Smiling matters: Oral health in care homes - progress report

In June 2019, we published our report, Smiling matters, which explored how care home and dental providers were implementing the NICE guideline on oral health for adults in care homes (NG48).

The report found that, although there were some examples of good practice between care homes and dental practices, many people living in care homes were not being supported to maintain and improve their oral health. Smiling matters set out 6 recommendations for improvement.

This new report reviews what progress has been made.

Awareness of the importance of oral health

• In 2019, our Smiling matters report highlighted the significant issues that care homes and people using services faced, and that change needed to happen. As a result, we heard from stakeholders how Smiling matters drove and increased awareness.
• However, oral health experts told us that the care home sector was still quite a hard space to engage with. With many competing awareness campaigns, it meant that oral health messaging could be quite easily lost.
• Another clear theme that came across from our review was the impact of COVID-19, which seriously hindered progress in prioritising oral health.
• Despite this, we also heard how the pandemic created opportunities for providers to do things differently, such as through online training.

Priority of oral health in care homes

• We have seen a notable increase in the awareness of the NICE guidance within care homes. 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.
• More than half of care home providers had a clear policy to promote and protect people's oral health in 2022 (53%), which had increased significantly from only a quarter (25%) in 2019.
• 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, such as supporting people with toothbrushing and caring for dentures.
• In 2022, 83% of the care home providers inspected for this review said that people had an oral health assessment on admission – up from 73% in 2019.
• The NICE guideline emphasises the importance of reviewing and updating people's oral care needs in their care plans to meet their changing needs. We reviewed 130 care plans across the 50 care homes 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).
• However, the amount of detail in care plans varied greatly between care homes. Some plans were very basic and only included whether a person had teeth or dentures. When people's changing oral health needs are not recorded on a regular basis, this can 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)
• In 2019, we recommended that care homes establish an 'oral health champion' within their portfolio of staff roles and responsibilities. Only 28% of the care homes we visited said they had a nominated oral health champion, with several care home providers mentioning that workforce issues were a barrier to doing this.

Professional training and guidance

• The percentage of care home providers saying that staff always (or mostly always) receive specific training in oral health has doubled from 30% in 2019 to 60% in 2022.
• 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 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)
• Our review for this progress report has shown that there is still a lack of up-to-date guidance for dental care professionals on how to manage the needs of people living in care homes, resulting in a lack of confidence in supporting their oral health.
• As a result of this lack of confidence, we heard that dentists would refer cases to an already stretched community dental service.

Dental care to meet people's needs

• Care home providers that were best able to care for the oral health needs of people using services had timely access to dental care.
• However, one of the strongest themes to emerge from our 2022 review was the extreme challenge care home providers were having in accessing dental care for people.
• In 2019, 6% of care home providers told us that the people who used their services could 'never' access NHS dental care. In 2022, this figure has sharply risen by more than 4 times, to 25%.
• In our discussions for this progress report, it was widely recognised that the solution to improving access to dental care for people in care homes did not simply mean commissioning more dentists or community dental services, but rather embracing the benefits of using the whole dental team.
• Care home providers highlighted a lack of dentists who were able or willing to visit care homes (to provide a domiciliary service).
• We continued to hear that the changes to the general dental services contract in 2006 make it difficult for dentists to provide dental care in care homes.
• However, we heard of numerous examples of commissioning being used to try and improve the oral health of people in care homes – through funding training, peer-to-peer support schemes, or increasing dental access.

Oral health in regulation and local commissioning

• It was unclear how much social care commissioners routinely included oral health as part of their assessment frameworks.
• Moving forward, there is a clear opportunity for services and local commissioning to be more integrated and sourced cohesively, rather than bound by existing contractual arrangements, in order to address the needs of their local population.
• We have added questions about oral health assessment, care planning and training to our routine care home inspections.
• However, we still have further work to do to make sure that oral health care is included as an important part of the findings we feed back to care home providers and the public.
• Incoming new powers in relation to local authorities and integrated care systems will give us the opportunity to ask systems directly how they are planning to address healthcare inequalities, such as the oral health needs of people living in care homes.