Guidance for CQC staff: Inspecting the quality of care for residents with diabetes mellitus living in care homes
This Guidance explains why people living with diabetes in UK care homes can be particularly vulnerable and dependent. It provides a series of indicators that can help inspectors to assess whether a service is meeting the particular needs of people with diabetes; has an assessment and support framework that is thorough and safe; and protects their dignity and rights.
Diabetes Mellitus is the most common metabolic problem in our ageing society. It affects up to one in four residents of care homes, both with and without nursing. People living with diabetes are vulnerable to chest and urine infections, are often frail, and have high rates of admission to hospital when their health deteriorates.
Research has shown that diabetes is often poorly understood and managed in care homes. People living with diabetes often don’t have access to specialist diabetes services; these include retinopathy screening, foot care services, and diabetes treatment reviews. A recent audit showed that screening for diabetes on admission is rare, and that the national care home workforce is not well trained in diabetes care.
1. Is diabetes a particular problem in care homes?
Yes it is – diabetes affects around 25% of residents in care homes (residential and nursing) and 15% or more in mental health care facilities. A large proportion of these residents are very frail. They can have vascular complications that can lead to blindness and foot disease. Many are nearing the end of their lives.
2. Are there any national standards for the care of diabetes in care homes?
Diabetes UK produced national guidance in 2010. The guidance includes information to help with treatment decisions, a tool for recording important information about diabetes care, and support for the development of a diabetes care policy.
Two sets of international diabetes guidelines have also been published that provide information and advice on supporting residents with diabetes in care homes (see appendix 1).
3. Has diabetes care in UK care homes ever been audited?
Yes. In 2013 the Institute of Diabetes for Older People and the Association of British Clinical Diabetologists undertook a collaborative national audit of diabetes care in care homes and received responses from more than 2,000 care homes (see Appendix 1).
The audit found few diabetes screening policies; low levels of awareness and knowledge about diabetes; and inadequate training and education for care home staff.
4. What health and wellbeing problems were found by audit, research and guidance development work?
People living with diabetes often have other health problems at the same time, both acute and longer term. They are particularly susceptible to infection and diabetic foot disease, and are often admitted to hospital because their diabetes is not managed well. This is usually due to avoidable ‘hypoglycaemia’ (very low levels of blood sugar).
Research has found similar levels of diabetes in all types of care home, including those specialising in mental health care. Levels of prevalence range from 15-25%.
5. What gaps in diabetes care processes were identified by audit, research and guideline development work?
Most diabetes-related problems in care homes are linked to failure to follow a structured approach to recognising and managing the condition;
· screening on admission
· good day to day diabetes care practice
· access to specialist medical advice
· comprehensive annual diabetes reviews
· regular diabetes assessments and care by GPs
6. What medical care services are available for people living with diabetes in care homes?
Most GPs provide ‘reactive’ care to residents on request by care home staff; audits and research have found little evidence of routine, proactive diabetes care being offered.
Community-based teams sometimes include a ‘DSN’ (Diabetes Specialist Nurse) or dietician, where these are available care homes can ask them for specialist advice and support.
Podiatry services are often available, but not always for diabetes-specific foot care.
Specialist diabetes care consultants and nurse-consultants are sometimes available, but appointments can be hard to arrange.
7. What are the elements of good diabetes care?
Good diabetes care begins with a diabetes policy. A good diabetes policy describes and requires the four elements set out below.
1. Diabetes screening on admission that is recorded and audited.
This can reduce the number of GP call-outs and hospital admissions linked to undiagnosed diabetes and associated complications.
2. Availability of a fully-stocked and maintained hypoglycaemia kit.
This can reduce ambulance call-outs and hospital admissions due to hypoglycaemia.
3. A risk-calculation and assessment tool for diabetes foot disease.
Use of such a tool by suitably trained staff can reduce unnecessary amputations.
4. Access to good quality diabetes education and training for care home staff.
Good training can lead to fewer GP call-outs and hospital admissions for hypoglycaemia, infections, and other common medical problems associated with diabetes.
Good leadership and management in relation to the care of diabetes includes regular audit and assessment of these elements in practice.
Appendix 1 below sets out a flow chart for assessing diabetes care in care homes.
8. What things should be included in care plans for people living with diabetes?
· Information about the signs and symptoms of hypoglycaemia and hyperglycaemia (very high levels of blood sugar).
· How and when the person’s urine should be tested for glucose, who should do this, and where the results should be recorded.
· When, how and by whom blood glucose levels are tested and recorded.
· What should be done in the event of hypoglycaemia, including where the hypoglycaemia kit is kept (it can be worth checking expiry dates as these kits can be stored for a long time).
· Guidance about when glucose/oral fluids should be given, and when not.
· The action that needs to be taken when glucose levels are above or below a certain level (for example, reducing insulin / giving glucose drinks).
· How the person’s skin should be cared for (for example on their feet, skin infections and abscesses, when to involve a podiatrist).
· Information about the person’s diet, and when to involve a dietician
· Continence care (where needed; people living with diabetes can be prone to urinary tract infections).
· Eye care for the person, including arrangements for their annual screening.
· How and when to involve a Specialist Diabetes Nurse/ Clinic
9. What information is available for providers who want to improve the quality of their care for residents with diabetes?
Appendix 2 below includes links to websites with information about diabetes and key references for this guidance. They include information from national and international sources, results from the First England-Wide Diabetes National Care Home Audit, and references for major research articles and reviews in this area.
Appendix 1 Service diabetes care assessment flow chart
Appendix 2: Further Guidance
National Guidance for Diabetes in Care Homes:
International Diabetes Federation (IDF) guidance on managing type 2 diabetes in older people:
England-wide Care Home Diabetes Audit:
Sinclair AJ, Allard I, Bayer AJ. Observations of diabetes care in long-term institutional settings with measures of cognitive function and dependency. Diabetes Care 1997; 20(5):778-784
Sinclair AJ, Gadsby R, Penfold S et al. Prevalence of diabetes in care home residents. Diabetes Care 2001; 24(6): 1066-1068
Abdelhafiz AH, Sinclair AJ. Hypoglycaemia in residential care homes. Br J Gen Pract. 2009 Jan;59(558):49-50
Milligan FJ, Krentz AJ, Sinclair AJ. Diabetes medication patient safety incident reports to the National Reporting and Learning Service the care home setting. Diabet Med. 2011 Aug 26. doi: 10.1111/j.1464-5491.2011.03421.x. [Epub ahead of print]
Gadsby R, Barker P, Sinclair A. People living with diabetes resident in nursing homes–assessing levels of disability and nursing needs. Diabet Med. 2011 Jul;28(7):778-80.
Sinclair AJ; Task and Finish Group of Diabetes UK. Good clinical practice guidelines for care home residents with diabetes: an executive summary. Diabet Med. 2011 Jul;28(7):772-7. doi: 10.1111/j.1464-5491.2011.03320.x. Review.
Sinclair AJ, Paolisso G, Castro M, Bourdel-Marchasson I, Gadsby R, Rodriguez Mañas L; European Diabetes Working Party for Older People. European Diabetes Working Party for Older People 2011 clinical guidelines for type 2 d iabetes mellitus. Executive summary. Diabetes Metab. 2011 Nov;37 Suppl 3:S27-38. Review
Speight J, Sinclair AJ, Browne JL, Woodcock A, Bradley C. Assessing the impact of diabetes on the quality of life of older adults living in a care home: validation of the ADDQoL Senior* Diabet Med. 2012 Jul 18. doi: 10.1111/j.1464-5491.2012.03748.x. [Epub ahead of print]
New IDF Guideline for managing type 2 diabetes in older people. Dunning T, Sinclair A, Colagiuri S.
Diabetes Res Clin Pract. 2014 Mar;103(3):538-40. doi: 10.1016/j.diabres.2014.03.005.