Oral Care Audit - Care Homes

Evidence to check

• • Current oral care policy is available and reviewed at least annually
• • Policy is accessible to care, nursing, domestic and management staff
• • Staff can explain key oral care expectations in practice
• • Observed practice and care records reflect the policy

Evidence to check

• • Policy includes consent, MCA, best interests, dignity and privacy
• • Policy includes IPC requirements for toothbrushes, dentures, PPE and storage
• • Policy explains how to escalate pain, infection, refusal or deterioration
• • Staff understand that oral care is part of essential personal care, not an optional task

Evidence to check

• • Named oral care lead, nurse, manager or senior staff member is identified
• • Role includes audit review, action tracking, staff guidance and escalation
• • Deputy arrangements are in place
• • Lead can explain current oral care risks and improvement actions

Evidence to check

• • Oral care audit schedule is in place
• • Completed audits include findings, actions, owners and deadlines
• • Actions are followed up and signed off
• • Repeat issues are escalated through governance

Evidence to check

• • Governance records include oral health themes where relevant
• • Weight loss, poor intake, chest infections, mouth pain or oral infections are reviewed together where appropriate
• • Repeated refusals or missed oral care are analysed for patterns
• • Learning leads to care plan, training or escalation changes

Evidence to check

• • Audit shortfalls are included in quality or governance meetings
• • Action plans are monitored by management
• • High-risk issues are escalated promptly
• • Follow-up audits confirm whether practice has improved

Evidence to check

• • Oral health assessment is completed for sampled residents
• • Assessment includes teeth, gums, tongue, dentures, pain, swallowing, dry mouth and ability to manage oral care
• • Resident preferences and usual routine are recorded
• • Assessment findings are transferred into the care plan

Evidence to check

• • Review dates are recorded
• • Reviews occur after weight loss, stroke, dementia progression, oral infection, medication change, new dentures or reduced intake
• • Changes are reflected in care plans and daily guidance
• • Staff are informed of updated oral care needs

Evidence to check

• • Care plan states whether resident is independent, needs prompting, supervision or full support
• • Preferred timing, products, approach and privacy needs are recorded
• • Care plan includes dentures, natural teeth, implants or no teeth where relevant
• • Daily records show care is delivered in line with the plan

Evidence to check

• • Care plan states toothpaste, fluoride strength, mouth moisturiser, denture products or prescribed oral treatments where relevant
• • Products are available and in date
• • Staff know how and when to use each product
• • Professional advice is followed where specific products are prescribed or recommended

Evidence to check

• • Care plan identifies triggers, preferred approach and de-escalation strategies
• • Staff use reassurance, choice, timing changes and familiar routines
• • Refusals are recorded with re-approach plans
• • Repeated refusal is escalated where health risks increase

Evidence to check

• • Care plan reflects dysphagia, aspiration risk, reduced gag reflex or SALT advice where relevant
• • Staff understand safe positioning during oral care
• • Mouth care products and fluid use are appropriate to swallowing risk
• • Concerns such as coughing, choking or wet voice are escalated

Evidence to check

• • Denture assessment is included in oral health assessment
• • Care records note whether dentures fit comfortably
• • Pressure areas, ulcers, looseness or pain are recorded and escalated
• • Dental referral is made where dentures are broken, missing or poorly fitting

Evidence to check

• • Decision-specific mental capacity assessment is completed where required
• • Best-interest decision includes resident wishes, family or advocate input where appropriate
• • Least-restrictive approaches are considered
• • Care plan avoids force and focuses on reassurance, timing and dignity

Evidence to check

• • Resident preferences are recorded in the care plan
• • Family or representative input is included where appropriate and lawful
• • Preferences around products, timing, privacy and approach are followed
• • Changes requested by the resident are acted on

Evidence to check

• • Observation shows staff ask before providing mouth care
• • Staff explain what they are doing in a calm and respectful way
• • Refusal is respected and recorded
• • Staff re-approach later and escalate if refusal creates significant risk

Evidence to check

• • Doors, curtains or screens are used where needed
• • Staff speak respectfully and avoid embarrassment
• • Residents are positioned comfortably and appropriately covered
• • Oral care is not rushed or carried out publicly without need

Evidence to check

• • Care plan records preferences around products, timing, fasting, modesty, gender of staff or religious practice where relevant
• • Staff avoid assumptions and ask respectfully
• • Preferred products are used where safe and available
• • Concerns about dignity or cultural insensitivity are addressed

Evidence to check

• • Repeated refusals are recorded and reviewed
• • Care plan includes re-approach and reassurance strategies
• • Senior staff, GP, dentist, family or advocate are involved where appropriate
• • Risk of pain, infection, malnutrition or aspiration is considered

Evidence to check

• • Daily records show oral care is completed as planned
• • At least twice-daily brushing is supported where appropriate
• • Missed care is recorded with reason and action
• • Audit checks actual delivery, not only care plan wording

Evidence to check

• • Observation or competency checks show effective technique
• • Care plans specify areas needing support
• • Staff use suitable toothbrushes, paste and positioning
• • Poor technique is addressed through coaching or retraining

Evidence to check

• • Care plans identify what the resident can do independently
• • Staff use prompting, set-up help, adapted toothbrushes or hand-over-hand support where appropriate
• • Staff do not take over unnecessarily for speed
• • Independence is reviewed when ability changes

Evidence to check

• • Denture cleaning routine is recorded in the care plan
• • Dentures are visibly clean and free from debris
• • Overnight storage follows resident preference and dental guidance
• • Staff know not to leave dentures wrapped in tissue or unsafe places

Evidence to check

• • Denture pots are labelled where appropriate
• • Dentures are stored separately and hygienically
• • Lost or damaged dentures are reported and investigated
• • Residents are supported to access replacement or repair promptly

Evidence to check

• • Care records identify dry mouth, soreness, cracked lips, ulcers or discomfort
• • Hydration support and mouth moisturisers are used where appropriate
• • Medication side effects are considered
• • Persistent discomfort is escalated to GP, dentist or pharmacist

Evidence to check

• • Toothbrushes are stored separately and not touching others
• • Storage areas are clean and dry
• • Toothbrushes are labelled where needed
• • No communal toothbrushes or shared cups are used

Evidence to check

• • Toothbrush replacement process is in place
• • Worn, contaminated or old toothbrushes are replaced
• • Replacement after infection is considered according to policy
• • Residents have access to suitable oral care equipment at all times

Evidence to check

• • Single-use swabs or items are disposed of after use
• • Reusable items are cleaned and stored safely
• • Staff understand which items must not be reused
• • IPC concerns are escalated and corrected

Evidence to check

• • Gloves and aprons are used where required
• • Eye or face protection is used if splash risk is present
• • Hand hygiene is completed before and after oral care
• • PPE use is proportionate and not a substitute for respectful care

Evidence to check

• • Oral care areas are visibly clean
• • No shared cups, communal toothpaste or unlabelled products are in use
• • Toothbrushes and denture pots are not stored near toilets or contamination risks
• • Cleaning responsibilities are clear

Evidence to check

• • Denture pots are cleaned regularly
• • Pots are labelled and used for one resident only
• • Dirty or damaged pots are replaced
• • Staff understand how to prevent cross-contamination

Evidence to check

• • Records identify ulcers, thrush, bleeding gums, toothache, broken teeth, swelling, halitosis or loose dentures
• • Staff ask about pain or discomfort where possible
• • Non-verbal signs of oral pain are recognised
• • Findings are recorded and escalated

Evidence to check

• • Referral records show date, reason and urgency
• • Urgent concerns such as pain, swelling, infection or broken teeth are escalated promptly
• • Follow-up is recorded until outcome is known
• • Care plan is updated after professional advice

Evidence to check

• • Symptoms are recorded and escalated
• • Treatment prescribed or advised is documented
• • Staff monitor whether symptoms improve
• • Infection prevention and oral hygiene advice is followed

Evidence to check

• • Oral checks include gums, palate and areas under dentures
• • Dentures are removed and checked where appropriate
• • Poorly fitting dentures trigger dental referral
• • Resident pain, eating difficulties or refusal of dentures are acted on

Evidence to check

• • Nutrition, hydration and oral care records are reviewed together where concerns exist
• • Poor oral health is considered when appetite, chewing or swallowing changes
• • Chest infections or aspiration risk trigger oral care review where relevant
• • Professional referrals are made where risk increases

Evidence to check

• • Medication reviews consider oral health side effects
• • Residents using inhaled steroids receive mouth care advice where appropriate
• • Dry mouth from anticholinergics, diuretics or other medicines is considered
• • Pharmacist, GP or dentist input is requested where needed

Evidence to check

• • Care plan includes mouth comfort for residents on oxygen
• • Dry mouth, cracked lips or discomfort are monitored
• • Safe products are used, avoiding inappropriate oil-based products where oxygen risk applies
• • Concerns are escalated to clinical staff or GP

Evidence to check

• • Weight loss reviews include oral health checks
• • Chewing, pain, dentures and mouth soreness are considered
• • Food texture or diet changes are not made without checking oral comfort where relevant
• • Dental or GP referral is made where oral issues may affect intake

Evidence to check

• • Care plans link oral health, chewing ability, dysphagia and diet texture
• • SALT, dietitian or dental advice is followed where relevant
• • Mouth pain or dental issues are considered before changing diet
• • Residents are reviewed if they avoid food or show discomfort while eating

Evidence to check

• • Dental registration or access arrangements are recorded
• • Routine dental checks are offered and supported
• • Urgent dental appointments are arranged where needed
• • Transport, escort and consent arrangements are planned

Evidence to check

• • End-of-life care plans include mouth care and comfort needs
• • Dry mouth, oral pain, secretions and cracked lips are managed
• • Mouth care is provided gently and according to comfort
• • Family or hospice advice is included where appropriate

Evidence to check

• • Training records show oral care training for relevant staff
• • Training includes dependent residents, dentures, refusal, dementia, IPC and escalation
• • Night staff and agency or bank staff receive appropriate guidance
• • Training is refreshed where gaps are identified

Evidence to check

• • Competency assessments or practice observations are completed
• • Staff can demonstrate safe and dignified oral care technique
• • Complex needs such as dysphagia, dementia, distress or oxygen therapy are included where relevant
• • Competency gaps lead to supervision or retraining

Evidence to check

• • Induction checklist includes oral care
• • New staff understand care plan expectations and recording requirements
• • Escalation routes for pain, infection, refusal or deterioration are explained
• • New staff are supervised until competent where needed

Evidence to check

• • Staff can explain re-approach, timing, choice, familiar staff and reassurance strategies
• • Staff understand not to force oral care
• • Care plans include resident-specific refusal strategies
• • Repeated refusal is escalated appropriately

Evidence to check

• • Training matrix shows oral care completion and refreshers
• • Overdue training is identified
• • Training gaps are included in action plans
• • Training effectiveness is checked through observation or audit

Evidence to check

• • Daily records or oral care charts show care delivered
• • Records include time, support given and any concerns where required
• • Documentation is factual and completed contemporaneously
• • Records match the resident's assessed support level

Evidence to check

• • Refusals or missed care are recorded clearly
• • Re-approach attempts are documented
• • Escalation occurs where repeated refusal creates risk
• • Family or representative involvement is considered where appropriate and lawful

Evidence to check

• • Handover records include oral pain, infection, broken dentures, refusal or dental appointments
• • Clinical notes reflect changes and actions
• • Care plans are updated where needs change
• • Staff on all shifts are aware of current concerns

Evidence to check

• • Incidents such as choking during oral care, denture injury, mouth injury or suspected neglect are recorded
• • Investigation considers care practice, training, equipment and resident risk
• • Immediate protective actions are taken
• • Learning is shared with staff

Evidence to check

• • Staff understand that repeated missed oral care, untreated pain or poor hygiene may indicate neglect
• • Safeguarding policy references neglect and poor care where relevant
• • Concerns are escalated to seniors, safeguarding lead or local authority where thresholds are met
• • Rationale is recorded where safeguarding is considered but not referred

Evidence to check

• • Complaints or concerns log includes oral care issues where raised
• • Concerns are investigated and responded to respectfully
• • Actions are taken to improve care where needed
• • Learning is shared through supervision, meetings or training

Evidence to check

• • Serious oral care incidents are investigated
• • Safeguarding, CQC, commissioners or other notifications are considered where required
• • Root causes are identified
• • Action plans prevent recurrence and are followed up

Evidence to check

• • Adapted toothbrushes, handles, positioning aids or mirrors are used where helpful
• • Staff support residents with reduced grip, tremor, stroke effects, arthritis or visual impairment
• • Equipment needs are reviewed when abilities change
• • Occupational therapy or dental advice is sought where needed

Evidence to check

• • Care plans include communication approaches for oral care
• • Staff use dementia-friendly, autism-informed, learning disability or sensory-sensitive approaches where relevant
• • Hearing aids, glasses, visual prompts or simple explanations are used
• • Residents are not rushed or overwhelmed

Evidence to check

• • Staff know who to contact for urgent dental concerns
• • Routine dental access arrangements are recorded
• • Out-of-hours or emergency pathways are known to senior staff
• • Dental appointment outcomes are documented and followed up

Evidence to check

• • Senior staff can show audit results, action plans and improvement outcomes
• • Oral care themes are reviewed in governance
• • Training, supervision and competency actions are linked to audit findings
• • Improvements are checked for impact on resident comfort, health and dignity

Evidence to check

• • Audit includes observation, resident feedback, staff questioning and record review
• • Audit checks oral comfort, denture fit, pain, hygiene, dignity and timely escalation
• • Findings are compared with nutrition, hydration, infection and complaint data where relevant
• • Actions lead to measurable improvement in oral care practice and resident wellbeing

Evidence to check

• • Clinical reviews consider oral care as part of whole-person health
• • Oral care is linked with MUST, SALT, medication review, infection review and end-of-life planning where relevant
• • Staff understand oral care can affect comfort, nutrition and respiratory health
• • Governance reviews oral care as a safety and quality issue, not just a personal hygiene task