Smiling matters: Oral health in care homes - progress report

Care home staff need better training in oral care

Our work from Smiling matters in 2019 highlighted that CQC and social care commissioners (both clinical commissioning groups and local authorities) did not routinely check if care home staff received training in oral care through their regulatory and monitoring processes. Due to this, homes rarely prioritised it as 'mandatory'.

As a result, we recommended that local social care commissioners introduced the need for oral health training as part of their assessment frameworks, so that all care home staff are routinely trained in the basics of daily mouth care, and that oral health should form a mandatory part of the Care Certificate.

Providing training

While the NICE guideline does not state that oral health training is a requirement, it does recommend that providers ensure care staff who provide personal care know how to deliver mouth care, report any concerns, and respond to a person's changing circumstances.

In 2019, we found that oral health training was not seen as a priority, with nearly a half (47%) of care home providers reviewed not providing specific training in oral health.

During our more recent review, the percentage of care home providers reviewed saying that staff always (or mostly always) receive specific training in oral health has doubled from 30% in 2019 to 60% in 2022 (figure 4). Staff were able to tell us of the benefits of this training to the overall health and wellbeing of people living in care homes.

"Oral healthcare is very interesting and it's a good way to maintain their whole health. From our training I realised how oral health needs to be supported. I now review for bleeding, wounds, the colour of the tongue, if there's any loose teeth."
(Member of care home staff)

Figure 4: Do staff receive specific training in oral health care?

Some care home providers and staff told us how they were lacking in certain areas of oral health care, including training, but there was a commitment to try and make it a part of the everyday.

"The registered manager understood and recognised the importance of oral healthcare, and the provider was actually in the process of looking at how to incorporate this further into the service, including additional assessments and mandatory training."
(Inspector)

As with establishing an oral health champion, stakeholders and providers told us that a barrier to offering specific training was the difficulty in retaining staff. We highlighted that staff shortages were a particular problem in adult social care in our most recent State of Care report.

"Generally, there is a high churn rate with care home staff, so they train [staff members] and then people leave, and the skillset is then lost, so you're almost starting from scratch."
(Dental professional)

"I think the training being delivered is very good; turnover of staff has impacted on number of staff that have had this."
(Inspector)

We heard that training was provided by dental professionals, external companies, Clinical Commissioning Groups (CCGs) and the care home providers themselves, both online and in-person. We also heard that the COVID pandemic drove forward more online training opportunities.

"Covid has hindered progress, but also created opportunities and helped people overcome them. Several [care homes] have taken training online...[it] would be brilliant to reflect some of the ways the boots on the ground workforce have risen to the challenge, like recorded webinars that can be watched later at a time that suits them. It's created those flexibilities."
(Dental professional and academic)

Some homes said that this switch to online training presented some issues though, as face-to-face training can enable a more practical and hands-on approach to learning, especially when caring for people with higher levels of support needs.

"What we do know is from a website. [Our] main difficulty is finding someone who can teach in person [as] virtual teaching isn't effective. We want to be shown how to care for those with dementia, those who can't spit out liquids etc."
(Care home manager)

"The care plans and assessments seen were very detailed and care staff received specific oral health eLearning training. People we spoke with said they were supported with oral health. Although I think staff still struggled to support people living with dementia even though plans did detail the support required and how to encourage."
(Inspector)

Incentivising oral health training

One of our recommendations in 2019 was that oral health needed to form a mandatory part of the Care Certificate, as well as be included routinely in local commissioners' assessment frameworks in order to encourage homes to prioritise it more.

Although we have seen an increase in the delivery of oral health training, the figures above show that it is still not seen by all providers as an essential part of training for all care home staff.

This should improve now that Skills for Care, with reference to Smiling matters, have included oral health in the Core and mandatory training requirements for adult social care staff, with some suggested learning outcomes.

From our engagement for this review, oral health doesn't appear to be used routinely in local commissioning.