Residential care - key issues

The new and updated guidelines (Diabetes UK 2010; Guidelines and Audit Implementation Network 2010) provide recommendations, standards and guidance designed to address identified deficiencies in care and to improve the effective provision of diabetes care within residential and care homes. The aim also is to eliminate inequalities in care across different care homes and settings.

Based on a literature review and the professional experience of members of the working party the updated guideline document from Diabetes UK (2010) identifies the gaps in provision of services and the barriers to effective diabetes care in care homes, some of which echo comments and recommendations made in earlier guidance and other reports (British Diabetic Association 1999; Diabetes UK 2006). These barriers include:

lack of resources in terms of staff time, catering services and equipment
lack of clear boundaries of both medical and nursing responsibilities exacerbated by poor communication channels
lack of national standards for diabetes care within care homes
lack of procedures for screening residents for diabetes
lack of understanding of dietary principles.

(Diabetes UK 2010 pp.20-21).

This is reinforced in the report Diabetes UK commissioned in preparing the guideline. Although the evidence highlighted areas of good practice this report also reveals that less than a quarter of homes are screening residents for diabetes on admission. There were no training structures in place in 17 per cent of homes. Diabetes UK estimates from the evidence they gathered via surveys and Freedom of Information requests that someone with diabetes is admitted to hospital from residential care every 25 minutes – see Diabetes in care homes: awareness, screening, training.

These potential barriers are further complicated by high levels of co-morbidities and communication difficulties in residents.

Some of the key areas that both of the 2010 guideline publications focus on are:

Individualised care planning

The aim should be “a well-designed, individualised, and implementable careplan” which has been based on a full assessment of a resident’s diabetes and other medical co-morbidities (Diabetes UK 2010, p.69). In both guideline documents recommendations are made about the content of the careplan and examples and templates are included.

Involvement of residents

The involvement of residents in their care planning and management of their diabetes including testing and recording of blood glucose levels, is to be encouraged as much as mental and physical abilities allow.

Health care professional roles

Clear links with and input from other health care professionals needs to be identified and good communication between different professionals involved in care planning is essential. Clear lines of communication also need to be established if a resident is unwell and specialist advice is required.

In the Diabetes UK guidelines a chapter is dedicated to looking at the role of different healthcare professionals in the provision of diabetes care in care homes. The importance of contact with specialist practitioners and their potential role in upskilling care home staff and acting as a source of advice and education is emphasised.

Annual review

This should be documented as part of the careplan. Again both guidelines suggest in detail the content of the reviews. The Diabetes UK document also highlights aspects of a review which are particularly specific to residents of care homes.

Nutrition

Nutrition and dietary issues are an important consideration for all residents in care homes and even more so for residents with diabetes. This is particularly so because of the frailty of many residents, the dangers of undernourishment or malnutrition, effects of other illnesses and potential lack of specialist dietary knowledge amongst care home staff. Nutritional assessment is essential and a key message is that “all residents require an individualised nutritional plan and should have access to a registered dietitian” (Diabetes UK 2010, p. 27).

A report of an action research project aiming to improve diabetes care across three care homes in Wales highlights some of these issues and the variation across the homes in knowledge, confidence and practice in relation to appropriate diets for residents. The report describes the changes achieved as a result of the project (Jones et al 2010).

Screening for diabetes

Both guideline documents emphasise the importance of regular screening of residents for diabetes and in Northern Ireland the annual screening of residents is identified as one of the four standards of care. The difficulties around diagnostic screening methods are discussed within the Diabetes UK document.

Monitoring implementation and outcomes

Monitoring the effectiveness of the implementation of these guidelines and standards is important at a number of levels. The guidelines published by Diabetes UK (2010) are seen as providing a framework for assessing the quality of diabetes care within care homes by the appropriate regulatory bodies. There is also discussion around the use of outcome measures and some of the difficulties that this poses in a residential care setting – “outcomes chosen require to be sensitive to an intervention but care delivered within care homes consists of multiple interventions making the correct choice of suitable outcomes complex and difficult” (Diabetes UK 2010, p.61). The document makes recommendations on specific outcome data that can be collected and responsibilities for this.

The use of an audit tool is also recommended and a key aim of the guidelines is “to provide local diabetes teams and the Care Quality Commission (CQC) with a diabetes audit tool which can be used to assess the quality and safety of diabetes care within care homes” (Diabetes UK 2010, p.7). In Northern Ireland it is intended that the four standards of care identified be “subject to audit” (Guidelines and Audit Implementation Network 2010, p.8).

Education and training in care homes

Both guidelines emphasise the importance of training and education on diabetes care for all staff working in care homes. The Diabetes UK document discusses some of the difficulties encountered in providing and maintaining training. In the Northern Ireland guideline training and education is the subject of one of the four care standards which states that “each care home will have a named member of staff, trained in the care of people with diabetes” and specifies that training should be available to all nursing and health care staff including chefs and cooks and should be updated every three years (Guidelines and Audit Implementation Network 2010, p.18). Both guidelines make recommendations on the content of training courses.

A table within the guidelines published by Diabetes UK (2010) outlines a wide range of courses and workshops which have been run for care home staff. Experiences of providing training courses are also documented elsewhere in journal literature and through other initiatives sharing practice experiences. Establishing contact and good working relationships can be an important outcome if local diabetes specialist nurses are involved in delivering training (Knight and Platt 2005).

References

Full details of the bracketed citations in the text above and, in many cases, links to the actual documents are available in the reference list within this resource. Go to the Reference list.