Over a period of three months between October 2018 and January 2019 the CQC dental inspectors attended 100 routine planned inspections with adult social care teams. They spoke with staff, residents and their relatives to assess the management of oral health concerns in care homes. The recently published report – ‘Smiling Matters’ details their findings. The recommendations for Providers are detailed below.
Despite oral health across the population improving since the NHS began in 1948 this has not been reflected in adult social care populations. The report emphasises how poor oral health can lead to mouth pain and problems with eating and drinking and thereafter to malnutrition. There is a risk that bacteria and dental plaque may be inhaled by residents leading to aspiration pneumonia in some cases.
‘Oral health for adults in care homes’ NICE guideline NG48 (July 2016) recognised the importance of good oral health, the guideline can be accessed via the link below. It includes recommendations for care home managers, staff and people who use services, focusing on:
- Policies – care homes should ensure these set out plans to promote and protect oral health.
- Oral health assessments and mouth care plans.
- Daily mouth care – provide support as needed.
- Staff knowledge and skills – ensure staff know how and when to support service users and how to respond to changing need.
Are people in care homes supported in a way that meets the NICE Guidance and given access to oral healthcare services?
The CQC found that the 39% of care home managers had no awareness of the guidance and only 28% had read it. One of the reasons for low take up appears to be because the guideline does not form part of the contractual and regulatory frameworks. Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014: Safe Care and Treatment, does however require providers to follow good practice guidance when delivering all aspects of care.
- Nearly half the care homes inspected did not provide training on how to support daily mouth care. Other areas of personal care were prioritised.
- Dental care was not always recorded in care plans or records. Only 27% of all care plans reviewed covered oral health fully. Plans from homes caring for individuals with dementia were less likely to have oral health care plans.
- 52% of care homes did not have a policy as required by the guidelines. Where policies existed, staff were not always aware of the contents and what was expected of them.
- 17% of care homes said they never assess oral health on admission.
- Some issues with dentures were identified. In the absence of supplemental records, the CQC found that it was difficult to assess when/ whether they had been cleaned and it was particularly difficult in relation to those with behaviours that challenge, to ensure that dentures were being removed and cleaned regularly.
- Lack of dentists willing or able to visit care homes.
- Practicalities of transport to dental services (some care home managers noted they could not afford to send two members of staff out with residents and pay for transport).
- Treating people with complex conditions was perceived as too difficult for some dentists.
- Confusion in relation to costs and eligibility for free dental care.
- Treatment sought primarily when residents were in pain. 10% of homes said they had no way of accessing emergency treatment for individuals however.
Recommendations for Care Home Providers
- Make the NICE guideline the primary standard for planning, documenting and delivering oral care.
- Assess people’s oral health care needs on admission.
- Ensure oral health is given the same level of priority as other personal care tasks. Training will be required to achieve this.
- Make sure oral hygiene is a fundamental part of person centred care planning. Every individual should have a comprehensive oral care plan which identifies the person’s dentist, lists the dates for routine check-ups and records the outcomes.
- Make sure each care plan records whether the individual is exempt from NHS dental charges, if not their ability to fund dental treatment in order to plan for these costs.
- Routinely check the state of people’s oral health if they experience significant weight loss that cannot be explained by ill health. This should include a review of the fit of any dentures.
- Establish an ‘oral health champion’, to promote the guidance, act as a conduit between the home and dental professionals and ensure people have appropriate products for day to day care. A key aspect of this role would be to liaise with families and residents to ensure care is planned in accordance with preference and where people lack capacity, in their best interests.
The report recommends a review of how oral care should form part of the monitoring and inspection regime. It is likely that expectations will be reflected within the Key Lines of Enquiry and/or ratings characteristics in due course. In the meantime, we advise providers to review compliance with the recommendations as above and take steps to address any identified shortfalls as soon as possible.