Last reviewed 3 December 2019

The summer saw the Care Quality Commission publish a new report, Smiling matters — Oral health care in care homes. The report is critical of oral care standards in care homes in England. It concludes that inspectors will be looking for improvements across the sector and calls for action from care providers, commissioners and the dental profession.

Here are the seven ways that care providers can improve oral healthcare and ensure compliance with inspectors’ requirements.

1. Make oral health a key service priority

All service users in adult social care have the right to effective oral care and access to appropriate dental services.

Having a healthy mouth and teeth is vital for people’s health, happiness, dignity and self-respect. Someone with poor oral health may suffer pain from toothache and may be more at risk from serious disease and infections. They may also have problems eating, speaking and socialising because of their poor oral hygiene.

There is no excuse for poor care.

Oral and dental health in adult social care should never be treated as an afterthought. Care managers in all settings should ensure that it is given the high priority it deserves as a key element in the wellbeing of service users.

2. Implement NICE guidelines and standards

The National Institute for Health and Care Excellence (NICE) publish evidence-based guidelines and standards for oral health in care homes. The Care Quality Commission requires care providers to base their programmes of care on the guidelines and their inspectors will check that this is the case when they visit. Care managers should therefore ensure that they are aware of the guidelines and have fully implemented them.

NICE guideline NG48 (published July 2016) covers oral health, including dental health and daily mouth care. The guidelines help care home managers to prevent oral ill health in their residents and to promote and protect their good oral health.

The guideline is supported by a quality standard, QS151 which states that:

  • adults who move into a care home should have their mouth care needs assessed on admission

  • adults living in care homes should have their mouth care needs recorded in their personal care plan

  • adults living in care homes should be supported to clean their teeth twice a day and to carry out daily care for their dentures.

A similar standard, QS139, covers oral health promotion in the community.

3. Have adequate oral health policies in place

All adult social care providers should have suitable oral health care policies. In England the CQC strongly recommend that care homes implement the NICE guidance (NG48) in full and use the guideline as their “primary standard” for planning, documenting and delivering oral care. NICE recommend that policies align with the Delivering better oral health toolkit developed by Public Health England.

Policies should be fully implemented and subject to regular review. See template policies: Oral Health in Care Homes and Oral Health in Domiciliary Care.

4. Assess oral health needs and include the results in person-centred care planning

The oral healthcare needs of service users should be fully assessed and regularly reviewed in all adult social care settings. Any oral care interventions should be agreed with the service user and recorded in their person-centred plan of care.

Assessments should be carried out by competent staff. Family or representatives should be involved as appropriate. NICE recommend that, in care homes, the mouth care needs of residents are assessed as soon as they start living in a care home, regardless of the length or purpose of their stay.

The Social Care Institute for Excellence and NICE have together published a guide, Improving oral health for adults in care homes.

The guidance suggests that assessments include questions such as:

  • how do you usually manage your daily mouth care and what help would you like?

  • what dental aids do you currently use?

  • do you have dentures, and if so are they marked with your name?

  • when did you last see a dentist, and who did you see?

  • if you don't have a dentist would you like help to find one?

The guidance includes a sample oral health assessment tool.

Following the needs assessment an appointment should be made for a service user to see a dental practitioner if required.

5. Give day-to-day oral health care sufficient priority

Care providers must ensure that service users are given suitable assistance to meet their daily oral care and hygiene needs, as set out in their plan of care. This aspect of care should be given sufficient priority by care managers, equal to other personal hygiene tasks. It should be supported with effective training, supervision, equipment, time allocation and resources.

In both care home and domiciliary care settings daily care will include, where necessary:

  • brushing natural teeth (at least twice a day with fluoride toothpaste) and

  • caring for full or partial dentures (such as brushing, removing food debris, removing dentures overnight and using appropriate cleaning products).

Care staff in all settings should make every effort to provide daily care in such a way as to support service users’ preferences. For instance, relating to types of toothbrush (electric or manual), types of toothpaste (fluoride is recommended) and types of denture products.

Managers and supervisors should ensure that staff always respect the dignity and privacy of service users when they provide oral care.

6. Help service users to access dental services

All service users should have appropriate and timely access to good quality dental care, including regular check-ups and any necessary dental treatment.

Some service users in care homes and in domiciliary care may already have a dentist and attend regularly. Some may just need “sign-posting” to help them register with a dentist. Others may require more support in accessing services, including NHS services and emergency dental services.

Access to dental services can be difficult in some areas. In their report, Smiling matters, the CQC identify problems as including:

  • a lack of dentists who are able or willing to visit care homes

  • local dentists not accepting new patients and

  • long waiting times to get an appointment with an NHS dentist.

The CQC have called for a cross-sector approach to tackle these concerns.

7. Ensure care staff have sufficient knowledge and skills

Care managers should ensure that appropriate staff training is in place.

As a minimum training should cover:

  • how to carry out daily oral care tasks

  • recognising and responding to changes in a service user’s mouth care needs

  • how to respond if a service user does not want daily mouth care

  • how and when to report oral health concerns and who to go to for advice and support.

Training should include awareness of relevant NICE guidance and standards. It should be included in refresher programmes to ensure that staff are periodically reminded of the need for high standards of mouth care. It should also be included in induction training for new care staff.

In Smiling matters the CQC criticise the lack of oral care training in care homes. According to inspection findings they state that nearly half (47%) of care homes visited say that staff do not receive any specific training in oral health care. The inspectors saw this lack of detailed training as a clear barrier to implementing NICE guidelines.

The CQC note that current regulatory and contractual arrangements do not necessarily promote oral health training as “mandatory” in social care. The report recommends that local social care commissioners introduce this as a requirement.

The CQC also recommend that Skills for Care, Health Education England, and Skills for Health introduce a mandatory oral health component in the next update of the Care Certificate qualification that must be completed by new care staff.

Further Information

Smiling matters — Oral health care in care homes (June 2019) can be downloaded from the CQC website.

NG48, Oral health for adults in care homes, can be downloaded from the NICE website.