① If a resident is currently overweight or was overweight prior to unplanned weight loss, consider whether regaining                             High risk 
        weight is in their best interests. If weight regain is not in the residents best interests, consider treating resident as lower risk        (Score 2 or more) 
                   
        category to avoid significant weight regain. Record reason for this in residents nutrition care plan 
        ② All Homemade Supplements must be made exactly according to the recipes provided by Herts CCGs 
                                                                                                                                         At significant risk of malnutrition① 
        ③ Make fortified milk by adding 4 tablespoons/60g dried, skimmed milk powder to each pint of full fat milk 
                                                      
                            Low risk                                       Medium risk                                        Update nutrition care plan - include treatment goal 
                            (Score 0)                                        (Score 1) 
                                                                                                              Aim to increase intake by 500 calories (+ other nutrients) per day using ‘food first’ 
                    Does resident have high                         At risk of malnutrition①                   
                    nutritional needs due to                                                                   Does resident have             Yes              Speak to Dietitian for advice 
                    pressure ulcer or similar                                                                 thickener prescribed?                         regarding thickened supplements 
                           condition?                            Update nutrition care plan                                                   No 
                                                                  - include treatment goal              R       In addition provide 2 portions per day of either Homemade Fortified Milkshake② 
                         No              Yes                                                                r
                                                                                                         MAntikec           or over the counter Complan, Meritene or Aymes Retail  
              Not at risk of             At risk of            Aim to increase intake by 500            o    s If milk is disliked provide 2 portions per day of Homemade Fortified Fruit Juice② 
           malnutrition – no           malnutrition           calories (+ other nutrients) per          takeMAR
          treatment required             – treat as                 day using ‘food first’              ly inect If patient dislikes sweet drinks – provide 2 portions per day of a cup-a-soup 
                                        Medium or                                                       dia orr   (avoid Slim a Soup varieties) made with fortified milk③ (instead of water)  
                                         High risk                                                      r d g c      If pt is unable to drink 2 x 200ml homemade supplements per day –  
            Update nutrition                                                                            o   sin                                            
                care plan                                     Every month (or earlier if you            Rec u      provide 1 portion per day of either Homemade Fortified Lemon Cream② 
                                                              are concerned) screen patient                                   or Homemade Fortified Chocolate Caramel Cream② 
                                                                    again using MUST 
                                                                                                                                                           
          Every month (or earlier if                                                                                                          Weigh resident weekly 
              you are concerned)                                Evidence of improvement                        Every month (or earlier if you are concerned) screen resident again using MUST 
            screen resident again                                     after 1 month?                           
                  using MUST  
                                                                        Yes                 No                                     Evidence of improvement after 1 month? 
         Version No       2.0                                                                                                  Yes                                    No 
         Developed by     Alison Smith, Prescribing 
                          Support Consultant            Continue until treatment              Treat as         Continue until treatment                  If you think you now need to refer to 
                          Dietitian, Herts Valleys           goal is reached                  High risk 
                          CCG                                                                                        goal is reached                     the Dietitian – follow chart overleaf 
         Date ratified    (Dec 2018) Review date 
         by HMMC          extension agreed July 
                          2021 
         Review date      July 2022 
                                                                 - Referring a care home resident to the Dietitian because of malnutrition 
                   
                                  Please note: In most cases referral of a resident will be treated as a 
            START HERE            referral for your whole Home. The Dietitian is therefore likely to 
                                  review nutrition for all residents 
                                                                                                        •    Complete ‘Nutrition assessment/referral form’ + 3 days detailed food record charts  
                                                                                                        •    Think about what the Nutrition assessment and food record charts are telling you 
                      Is resident at high risk of malnutrition?                                         •    Ensure that for at least 1 month you and your colleagues have done everything 
                                                                                                             you can to assist the resident to eat and drink enough 
                        No                                 Yes                                          If you still think you need to refer to the Dietitian, email (via nhs.net account) or post: 
                                                                                                        •    completed ‘Nutrition assessment/referral form’ 
          Referral to a Dietitian is not             Has food first treatment been provided             •    + completed 3 day detailed food record charts  
                                                                                                        •    + copy of current MAR to Hertfordshire Community NHS Trust Nutrition & 
          appropriate unless resident is             every day for at least 1 month?                         Dietetics 
          being treated as high risk for 
          another reason – Follow low,            No                    Yes 
          medium or high risk plan                                                                   No                                             Dietitian checks referral  
          Ensure that food first is                  Has resident improved? 
                                                     Please note: Improvement can mean weight 
          provided every day for at least            gain or, if resident was losing weight before, it                                             Referral is complete and 
          1 month                                    could mean no further weight loss or even a                                                    resident meets referral 
                                                     slower rate of weight loss                      Yes 
          This means the kitchen/ unit                                                                                                                      criteria? 
          staff must:                                                                                                                                 No                    Yes 
          •    Fortify foods like milk,                                             Referral to a Dietitian is 
               porridge, soup, custard,                                             probably not appropriate -                 Incomplete/inappropriate referral will     Dietitian will accept 
               mashed potato for the                                                Follow ‘Malnutrition                          be returned to Care Home with          referral and will work 
               resident,  at every meal                                             Management Guidelines’                      guidance on how to meet residents 
          •    Provide 2 nutritious                                                 overleaf                                            nutritional needs                  with whole Home  
               snacks between meals                                                                                             
               every day                                        NB: Referral to Dietitian is unlikely to be appropriate/accepted if: 
          •    Provide homemade                                 •   Adequate food first has not been provided every day for at least 1 month 
                                                                •   Resident has been unwell and/or has had hospital admission recently - this is likely to be the reason for weight loss 
               supplements every day –                          •   Resident has been admitted to the Home within the last 1 month - admission is likely to be reason for reduced appetite/intake 
               follow high risk plan                            •   Resident is reaching end of life (last few weeks of life)