Progress on recommendation 2

Care home services need to make awareness and implementation of NICE guideline a priority

In 2019, we recommended that care home providers should:

• make the NICE guideline the primary standard for planning, documenting, and delivering oral care
• make day-to-day dental hygiene of equal priority to other personal care tasks
• assess people's oral health and needs when they enter the home
• routinely check the state of people's oral health when they lose weight through a qualified dental professional, including an assessment of the fit of dentures
• establish an 'oral health champion'.

Awareness and implementation of the NICE guideline (NG48)

The NICE guideline includes recommendations for care home providers, staff and people who use services and their carers in order to maintain and improve the oral health of adults in care homes.

Following up on our work from 2019, we have seen a notable increase in the awareness of the NICE guideline – from 61% to 91% (see figure 1). From the care home managers we spoke to in 2022, only 9% were not at all aware of the guidance. This compares with 39% in 2019.

Figure 1: To what extent are you aware of the 2016 NICE guideline (NG48) in relation to oral health in care homes?

Source: CQC
Note: base numbers differ in 2022, as not all care homes answered the question

However, although awareness had increased, at times inspectors found that care home providers had no plans on implementing the recommendations.

As well as the pressures created by the pandemic and workforce issues, stakeholders told us the barriers to implementation included the complexity of the guidance and the lack of time for care home staff to carry out oral care.

"We need to recognise that NG48 needs to be more understandable in this environment of high staff turnover... In some areas the current guidelines are not that realistic, and perhaps there is a need to modify it to account for the realities that care home staff and managers face."
(Dental professional and academic)

Currently, work is in progress to explore this issue. One such project, known as TOPIC, is a feasibility study looking to understand how realistic and effective the NICE guideline is to implement in practice. This programme is currently being evaluated.

Care homes' policies

The NICE guideline (NG48) also recommends that providers ensure their care homes' policies set out plans and actions to promote and protect residents' oral health, to include information about:

• local dental services
• assessing people's oral health and daily mouth care
• what to do if a resident refuses oral care (in line with the Mental Capacity Act)
• supply of oral hygiene equipment.

Findings from our 2022 inspections show that more than half of care home providers had a clear policy in place in 2022 (53%), which had increased significantly from only a quarter (25%) in 2019 (figure 2). However, similar to 2019, even with clear policies in place we noted that care staff were not always made aware of them.

"A policy in relation to oral health had been introduced by the organisation in September 2018. This was stored on the care home's computer system and was not accessible to staff. The policy had not yet been implemented into practice."
(Inspector)

Figure 2: Do you have a policy that sets out plans and actions to promote and protect residents’ oral health?

Source: CQC

When our inspectors reviewed the policies to see how they promoted and protected people's oral health, most included information on how to assess oral health, care planning and daily mouth care. Commonly missed sections, or those lacking detail, were about local dental services and what to do if a person refused oral care.

"Mouth care policy gives clear simple instructions about how to support residents... There are separate sections about care of dentures, dry mouth, lip care and oral infections. The policy reminds staff to listen if people have concerns about their mouth or mouth care and to document these or any changes. There is no information about what staff should do if a person refuses oral health care."
(Inspector)

Daily oral care

The NICE guideline recommends that care homes ask people living in services how they usually manage their daily oral care (for example, toothbrushing and caring for dentures), and provide any support needed.

During our inspections for this progress report, as well as other engagement carried out for it, providers and other stakeholders were generally positive about the importance of good daily oral care. When we found issues during our care home visits, many providers made changes immediately.

"The manager told us she conducts a daily 'walk around' which includes looking at a selection of people's oral care and checking toothbrushes and dental products for use. She said that any concerns she finds she discusses with the care workers who have provided care that morning."
(Inspector)

"There was one issue identified during the inspection...two rooms were without toothbrushes. This was raised with the registered manager who responded immediately by purchasing new toothbrushes so that this wouldn't happen again. They also then raised this the following week at the staff meeting to remind staff of the importance of oral hygiene. The manager also contacted the local dental service to visit the home to check people's oral hygiene."
(Inspector)

People living in care homes and their relatives we spoke with during our inspections reported a mixed picture of day-to-day oral care. Many talked about a high level of support, but some relatives said they had to provide oral care themselves.

"The staff help me clean my dentures. The staff take my dentures and clean them overnight. I always have them back before breakfast."
(Person living in a care home)

"I've just had two teeth taken out. A carer took me to the dentist to have this done. There is a community dentist who visits the home. I clean my own teeth and the carers hold a bowl for me."
(Person living in a care home)

"Mum's teeth are looking better since being in the home, as I don't think she was cleaning them prior to that and hadn't attended a dentist for about 20 years."
(Relative of a person living in a care home)

"I take care of my relative's teeth. The carers don't seem to clean them all the time. It is a bit hit and miss. My relative has dental appointments. I take [them]."
(Relative of a person living in a care home)

Oral health assessments on admission

The NICE guideline recommends that care staff "assess the mouth care needs of all residents as soon as they start living in a care home, regardless of the length or purpose of their stay".

In 2022, 83% of the care homes inspected for this review said that people had an oral health assessment on admission – up from 73% in 2019.

We often saw homes using the Australian Institute of Health and Welfare Oral Health Assessment Tool, which is suggested in the NICE guideline, or an adapted version of it. One home was using a version of the Australian tool with text and pictures to support people to inform their own assessment. There were also several examples of care home providers using their own templates, local hospital trust forms or, if they used electronic software, inbuilt tools that were part of the system.

Where homes did not carry out oral health assessments or completed them poorly, we heard that it was because of a lack of suitably trained staff or that they would rather do it at a later date.

"The registered manager confirmed people's oral healthcare is not assessed prior to or on admission but it is completed at a later stage... This is because staff needed time to get to know people newly admitted to the service."
(Inspector)

"The assessments of oral health are not very well executed. They appear to be a basic tick list which is sometimes completed. But the staff have not had the training or skills to understand about this assessment and have not provided actions where they cannot find information or there is a problem."
(Inspector)

Care planning and recording

The NICE guideline emphasises the importance of reviewing and updating people's oral care needs in their care plans to meet their changing needs. Of the care homes we visited, 79% said they included an oral health section in all, or mostly all, of their care plans. This is up from 70% in 2019. Only 4% of care home providers said they never include an oral health section in their care plans.

We also reviewed 130 care plans across the 50 care homes that we visited. This showed that more than double the proportion of care plans fully covered oral health needs, compared to our review of care plans in 2019 (60% in 2022; 27% in 2019 – see figure 3).

Figure 3: Inspector reviews of care plans: How well do care plans cover oral health needs of residents?

As in 2019, the amount of detail in care plans varied greatly between care homes and, in some cases, even between different people living in the same home. Some plans were very basic and only included whether a person had teeth or dentures. When people's changing oral health needs weren't recorded on a regular basis, this could have an impact on their quality of life, including their diet.

"I've lost a lot of teeth so I can't chew hard things. I say that I don't want battered fish but still it comes."
(Person living in a care home)

As we highlighted in Smiling matters in 2019, there is a strong link between poor oral health and weight loss, which can lead to a deterioration in health. We recommended that care home providers arrange for people's oral health to be checked by a dental professional when they lose weight when this cannot be explained through ill-health or other conditions.

"We recently changed the oral health tool, which includes a monthly review. We look at the impact of oral health on things like swallowing and weight loss."
(Care home manager)

The vast majority of residents and their relatives said that they had not seen their oral healthcare plan, or couldn't remember seeing it.

"[Resident] confirmed they had not seen their plan and stated, "I would like to see something in black and white. That way I would know if staff have the right information."
(Person living in a care home)

We did see examples of homes that had quite detailed oral health plans which included:

• what level of support the person needed
• their preferred time to receive oral care
• what products they preferred to use
• details of their dental practice and any outcomes of visits.

"[The plan] includes that the person used to wear dentures but had now chosen not to use these and how the staff could support them to care for their gums. It also talked about how this has affected their diet. [I was] fully assured by this plan."
(Inspector)

In both the original Smiling matters and this progress report, poor awareness of eligibility for free or subsidised NHS dental care was a barrier to good oral health. We found that this information was omitted in more than 4 out of 5 care records in our 2019 review (83%). This figure had reduced in 2022, but it is still omitted in a majority (61%) of cases.

One of the barriers to recording this information was that it was hard to find out the details, either because it was not known by the person or family, or that it was difficult to confirm from the person's funding authority.

"Homes often don't have financial information on their residents. When they'd even ask us to ask the council, the council would reply that they couldn't because they were archived records."
(Dental professional)

"It's very difficult to get the information about benefits and whether residents have to pay as we don't always have access to the financial history."
(Care home manager)

We also saw how electronic care management systems could help support good oral care. As well as providing a way of storing detailed and personalised plans, we also saw examples where software was used to prompt staff to support people to clean their teeth and then enter this into their daily care records.

"We have special icons in our care management software to remind the carers to clean the teeth. It reminds the carers if the resident has dentures and to apply the denture adhesive."
(Care home manager)

There was some concern, however, that these electronic systems could lead to a 'tick-box exercise' rather than true person-centred care planning that focuses on the needs of the individual.

"The electronic system was good, but there's a danger it can be 'tick-boxy' and not person-centred. We found plans that talked about maintaining teeth when the person had none (they had dentures)."
(Inspector)

Oral health champions

In 2019, we recommended that care home providers establish an 'oral health champion' within their portfolio of staff roles and responsibilities in their care home settings. This champion would:

• work to promote the implementation of the NICE guideline
• act as a conduit between the home and dental professionals
• ensure people have the right products in the right condition to assist with day-to-day care
• work with people and their families and carers to ensure that care is planned in line with their preferences and, for those who lack capacity, any decisions are made in their best interests.

During our review in 2022, only 28% of care homes we visited said they had a nominated oral health champion in the service, though several said they were in the process of sourcing one or committed to nominating an individual following the inspection.

Homes that had an oral health champion in place were seeing benefits in terms of improving processes, focusing training and enabling the cascading of good practice.

"The deputy manager is the oral health care champion and ensures that all residents have a clean toothbrush and toothpaste in their bathroom. They were also planning to audit residents' care plans to ensure all staff were recording what and when care and support was provided."
(Inspector)

Care homes were responsive to the findings from our inspections and the concept of oral health champions as good practice.

"The manager was open to learning and wanted to provide the best care for their residents. They took our advice about NICE guidance and looked into putting an oral health champion in place."
(Inspector)

However, several homes mentioned that workforce issues were a barrier to nominating a champion.

"Our challenge is having enough permanent staff. The few that we have, some only work three days, or minimal hours. So, to make them a champion is a lot more burden."
(Care home manager)