Oral Health Care Documentation in Care Homes

Why Oral Health Documentation Matters

Poor oral health affects over 70% of care home residents and is linked to aspiration pneumonia, malnutrition, pain, and reduced quality of life. CQC increasingly focuses on oral health as part of person-centred care. Good documentation ensures consistent mouth care, early identification of problems, and evidence of quality care.

Oral Health Assessment

Complete an oral health assessment on admission and review regularly:

Daily Mouth Care Records

Document mouth care provision at least twice daily:

• Time of mouth care
• Assistance level required (independent, prompted, full assistance)
• Products used (toothpaste, mouthwash, moisturiser)
• Denture care provided (cleaned, soaked overnight)
• Any difficulties encountered
• Resident's cooperation and response
• Staff member providing care

For Residents Who Refuse

If a resident declines mouth care, document:

• Reason given (if any)
• Alternative approaches tried
• Whether care was accepted later
• Pattern of refusals (time of day, specific staff)
• Escalation if persistent refusal

Denture Care Documentation

Signs to Watch For and Escalate

Mouth Care for Specific Needs

Residents with Dementia

• Document preferred approach (demonstration, hand-over-hand)
• Record best time of day for cooperation
• Note triggers that cause distress
• Document successful techniques to share with team

End of Life Care

• Increased frequency of mouth moistening
• Use of lip balm and oral swabs
• Comfort-focused approach documented
• Family involvement in mouth care if wished

Residents with Dysphagia

• Mouth care before meals to stimulate saliva
• Thorough mouth care after meals to remove debris
• Checking for food pocketing in cheeks
• Upright position during mouth care

Care Plan Requirements

The oral health care plan should include:

• Current oral health status
• Natural teeth present and condition
• Denture details and storage preferences
• Assistance level required
• Products to use (including any allergies)
• Frequency of mouth care
• Resident preferences and best approaches
• Dental registration details
• Date of last dental check and next due

Annual Dental Access

Document access to dental services:

• Registered dentist details
• Date of last dental examination
• Any treatment received
• Barriers to accessing dental care and how addressed
• Domiciliary dental service use if applicable