NHS Scotland’s Caring for Smiles: improving the oral health of adults in care settings in line with NICE Guidance and Quality Standards

Aim:

• To improve the oral health of elderly people living in care settings

Objectives:

• raise awareness of the importance of good oral health
• deliver oral health training to care workers
• work with partner agencies to improve implementation of the programme

The oral health status of Scotland’s older people is changing. Many more older people are retaining their natural teeth well into old age. As a result, the oral care needs of residents are becoming more challenging for those staff who are given the responsibility for delivering this aspect of care to dependent older people. Thinking of oral care as basic does not accurately reflect the complex skills required to care for someone else’s mouth, especially those with physical or cognitive impairment.

The purpose of the Caring for Smiles programme is to provide care staff with the necessary knowledge and skills to equip them to confidently and proficiently provide the best oral care for the people they look after.

Why this guide was developed:

In 2005, the “action plan to improve oral health and modernise NHS dental services” identified dependent older people as a priority. This was followed in 2012 by the Scottish Government’s National Oral Health Improvement Strategy for Priority Groups, which includes frail older people. This recommends action to improve the oral health of older people in care homes.

The main reasons oral care is important for older people are:

• Poor oral health affects overall health, nutrition, quality of life, communication and appearance.
• The number of older people in the population, including dependent older people, continues to rise.
• Many older people are now retaining their natural teeth which makes caring for their mouth more challenging for care staff.
• The number of vulnerable older people in care homes is rising and inadequate oral care can have a detrimental impact on their nutrition and hydration levels.
• People often come into care homes with pre-existing oral problems as a result of inadequate oral care while living on their own.
• Many dependent older people cannot perform their own oral care satisfactorily and rely on others for help to maintain their health and welfare.

An area which is particularly challenging for care staff is the provision of oral care to residents who reject or become distressed during care, often as a result of dementia. The number of care home residents who have dementia and also have retained their own teeth is expected to rise significantly in the future.

Challenges to achieving and maintaining good oral health in care homes:

Research has found the main obstacles to care staff carrying out mouth care are as follows:

• This aspect of care is considered by some as distasteful.
• With residents who retain some of their teeth, care staff can show a reluctance to carrying out care inside the mouth. This is not such an issue with denture care.
• Confusion over consent issues, fear of personal harm from resistant residents or a lack of dementia-specific care skills can discourage care staff from carrying out oral care.
• Care staff (and managers) may not give oral care the priority that other care tasks receive. They may also be influenced by other factors such as workplace pressures.

In recognising these challenges, the team sought to bring together a comprehensive training and education package for staff in adult care settings in order for them to have the confidence and capabilities to meet these challenges and deliver evidence-based oral health care to their residents.

We recognised early on the life of the programme that we needed to upskill our own oral health staff before targeting our audience of care workers. We initially developed a Guide for Trainers that was published in 2010 and that was very much around building knowledge on the topic of dependent older people for oral promotion teams and giving them the tools to go out and deliver the training to care home staff.

We began to get a lot of requests for something to leave behind after training and this evolved into our Guide for Carers. However, we still needed an overarching resource which became the Guide for Care Homes. Every care home in Scotland has a copy and it was very much about using the content for training.

We recognise that training is never a one-off intervention. Although the programme has been rolled out by the 14 health boards in slightly different ways, we encourage those leading it from each health board to form a relationship with the care home so that they are offering ongoing support and top-up training.

NES have helped us develop credit-rated training, to give formal recognition to those who completed the training and subsequent assessments. In Scotland, all care home staff have to be registered with Scottish Social Services Council (SSSC) and workers are required to have or be working towards SVQ level 2, equivalent to an NVQ in England. For the credit-rated training, they have to do a written assessment following face-to-face training, then go on to do 10 reflective learning cases. Finally, the assessor watches them delivering oral care in a “direct observation of practice”. Gaining accredited training works as an incentive and even if the carer already has their SVQ, the credit-rated training counts towards their professional development so this encourages buy-in with the programme. What we are trying to do is make it as appealing as possible and align Caring for Smiles training with the competencies they have to cover as part of their SVQ qualifications.  SSSC have helped us by mapping the Caring for Smiles competencies to SVQ2.   This is another example of working in partnership with wider stakeholders to implement our programme, this time with the SSSC and their broader requirements for training.

Challenges:

We learned as we went along, so adapted and changed our approach as required. We became aware of issues around dementia and how this can affect care delivery. Many people in care homes suffer from some form of dementia which can make delivering any kind of personal care extremely challenging if the person becomes distressed. We gave examples of some strategies for overcoming distress which were focused around the ethos of not attributing blame to the resident. These included communication strategies, behaviour strategies, as well as some more specific techniques, such as distraction and rescuing.  In addition, we developed a flow chart, giving advice on who to contact for help if a resident repeatedly refuses care.  This may be a sign of some other underlying problem, so we encourage staff not to ignore the issue.

However, we were also advised that not everyone needs care delivered to them, so some residents just need a bit of prompting, and others encouragement, before moving on to actually requiring full support. In this way, we are allowing residents to maintain independence for as long as possible and is line with good practice advocated by the Care Inspectorate.

As we worked with wider partners, we also became aware that our oral health teams would benefit from further training relevant to the care home setting. We continued to roll out training of trainers, incorporating the NES resource, “promoting excellence in dementia”. Oral health professionals were trained in line with this so that they took into account dementia aspects of a resident’s needs when advising care staff on oral health. Care home workers have often had training in dementia, so we felt there was a knowledge gap in dementia that we needed to close for our oral health trainers. Therefore, we did three roadshows across Scotland, incorporating dementia one year, then palliative care training the following year.

In terms of staff turnover in care settings, there is evidence in the literature that staff do move on. However, what we’ve found in our experience is that they often stay within the care sector and take the training they’ve received elsewhere. Increasingly in Scotland there is a focus on care in the community and home settings so there is an aim to widen out the target audience for oral care training to account for this.

The Guide for Care Home is now available across Scotland.

In terms of raising awareness, oral health now has a much higher profile. The consistent picture/branding has been helpful in doing this.

Regarding training, by September 2016, 94% of care homes have now received some form of oral health training since the programme started in 2010. In total, 38,117 care workers have attended a training session, although some carers have attended more than one.  By March 2017, three years into credit-rated training, over 1088 carers had achieved passes, with a further 535 in training.

Our work with partners has been crucial to implementing the programme. Recently, the Care Inspectorate undertook an “Inspection Focus Area” on dementia, which included oral health.  Early results indicate that oral care is a good indicator for the quality of care and support in homes. In terms of formal evaluation, the Scottish Oral Health Research Consortium, which links the four dental institutions in Scotland, has the oral health of older people as one of the topics in their research programme. There a few projects, including a systematic review of the role of champions and a feasibility study to undertake oral inspections in care homes.  There is also an in-depth study looking at the human factors in how care homes deal with the plethora of guidance they are given, with the aim of producing a toolkit to help them deal with these pressures.

While we await the findings of our academic partners, there is some softer evaluation available. Anecdotal evidence from dental teams tell us that mouths are cleaner.  Feedback from families is also encouraging:

"I was able to kiss my wife because her mouth was clean".

A survey of care home managers gave feedback on Caring for Smiles which was overwhelmingly positive:

"Excellent training course in general, very informative and enhances care to older client group".

"It is very good – highly pro-active organisers, using an imaginative approach to maintaining interest and commitment".

"We would love to have more of this in our home".

"Very beneficial, well supported".

"I think it is a good program, and has improved and emphasized the importance of good oral health, and why it plays such a crucial role in the care of older people".

"We have had a great experience with the girls coming annually to do the training".

"Think it’s a great idea for staff to be aware of the importance of oral health".

"We have worked with CfS staff for several years and still find it useful and beneficial".

• Adopting a supportive approach towards the target audience:

Try not to go in with the big stick and say “you’ve not done this…”. We’ve approached care homes in a supportive way, adopting a practical hands-on approach. Where felt to be beneficial, some of our teams work with the carers and staff delivering care and give them support on how to approach challenging cases and situations. We support them rather than regulate them.

• Collaboration with other partners and the wider care sector:

Throughout the life of the programme we have sought to work in collaboration with system partners including the Care Inspectorate. They are the regulator and they inspect care home settings. As part of this they have a periodic inspection focus area and last year dementia was the focus. Within that assessment framework, oral health was covered so the training we provided enabled the care homes to ensure they were delivering care that is expected of them in the inspection model for that particular domain. A care home will deliver oral health care but it’s a marker for how good the quality of care is that’s delivered by the care provider.

• Recognising the particular needs and requirements of the target group:

A key lesson we learned along the way was that the nutrition messages had to be slightly different for older people. With children the general advice is to advise keeping sugary snacks to meal time and that’s a consistent message. With the elderly population they may be nutritionally vulnerable and have to have a slightly different diet. It’s also important to factor the whole social aspect of having their afternoon tea so we had to find middle ground that satisfied both nutritionists and the oral health team. Accepting that they needed a sugary diet meant that we had to ensure that their oral health care was particularly good.