Residential Oral Care Sheffield (ROCS) is a comprehensive dental service for adults in care homes. Local General Dental Services (GDS) work in partnership with Community Dental Services (CDS) to provide an oral health needs assessment screening and any necessary dental treatment for all consenting adults in each care home.
We also provide oral healthcare training for staff to increase knowledge and skills to improve mouth care of the residents. The training is provided by the Community Dental Services Oral Health Promotion Team in conjunction with the Programme in Dental Hygiene and Therapy at the University of Sheffield. We utilise the dental hygiene therapy students to deliver oral healthcare training for staff in care homes.
The ROCS project is in line with the recommendations 1.2 and 1.4 in the NICE Guidance for Oral Health for Adults in Care Homes (NG48) covering oral health assessment and knowledge and skills of care staff.
Aims and objectives
- To design and evolve a domiciliary dental care scheme to improve oral health care for patients in care homes
- To design and evolve a scheme to be attractive to GDP’s in the future so as to increase coverage of oral health provision in residential homes
- To deliver domiciliary oral healthcare to residents in care homes
- To improve the quality of oral health care and the patient experience
- To provide an oral health needs assessment screening for all consenting clients in care homes identified and to integrate this into their care plan
- To promote collaboration between dental health professionals and care home staff
- To improve oral health by developing oral health promotion in care homes
- To enable dentists to explore innovative approaches to the delivery of oral health care to an elderly client group in a domiciliary care setting
- To increase skill levels in GDP’s by specialisation and support from a Senior Dental Officer in Gerodontology
Reasons for implementing your project
Sheffield has the highest proportion of older residents of any of the major cities in England, with approximately 87,000 registered people over the age of 65. Of these, over 4000 (4.5%) are living in care homes and may be reliant on others to ensure they receive regular oral care.
The proportion of older people continues to grow worldwide, especially in developing countries. Chronic disease and most oral diseases share common risk factors. Globally, poor oral health amongst older people has been particularly evident in high levels of tooth loss, dental caries experience, and the prevalence rates of periodontal disease, xerostomia and oral pre-cancer/cancer.
The negative impact of poor oral conditions on the quality of life of older adults is an important public health issue, which must be addressed by policy-makers. With increasing age, teeth may become brittle and darker in colour. Surface enamel may be lost, and teeth may become loose as a result of breakdown of supporting tissues and bone loss. Residents and people in continuing care are entitled to equal access to general and specialist dental services appropriate to their needs, continuing dental care should be available for anyone in long-stay and residential accommodation.
Previously, the residents in care homes for older people in Sheffield had very ad-hoc dental provision and it was recorded that their dental health was poor and impacting on their general health. The ROCS project was initially funded by a dental public health consultant following an idea by a dental advisor in Sheffield and a Senior Dental Officer in Gerodontology working in Community and Special Care Dentistry. Money from the 'Modernising Dentistry Options for Change' initiative funded equipment and resources for the programme. There are 82 care homes in Sheffield and now 78 are receiving the ROCS service provided by 10 General Dental Practitioners. The total number of individuals who are in receipt of this service is 3579.
How did you implement the project
To implement the project it was important to recruit the right motivated staff. This was achieved by the Dental Advisor and Senior Dental Officer speaking to work colleagues to ask if they would be interested in their dental practice taking part in ROCS.
Colleagues from commissioning were involved and have ensured that ROCS is commissioned through a service level agreement with a service specification appended to the contractors GDS contract.
To encourage the homes to take part in the ROCS programme the home managers were contacted to arrange a meeting with the dental practice staff who would potentially be looking after the dental care for their home. This was followed by a free training session for staff about mouth care and the ROCS programme.
Once the homes agreed to take part they were given a copy of the ROCS charter which explained what to expect from the dental practice and is expected from the care home (see supporting material).
The dental practice carries out annual screening for residents followed by any treatment requirements. For residents with complex medical issues or for treatment that cannot be carried out within the care home they are referred to the CDS.
The homes also receive oral healthcare training updates every 2 years, unless extra training is requested for new starters.
The oral health promotion (OHP) team were already delivering training within the care homes, developed by a Senior Dental Officer in Community and Special Care Dentistry and a member of the OHP team.
The aim is to provide practical training on oral health to staff involved in the care of adults living in a care home. The content includes how to support residents in maintaining daily mouth care including brushing teeth twice a day with fluoride toothpaste and how to care for dentures. The training also includes information about denture marking and how to report any oral health concerns. Following training staff receive a certificate to confirm their attendance and the ROCS dentist will assess oral hygiene of residents. If they have any concerns they will speak to homecare managers and also contact oral health promotion team to check if the home has recently had any training.
The dental practices are each assigned a number of care homes within the postcode area of the practice. It is the dental practices responsibility to contact the individual care homes to arrange for dental screening and provide individual care plans for each of the residents.
At the end of the training session care staff are asked to complete an evaluation form which has resulted in very positive feedback.
Before ROCS the Oral Health Promotion Team delivered training to 25 homes a year. Now that we work in partnership with hygiene therapy students in delivering oral health care training, we deliver training to 47 care homes a year.
The ROCS service is monitored via the submission of monthly timesheets and screening forms by the GDPs involved. This allows the Area Team to record the number of sessions completed as well as important information regarding clinical status, rate of dental disease and treatment requirements. It is this data that forms the basis of the ROCS report.
In 2013/14 eleven ROCS dentists carried out a total of 763 sessions for ROCS. This is an increase on 2011/12 when eight ROCS dentists carried out a total of 688 sessions for ROCS. A session equates to 3 ½ hours and this time consists of screening, providing treatment, administration, meeting attendance and travelling.
In 2013/14 the ROCS dentists provided a service to 75 out of the 86 care homes in Sheffield (an increase compared to 62 out of 86 care homes in 2011/12)
Of the 11 homes not covered by ROCS, 6 were covered by the Sheffield Community and Special Care Dentistry and the remainder were covered by GDPs not in the ROCS scheme.
Approximately 2359 care home residents were screened during 2013/14 and 357 refused screening. The number screened has increased over the past three years.
Most treatment was completed in the care homes. 739 (31%) patients required some form of treatment and of these, 581 (25%) received this treatment in the care home. 161 (7%) patient’s treatment was deferred, with 45 (2%) requiring referral to other services. Please see the supporting material for further information.
Key learning points
Partnership working is key for a project like ROCS to be successful. Community and Special Care Dentistry, NHS England, Public Health England, University of Sheffield and initially 6 General Dental Practitioners worked together with care home managers in order to provide this comprehensive service to care homes.
Where it works well the care staff become part of the ROCS team, working with us to help maintain good oral health for every resident. The ROCS project has been cited as an example of good practice in a number of journals (see supporting material).
The project has faced challenges with regard to continued funding. GDP’s have now been able to convert units of dental activity (UDA’s) to an agreed number of sessions and agreed number of homes and patients seen within a year. This includes staff costs, laboratory bills, materials, admin and travelling time. Two peer review sessions a year are also included in this agreement.
The programme is monitored by NHS Dental Services with a separate suffix to the contract number. The GDP’s also complete a monthly time sheet and have annual meetings with the contracts manager.
The programme also links well with the recently published commissioning guides and the levels of working dependant on patient needs and differing times e.g. GDP’s carry out most of the patient’s treatment but can refer to Community Dental Services for more complex work i.e. if a hoist is needed or a patient is medically compromised. Following treatment for Community Dental Services the patient is referred back to the GDP for routine care.
Efficiency could be improved by using skill mix within the dental team including hygiene/ therapists with direct access and dental nurses with extended duties providing fluoride varnish application.
The accuracy of reporting data is reliant on ROCS GDPs completing their timesheets and screening forms accurately and with all relevant information recorded.
The project was originally a Modernising Dentistry Options for Change Field Site programme and now the General Dental Practitioners taking part in ROCS have a block contract from NHS England. The oral healthcare training is funded as part of the Sheffield City Council contract for oral health improvement within the city.