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Consent to Dental Treatment Policy

1. Purpose

The purpose of this policy is to ensure that all people supported by {{org_field_name}} are supported to access safe, appropriate and timely oral health care and dental treatment, and that any care or treatment is provided only where valid and informed consent has been obtained, or where there is lawful authority to proceed.

This policy supports compliance with the Health and Social Care Act 2008, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including Regulation 9 (Person-centred care), Regulation 10 (Dignity and respect), Regulation 11 (Need for consent), Regulation 12 (Safe care and treatment), Regulation 13 (Safeguarding service users from abuse and improper treatment), Regulation 17 (Good governance), Regulation 18 (Staffing) and Regulation 20 (Duty of candour), together with the Mental Capacity Act 2005 and associated Code of Practice.

The policy also supports implementation of NICE Guideline NG48, Oral health for adults in care homes, and current CQC expectations that people understand their rights around consent, receive information in a way they can understand, and are supported to make informed decisions about care and treatment.

{{org_field_name}} recognises that dental practitioners are responsible for obtaining valid consent for dental examination, diagnosis and treatment. Care home staff are responsible for supporting people to understand information, express their wishes, access dental services, attend appointments, maintain daily mouth care, and ensure that relevant care records, communication needs, capacity assessments and best interest decisions are available where appropriate.

2. Scope

This policy applies to all staff employed or engaged by {{org_field_name}}, including the Registered Manager, nurses, senior care staff, care workers, activity staff, agency staff, volunteers where relevant, and any staff involved in supporting residents with oral health, dental appointments or daily mouth care.

This policy applies to all adults living at the care home, including people who have capacity to make their own decisions, people who may require support to make decisions, and people who may lack capacity for a specific decision about oral health care or dental treatment.

This policy applies when residents are supported with:

• daily mouth care, including toothbrushing, denture care and prescribed or recommended mouth care products;
• oral health assessments and mouth care plans;
• routine dental check-ups;
• urgent or emergency dental appointments;
• domiciliary dental visits within the care home;
• external dental appointments;
• communication with dentists, community dental services, special care dentistry services, families, advocates, attorneys, deputies and other professionals.

Dental practitioners remain professionally responsible for diagnosis, treatment planning and obtaining valid consent for dental treatment. Care home staff must not diagnose dental disease, provide treatment outside their role, or consent to treatment on behalf of a resident unless they have specific lawful authority to do so.

3. Related Policies

• CH07 – Person-Centred Care Policy
• CH08 – Dignity and Respect Policy
• CH09 – Consent to Care Policy
• CH13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• CH27 – Staff Supervision, Training, and Development Policy
• CH36 – Initial Assessment and Care Planning Policy
• CH39 – Mental Capacity and Deprivation of Liberty Safeguards Policy
• CH42 – Communication and Engagement with Service Users and Families Policy

4. Legal and Best Practice Framework

This policy must be read and implemented in line with the following legal and best practice framework:

• Health and Social Care Act 2008;
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014;
• Care Quality Commission guidance on Regulation 11: Need for consent;
• CQC Single Assessment Framework quality statement: Consent to care and treatment;
• Mental Capacity Act 2005 and the Mental Capacity Act Code of Practice;
• Human Rights Act 1998;
• Equality Act 2010;
• Care Act 2014, including safeguarding duties;
• UK GDPR and Data Protection Act 2018;
• NICE Guideline NG48, Oral health for adults in care homes;
• NICE guidance on decision-making and mental capacity, where applicable;
• General Dental Council Standards for the Dental Team;
• The Oliver McGowan Code of Practice on statutory learning disability and autism training.

Staff must understand that consent is not a one-off event. Consent must be sought and respected on each occasion where care, support or treatment is provided. A resident may withdraw consent at any time, even if they previously agreed.

Where there is a conflict between a resident’s expressed wishes, professional advice, family views, risk management or staff concerns, the matter must be escalated to the Registered Manager and, where appropriate, the relevant dental practitioner, GP, community dental service, safeguarding team, advocate or legal representative.

5. Policy Statement and Responsibilities

Legal Framework and Best Practice

Under Regulation 11, care and treatment must only be provided with the consent of the relevant person, unless there is lawful authority to provide it. Consent must be obtained lawfully, and the person seeking consent must have enough knowledge and understanding of the care or treatment to explain it properly and answer questions within the limits of their role.

For dental treatment, the dental practitioner is responsible for explaining the proposed examination, treatment options, benefits, risks, likely consequences of refusing treatment, and alternatives, and for obtaining valid consent. Care home staff must support the resident to understand information, communicate their wishes, attend appointments and access appropriate advocacy or representation where required.

Staff must always start from the presumption that the resident has capacity to make the specific decision unless it is established otherwise. A resident must not be treated as lacking capacity simply because they make a decision that others consider unwise. Where a resident lacks capacity for a specific decision, any act or decision must be made in accordance with the Mental Capacity Act 2005, in the resident’s best interests, and in the least restrictive way.

This policy applies to routine dental checks, oral health assessments, daily mouth care, denture care, prescribed mouth care products, urgent dental appointments, invasive dental treatment and emergency dental treatment.

Types of Consent

Consent may be given in different ways, depending on the person, the decision and the circumstances. Staff must record the form of consent and any support provided.

Consent may be:

• Verbal consent: where the resident clearly agrees by spoken words to support, care or an appointment.
• Non-verbal consent: where the resident communicates agreement through gestures, signs, facial expression, communication aids or other recognised methods of communication.
• Written consent: where written confirmation is requested by a dental practitioner or is appropriate because the proposed treatment is complex, invasive or carries significant risks. Written consent is evidence of consent, but it does not replace the need for the resident to understand the decision and agree voluntarily.
• Implied cooperation: for example, a resident opening their mouth during routine mouth care. Staff must be cautious when relying on implied cooperation. It must not be used where the resident appears distressed, resistant, confused, unable to understand, or where the care or treatment is invasive or higher risk.

For consent to be valid, the resident must have capacity for the specific decision at the time it needs to be made, must receive enough information in a way they can understand, and must make the decision freely without pressure, coercion or manipulation.

Staff must never assume that consent to one aspect of oral care means consent to all dental care. Consent to daily toothbrushing, a dental check-up, an X-ray, extraction, filling, sedation, denture work or referral to another service must be considered separately where appropriate.

Refusal or Withdrawal of Consent

A resident who has capacity has the right to refuse dental treatment, oral health assessment, daily mouth care or support with a dental appointment, even where staff, family members or professionals believe the decision is unwise.

Where a resident refuses or withdraws consent, staff must:

• stop the care or support unless there is immediate risk requiring urgent lawful action;
• remain calm and respectful;
• check whether the refusal relates to pain, fear, trauma, communication difficulties, timing, embarrassment, cultural needs, sensory needs, gender preference, previous negative experiences, or lack of understanding;
• offer information in a different format or at a different time;
• consider whether another member of staff, advocate, interpreter, family member or trusted person may help the resident understand and express their wishes;
• record the refusal, the resident’s stated reasons where known, the information provided, actions taken, and any follow-up required;
• inform the nurse in charge or senior staff member and escalate to the Registered Manager where refusal may lead to deterioration, pain, infection, weight loss, distress or safeguarding concerns;
• seek advice from the dentist, GP, community dental service or other relevant professional where refusal creates a risk of harm.

Repeated refusal of mouth care or dental treatment must trigger a review of the resident’s oral health care plan, risk assessment and mental capacity where there is reason to doubt capacity for the specific decision.

No resident must be forced, deceived, threatened, restrained or coerced into oral care or dental treatment. Any proposed restrictive intervention must be considered under the Mental Capacity Act 2005, safeguarding procedures, deprivation of liberty requirements and the organisation’s restrictive practice policy.

Capacity Assessment

Mental capacity is decision-specific and time-specific. A resident may have capacity to consent to daily mouth care but lack capacity to consent to a complex dental procedure, or may have capacity at one time of day but not another.

Where there is doubt about a resident’s capacity to make a decision about oral care, dental appointments or dental treatment, staff must follow the Mental Capacity Act 2005 and the organisation’s Mental Capacity and Deprivation of Liberty Safeguards Policy.

The capacity assessment must consider whether the resident can:

• understand the relevant information about the decision;
• retain the information long enough to make the decision;
• use or weigh the information as part of the decision-making process;
• communicate the decision by any means.

All practicable steps must be taken to support the resident before concluding that they lack capacity. This may include using plain language, pictures, objects of reference, communication aids, interpreters, hearing aids, glasses, dentures, pain relief, familiar staff, family input, advocates, quiet environments, shorter conversations, and choosing the best time of day.

For decisions about dental examination, diagnosis or treatment, the dental practitioner is usually the decision-maker responsible for assessing capacity to consent to that treatment. Care home staff must provide relevant information to support the assessment, including the resident’s communication needs, usual presentation, known wishes, care plan, medical history, risk information, and any previous capacity or best interest records.

For decisions about daily mouth care or support provided by care home staff, the relevant staff member may assess capacity if trained and competent to do so, with support from senior staff or the Registered Manager where required.

Capacity assessments must be recorded clearly, including the specific decision, information provided, support offered, the outcome of the assessment, who completed it, who was consulted, and the date and time.

Best Interest Decisions, Legal Representatives and Advocacy

Where a resident lacks capacity for a specific decision, any decision or act must be made in the resident’s best interests and in accordance with the Mental Capacity Act 2005.

Family members, friends and representatives must be consulted where appropriate and practicable, particularly where they know the resident’s wishes, feelings, beliefs, values and previous preferences. However, family members or friends cannot give legal consent to dental treatment unless they have lawful authority, such as a valid and applicable Health and Welfare Lasting Power of Attorney, deputyship from the Court of Protection, or other lawful authority.

Before relying on an attorney or deputy, staff must check and record:

• the person’s name and relationship to the resident;
• the type of legal authority;
• whether the authority covers health and welfare decisions;
• whether the authority applies to the specific decision;
• any restrictions or conditions;
• whether a copy of the relevant document has been seen and stored or referenced securely.

Where the resident lacks capacity and there is no appropriate family member, friend, attorney or deputy to consult, the Registered Manager must consider whether advocacy is required. An Independent Mental Capacity Advocate must be instructed where the statutory criteria apply, including where the decision amounts to serious medical treatment and there is no one appropriate to consult, or where otherwise required by the Mental Capacity Act 2005.

Best interest decisions must take account of:

• the resident’s past and present wishes and feelings;
• any beliefs and values likely to influence the resident’s decision;
• the views of those involved in the resident’s care;
• clinical advice from the dental practitioner;
• risks and benefits of the proposed treatment;
• risks of not proceeding;
• less restrictive options;
• whether the decision can wait until the resident may regain capacity.

A formal best interest meeting must be considered for significant, invasive, complex or disputed dental treatment, including extractions, treatment under sedation or general anaesthetic, repeated treatment refusal where there is risk of harm, or any situation involving disagreement between professionals, family, advocates or legal representatives.

The outcome of any best interest decision must be recorded in the resident’s care file and shared with the dental practitioner and other relevant professionals.

Deprivation of Liberty, Restraint and Restrictive Practice

Oral care and dental treatment must not involve restraint, restriction, covert action, deception or deprivation of liberty unless there is lawful authority and the action is necessary, proportionate and in the resident’s best interests.

Staff must not physically force a resident to receive mouth care, attend a dental appointment, open their mouth, remove dentures, accept medication, or undergo dental treatment.

Where a resident lacks capacity and some form of restriction is being considered to prevent harm or enable essential care, staff must escalate to the Registered Manager before any action is taken, except in an immediate emergency where urgent action is necessary to prevent serious harm.

The Registered Manager must ensure that any restrictive practice is:

• lawful under the Mental Capacity Act 2005;
• necessary to prevent harm;
• proportionate to the likelihood and seriousness of harm;
• the least restrictive available option;
• recorded and reviewed;
• referred for safeguarding advice where required;
• considered in relation to any existing DoLS authorisation or need for a new or varied authorisation.

Where planned dental treatment may require sedation, restraint, close supervision, transport restrictions or continuous control, the care home must work with the dental practitioner, GP, local authority, advocate and legal representative as appropriate to ensure the correct legal framework is followed.

Emergency Situations

In a dental emergency, staff must seek urgent advice from a dental practitioner, NHS 111, emergency dental service, GP, ambulance service or emergency services, depending on the severity of the situation.

Examples of dental or oral health emergencies may include severe dental pain, facial swelling, suspected dental abscess, uncontrolled bleeding, dental trauma, signs of sepsis, difficulty swallowing, difficulty breathing, or sudden deterioration linked to oral infection.

Where the resident has capacity, their consent must be sought and respected, including the right to refuse emergency dental treatment. Staff must explain the risks of refusing treatment in a way the resident can understand and must record the discussion and outcome.

Where the resident lacks capacity and urgent action is needed, treatment or support may be provided where it is necessary, proportionate and in the resident’s best interests under the Mental Capacity Act 2005. The least restrictive option must be used.

Where immediate treatment is required to save life or prevent serious deterioration, the treating dental or medical professional is responsible for deciding what emergency treatment is clinically necessary and lawful. Care home staff must provide relevant information, support communication, contact legal representatives or family where practicable, and document all actions taken.

Following any emergency, the Registered Manager or delegated senior staff member must ensure that the resident’s care plan, oral health risk assessment and consent records are reviewed.

Role of Staff and Dental Practitioners

Care home staff must support residents to maintain oral health and access dental services, but they must not diagnose dental disease, recommend clinical dental treatment, or provide treatment outside their role and competence.

Care home staff are responsible for:

• supporting residents with daily mouth care in line with their care plan and consent;
• identifying and reporting changes in oral health, pain, infection, bleeding, loose teeth, broken dentures, ulcers, swelling, poor food intake or distress;
• arranging routine, urgent or emergency dental appointments where needed;
• supporting residents to attend appointments;
• helping residents understand appointment arrangements and general information;
• identifying communication needs and arranging support such as interpreters, advocates, visual aids or familiar staff;
• sharing relevant care records, medication information, allergies, medical history, capacity assessments, best interest records and risk assessments with dental professionals where lawful and relevant;
• recording consent, refusal, communication support, appointments, outcomes and follow-up actions.

Dental practitioners are responsible for:

• assessing oral health and diagnosing dental conditions;
• explaining proposed dental treatment, risks, benefits, alternatives and consequences of refusal;
• assessing capacity for the specific dental treatment decision where there is doubt;
• obtaining valid consent for dental treatment;
• making clinical decisions about treatment, referral, sedation, urgent care or specialist input;
• keeping appropriate clinical records.

Where dental practitioners visit the care home, staff must ensure the resident’s privacy, dignity, communication needs, infection prevention needs and any relevant risk information are addressed. Where treatment is provided in the care home, staff must check that the visiting dental team has considered the suitability and safety of the environment for the proposed care.

Oral Health Assessment and Mouth Care Plans

All residents must have their oral health and mouth care needs assessed when they move into the care home, or as soon as practicable afterwards. This applies regardless of the length or purpose of their stay.

The assessment must consider:

• the resident’s usual mouth care routine;
• whether they have natural teeth, dentures, partial dentures, implants or bridges;
• whether dentures are marked;
• the name and contact details of their dentist, if known;
• when they last saw a dentist;
• whether they require support to find or access a dentist;
• mouth pain, ulcers, bleeding, swelling, dry mouth, loose teeth, broken teeth, broken dentures or signs of infection;
• support required with toothbrushing, denture care or prescribed mouth care products;
• communication needs, sensory needs, cultural needs, trauma history or preferences affecting oral care;
• whether the resident consents to support and what they may refuse;
• any risks associated with refusal of oral care or dental treatment.

The outcome must be recorded in the resident’s care plan. Where a dental appointment is needed, staff must support the resident to access an appropriate dental service.

The mouth care plan must be reviewed:

• when the resident’s needs change;
• after dental appointments;
• after refusal of oral care or treatment;
• following weight loss, reduced eating or drinking, unexplained distress or behavioural changes;
• following hospital admission or discharge;
• when dentures are lost, damaged or no longer fit;
• during scheduled care plan reviews.

Daily Mouth Care and Consent

Daily mouth care is part of personal care and must be provided in a way that respects the resident’s dignity, preferences, consent and communication needs.

Staff must offer and support mouth care in line with the resident’s care plan, including:

• brushing natural teeth at least twice daily with fluoride toothpaste, where this forms part of the care plan;
• cleaning full or partial dentures and removing food debris;
• supporting residents to remove dentures overnight where appropriate and agreed;
• using the resident’s preferred toothbrush, toothpaste, denture products or prescribed mouth care products where safe and available;
• supporting use of prescribed mouth rinses, high-fluoride toothpaste or other dental products in line with medication and care planning procedures;
• reporting pain, bleeding, ulcers, swelling, broken teeth, loose teeth, broken dentures, dry mouth or signs of infection.

Consent must be sought before providing mouth care. Where a resident refuses, staff must follow the refusal procedure in this policy and must not force care.

Where a resident repeatedly refuses mouth care, staff must consider whether the approach, timing, staff member, equipment, pain, fear, sensory needs, communication needs or mental capacity may be contributing to the refusal. The care plan must be reviewed and advice sought from senior staff, the dentist, GP or community dental service where needed.

Access to Dental Services

{{org_field_name}} will support residents to access routine, urgent and emergency dental care in line with their needs, preferences and consent.

The Registered Manager will ensure that the service maintains up-to-date information about:

• local NHS and private general dental services;
• urgent and emergency dental services;
• out-of-hours dental support;
• community dental services;
• special care dentistry services;
• oral health promotion services;
• local Healthwatch and public health contacts where concerns arise about access to dental care.

Where a resident does not have a dentist, staff will support them or their lawful representative to identify and contact appropriate dental services.

Where a resident needs specialist dental support because of disability, dementia, complex health needs, communication needs, anxiety, behaviour that may challenge, or inability to access standard dental care, staff will seek advice from the dentist, GP, community dental service or special care dentistry service.

Concerns about inability to access appropriate dental care must be escalated to the Registered Manager. Where there are repeated or systemic access problems, the Registered Manager will consider raising concerns with the relevant commissioner, local Healthwatch, local authority public health team or dental public health lead.

Training and Competency

Staff who support residents with oral health, daily mouth care, dental appointments or consent must receive training and supervision appropriate to their role.

Training must include:

• principles of valid and informed consent;
• Regulation 11: Need for consent;
• Mental Capacity Act 2005 principles;
• decision-specific capacity assessment;
• best interest decision-making;
• refusal and withdrawal of consent;
• advocacy, Health and Welfare Lasting Power of Attorney and deputyship;
• communication support and accessible information;
• dignity, privacy and trauma-informed approaches to mouth care;
• recognising signs of dental pain, infection, poor oral health and ill-fitting dentures;
• daily mouth care and denture care;
• supporting access to dental services;
• safeguarding concerns linked to neglect of oral health, coercion, restraint or untreated pain;
• record keeping and confidentiality.

Staff must also receive learning disability and autism training appropriate to their role, in line with the statutory requirement for CQC-registered providers and the Oliver McGowan Code of Practice.

The Registered Manager will ensure that staff competence is reviewed through induction, supervision, observation of practice, competency checks, appraisal, audits, feedback, incidents, complaints and care plan reviews.

Where staff lack confidence or competence in supporting mouth care or consent, additional training, supervision or support must be provided.

Communication and Documentation

Staff must communicate with residents in a way that meets their individual needs and enables them to make informed decisions wherever possible. This may include plain language, large print, pictures, easy read information, objects of reference, communication aids, interpreters, hearing support, glasses, dentures, quiet environments, familiar staff, additional time or support from a trusted person.

The following must be recorded in the resident’s care records where relevant:

• oral health assessment;
• mouth care plan;
• resident’s preferences and routines;
• communication needs and support used;
• dental appointments arranged, attended, declined or missed;
• information provided to the resident;
• consent given, refused or withdrawn;
• the form of consent, such as verbal, written or non-verbal;
• any capacity assessment and outcome;
• best interest decision records;
• details of attorneys, deputies, advocates or representatives involved;
• dental practitioner advice and treatment outcomes;
• follow-up actions;
• risks, incidents, safeguarding concerns or complaints;
• review dates.

Records must be accurate, contemporaneous, respectful, factual and stored securely. Information must only be shared with dental professionals, representatives, advocates or others where lawful, necessary and proportionate.

The Registered Manager must ensure that records demonstrate compliance with Regulation 17: Good governance and provide clear evidence for inspection, audit, safeguarding review or complaint investigation.

Safeguarding, Equality and Human Rights

Forcing, misleading, threatening or coercing a resident into dental treatment or mouth care may amount to abuse, unlawful treatment or a breach of human rights. Staff must respect each resident’s autonomy, privacy, dignity, bodily integrity and right to make decisions.

Safeguarding concerns may arise where:

• a resident is forced or coerced into oral care or dental treatment;
• a resident is prevented from accessing dental care;
• oral pain, infection or dental deterioration is ignored;
• dentures, toothbrushes or oral hygiene products are not provided or maintained;
• refusal of oral care is not reviewed and leads to harm;
• a resident who lacks capacity does not receive appropriate best interest decision-making;
• family members or others attempt to consent without legal authority;
• restraint or restriction is used unlawfully;
• discriminatory assumptions are made about age, dementia, disability, communication needs, learning disability, autism, mental health or quality of life.

Staff must raise concerns immediately with the Registered Manager or safeguarding lead. The Registered Manager must consider whether a safeguarding referral, professional advice, complaint response, duty of candour process or notification is required.

Residents must be supported equally and without discrimination to access oral health care and dental treatment. Reasonable adjustments must be made for residents with disabilities, sensory needs, communication needs, dementia, learning disability, autism, mental health needs or other protected characteristics.

Monitoring and Audit

The Registered Manager will monitor implementation of this policy through routine governance systems, care plan audits, consent audits, mental capacity audits, oral health audits, incident reviews, safeguarding reviews, complaints analysis, supervision and feedback from residents, relatives, representatives and professionals.

Audits will include checks that:

• each resident has an oral health assessment;
• each resident has a mouth care plan where required;
• consent to mouth care and dental support is recorded;
• refusals are documented and followed up;
• capacity assessments are decision-specific and properly recorded;
• best interest decisions are completed where required;
• attorneys, deputies and advocates are involved appropriately;
• residents have access to routine and urgent dental care;
• dental appointment outcomes and follow-up actions are recorded;
• staff have completed relevant consent, MCA, oral health, safeguarding and learning disability/autism training;
• concerns about oral health, pain, infection, dentures or access to dentistry are escalated;
• records demonstrate person-centred care, dignity, safety and good governance.

The Registered Manager will use audit findings to identify themes, improve practice, update training, revise care plans and share learning with staff.

Where audits identify a risk of avoidable harm, unsafe care, poor records, repeated refusal, lack of access to dental care, or possible abuse or neglect, immediate action must be taken and recorded.

Oral Health Champion

{{org_field_name}} will identify an Oral Health Champion or named lead for oral health where practicable.

The Oral Health Champion will support the Registered Manager by:

• promoting awareness of oral health and mouth care;
• supporting implementation of NICE NG48;
• helping staff understand this policy and related procedures;
• supporting audits of oral health assessments and mouth care plans;
• helping maintain information about local dental services;
• encouraging staff to report oral health concerns promptly;
• supporting learning from incidents, complaints, refusals and dental access issues;
• promoting dignity, consent and person-centred approaches to mouth care.

The Oral Health Champion does not replace the responsibilities of the Registered Manager, nursing staff, care staff or dental practitioners.

6. Policy Review

This policy will be reviewed annually or sooner if there are changes to legislation, CQC guidance, NICE guidance, General Dental Council standards, Mental Capacity Act guidance, safeguarding requirements, learning disability and autism training requirements, or local dental service arrangements.

The policy will also be reviewed following relevant incidents, complaints, safeguarding concerns, audit findings, inspection feedback, resident or representative feedback, or evidence of poor access to dental care.

Updates will be communicated to staff through supervision, team meetings, training, policy briefings and competency checks.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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