dishesin children’s menus, but older childrenshould be given the opportunity to choosemeals from the hospital’s main menu (whereavailable) which will include Leading Chefdishes. Where this is the case, it isimportant to make children’s choicesappropriate in both content and preparation.

Many parents are concerned that thenutritional needs of children may not beadequately met by the catering serviceson offer. This can lead not only to increasedanxiety on the parents’ part, but also toincreased provision to children of food fromoutside the hospital. This in turn can resultin children eating too many inappropriate

snacks at inappropriate times, leading toreduced appetite at meal times and theconsumption of foods high in sugar, fat andsalt. Whilst the involvement of parents andother family members in the provision offood services to children is to beencouraged, it is important that where thistakes place it does so in a way whichcomplements the services provided by thehospital in a partnership which will supportand enhance the nutritional status andrecovery of the child.

It is acknowledged that the best formof food service for children is one thatallows the child to choose food at thepoint of delivery. The child’s ability to‘see before choosing’ and to monitortheir own portion size plays a significantrole in encouraging eating.

It is equally important that catering servicesin hospital should follow as closely aspossible an acceptable domestic pattern,so that poor eating habits such as grazing(the constant snacking of inappropriatefoods regardless of mealtimes) are notencouraged, that can interrupt a child’sspeedy return to a ‘normal’ life afterdischarge. The acceptable domestic routineinvolves a pattern of three meals a day withadditional snacks provided at set times.

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The Better Hospital Food programme5

Long-stay patients and thosewith special dietary needs

Whilst many of the recommendationscontained in this report apply equally tolong-stay patients and those with specificdietary needs, it is not within the scope ofthis document to provide further specificadvice on these patients. However, thefollowing points should be noted:

• there should be close involvementof specialist paediatric or otherappropriate dietitians in the provisionof catering services for these patients;

• there is a need for close monitoringof nutritional intake;

• particular attention should be paid toVitamin D intake for long-stay patients;

• ward staff should be aware ofe.g. birthdays and make suitablearrangements with the cateringdepartment for these to be recognised;

• where practical and possible, provisionshould be made for long-stay patientsto receive different meals to preventmenu fatigue. The opportunity to eatin the hospital restaurant, if this has theagreement of clinical and dietetic staff,could be of particular benefit in thisinstance.

The mealtime framework

(i) Introduction

With regard to children, the aim of a hospitalcatering service should be to ensure thatthe food on offer meets the nutritionalneeds of the patient. The service shouldalso be delivered in a manner, and in anenvironment, that encourages childrento eat.

A range of factors can have an adverseimpact on children’s eating habits when inhospital. In addition to the anxiety which canbe caused by hospitalisation and the effectsof treatment, these can also include theenvironment, which may be very differentfrom that which they are used to, and thefoods on offer which may also be differentfrom those the child is used to.

In designing catering services for children,it is therefore important to do all that is

possible to create an atmosphere which willmake children feel comfortable about eating.For children, especially younger children,this policy includes making mealtimes fun.

Recommendation:

When designing catering services forchildren, hospitals should:

(i) ensure that all non-essential activity onthe ward is kept to a minimum atmealtimes. In particular, this shouldinclude ensuring, for instance, thatconsultant ward rounds or other medicalactivity that could increase anxiety atmealtimes, does not occur exceptwhere unavoidable;

(ii) set aside time in the period leading upto the meal service to concentrate onfood-based activities, for instance, byencouraging children to be involved inthe meal service e.g. laying the table;

(iii) provide entertainments such asactivity/play sheets with menus*;

(iv) consider introducing incentives orrewards to recognise good eatinghabits. For example, in exchange formeals eaten, children may win stickersor stars that can be traded in for giftsor rewards. (It should be noted thatdietetic advice states that any rewardsissued under such a scheme shouldnot be food-based – it is inappropriateto give food as a reward for eating);

(v) ensure that all patients have access toa meals service which which is inaccordance with their religious, ethnicor cultural background.

See also ‘Choice of Eating Environment’(page 15)

* To assist hospitals, a range of suitable activity sheets willbe produced through the Better Hospital Food programmeand will be made available through the Better HospitalFood website at www.betterhospitalfood.com.

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THE BETTER HOSPITAL FOOD PROGRAMME

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(iv) Mid-morning

Provision of a mid-morning snack is animportant opportunity to provide childrenwith a high-calorie snack and drink.

Recommendation:

Hospitals should provide during themid-morning (but not within one hour of themain mid-day meal), a range of high-caloriesnacks and drinks, such as:

• milk/mousse-type desserts;

• biscuits;

• cakes/scones;

• tea cakes;

• cereals;

• cheese dippers;

• fresh fruit or fruit canned in juice;

• cheese/biscuits;

• crisps;

• fun-size chocolate bars;

• a range of hot and cold drinksincluding tea, coffee, water, milk,milk-shakes, 100% fruit juice andreduced-sugar fruit squash.

v) Mid-day meal

The mid-day meal should provide childrenwith the opportunity to choose from as widea range of popular foods as possible. Thischoice should preferably be made at thepoint of service. Hospitals should undertakeregular local surveys to ensure that thechoices offered accurately reflect localpreferences.

Recommendation:

Hospitals should provide:

• a minimum of six main courses withtwo choices of potatoes/rice and achoice of four popular vegetables suchas sweetcorn, carrots, broccoli, peas,baked beans, tomato, cucumber;

• a range of condiments/sauces,including ketchup, saladcream/mayonnaise, brown sauce,pepper and vinegar. Salt should notroutinely be offered;

• a minimum of three desserts whichcan include fruit canned in juice.

• older children (13 upwards) should begiven the opportunity to choose fromthe hospital’s main menu whereavailable. When offering dishes fromthe main menu, care should be takento ensure that these are appropriatein both content and preparation;

• a range of hot and cold drinks,including tea, coffee, water, milk,milk-shakes, 100% fruit juice andfruit squash.

(ii) General principles

The following should be available toall children every day:-

• 200 ml of 100% fruit juice richin Vitamin C;

• 350–500 ml of full fat milk(semi-skimmed should be availableon request for children over 2 yearsof age only);

• fresh fruit – smaller fruits such askiwi fruit and satsumas should beoffered in addition to pears, applesand bananas. Fruit canned in juicecan also be given.

Recommendation:

It is recommended that five helpings of fruitsand vegetables (in the appropriate portionsize for the child’s age) are given daily. Thiscan be given as part of the main meal or ata set snack time. Fruit juice can be countedas one of these helpings.

(iii) Breakfast

Research shows that breakfast is the mostpopular meal of the day. Its importance innutritional terms remains paramount.

Recommendation:

Breakfast should be available over anextended period from 6am to 9am andshould be served buffet-style.

Hospitals should make available as aminimum:

• a choice of four cold cereals popularwith children;

• one hot cereal;

• white and wholemeal bread or toastwith butter or a vegetable oil spreadrich in polyunsaturated ormonounsaturated fats and a range ofspreads such as jam, Marmite, nut-freechocolate spread* (SEE NOTE) andhoney;

• fresh fruit or fruit canned in juice;

• yoghurt;

• a range of hot and cold drinksincluding tea, coffee, water, milk,milk-shakes, 100% fruit juice andreduced-sugar fruit squash.

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5THE BETTER HOSPITAL FOOD PROGRAMME

* NOTE: The Department of Health recommends thatchildren with a parent or sibling with atopic disease shouldnot have peanuts or food containing peanuts until at leastthree years of age.

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(viii) Mid-evening

Hospitals should offer a similar range ofsnacks and drinks to those offered atmid-morning and mid-afternoon, withthe addition of warm milk-based drinks.

Recommendation:

Hospitals should provide during themid-afternoon (but not within one hourof the main evening meal), a range ofhigh-calorie snacks and drinks, such as:

• milk/mousse-type desserts;

• biscuits;

• cakes/scones;

• tea cakes;

• cereals;

• fruit or fruit canned in juice

• cheese dippers;

• fun-size chocolate bars;

• cheese/biscuits;

• crisps;

• fun-size chocolate bars;

• a range of hot and cold drinks includingtea, coffee, water, milk, milk-shakes,fruit juice, fruit squash, warm milk,hot chocolate.

24-hour services

The mealtime service, as set out above,will cater for the vast majority of nutritionalneeds. However, there will be occasionswhen this service may need to besupplemented by the provision of additionalfood and drink at other times – particularlylater in the evening and at night.

Through the Better Hospital Foodprogramme, hospitals already have in placea Children’s Snack Box. The aim of theSnack Box is to provide both a mealreplacement service where patients mayhave missed their meal from the mainservice and, when approved by nursingand dietetic staff, as an alternative tothe main meal(s) on offer.

Additionally, hospitals should ensure thatward kitchens have in stock a range of

popular foods so that a nourishing meal canbe provided when necessary outside normalmealtime services. It may also be desirableto provide packed lunches where desired,as these may encourage a sense ofnormality for the child.

Recommendation:

Hospitals should ensure that ward kitchensupplies include a range of foods that canbe quickly and easily prepared at ward levelto meet children’s needs outside the normalmealtime service. Typical foods whichshould be made available, in addition tothe Children’s Snack Box, include:

• toast;

• baked beans;

• tinned pastas, such as ravioli andspaghetti;

• soups.

Where there are no ward kitchens, thisfacility should be available from elsewhere inthe hospital.

Choice of eating environment

Studies suggest that improving the eatingenvironment could improve both nutritionalstatus and general well-being. For mostpeople, eating is a social occasion, andevery effort should be made to ensure thatthis is provided for.

The Council of Europe report recommendsthat all patients should have the opportunityto choose their dining environment, andshould also have the opportunity to sit ata table when eating their main meals. Inaddition, the Better Hospital Foodprogramme emphasises the importanceof encouraging patients to eat in a socialsetting wherever this is possible andpatients wish it. Furthermore, whenconsidering the needs of young children,it is also important to ensure that parents,family and/or friends have the opportunityto be involved in their children’s mealtimeswhere they wish to and where this ispractical. It is also important to recognisethat even children who may not be currently

(vi) Mid-afternoon

A similar range of snacks and drinksshould be made available as set out in‘Mid-morning’ above. This should not beoffered within one hour of the evening meal.

Recommendation:

Hospitals should provide during themid-afternoon (but not within one hourof the main evening meal), a range ofhigh-calorie snacks and drinks, such as:

• milk/mousse-type desserts;

• biscuits;

• cakes/scones;

• tea cakes;

• cereals;

• cheese dippers;

• fruit or fruit canned in juice;

• cheese/biscuits;

• crisps;

• fun-size chocolate bars;

• a range of hot and cold drinks includingtea, coffee, water, milk, milk-shakes,100% fruit juice and reduced-sugarfruit squash.

(vii) Evening meal

A similar range of meals should be offeredat the evening meal to that offered atmid-day.

Recommendation:

Hospitals should provide:

• a minimum of six main courses withtwo choices of potatoes/rice and achoice of four popular vegetables suchas sweetcorn, carrots, broccoli, peas,baked beans, tomato, cucumber;

• a range of condiments/sauces,including ketchup, saladcream/mayonnaise, brown sauce,pepper and vinegar. Salt should notroutinely be offered;

• a minimum of three desserts whichcan include fruit canned in juice;

• older children (13 upwards) should begiven the opportunity to choose fromthe hospital’s main menu whereavailable. When offering dishes from themain menu, care should be taken toensure that these are appropriate inboth content and preparation;

• a range of hot and cold drinks,including tea, coffee, water, milk,milk-shakes, 100% fruit juice andfruit squash.

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5THE BETTER HOSPITAL FOOD PROGRAMME

24

Professional advice is that with appropriatehelp even very young children can choosetheir own meals, provided the informationavailable is presented in the appropriateway. The Council of Europe reportrecommends that all patients should beinvolved in and have some control overfood selection, and whilst it is recognisedthat the ability to do so will vary accordingto age, the overall principle is confirmedin this report.

Even adults can find the requirement tochoose meals too far ahead difficult, andthis often leads to inappropriate choicesbeing made which, in turn, increases wasteand leads to patients missing their meals.This report is mindful of the fact thathospitals often have well establishedordering systems, and that changes tothese cannot necessarily be easily achieved.Nevertheless, in terms of setting out themost appropriate form of catering servicefor children, recommendations are madein this area to which hospitals are askedto respond wherever possible.

Recommendation:

Hospitals should:

• provide at least two menu designs –one for age ranges 1-11 and a secondfor 12 upwards. The content of thesemenus need not differ*;

• ensure that menus set out clearlythe meals on offer, with narrativedescriptions and appropriate useof photographs;

• in addition to personal menus, providefor ward display a poster sized versionof the menu;

• ensure that menus set out clearly therange of food services which will beprovided, and those which are available‘on request’ together with clear adviceon how to access these;

• ensure that all patients and/or theirparents/family/friends are involved inchoosing the meals they want whereverthis is possible;

• ensure that meals are chosen as closeto the point of service as possible, andin any event no more than two mealsin advance. Ideally children should beable to choose their meals ‘A La Carte’– at the time of service from apre-advertised range;

• review menu content at least annually(see the next section on patientsatisfaction surveys).

* Many hospitals already have ‘themed’menus – for instance, Thomas the TankEngine or Fireman Sam, and this is to beencouraged. However, to assist thosehospitals that do not have themed menus,through the Better Hospital Foodprogramme two menus will be designed forthe age ranges mentioned above. Hospitalswill be able to use and adapt these to localneeds. The menus will be provided tocatering managers and be available throughthe Better Hospital Food website atwww.betterhospitalfood.com.

Patient satisfaction surveys

Continuous feedback is crucial to anycatering system if it is truly to reflect theneeds of those it serves. Feedback is alsovital to the design of services locally within anational framework, so that specific needscan be taken into account whereverpossible.

Whilst there are inherent difficulties inseeking constructive feedback from youngchildren, parents, family and/or friends willoften undertake this role. Olderchildren/adolescents are fully capable ofexpressing their views if the questions areappropriately phrased.

Recommendation:

Hospitals should ensure they have in placea regular survey designed for children,offering the opportunity for them toexpress views on the catering service.

Hospitals may also wish to use this exerciseas a means of capturing information relatingto menu content in order that annualreviews may be carried out.

eating for medical reasons may benefit fromthe socialisation opportunities offered bymealtimes.

However, it may on occasion be undesirablefor children to eat with others (cases inwhich children have certain eating disorders,for instance). Hospitals must be sensitive tothe specific needs and circumstances ofindividual patients.

Recommendation:

Hospitals should, wherever practical andpossible, ensure that:

• children eat together in a social group;

• children are provided with theopportunity to eat in a dining-room orother suitable location that resemblesa home rather than a hospital;

• the involvement of parents, familyand/or friends is encouraged andfacilitated.

Hospitals should also consider, through theintroduction of voucher or similar systems,allowing children to take their meals inhospital restaurants where this does notconflict with their medical treatment andhas the approval of the dietitian and theward manager.

Crockery, cutlery andtableware

Children respond well to attractivepresentation of such items as crockery.For example, Great Ormond Street Hospitalcrockery features the crocodile from thePeter Pan story on plates and bowls –

children are encouraged to eat their foodbefore the crocodile does. Additionally,provision of appropriately-sized cutlery forboth young children and adolescents,together with ‘child-friendly’ trays, can domuch to enhance the overall mealtimeservice.

Recommendation:

Hospitals should:

• ensure that crockery, cutlery, trays andother tableware are attractive andsuitable to children and adolescents.

To assist in this, a standard range ofcrockery, cutlery and trays is beingdeveloped through the Better HospitalFood programme, and this will includea range for children. More details on thiswill be made available as soon as possible.

Menus and ordering

The Better Hospital Food programmerecognises the importance of a menu whichis attractive, informative and allows patientswherever possible to make informedchoices about their meal selections. Thisapplies as much to children as to adults.

However, the difference in age betweenadults and children mean that alternativeforms of menus should be made availablefor children. Additionally, the age range thatencompasses children and adolescentsmeans that the presentation of menusneeds to differ since adolescents may finda children’s menu condescending, whilstyounger children may find little appeal ina menu aimed at adolescents.

Menus for children should be thereforebe exciting, reflect modern trends, beattractively presented and be easy tounderstand and appropriate to the agerange targeted. They should describe thedishes on offer accurately and appropriately.The use of pictures is recommended. It isdesirable to use imaginative, playful namesfor dishes, and children’s menus shouldalso try to include colourful food whereverpossible and appropriate.

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26

No Practice Achieved Partially Not Target date to

achieved achieved be achieved

Yr1/Yr2/Yr3

Menu design

9 Is a specialist Children’s

menu in place?

10 Are activity/play sheets used

to encourage appropriate

eating?

11 Are surveys regularly

conducted to identify

local preferences?

12 Are menus appropriate to

age group available

13 Is menu content appropriately

described with pictures

or photographs?

14 Are poster – sized menus

available at ward level?

15 Are Children’s menus

‘A la Carte’?

16 Are menu contents reviewed

annually?

17 Do menus include healthy

options

18 Are young people able to

select from the main

patients’ menu?

19 Do all children have access

to a meal service appropriate

to their religious, ethnic and

cultural background?

20 Do children have access to

200ml 100% fruit juice daily?

21 Do children have access to

350–500mls of full fat milk daily?

22 Will the menu facilitate

5 servings of fruit or vegetables?

23 Are smaller fruits available

such as Kiwi or Satsumas?

24 Is a minimum of 4 cold and

one hot cereal available

at breakfast?

No Practice Achieved Partially Not Target Date to

Achieved Achieved be achieved

Yr1/Yr2/Yr3

Literature/Education

1 Are pre-admission leaflets

sent to parents/carers

advising them of Catering

services available?

2 Is a post-discharge leaflet

given to parents/carers?

3 Is there advice available

from a specialist paediatric

Dietitian?

4 Are Children encouraged to

become involved in meal

service?

5 Is a reward system in place

for meals eaten?

Nutrition/Assessment

6 Is nutrition assessment

undertaken at the point

of admission?

7 Is a nutrition-screening tool

in place?

8 Are vitamin D levels monitored

for long stay patients?

25

Appendices6Appendix 1

Children and adolescents’ catering services assessment andprogress monitoring toolkit

28

No Practice Achieved Partially Not Target Date to

achieved achieved be achieved

Yr1/Yr2/Yr3

Service arrangements/dining environment (continued)

40 Is a specific child friendly

dining environment available?

41 Are specialised crockery,

cutlery and trays available?

42 Are children encouraged to

choose their own meals?

43 Are meals chosen as close to

the point of service as is

possible?

44 Is equipment suitably themed

e.g. Fireman Sam food trolley?

Snacks/beverages/snack boxes

45 Is fresh fruit or fruit canned

in juice available on the ward

at all times?

46 Is there a wide range of hot

and cold drinks available

through 24hrs?

47 Are high calorie snacks

available at mid morning,

mid afternoon and mid evening?

48 Are children’s snack

boxes available?

Ward kitchen service

49 Is a snack service available

on request?

50 Are children’s ward kitchens

stocked with a range of

popular branded foods?

No Practice Achieved Partially Not Target Date to

achieved achieved be achieved

Yr1/Yr2/Yr3

Menu design (continued)

25 Is white or wholemeal bread

and toast available?

26 Are nut based products

avoided & does the menu

contain a statement about nuts?

27 At main meal times are

6 main courses on offer

at each meal?

28 Are 2 complex carbohydrates

on offer at each mealtime?

29 Is there a minimum choice of

4 popular vegetables on offer

at each mealtime?

30 Is there a choice of 3 desserts

on offer at each mealtime?

Service arrangements/dining environment

31 Can Children choose food at

the point of delivery?

32 Is a main meal service time

pre-defined?

33 Are Birthdays and other

special events recognised?

34 Are patients permitted to use

Hospital Restaurant facilities

where appropriate?

35 Are meal service times as

interruption free as is

practicably possible

e.g. are protected meal

times in place?

36 Is breakfast service available

from 6am to 9am and served

buffet style?

37 Table salt should not be

routinely offered!

38 Are packed lunches available

if required?

39 Do children eat together in

a social group?

27

6APPENDICES

Appendix 2

Members of the group

Graham Jacob NHS Estates

Fiona Bartlett Paediatric Dietitian, Variety Club Children's Hospital,

King's College Hospital

Lynn Cherry Restaurant Supervisor, Alder Hey Hospital

Philip Hassan Hotel Services Manager, Birmingham Childrens Hospital

Paul McDonald Catering Manager, Alder Hey Hospital

Katrina McNamara Nursing Officer, Department of Health

Anne Owen Catering Manager, Sheffield Childrens Hospital

Sophie Rees Policy Officer, Child Health Services, Department of Health

Vanessa Shaw Head of Dietetics, Great Ormond Street Hospital for Children

Faroukh Sorab Hotel Services Manager, Great Ormond Street Hospital

Graham Walker General Manager of Catering and Recreational Services,

St Thomas’ Hospital

Emma Wilson Catering Services Manager, Royal Hallamshire Hospital

Linda Wilson Paediatric Dietitian, United Hospitals Leicester

and with thanks to

Marcelle De Sousa University College London Hospital

Secretary

Ruth Benjamin NHS Estates

29

APPENDICES