Introduction

About this review

In June 2019, three years on from the publication of the National Institute for Health and Care Excellence (NICE) guideline on oral health for adults in care homes (NG48), we published our report, Smiling matters, which explored how care home and dental providers were implementing the guideline.

The report found that oral health did not appear to be a priority in care homes, and that many people living in care homes were not being supported to maintain and improve their oral health. Although there were some examples of good, joined-up practice between care homes and dental practices, this was rare and the majority of people were not able to access dental care when needed.

The report concluded that in order to improve oral health and enhance the quality of life for people living in care home settings, change would need to come from all parts of the health and care system working together.

The report also set out 6 recommendations:

1. People who use services, their families and carers need to be made more aware of the importance of oral care
2. Care home services need to make awareness and implementation of the NICE guideline a priority
3. Care home staff need better training in oral care
4. The dental profession needs improved guidance on how to treat people in care homes
5. Dental provision and commissioning needs to improve to meet the needs of people in care homes
6. The NICE guideline needs to be used more in regulatory and commissioning assessments

In addition to these recommendations, we committed to review the progress made by key stakeholders and organisations to improve oral health in care homes. This report gives the key findings from that review.

How we carried out this review

For our first Smiling matters report, our dental inspectors attended 100 routine inspections of care homes between October 2018 and January 2019 to speak with managers and staff about their implementation of the NICE guideline. They also spoke to people who use services and their relatives to find out about their experiences of oral care. We refer to the findings from these inspections as '2019' findings in the rest of this report.

For this progress review, we inspected 50 care homes between April and June 2022, where we asked in-depth questions about oral health, in addition to our routine inspection activity. This work was carried out by our adult social care inspectors but, where possible, our oral health inspectors joined alongside. We refer to the findings from these inspections as '2022' findings in the rest of this report.

We inspected care homes from across England using our existing adult social care inspection schedule. This enabled us to gather information and feedback from a range of areas, ratings, sizes and service types. None of the care homes included in 2019 were included in 2022.

Like the first set of inspections, we mostly spoke with managers and senior members of staff about their awareness and implementation of the NICE guideline. We also talked with people who used the service and their relatives to understand how their oral health was being cared for. We have used their experiences and direct quotes anonymously to support our findings throughout this report.

We have also included in this report anonymised personal stories of oral care from people who have used services in the last year or their family members. These were gathered through interviews carried out for this review to provide in-depth accounts, to supplement the feedback we received on inspection.

As with the first Smiling matters, we also engaged with dental professionals, social care providers, professional groups and public bodies to find out what progress had been made since 2019, and where barriers continued to persist.

Progress against the Smiling matters recommendations

Our work in 2019 highlighted that too many people living in care homes were not being supported to maintain and improve their oral health. Staff awareness of the guideline's recommendations was low, and less than half of the care homes inspected provided staff training to specifically support people's daily mouth care. It was clear then that positive change in England could only realistically happen with different parts of the health and care system coming together to improve the quality of life of people in care homes.

The following sections discuss the progress that has been made towards the original 6 recommendations in Smiling matters, the barriers providers and stakeholders have had in achieving them, and the experiences of people receiving care.