Oral Care Audit - Care Homes

Q1 | Unanswered

Is there a current Oral Health / Oral Care policy in place that is accessible to staff and reviewed at least annually?

Q2 | Unanswered

Does the Oral Care policy reference relevant requirements such as dignity, consent, infection prevention, and person-centred care?

Q3 | Unanswered

Is there a named lead (e.g., nurse/manager) responsible for oral health oversight and audit follow-up?

Q4 | Unanswered

Are oral care audits carried out at a defined frequency and documented (including actions, owners, and timescales)?

Q5 | Unanswered

Are trends from oral health issues (e.g., infections, weight loss, aspiration pneumonia links, complaints) reviewed and acted upon?

Q6 | Unanswered

Are any shortfalls identified through audits escalated via governance (e.g., quality meetings) with evidence of improvement actions?

Q7 | Unanswered

Is an oral health assessment completed on admission (or within an agreed timeframe) for every resident?

Q8 | Unanswered

Are oral health assessments reviewed regularly and whenever needs change (e.g., weight loss, stroke, dementia progression, new meds)?

Q9 | Unanswered

Do care plans clearly describe the resident’s usual oral care routine, preferences, and required support level?

Q10 | Unanswered

Does the care plan specify products required (e.g., fluoride toothpaste strength, mouth moisturisers) and how they should be used?

Q11 | Unanswered

Is there a documented risk assessment for residents who resist oral care or have behaviours that challenge during mouth care?

Q12 | Unanswered

Are swallowing risks considered in oral care planning (e.g., aspiration risk, thickened fluids, reduced gag reflex)?

Q13 | Unanswered

Are residents with dentures assessed for correct fit, comfort, and risks of pressure sores/ulcers?

Q14 | Unanswered

For residents without capacity, is there evidence of a best-interests decision and least restrictive approach for oral care support?

Q15 | Unanswered

Is the resident (and/or family/representative) involved in oral care decisions, with preferences recorded and respected?

Q16 | Unanswered

Do staff consistently seek consent before providing oral care and respect refusal (with appropriate re-approach/escalation plans)?

Q17 | Unanswered

Is oral care delivered in a way that protects privacy and dignity (e.g., doors/curtains, respectful communication)?

Q18 | Unanswered

Are cultural, religious, and personal preferences considered (e.g., preferred products, timing, approach, gender of staff if requested)?

Q19 | Unanswered

Is there a clear pathway for escalating concerns when repeated refusals create significant health risks?

Q20 | Unanswered

Is oral care provided at the frequency required by the care plan (e.g., at least twice daily brushing where appropriate)?

Q21 | Unanswered

Are residents who are dependent supported to brush effectively (including gumline, tongue cleaning where appropriate)?

Q22 | Unanswered

Are residents encouraged and enabled to maintain independence with oral care wherever possible?

Q23 | Unanswered

Are dentures cleaned correctly and as often as required (including overnight storage where clinically appropriate)?

Q24 | Unanswered

Are dentures clearly labelled and stored safely to reduce loss, damage, or cross-contamination?

Q25 | Unanswered

Are mouth dryness (xerostomia) and comfort issues identified and managed (e.g., hydration prompts, saliva substitutes as appropriate)?

Q26 | Unanswered

Are toothbrushes stored hygienically, upright, and separated to prevent cross-contamination?

Q27 | Unanswered

Are toothbrushes replaced at appropriate intervals and after infection (as per policy/best practice)?

Q28 | Unanswered

Are single-use items (e.g., mouth swabs where used) disposed of safely, and reusable items cleaned according to IPC guidance?

Q29 | Unanswered

Do staff use appropriate PPE for oral care, based on risk assessment (e.g., gloves/aprons/eye protection if splash risk)?

Q30 | Unanswered

Are oral care sinks/areas kept clean and free from contamination risks (e.g., no shared cups, no communal toothpaste)?

Q31 | Unanswered

Is there a safe process for cleaning and storing denture pots/containers to prevent contamination?

Q32 | Unanswered

Are residents checked for signs of oral disease (e.g., ulcers, thrush, bleeding gums, toothache, broken teeth) and recorded?

Q33 | Unanswered

Is there timely escalation to dental services/GP when oral concerns are identified?

Q34 | Unanswered

Are suspected oral infections (e.g., thrush) managed promptly, with treatment and follow-up documented?

Q35 | Unanswered

Are pressure sores or lesions from dentures identified promptly and addressed (including refitting referrals)?

Q36 | Unanswered

Are risks linked to poor oral health considered (e.g., malnutrition, dehydration, aspiration pneumonia) and addressed in care planning?

Q37 | Unanswered

Are residents on medications that impact oral health (e.g., anticholinergics, inhaled steroids, diuretics) monitored for side effects like dry mouth/thrush?

Q38 | Unanswered

Are residents receiving oxygen therapy supported to manage mouth dryness safely and effectively?

Q39 | Unanswered

Where residents have weight loss, reduced appetite, or chewing difficulties, is oral health considered as a possible contributing factor?

Q40 | Unanswered

Are texture-modified diets and oral comfort needs aligned (e.g., pain-free chewing, mouth soreness, dental issues)?

Q41 | Unanswered

Are residents supported to attend routine dental checks, and is access to NHS/private dentistry documented?

Q42 | Unanswered

Are oral health needs considered within end-of-life care plans (comfort-focused mouth care, symptom control)?

Q43 | Unanswered

Have staff received oral care training that is role-appropriate (including dementia-sensitive approaches and IPC)?

Q44 | Unanswered

Are staff assessed as competent in providing oral care (including for dependent residents and those with complex needs)?

Q45 | Unanswered

Do new staff receive induction covering oral care expectations, documentation, and escalation pathways?

Q46 | Unanswered

Can staff describe how to support a resident who refuses oral care using reassurance, choice, and least restrictive approaches?

Q47 | Unanswered

Are training records current and monitored, with refresher training scheduled as needed?

Q48 | Unanswered

Is oral care delivery documented consistently (e.g., daily records, charts) in line with the care plan and provider policy?

Q49 | Unanswered

Are missed/refused oral care episodes recorded with reasons and actions taken (re-approach plan, escalation, family involvement if appropriate)?

Q50 | Unanswered

Are changes in oral condition recorded and communicated at handover and/or via clinical notes?

Q51 | Unanswered

Are incidents involving oral harm (e.g., choking during oral care, denture-related injury, suspected neglect) recorded and investigated?

Q52 | Unanswered

Are there clear safeguarding triggers for oral neglect (including repeated missed care) and do staff know how to escalate concerns?

Q53 | Unanswered

Are complaints/concerns from residents or families about oral care responded to promptly with documented outcomes and learning?

Q54 | Unanswered

Where significant harm occurs linked to oral care (or lack of), is there evidence of appropriate reporting, investigation, and learning shared with staff?

Q55 | Unanswered

Are reasonable adjustments made for residents with disabilities (e.g., adapted toothbrush handles, positioning aids, communication aids)?

Q56 | Unanswered

Are communication needs supported during oral care (e.g., hearing impairment, learning disability, autism, dementia-friendly approach)?

Q57 | Unanswered

Can staff describe the local process for arranging urgent dental care and routine dental reviews?

Q58 | Unanswered

Can a senior staff member evidence how oral care quality is monitored (audit results, action plans, improvement outcomes)?