In 2016, the National Institute for Health and Care Excellence issued guidance on oral health care and this made a number of recommendations in relation to oral health care for adults in care homes. However, in a recent report issued by the Care Quality Commission (CQC), “Smiling matters: oral health care in care homes”, the CQC highlight that the operation of this guidance is limited within the adult social care and primary care sectors, with people generally not being adequately supported to maintain their dental care and staff having a lack of awareness of the guidance.
Whilst this guidance is not mandatory for providers to apply, the CQC found that the care homes that did exercise good oral health care had based their practices on the NICE guidance and recommendations. The purpose of the CQC’s report, “smiling matters”, was to outline the CQC’s findings from their review of how providers were using this guidance. This review consisted of 100 inspections of care homes by both dental inspectors and adult social care inspectors.
Oral health care has increasingly become more prominent on the CQC’s agenda in recent years. The importance of oral health has been widely discussed and criticised amongst the dental profession, care sector and key stakeholders as the issue has grown. Oral health care is included within the NHS Long Term Plan and has been a key feature of Healthwatch England’s 2016 and 2017 reports, as well as the Regulation of Dental Services Programme Board, which was chaired by the CQC and prompted this review.
Whilst the CQC found some clear evidence of good oral health care in some care homes during their review, the CQC also found that there was an overall lack of implementation and awareness of the NICE guidance and as a result, this was having an impact on people to the extent that they were not receiving the required oral health care to ensure their dignity was respected and they remained comfortable and pain free.
The CQC’s key findings
The CQC’s key findings included the following:
- It could be difficult for residents to access dental care;
- 52% of care homes had no policy to promote and protect service users’ oral health
- 57% were not providing training to staff to support daily oral healthcare
- 73% of care plans that were reviewed only partly covered, or did not cover oral health; and
- 10% of care homes had no way to access emergency dental treatment for residents.
One of the main challenges for care homes is the accessibility of dentists who are willing and able to visit care homes. Whilst some service users can access NHS dental care, for others this may be more difficult where their mobility is restricted. However, even those who can access NHS services often find that there are long delays for appointments and it is difficult to find an NHS service who will accept new patients for those residents who are not already registered or move out of their area.
All of these challenges can increase the risk of a deterioration in a service user’s oral health which can, in turn, adversely affect a person’s general health and lead to issues such as malnutrition. This deterioration in a resident’s health, and the lack of appropriate action to monitor or mitigate this risk, could also lead to a negative rating at an inspection by the CQC, including allegations that the care home has breached the fundamental standards contained within the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. In the most serious of cases, this could lead to civil or criminal enforcement action such as the issuance of warning notices or fixed penalty notices, amongst other enforcement powers.
What should care providers be doing?
If care providers have not already done so, they should review the NICE oral health guidelines and carry out a review of their current oral care arrangements. Firstly, care providers should ensure that these guidelines are appropriately disseminated amongst all of their care staff. There are different ways that this could be done effectively, and the most appropriate and effectual way will likely depend on the size of the care home and its current policies and procedures in respect of oral health. Some care providers may want to discuss the guidelines during staff meetings, focusing on their importance and how the particular care home could implement the guidance effectively, as well as the oral health needs of the service users and any concerns they may have.
Care providers could also enforce the guidelines as a mandatory reading topic or training session, followed by an assessment to test staff learning and understanding of the guidelines, for all care staff. At present, care homes do not always prioritise oral health as a mandatory training topic. It would also be wise to monitor training in this area by adding it to the home’s existing training matrix or schedule to ensure it is refreshed on a regular basis and any new staff are provided with this training. In one example of good practise provided by the CQC, it is noted that a care home appointed an oral health champion, who had attended specific oral health training provided locally by the NHS and they were responsible for staff training in oral health, particularly new staff. The champion could also be used to ensure that all of a resident’s oral health needs are assessed and planned in line with their preferences and the NICE guidance and to ensure appropriate communication between the care home and the dental profession.
NICE’s recommended oral health assessment tool may also be utilised. In an example provided by the CQC of a care home who is implementing the guidelines appropriately, it is highlighted that an oral health assessment is completed at least monthly for each person living in the care home to ensure that referrals to a dental professional are made where required. Care providers should also consider how they assess a service user’s oral health on admission and how they will be able to ensure the service user’s day-to-day dental hygiene is maintained. This will likely need the involvement of the service user and their family during the care planning process, and possibly a separate oral health care plan if appropriate. The CQC will most likely be looking at whether care homes treat oral health as an equal priority to other personal care needs during an inspection and care homes will therefore need to document that an effective assessment of a person’s oral hygiene has taken place. More specifically, the CQC recommend within their report that oral health care plans should be reviewed every six to 12 months and should identify the resident’s dentist, together with details of their routine check-ups and the outcomes of each one, as well as confirmation of whether they are exempt from NHS dental charges. Where a resident is not exempt, a plan will need to be in place to deal with how those costs will be covered.
The CQC have also recommended that care homes should have oral health check-ups for all residents who are moving into a care home, better signposting to local dentists and a multi-agency group with the aim to raise awareness of the importance of day-to-day oral hygiene and the need for routine check-ups.
It is further highlighted that some care homes utilise a domiciliary dental service to carry out routine checks of service users’ oral health, particularly where it is difficult to transport a particular service user. Other care homes may be able to work together with local dental practices to arrange routine appointments and emergency care, for example. This is in line with the CQC’s aim of achieving a collaborative approach.
Action should also be taken by care providers to ensure that residents have easy access to toothbrushes, toothpaste and other dental hygiene products. These should be purchased for people living in care homes and replaced often. In some cases, it might be beneficial to use signage around the home to promote good oral hygiene and encourage this amongst the residents of the care home.
Some of these actions and the recommendations of the CQC may take time to implement and embed into a care home, particularly where they require some planning or resources to effect, although others might be quite quick and easy to enforce. However, what is clear is that, for the concerns highlighted by the CQC to be addressed appropriately, there needs to be a collaboration between all key stakeholders to support care homes, dentists and dental practices to make the required changes. This should include other care homes sharing best practise with each other. It is also important for service users, their families and the wider public to have a better understanding of what they can expect from care homes and the importance of good oral health care in order for these changes to make a positive impact on service users’ quality of life.
In addition, the CQC suggest in their report that the dental profession needs improved guidance on how to treat people in care homes. Specifically, the CQC recommend that Health Education England updates and re-issues guidance for the training of dental professionals on how to provide care within care homes. The CQC further recommend dental providers assist care homes in making applications for exemption from charges where applicable. The CQC further acknowledge that NHS England and local commissioners have a part to play in that they need to work with care homes to avoid lengthy waiting times for appointments and treatment, provide adequate capacity for routine and emergency treatment, and develop accessible information for the public and care home staff to signpost them to the correct dental provisions.
Commenting on the report, Kate Terroni, chief inspector for adult social care at the CQC said: “Oral health has a huge impact on our quality of life and we need professionals across a number of sectors to make changes to ensure it is given the priority it needs in care home settings.
“Oral health cannot be treated as an afterthought. It can make the difference between someone who is free from pain, enjoys eating and is able to confidently express themselves through talking and smiling – and someone who is in pain, unable to enjoy their food and who covers their mouth with their hand when they smile because they are ashamed of their poor oral hygiene but unable to address it themselves. No one should have to live like that.
“Care home managers must recognise the significance of oral health – and professionals including GPs, dentists, dental hygienists and community nurses need to work together to elevate the importance of oral health in care homes and to prioritise this as part of their work.
“The changes needed can only happen with the efforts of all parts of the health and care system coming together, helping people who use services, their families and carers to be aware of the importance of oral care. By working in partnership, we can make a positive impact on the quality of life of people living in care homes.”
Charlotte Waite, chair of the BDA's England Community Dental Services Committee also commented: “This welcome report shines a light on services that are failing some of the most vulnerable in our society. There are residents left unable to eat, drink and communicate, as an overstretched NHS struggles to provide the care they need. We require nothing short of a revolution in the approach to dentistry in residential homes. Oral health can no longer remain the missing piece when it comes to care planning and budgets.”
What does this mean for care providers?
In light of the CQC’s findings in this report, oral health is likely to form a significant part of the CQC inspectors’ consideration and focus at future inspections. Inspectors will be looking for evidence that a care home has considered and appropriately implemented the guidance, and that all staff have a good understanding and awareness of the relevant guidelines. It is also likely that local social care commissioners will start to include a requirement for oral health training as part of their assessment frameworks too, in line with the CQC’s recommendations in their report, and this will further impress the importance of compliance and proactive action on oral health moving forwards.
As such, training records, care plans and risk assessments will likely be scrutinised for evidence of this and care homes will therefore need to ensure oral health is a key consideration during the admission, care planning and risk assessment processes, as well as during the day-to-day care provided by staff. Any steps taken to assess, maintain or support a service user’s oral health should be clearly documented and readily accessible to inspectors.
The consequences of failing to acknowledge the importance of this issue and take any steps to adequately support a service user’s health, particularly in light of this recent report, will most likely cause problems for care homes at future inspections. Over recent years, the CQC have been taking a harder stance against care providers who are failing to meet the regulations and are achieving ratings of 'requires improvement' or 'inadequate'. The statistics contained within the CQC’s annual report 2018 – 2019, which was published in July 2019, highlight that the CQC have been using their enforcement powers increasingly more against care providers in the past few years. For instance, the CQC took criminal enforcement action against 211 care providers last year, which reflects a 32% increase from 2017/2018. The CQC also took civil action, including cancellation of registration, against 906 providers compared to 781 the previous year which is an increase of 16%.
It is therefore vital that care providers do not ignore these warnings and face the issue of oral health head on, ensuring that this forms a key part of their care home’s agenda along with any other physical or mental health care needs.
At Stephensons we have a team or solicitors who are specialists in CQC regulation and compliance and help care homes challenge CQC inspection reports, enforcement action and criminal investigations. If you would like to speak to a member of our team please call us on 01616 966 229.