Residential care homes: how can diabetes care be improved?

A complaint was made by a pharmacist, who visited a residential home, that insulin was being drawn up by community nurses and left for administration at a later time by staff within the home. This practice contravenes the recommendations from the National Care Standards Agency. The advice from the Royal College of Nursing was also against this practice (RCN, 2001). Action was needed to move away from secondary dispensing. There were also concerns regarding residents within the home administering their own insulin when someone else had drawn it up, and a general lack of understanding of the care needs associated with diabetes in the elderly.

A starting point
A meeting was held with representation from social services, care homes, pharmacy, district nursing, diabetes link nurses, specialist nurse and clinical governance lead. At the initial meeting the practice was explored in depth and possible options were discussed.

Dosing boxes
The use of dosing boxes was considered. However, this option did not solve the problem that secondary dispensing was still needed. The ideal box was hard to find; there were costs involved and so dosing boxes were excluded.

Labelling of syringes
Labelling of individual syringes was also considered. Again this system was flawed because:

• Secondary dispensing would still be an issue. 
• The labels suggested and which the pharmacist would supply contained all of the ‘legal’ information and proved to be so large that it would be difficult for patients to handle the syringe and safely administer the insulin.

Personal refrigerators
The use of personal refrigerators for the residents was discussed. This suggestion fell at almost the first hurdle:

• Too expensive
• Too large for the space available within the care home setting
• Could highlight the difference between residents with and without diabetes which could also be seen as a stigma.

The way forward
It was agreed that the best way forward would be for the care home workers to administer the insulin. Everyone was happy with this suggestion which would mean no secondary dispensing and no concerns with labels.

However, training needs would need to be addressed and insurance within the homes became an issue. It was confirmed with the trusts’ insurers that nursing assistants were covered by insurance if it was considered that:

‘…the staff be competent and that they received appropriate management, training and supervision.’

Once a proposal was agreed the director of social services was made aware of all of the issues and decided that as long as joint protocols and training were in place the plan could go ahead.

The next stage was to produce documentation and a training package, and to gain the support of the staff for whom this training was applicable. The development of single use documentation was necessary because within the care home setting district nurses used a medication sheet signed by the local GP which did not necessarily contain all of the other medications. Similarly, the documentation used by the care home staff may not have had any mention of the insulin.

Competency needed to perform this task was also addressed and a simple training package was designed. It was also decided that the specialist nurse would assess all of the patients who would be affected by this change in practice, in order to ensure that appropriate injection devices were being used. The reason for this was that the most simple method was to be taught to the residential care home staff, and patients (with their informed consent) would be changed to pen injectors where appropriate (to reduce the risk of incorrect dosing).

Pilot stage
A pilot scheme was commenced in a single social service run care home. Training is currently being undertaken by the specialist nurse and a district nurse. All of the community nurses are kept informed of the situation by communication through the link nurses. The training addresses all areas around the administration of insulin, from ensuring that the right drug and dose are selected, to injection technique, including timing (particularly related to food) and disposal of the equipment. For some participants it is not necessary to administer the injection, but rather to help them inject themselves. Social services managers are involved and informed throughout the process.

At the end of the pilot scheme (which is planned to be 6 months) the lessons learned will be evaluated by the original team and the practice will be cascaded to all social service residential homes within the PCT. A decision will be made as to how the project is taken forward in private homes.

Audit
The possibility of an audit was discussed with the PCT audit facilitator and it was decided that a qualitative audit would be the most suited to the purpose. Consent for the audit will be obtained from the residents before the audit takes place. It will include how the residents feel about the service they receive from the district nursing staff and how they feel with regard to receiving help from a carer. The interview will be repeated with all residents after the training and change in service.

Lessons learned
The enthusiasm of the district and link nurses to be involved in such a project has been refreshing. Another revelation has been their need for support and education in the management of people with diabetes, especially the elderly and vulnerable.

Other issues which have been raised as areas of concern include blood glucose monitoring, especially in care homes where there appears to have been little in the way of education or support, with no quality assurance scheme in place. Diet is another area where there have been requests for help. Staff have asked for education and support and there appears to be a great interest and desire to provide high quality care for people with diabetes within care homes.

Working across the boundaries of healthcare and social care can be achieved. The goals of both services are very similar: to improve the physical and psychological health of their client groups, and to provide staff with the necessary tools.