In this article
The Care Quality Commission (CQC) inspects safeguarding as part of its general inspections of dental practices. Dentists have a statutory duty of care to the general public, patients, colleagues and other visitors to the practice. This includes ensuring that safeguarding arrangements are in place and acted on.
What is safeguarding?
Safeguarding means protecting people’s health, wellbeing and human rights, and enabling them to live free from harm, abuse and neglect. Safeguarding is an integral part of patient care and it is fundamental to high-quality health and social care, including dental care.
Safeguarding adults at risk means protecting their right to live in safety and free from abuse and neglect.
Adults at risk means anyone aged 18 or over who:
- Has needs for care and support
- Is experiencing, or is at risk of, abuse or neglect
- As a result of those care and support needs, is unable to protect themselves from either the risk of or the experience of abuse or neglect
Child safeguarding applies to all children up to the age of 18 years whether living with their families, in state care, or living independently.
Safeguarding children is defined in Working Together to Safeguard Children as “protecting children from maltreatment; preventing impairment of children’s health or development; ensuring that children are growing up in circumstances consistent with the provision of safe and effective care.”
Child safeguarding is a set of actions that can be taken to encourage children’s welfare and protect them from harm.
- Preventing children’s health and development from being damaged
- Making sure that children are safe and well cared for as they grow up
- Doing things to make sure that children have the best outcomes
- Protecting children from abuse and harm
The Care Act 2014 lists six key principles of safeguarding. These are intended to form a core set of standards for anyone who has a responsibility for safeguarding. Although these principles have been designed with a focus on vulnerable adults, they should be applied to any type of vulnerable individual, children included.
The principles are as follows:
- Accountability – in the event of a disclosure, if an adult or young person entrusts you with information that you know could be indicative of abuse, you must be clear with the individual that you need to report what you have heard.
- Empowerment – it’s important for any person who has been a victim of abuse to feel that they have control over their situation. Support and encouragement are key to effective working with a victim of abuse or neglect.
- Partnership – it is important to work in partnership with your local authority and all services or organisations in your community that might be able to assist in detecting and reporting abuse.
- Prevention – it is sometimes possible to take action before harm has come to an individual. If you know the signs and indicators of abuse, you will understand when something is not quite right and will be better placed to report any concerns for an individual’s wellbeing.
- Proportionality – when a safeguarding incident occurs, you should report your concerns in a manner that is appropriate for the risk presented. For example, if you suspect that a child is in immediate danger, dialling 999 is the recommended response.
- Protection – it is crucial to be an ally for individuals who have experienced or are at risk of abuse. Supporting and representing these individuals in the appropriate manner can help to protect them from further harm.
Dentists are in a position where they may identify the signs of abuse or neglect or hear something that causes them concern. Duties to safeguard patients, whether adults or children, are required by professional regulators and service regulators and are supported by law.
What risk factors make someone more likely to experience abuse?
There is no way to know which children are most vulnerable to abuse, but there are some factors for abuse and neglect risk to be aware of, including but not limited to:
- Very young children
- Children with disabilities and health problems
- Children who have already been, or who are currently being, abused and/or neglected
- Parents who are young when their child is born
- Parents who are poorly informed about parenting
- Parents with mental health issues, especially untreated issues, for example depression, antisocial personality disorder, substance abuse and related disorders
- Single parent households
- Intimate-partner violence
- Parents experiencing emotional and/or financial stress
- Poverty, poor housing and deprivation
- Social isolation
- Violence in the community
Adult abuse and neglect can occur anywhere to anyone; however, there are risk factors that can make a person more vulnerable to abuse.
An adult at risk of abuse may:
- Have an illness affecting their mental or physical health
- Be physically dependent on others
- Have a sensory impairment
- Have a learning disability
- Suffer from drug or alcohol problems
- Have low self-esteem
- Be unable to make their own decisions
- Have a previous history of abuse
- Have negative experiences of disclosing abuse
- Be of increasing age
- Be frail
- Have experienced a lack of access to health and social services or high-quality information
This list is not exhaustive, and other people might also be considered to be adults at risk.
The types of abuse children can encounter
Statutory guidance across the four countries of the UK describes four main categories of child abuse, and these definitions will normally be reflected in local organisations’ policies and procedures.
The four categories are:
- Physical harm/abuse – this may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child/young person. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child/young person. Harm can also occur due to practices linked to faith and culture, for example, Female Genital Mutilation (FGM).
- Emotional harm/abuse – this is the persistent emotional maltreatment of a child/young person such as to cause severe and persistent adverse effects on the child/young person’s emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may include not giving the child the opportunities to express their views, deliberately silencing them or “making fun” of what they say or how they communicate. It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond a child’s developmental capacity, as well as overprotection and limitation of exploration and learning, or preventing the child from participating in normal social interaction. It may involve seeing or hearing the ill treatment of another. It may involve serious bullying, including cyberbullying, causing children/young people frequently to feel frightened or in danger, or the exploitation or corruption of children/young people. Some level of emotional abuse is involved in all types of maltreatment of a child/young person, though it may occur alone.
- Sexual abuse – this involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening. The activities may involve physical contact, including assault by penetrative acts, for example rape or oral sex, or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing. They may include non-contact activities, such as involving children in looking at, or in the production of, pornographic sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse, including via the internet. Sexual abuse is not solely perpetrated by adult males; women can also commit acts of sexual abuse, as can other children.
- Neglect – this is the persistent failure to meet a child/young person’s basic physical and/or psychological needs, likely to result in the serious impairment of the child/young person’s development. Neglect may occur during pregnancy, for example as a result of maternal substance abuse, maternal mental ill health or learning difficulties or a cluster of such issues. Where there is domestic abuse and violence towards a carer, the needs of the child may be neglected. Once a child is born, neglect may involve a parent or carer failing to:
– Provide adequate food, clothing and shelter, including exclusion from home or abandonment
– Protect a child/young person from physical and emotional harm or danger
– Ensure adequate supervision, including the use of inadequate caregivers
– Ensure access to appropriate medical care including dental care or treatment and also include the neglect of, or unresponsiveness to, a child/young person’s basic emotional needs
The types of abuse adults can encounter
There are ten types of abuse listed in the Care Act (2014).
- Physical abuse – this may involve physical violence, misuse of medication, inappropriate restraint or sanctions.
- Sexual abuse – this can include verbal sexual abuse, non-consensual touching, fondling, physical restraint, cornering, tickling, kissing, excessive cleaning of genitals, enemas, intercourse, sodomy, oral sex, invasion of privacy and stalking.
- Psychological abuse – this includes emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, harassment and verbal abuse.
- Financial or material abuse – including theft, fraud, exploitation, pressure in connection with wills, property, inheritance or financial transactions, and misuse or misappropriation of property, possessions or benefits.
- Neglect and acts of omission – including ignoring medical or physical care needs, failure to provide access to appropriate health, social care or educational services, withholding medication, and inadequate nutrition and heating.
- Discriminatory abuse – including racist or sexist abuse or abuse based on a person’s disability.
- Domestic abuse – including psychological, physical, sexual, financial or emotional abuse, and so-called honour-based violence.
- Modern slavery – includes slavery, human trafficking, forced labour and domestic servitude.
- Organisational abuse – including neglect and poor care practice within an institution or specific care setting such as a hospital, dental practice or care home.
- Self-neglect – includes a wide range of behaviour neglecting to care for personal hygiene, health or surroundings and includes behaviour such as hoarding.
What safeguarding issues do dentists need to be aware of?
Abuse and neglect can take many forms, ranging from exploitation and disrespectful treatment to physical harm. It can be at a low level, and take place over a long time, or it can take place over a short time and be more extreme. It is all abuse.
Dentists should not be constrained in their view of what constitutes abuse, neglect or harm and should always consider the circumstances on a person-centred basis. Child and adult safeguarding concerns vary according to the nature of harm, the circumstances it arose in and the people concerned.
Dentists often see patients in times of distress and difficulty. It is likely that you may come into contact with someone who is at risk or suffering from abuse or neglect. The abuse or neglect can be deliberate, or the result of ignorance or a lack of proper training.
Recognising abuse or neglect is crucial, and it may:
- Be a single act or repeated acts
- Cause harm temporarily or over a period of time
- Occur when a person is persuaded to enter into a transaction to which they have not consented to, or cannot consent to
- Be an act of neglect or an omission to act
- Occur through deliberate targeting/grooming
- Occur in any relationship
- Be perpetrated by an individual or as part of a group/organisation
- Be the result of deliberate intent, be unintentional, or be through negligence or ignorance
- Involve several abusive acts which are crimes, and informing the police must be a key consideration
The roles and responsibilities of a dentist in regard to safeguarding
Dentists have an individual responsibility to safeguard people, and to identify and respond to allegations of abuse and neglect. Dental services have a duty to safeguard all patients but should provide additional measures for patients who are less able to protect themselves from harm or abuse. Safeguarding adults and children covers a spectrum of activity from prevention through to multi-agency responses where harm and abuse occurs. Multi-agency procedures apply where there is a concern of neglect, harm or abuse to a patient defined under the Care Act (2014) guidance as vulnerable.
A dentist’s role in adult and child safeguarding is to:
- Recognise – you should have a clear understanding of what the different signs and symptoms of potential abuse, harm and neglect can be. Robust safeguarding training can help you to spot these signs and symptoms.
- Respond – it is essential that you respond appropriately and do not ignore the situation.
- Report – concerns need to be reported without delay. Confidentiality is important, so only share information with those who are a part of the safeguarding process.
- Record – you should make precise, comprehensive notes that detail everything about your safeguarding concern.
- Refer – if the safeguarding risk is urgent and you suspect somebody is under immediate or severe threat, you should contact the relevant local authority or police services.
The safeguarding issues dentists may come across
Dental professionals are likely to observe and identify injuries to the head, eyes, ears, neck, face, mouth and teeth, as well as other welfare concerns. Bruising, burns, bite marks and eye injuries are the types of injury that suggest a concern should be raised. Dental professionals are also well placed to identify the risks to oral and general health associated with poor oral hygiene and dental neglect.
Dentists may identify abuse pertaining to the oral cavity which may manifest as abrasions or lacerations of the tongue, lips, oral mucosa, hard and soft palate, gingiva and frenum. The dentist may also observe dental, maxilla and mandible fractures.
Other potential signs of domestic violence that may present at a dental appointment might include:
- The patient is always accompanied by a partner or family member, who frequently speaks for the patient or cancels the patient’s appointments
- The patient displays high levels of anxiety
- Presentation doesn’t fit the explanation provided
- Repeated cancelling or rescheduling of appointments
Neglect of oral health may also lead to current and/or future harm such as toothache, difficulty eating a balanced diet leading to deficiencies and/or malnutrition, sleep deprivation, and absences from school or work. In addition, the individual may get teased or bullied due to the unusual appearance of their teeth.
Child or adult abuse or neglect may present with the parent and or carer agreeing to make the changes needed to improve the patient’s oral health but then making little or no effort with this. Disguised compliance involves a parent or carer giving the appearance of co-operating with a patient’s dental treatment to avoid raising suspicions of unsafe parenting or caring. The aim is to avoid social care interventions by allaying professional concerns. Concerns may also be raised in respect of how a parent or carer has related to, or behaves towards, a child or adult at risk.
A patient may also disclose abuse or other indicators of it; such safeguarding concerns should always be recorded. Accurate record keeping is an essential part of the accountability for safeguarding.
Missed healthcare appointments are the most common reason for dentists to make child protection referrals.
They cause concern because they:
- May be an alerting feature that a child or young person is being neglected
- Are often found when a child has died or been seriously harmed by maltreatment, when a serious case review is conducted
- Should be followed up rigorously but that isn’t always easy to do
Describing children and young people as “Was not brought” (WNB) instead of “Did not attend” (DNA) encourages dentists to think about the situation from the child’s perspective and potentially take action to safeguard them.
Where should dentists go with a safeguarding concern?
Some concerns may be minor in nature but provide an opportunity for early intervention, for example advice to prevent a problem from escalating. Other safeguarding concerns may be more serious and need a response through multi-agency procedures and possible statutory intervention through regulators, the criminal justice system or civil courts.
The General Dental Council’s (GDC) Standards for the dental team states that as a registered dental professional “You must raise any concerns you may have about the possible abuse or neglect of children or vulnerable adults. You must know who to contact for further advice and how to refer your concerns to an appropriate authority such as your local authority social services department.”
Dental professionals are frequently uncertain as to whether their concerns reach a threshold for action. In these circumstances, advice should be sought from a professional with expertise in safeguarding such as the Social Care Duty and Assessment Team of their local authority.
Documentation within dental practices should accurately reflect not only the care provided but also any concerns in respect of a child, young person or adult at risk.
It may feature information on anyone attending with the patient, any injury observed using diagrams where appropriate and a record of discussions concerning the patient.
In cases of abuse records should include:
- Description and location of injury
- Nature of injury, such as bruise or laceration
- Size and shape of injury
- Comments and observations made by the patient, parent or carer
Each dental practice should have a safeguarding practice lead. This individual is not an expert but rather a central named person that all staff are aware of and who oversees all safeguarding matters. The lead should ensure that all staff have appropriate training and are aware of who to contact locally. Relevant and up-to-date local points of contact for concerns can be accessed via the NHS safeguarding app: www.myguideapps.com/nhs_safeguarding/default/index.html
What legislation do dentists have to follow in regard to safeguarding?
There are a number of pieces of legislation that dentists must follow for safeguarding of both adults and children, including several Acts and statutory guidance documents which are always being amended or updated.
The Children Act 2004 – this states that safeguarding is everyone’s responsibility. Section 11 places duties on organisations and individuals to make arrangements for ensuring their functions, including services that they contract to others, are discharged with due regard to the need to safeguard and promote the welfare of children.
The Care Act (2014) – Chapter 14 of the Care Act provides guidance on adult safeguarding. It cites neglect and acts of omission as behaviour which could give rise to a safeguarding concern.
- Ignoring medical, emotional or physical care needs
- Failure to provide access to appropriate health, care and support or educational services
- The withholding of the necessities of life, such as medication, adequate nutrition and heating
This is particularly relevant in the dental setting given the potential impact on oral care and consequently the scope for dentists to detect it. The Act also includes self-neglect in the categories of abuse or neglect. In some circumstances, where there is a serious risk to the health and wellbeing of an individual, it may be appropriate to raise self-neglect as a safeguarding concern. It is vital to establish whether the person has the capacity to make decisions about their own wellbeing, and whether they are able or willing to care for themselves. An adult who can make choices may make decisions that others think of as self-neglect. Risk and capacity assessments are likely to be useful. The legislation makes clear that adult safeguarding responses should be guided by the adult themselves, to achieve the outcomes that they want to achieve.
The Mental Capacity Act (2005) – this states that “a person lacks capacity in relation to a matter if at the material time they are unable to make a decision for themselves in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain.” It does not matter whether the impairment or disturbance is permanent or temporary. It cannot be assumed that someone lacks capacity based upon age, disability, beliefs, condition and behaviour or because they make a decision that is considered inappropriate. In all cases the patient must be fully informed of the decision to be made, the consequences of decisions or the lack of decision. This requires professionals to have a frank and open conversation with patients to support their understanding. There is a legal duty to refer vulnerable people who may lack the capacity to make critical decisions about dental treatment to the Independent Mental Capacity Advocate (IMCA) service.
The Mental Capacity Act 2005 does not apply to children under 16. Children under 16 are not presumed to have the capacity to consent but must demonstrate their competence. The principles of assessing capacity are the same as for adults. A child can give consent if the treatment or action is in their best interests and if they have the maturity and ability to fully understand the information given and what they are consenting to.
The Children and Social Work Act 2017 replaced Local Safeguarding Children Boards with new local safeguarding arrangements, led by three safeguarding partners:
- Local authorities
- Chief police officers
- Clinical Commissioning Groups
The Act places a duty on those partners to make arrangements for themselves and relevant agencies to work together for the purpose of safeguarding and promoting the welfare of children in their area.
Prevent Duty Guidance (2015) – the Prevent Duty Guidance forms part of the UK Government’s counter-terrorism strategy. It identifies a key challenge for the healthcare sector to ensure that: “where there are signs that someone has been or is being drawn into terrorism, the healthcare worker is trained to recognise those signs correctly and is aware of and can locate available support”. Dedicated resources for health professionals are available at: www.england.nhs.uk/ourwork/safeguarding/our-work/prevent/
CQC regulation requirements are that dentists have a process in place for undertaking criminal record checks at the appropriate level for staff that require a check. Dentists should assess the different responsibilities and activities of staff to determine if they are eligible for a DBS check and to what level. The eligibility for checks and the level of that check depends on the roles and responsibilities of the job, not the individual being recruited, and is based on the level of contact staff have with patients, particularly children and adults at risk.
GDPR – ethical and statutory codes concerned with confidentiality serve to protect individual patients but are not intended to prevent the exchange of information between different professionals and staff who have a responsibility for ensuring the protection of children, young people and adults at risk. In cases where there are safeguarding concerns, there is a duty to share all relevant information with professionals and agencies who need to know. This may include disclosing information with or without the permission of the child, young person, parents or carers or adult at risk, with other professionals for the purposes of safeguarding.
Why is safeguarding training important?
It is important that we all understand safeguarding and know what to do should safeguarding concerns arise. It is a requirement of the Care Quality Commission (CQC) that every member of the dental team has an up-to-date safeguarding training certificate.
Dental practices must make sure that all staff working in the practice have the appropriate level of competence for their role including:
- Information on types of harm, abuse and neglect
- How to spot abuse
- How to respond to concerns
- Who to report concerns to
An example of appropriate safeguarding training includes Safeguarding Vulnerable Adults (SOVA) Level 2, designed for people who are working with vulnerable adults and teaches the skills needed to safeguard people who are at higher risk of abuse, and Safeguarding Children Level 2, designed for people who are working with children and teaches the skills needed to safeguard children who are at higher risk of abuse.
The practice safeguarding lead should complete the Safeguarding Children Level 3 Designated Officer course and Safeguarding Vulnerable Adults Level 3.
Dentists and/or practice managers will also need to complete a Safer Recruitment course if they recruit staff to the practice.
How often should dentists renew their safeguarding training?
To help dentists to increase their confidence in managing safeguarding concerns, they should at a minimum refresh their safeguarding training at least every 2 years and participate in continuing professional development (CPD). Some professional memberships require dentists to refresh their safeguarding training on an annual basis.