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Registration Number: {{org_field_registration_no}}

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Managing Service Users Living with Diabetes Policy

1. Purpose

The purpose of this policy is to set out the arrangements used by {{org_field_name}} to ensure that people living with diabetes receive safe, effective, person-centred and lawful care and treatment.

Diabetes care will be based on an assessment of each person’s individual needs, preferences, clinical risks, level of independence, capacity to make relevant decisions and instructions from the person’s GP, diabetes specialist team or other appropriately qualified healthcare professional.

This policy supports compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as amended, including:

• Regulation 9 – Person-Centred Care;
• Regulation 11 – Need for Consent;
• Regulation 12 – Safe Care and Treatment;
• Regulation 14 – Meeting Nutritional and Hydration Needs;
• Regulation 17 – Good Governance; and
• Regulation 18 – Staffing.

{{org_field_name}} will ensure that diabetes care is delivered in a way that protects people from avoidable harm while promoting dignity, choice, independence and involvement in decisions about their own care.

Where responsibility for any part of a person’s diabetes treatment remains with, or is shared with, a GP, community nursing team, diabetes specialist team, pharmacy or other healthcare provider, {{org_field_name}} will work collaboratively with those professionals and will ensure that relevant information is shared promptly and safely to support continuity of care.

2. Scope

This policy applies to all service users diagnosed with diabetes, whether Type 1, Type 2, or other forms. It also applies to all staff, including care workers, nurses, kitchen staff, and senior management, who have a role in supporting individuals with diabetes. The policy covers all aspects of diabetes care, including monitoring, medication administration, nutritional management, physical activity, prevention of complications, and emergency response.

3. Legal and Regulatory Framework

This policy will be implemented in accordance with the following legislation, regulations and nationally recognised guidance, as applicable:

• Health and Social Care Act 2008;
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as amended, including:
  • Regulation 9 – Person-Centred Care;
  • Regulation 11 – Need for Consent;
  • Regulation 12 – Safe Care and Treatment;
  • Regulation 14 – Meeting Nutritional and Hydration Needs;
  • Regulation 17 – Good Governance;
  • Regulation 18 – Staffing; and
  • Regulation 20 – Duty of Candour, where the requirements of that regulation are engaged;
• Care Quality Commission (Registration) Regulations 2009, including notification requirements where applicable;
• Mental Capacity Act 2005 and its Code of Practice;
• Equality Act 2010;
• Data Protection Act 2018 and UK General Data Protection Regulation requirements concerning health and care records;
• NICE guideline NG17 – Type 1 diabetes in adults: diagnosis and management;
• NICE guideline NG28 – Type 2 diabetes in adults: management;
• NICE guideline NG19 – Diabetic foot problems: prevention and management; and
• other current nationally recognised medicines, diabetes and patient-safety guidance relevant to the person’s treatment.

Where national guidance, medicines safety advice or an individual clinical treatment plan is updated, staff must follow the most current applicable instructions. Any change affecting the person’s day-to-day diabetes care must be incorporated into the person’s care plan and communicated promptly to staff responsible for providing that care.

4. Person-Centred Diabetes Management

Each person living with diabetes will have their diabetes-related needs assessed and a personalised Diabetes Care Plan developed with them and, where appropriate, with a person lawfully acting on their behalf and relevant healthcare professionals.

The person must be involved in decisions about their diabetes care to the maximum extent possible and must be supported to maintain or develop their independence. Where a person wishes and is able to undertake elements of their own diabetes management, including glucose monitoring, use of diabetes technology or self-administration of medicines, this must be supported following an individual assessment of the risks and the support required.

The Diabetes Care Plan must contain, as applicable:

• the type of diabetes and relevant medical history;
• the person’s usual diabetes treatment and current prescribed medicines;
• the person’s individual blood glucose or sensor-glucose target range, where this has been specified by the responsible healthcare professional;
• the frequency and timing of blood glucose monitoring or arrangements for continuous or flash glucose monitoring;
• clearly documented lower and upper glucose thresholds requiring action and the action staff must take;
• insulin type, dose or dose-calculation instructions, timing and relationship to meals where insulin is prescribed;
• instructions for any variable-dose insulin regimen;
• the person’s usual signs and symptoms of hypoglycaemia and hyperglycaemia, including any history of impaired awareness of hypoglycaemia;
• an individual hypoglycaemia treatment and escalation plan;
• arrangements for managing hyperglycaemia, illness and ketone testing where clinically required;
• nutrition and hydration needs and any professionally advised dietary requirements;
• relevant allergies, intolerances and contraindications;
• mobility and physical activity considerations;
• diabetic foot-care risks and arrangements;
• use of insulin pumps, continuous glucose monitors, flash glucose monitors or other diabetes technology, where applicable;
• the person’s ability and wish to self-manage any aspect of their diabetes;
• the support required to enable the person to make informed decisions;
• relevant mental-capacity assessments, best-interests decisions or lawful authority where required;
• contact details for the GP, diabetes specialist team and other relevant healthcare professionals; and
• clear instructions describing when staff must seek routine, urgent or emergency medical assistance.

Diabetes targets and treatment must be individualised. Staff must not impose a standard glucose target, diet, medication regimen or treatment objective on all people living with diabetes.

The care plan must be available to staff providing care and must be updated promptly following changes to treatment, professional advice, health status, risk, capacity, preferences or diabetes technology.

5. Blood Glucose Monitoring

Blood glucose monitoring, continuous glucose monitoring or flash glucose monitoring must be undertaken in accordance with the person’s individual Diabetes Care Plan and the instructions of the responsible healthcare professional.

Where staff undertake blood glucose monitoring, they must have received appropriate training and have been assessed as competent to use the relevant equipment safely.

The person’s care plan must state:

• when monitoring is required;
• the person’s individual target range where one has been set;
• the glucose level or other circumstances at which staff must take action;
• what action must be taken for a low or high reading;
• when a reading must be repeated;
• when ketone testing is required, if applicable; and
• when the GP, NHS 111, diabetes specialist team or emergency services must be contacted.

Staff must not rely solely on a numerical result where the person’s presentation suggests hypoglycaemia, hyperglycaemia or acute illness. The person’s symptoms and clinical presentation must also be considered and the relevant escalation plan followed.

Where a continuous glucose monitor or flash glucose monitor is used, staff must understand the person’s individual device and care plan, including any circumstances in which a capillary blood glucose test is required to confirm a reading or inform treatment.

Blood glucose meters and associated equipment supplied or used by the service must be suitable for their intended purpose, maintained in accordance with the manufacturer’s instructions and used in accordance with infection prevention and control requirements. Test strips and other consumables must be stored correctly and must not be used after their expiry date.

Each blood glucose or relevant sensor reading obtained or acted upon by staff must be recorded accurately and contemporaneously, together with any symptoms, intervention, repeat reading, medicine administered and escalation undertaken where applicable.

Abnormal, unexpected or recurrent readings must not simply be recorded. Staff must take the action specified in the person’s care plan and seek clinical advice where required.

6. Medication and Insulin Administration

All medicines used to manage diabetes must be managed in accordance with the person’s current prescription, Medication Administration Record, individual Diabetes Care Plan, the Medication Management and Administration Policy (CH21) and current medicines legislation and guidance.

Medicines must be available in sufficient quantities to avoid missed treatment and must be ordered, received, stored, administered, recorded and disposed of safely.

Insulin must be:

• stored in accordance with the manufacturer’s instructions;
• protected from inappropriate temperatures and other conditions that could affect its effectiveness;
• clearly identifiable for the individual for whom it has been prescribed; and
• administered only by the person themselves where this has been assessed as safe, or by staff who have received appropriate training and have been assessed as competent for the task.

Where staff administer insulin, the correct person, insulin, dose, route and prescribed timing must be checked before administration. Any relationship between the insulin dose and the timing or carbohydrate content of a meal must be followed exactly as set out in the prescription and individual care plan.

Where a variable dose or dose determined by a glucose reading is prescribed, the written instructions must clearly state how the dose is calculated. Staff must not calculate, vary, omit or alter an insulin dose unless they are authorised and competent to do so and are acting in accordance with a valid prescription or specific instruction from an authorised prescriber.

The Medication Administration Record or other approved insulin administration record must state the actual insulin administered, including the dose and time. Statements such as “insulin given as prescribed” must not be used in place of recording the actual dose where the dose can vary.

Where the person uses an insulin pump or other insulin-delivery device, their care plan must describe who is responsible for operating the device, what support staff are authorised and competent to provide, and what action must be taken if the device fails or an alarm occurs.

Where a person wishes to self-administer medicines or insulin, an individual risk assessment must be completed and reviewed. The assessment must consider the person’s wishes, ability, capacity, medicine-storage arrangements, ability to use relevant equipment and any support required.

A missed, omitted, delayed, incorrect or duplicated dose, or any other medication error, must be dealt with immediately in accordance with the medication incident procedure. Staff must obtain appropriate clinical advice where there may be a risk to the person, monitor the person as advised, record the incident accurately and ensure that the incident is reviewed to identify and reduce the risk of recurrence.

7. Managing Hypoglycaemia (Low Blood Glucose)

Every person who is at risk of hypoglycaemia must have an individual written hypoglycaemia management plan. This must state the person’s relevant glucose threshold, usual symptoms, agreed treatment, repeat-monitoring arrangements and escalation instructions.

Possible signs and symptoms may include sweating, shaking, hunger, dizziness, palpitations, weakness, confusion, altered behaviour, irritability, drowsiness, reduced coordination, seizure or loss of consciousness. Some people may have reduced or absent warning symptoms.

Where hypoglycaemia is suspected and the person is conscious and able to swallow safely, staff must:

• check the person’s glucose level where this can be done without delaying necessary treatment;
• give the fast-acting carbohydrate treatment specified in the person’s individual care plan;
• repeat the glucose measurement within the period specified in the person’s care plan or clinical guidance;
• repeat treatment if hypoglycaemia persists, in accordance with the person’s plan;
• once the glucose level and symptoms have recovered, provide any follow-on carbohydrate or meal specified in the person’s individual plan; and
• continue monitoring and escalation as required.

If the person has reduced consciousness, is having a seizure, is unconscious or cannot swallow safely:

• nothing must be given by mouth because of the risk of choking or aspiration;
• staff must immediately follow the person’s emergency hypoglycaemia plan;
• glucagon must only be administered where it has been prescribed or otherwise lawfully supplied for that person and the member of staff is trained and competent to administer it;
• the person’s airway and breathing must be monitored and first aid provided within the staff member’s competence;
• the person must be placed in the recovery position where appropriate; and
• 999 must be called in accordance with the person’s emergency plan and whenever severe hypoglycaemia, persistent reduced consciousness, seizure or another medical emergency is present.

All hypoglycaemic episodes must be recorded, including the glucose reading where available, symptoms, treatment provided, repeat readings, outcome and any professional advice sought.

Recurrent, unexplained, severe or nocturnal hypoglycaemia must be escalated for clinical review. The person’s Diabetes Care Plan and risk assessment must be reviewed following significant or recurrent episodes.

8. Managing Hyperglycaemia (High Blood Glucose)

Each person’s Diabetes Care Plan must specify their individual arrangements for managing hyperglycaemia, including the glucose threshold at which action is required and when healthcare advice or emergency assistance must be sought.

Possible signs and symptoms include increased thirst, frequent urination, tiredness, blurred vision, dry mouth, dehydration, nausea, vomiting, abdominal pain, drowsiness, confusion, deep or unusual breathing and deterioration in the person’s general condition.

Where a high glucose reading is identified, staff must:

• follow the person’s individual Diabetes Care Plan;
• repeat monitoring as instructed;
• encourage appropriate fluid intake where the person can drink safely and there is no clinical restriction;
• administer diabetes medicines only in accordance with the current prescription;
• never give an additional or corrective dose of insulin unless this is specifically authorised by the person’s prescription or individual clinical plan; and
• obtain advice from the appropriate healthcare professional where readings remain outside the person’s agreed range or where the person’s condition causes concern.

For people for whom ketone monitoring is clinically required, including relevant people with type 1 diabetes, the Diabetes Care Plan must include individual sick-day and ketone-testing instructions. Staff undertaking ketone testing must be trained and competent and must follow the person’s prescribed escalation thresholds.

Emergency assistance must be sought without delay where diabetic ketoacidosis (DKA), hyperosmolar hyperglycaemic state (HHS) or another acute medical emergency is suspected.

Signs requiring urgent escalation include significant deterioration, vomiting, marked dehydration, altered consciousness, severe drowsiness, difficulty breathing or other symptoms identified in the person’s emergency care plan.

Hyperglycaemic events, ketone results, actions taken and professional advice must be documented contemporaneously.

9. Dietary and Nutritional Considerations

Each person’s nutrition and hydration needs must be individually assessed and reviewed as part of their care planning. Diabetes alone must not result in the person being placed on a standard or unnecessarily restrictive “diabetic diet”.

Food and drink arrangements must take account of:

• the person’s assessed nutritional and hydration needs;
• diabetes treatment and the timing of medicines or insulin;
• individual clinical advice;
• swallowing difficulties, allergies, intolerances and other medical conditions;
• the person’s preferences and choices;
• cultural, religious, ethical and moral requirements;
• the person’s capacity and consent;
• risks of malnutrition, dehydration, unintended weight loss or weight gain; and
• any prescribed nutritional supplements or specialist dietary requirements.

Where a specific diet, nutritional supplement or timing of food has been prescribed or advised by an appropriate healthcare professional, this must be reflected in the person’s care plan and followed.

People must be supported to make informed choices about food and drink. Staff must not unnecessarily restrict food or drink solely because a person has diabetes.

Suitable food and drinks must be available in sufficient quantity, and people must receive any assistance they require to eat and drink safely and with dignity.

Where a person is at risk of hypoglycaemia, appropriate fast-acting carbohydrate treatment must be readily accessible in accordance with their individual hypoglycaemia plan.

Nutrition and hydration intake must be monitored and recorded where this has been identified as necessary through assessment. Changes or concerns, including poor intake, dehydration, unplanned weight loss or recurrent glucose disturbance associated with eating and drinking, must be escalated promptly.

10. Physical Activity and Mobility

• Service users are encouraged to engage in gentle physical activity, such as walking or seated exercises, where appropriate.
• Exercise plans are personalised to each resident’s mobility level and health status.
• Staff monitor for exercise-induced hypoglycaemia, ensuring safe participation.

11. Foot Care and Preventing Complications

Each person living with diabetes must be supported to reduce their risk of diabetic foot complications in accordance with their individual needs, clinical risk and advice from their GP, podiatry service or diabetes team.

The person’s care plan must identify any known diabetic foot risk and the level of observation or assistance required.

Where daily foot observation has been identified as necessary, the person must be supported to check their feet or staff must undertake the agreed observation within their competence. Staff must look for new:

• breaks in the skin or ulcers;
• blisters;
• redness;
• swelling;
• heat;
• discharge;
• bleeding;
• change in colour;
• unexplained pain;
• signs of infection; or
• other significant change from the person’s usual condition.

Any new active diabetic foot problem must be escalated promptly to an appropriate healthcare professional. Staff must not wait for a routine care-plan review.

Immediate emergency medical assessment must be sought where there are potentially limb-threatening or life-threatening features, including a diabetic foot ulcer accompanied by signs of sepsis, limb ischaemia, suspected deep soft-tissue or bone infection, or gangrene.

Other new active diabetic foot problems must be referred promptly through the appropriate NHS pathway in accordance with current NICE guidance and local arrangements.

Personal foot and nail care undertaken by staff must remain within the worker’s training and competence. Staff must not undertake podiatric treatment, remove callus or undertake nail-care procedures where this would require specialist assessment or skill. Concerns must be referred to an appropriately qualified professional.

People must be supported to use appropriate, well-fitting footwear and to attend diabetic foot assessments, retinal screening and other diabetes-related monitoring arranged by their responsible healthcare professionals.

12. Training and Competency of Staff

{{org_field_name}} will ensure that sufficient numbers of suitably qualified, competent, skilled and experienced staff are available to meet the assessed diabetes care needs of people using the service.

Staff whose role includes supporting a person living with diabetes must receive training appropriate to the tasks they undertake. The content must reflect the needs of people currently using the service and may include:

• basic understanding of diabetes;
• recognition and management of hypoglycaemia and hyperglycaemia;
• emergency escalation;
• blood glucose monitoring;
• continuous or flash glucose-monitoring systems used by people in the service;
• ketone monitoring where this forms part of a person’s care;
• nutrition and hydration;
• diabetic foot risks;
• safe medicines practice; and
• person-centred support and promotion of self-management.

Staff must not undertake a clinical or medicines-related diabetes task unless the task falls within their role and they have received the training, supervision and competency assessment necessary to perform it safely.

Staff administering insulin must have task-specific training and must have their competence assessed in practice before administering insulin without supervision. Competence must be reviewed at appropriate intervals and whenever there is reason to question competence, following a relevant incident, when practice or equipment changes, or where the needs of the person being supported change.

Where staff use specialised equipment or diabetes technology, they must receive appropriate training and competency assessment for the equipment concerned.

Records of training, competency assessments, supervision and any required reassessment must be retained.

Managers must take immediate action where a member of staff does not demonstrate the competence necessary to undertake a diabetes-related task safely. Until competence has been demonstrated, the staff member must not undertake that task without appropriate supervision.

13. Mental Capacity, Consent and Decision-Making

A person must be presumed to have capacity to make decisions about their diabetes care unless it is established otherwise in accordance with the Mental Capacity Act 2005.

Consent to diabetes care and treatment is an ongoing process. A person who has capacity has the right to make decisions about their care, including decisions that others may regard as unwise, and may refuse or withdraw consent to blood glucose monitoring, medicines, insulin, dietary interventions or other diabetes-related care.

Staff must provide information in a form the person can understand and make all practicable efforts to support the person to make their own decision before concluding that they lack capacity.

Where there is reason to doubt a person’s capacity to make a particular diabetes-related decision, a decision-specific and time-specific mental-capacity assessment must be completed and recorded.

A diagnosis of dementia, learning disability, mental illness or another condition must not, by itself, be treated as evidence that the person lacks capacity.

Where a person lacks capacity to make the relevant decision, staff must:

• establish whether there is a valid and applicable advance decision to refuse treatment;
• establish whether another person has lawful authority to make the relevant decision, including an attorney or deputy with the appropriate authority;
• act in accordance with the Mental Capacity Act 2005;
• make or obtain a best-interests decision where required;
• involve the person as fully as possible;
• consult those required and appropriate under the Mental Capacity Act 2005; and
• choose the least restrictive available option that can safely achieve the required purpose.

Family members or friends must not be treated as having authority to consent to or refuse treatment on behalf of an adult solely because of their relationship to the person. Their views may be relevant to a best-interests decision, but decision-making authority must be established lawfully.

Mental-capacity assessments, consent, refusals, advance decisions, consultation, best-interests decisions and the legal authority of any representative must be recorded accurately in the person’s care records.

Any restraint associated with diabetes care or treatment must be lawful, necessary, proportionate and undertaken in accordance with the Mental Capacity Act 2005 and the organisation’s relevant policies.

14. Emergency Protocols and Hospital Transfers

Every person whose diabetes presents a foreseeable risk of an acute emergency must have clear emergency and escalation instructions within their Diabetes Care Plan.

Staff must call 999 without delay where the person’s condition constitutes or is suspected to constitute a medical emergency. This includes severe hypoglycaemia with significant impairment or unconsciousness, suspected diabetic ketoacidosis, suspected hyperosmolar hyperglycaemic state or any other situation in which the person’s condition is immediately life-threatening.

Staff must provide first aid and emergency treatment only within their training, competence and the person’s individual emergency plan.

When a person is transferred to hospital or another healthcare service, staff must ensure that relevant information accompanies or is communicated promptly to the receiving service. As applicable, this must include:

• the person’s current Diabetes Care Plan;
• current medicines and Medication Administration Record;
• insulin type, usual dose and the time and dose of the most recent insulin administration;
• recent blood glucose or sensor-glucose readings;
• relevant ketone readings;
• details of the presenting concern and action already taken;
• known allergies;
• relevant medical history;
• communication needs;
• mental-capacity, consent or legal-representative information relevant to the person’s treatment; and
• contact details for the care home and relevant healthcare professionals.

Following a significant diabetic emergency, medication error or unplanned hospital transfer, the service must review the circumstances and determine whether changes are required to the person’s risk assessment, Diabetes Care Plan, staff deployment, training, medicines arrangements or other systems.

The incident must be reported and investigated under the organisation’s incident-management procedures.

Where the circumstances meet a statutory notification threshold, the registered person must make the required notification to the Care Quality Commission or other relevant authority.

Where an incident constitutes a notifiable safety incident for the purposes of Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the statutory Duty of Candour procedure must be followed.

15. Record-Keeping and Communication

Diabetes-related records must be accurate, complete, contemporaneous, legible and securely maintained in accordance with Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, data-protection legislation and {{org_field_name}}’s record-keeping requirements.

Records must include, where applicable:

• assessments and Diabetes Care Plans;
• blood glucose and sensor-glucose readings acted upon by staff;
• ketone readings;
• insulin and other diabetes medicines administered;
• actual variable insulin doses administered;
• refused, omitted, delayed or incorrect doses;
• symptoms of hypoglycaemia or hyperglycaemia;
• treatment and interventions provided;
• repeat observations or readings following treatment;
• food and fluid monitoring where required;
• relevant foot observations and concerns;
• telephone or face-to-face advice received from healthcare professionals;
• referrals and appointments;
• consent and refusals;
• mental-capacity assessments and best-interests decisions;
• emergency treatment and hospital transfers;
• diabetes-related incidents; and
• changes to the person’s treatment or care plan.

Information concerning a person’s diabetes must be communicated promptly to staff who require the information to deliver safe care.

Relevant information must also be shared promptly and lawfully with healthcare professionals where responsibility for the person’s care is shared or transferred.

Diabetes Care Plans and associated risk assessments must be reviewed regularly at a frequency appropriate to the person’s needs and level of risk. They must also be reviewed without delay where there is:

• a change in the person’s health or diabetes treatment;
• a change in medicines or insulin;
• new professional advice;
• recurrent or severe hypoglycaemia or hyperglycaemia;
• a significant change in food or fluid intake;
• a new diabetic foot problem;
• a significant medication error or diabetes-related incident;
• hospital admission or discharge relevant to diabetes care;
• introduction or change of diabetes technology;
• a change in the person’s ability or wish to self-manage;
• a relevant change in mental capacity; or
• any other change that may affect the safety or effectiveness of the person’s diabetes management.

The outcome of each review, including any changes made or a decision that no change is required, must be documented.

Where audits, incidents, complaints, professional advice or care-plan reviews identify shortcomings in diabetes care, the registered person must ensure that appropriate corrective action is taken and that improvements are monitored.

16. Related Policies

This policy should be read in conjunction with:

• CH07 – Person-Centred Care Policy
• CH11 – Safe Care and Treatment Policy
• CH12 – Meeting Nutritional and Hydration Needs Policy
• CH21 – Medication Management and Administration Policy
• CH18 – Risk Management and Assessment Policy

17. Policy Review

This policy will be reviewed annually or sooner if regulatory updates or changes in best practice require amendments. Updates will be communicated to all staff, and training will be provided as necessary.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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