In this Safeguarding Guide for Dental Nurses
Safeguarding Responsibilities for Dental Nurses
Dental nurses may be in a better position than dentists to identify the signs of abuse or neglect or hear something that causes them concern, as dental patients not only see them as an assistant to the dentist, but also as someone there to support them. Dental nurses often see the patient on their own if they are escorting them to reception or into the surgery, allowing time for a disclosure to occur.
Dental nurses will also see patients on a regular basis, so are in the perfect position to identify any signs of neglect and abuse, and can identify if there is a change in behaviour, physical condition or oral health since the last appointment.
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.
It means:
- 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 who are at risk of abuse. Supporting and representing these individuals in the appropriate manner can help to protect them from further harm.
Duties to safeguard patients, whether adults or children, are required by professional regulators and service regulators and are supported by law. The General Dental Council and the Care Quality Commission (CQC) include the quality of safeguarding provision when inspecting dental surgeries.
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
These lists are not exhaustive, and other people might also be considered to be adults and/or children 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:
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 or treatment – also including neglect of, or unresponsiveness to, a child/young person’s basic emotional needs
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.
The Types of Abuse Adults Can Encounter
There are ten types of abuse listed in the Care Act (2014).
These are:
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 and 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 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 Dental Nurses 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.
Dental nurses 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.
Dental nurses 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:
- Involve several abusive acts which are crimes, and informing the police must be a key consideration
- 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
The Roles and Responsibilities of a Dental Nurse in Regard to Safeguarding
Dental nurses 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 also to 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 concern of neglect, harm or abuse to a patient defined under the Care Act (2014) guidance as vulnerable.
A dental nurse’s role in adult and child safeguarding is to:
- 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.
- 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.
The Safeguarding Issues Dental Nurses 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.
Dental nurses may notice that a child’s basic oral health has been neglected; perhaps the parent or carer has neglected to bring the child for regular check-ups, or it is apparent that the child has not been taking care of basic oral hygiene such as brushing their teeth. The British Society of Paediatric Dentistry (BSPD) defines dental neglect as “the persistent failure to meet a child’s basic oral health needs, likely to result in serious impairment of a child’s oral or general health or development”.
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.
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
Dental nurses should recognise a pattern of irregular or missed/failed appointments, lack of compliance to a proposed dental plan, and/or repeated dental pain appointments, whilst recognising the extent of harm to the individual. Missed dentalcare appointments are the most common reason for dental professionals 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 dental nurses to think about the situation from the child’s perspective and potentially take action to safeguard them.
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.
Where Should Dental Nurses 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.
Sometimes a “feeling” or noticing something that “just doesn’t seem right” can play a vital part in the jigsaw that can make the difference to someone in a vulnerable position. Dental nurses should not feel inhibited to raise a concern. The dental team has a statutory duty of care to all patients and the wider public, which includes ensuring that safeguarding arrangements are in place and are acted on.
Immediate concerns about abuse or neglect should be dealt with under local safeguarding procedures first. The person who raises a safeguarding concern within their own surgery should follow their surgery’s policy and procedures. This concern may result from something that you have seen, been told or heard. Each practice should have a Designated Safeguarding Practice Lead. This individual is not an expert but rather a trained, centrally named person that all staff are aware of and who keeps an oversight on all safeguarding matters for the practice.
The role includes:
- Making sure appropriate systems for raising concerns are in place and that all staff can access them
- Making sure staff can see all concerns are taken seriously, even if they are later seen to be unfounded
- Investigating concerns promptly and including a full and objective assessment
- Taking action to deal with the concern and record and monitor this action
- Keeping the employee who raised the concern up to date with what is happening
- Having processes in place to support employees raising concerns
- Having a role in highlighting learning and may facilitate or be part of learning events
If you witness or suspect that there is a risk of immediate harm to a person in your care, you must act straight away to protect their safety. You should report your concerns to the appropriate person or authority immediately; this may be the police in some situations. Involvement of the police is indicated in incidents of suspected theft and common assault, including sexual assault, and assault causing actual bodily harm. However, police may also be involved in other patient safety incidents such as wilful neglect for a person lacking capacity.
You should also keep an accurate record of your concerns and action that you have taken, and you should always inform the designated safeguarding lead of your actions.
What Legislation Do Dental Nurses Have to Follow in Regard to Safeguarding?
The Care Act 2014
Sets out statutory responsibility for the integration of care and support between health and local authorities. NHS England and Clinical Commissioning Groups are working in partnership with local and neighbouring social care services. Local authorities have statutory responsibility for safeguarding. In partnership with health, they have a duty to promote wellbeing within local communities.
Safeguarding Vulnerable Groups Act 2006 and the Protection of Freedoms Bill
This Act was passed to help avoid harm, or risk of harm, by preventing people who are deemed unsuitable to work with children and vulnerable adults from gaining access to them through their work. Organisations with responsibility for providing services or personnel to vulnerable groups have a legal obligation to refer relevant information to the Disclosure and Barring Service (DBS).
The Equality Act 2010
This Act aims to protect people or groups of people who have one or more “protected characteristics”. These protected characteristics are features of people’s lives upon which discrimination, in the UK, is now illegal.
The protected characteristics listed in the Act are:
- Age
- Disability
- Sexual orientation
- Sex
- Gender reassignment
- Marriage and civil partnership
- Pregnancy and maternity
- Race
- Religion and belief
Under the Act:
- Every individual has the right to be treated equally and fairly and not be discriminated against regardless of any “protected characteristics”.
- Every individual has the right to be treated with respect and dignity.
- Health services have a duty to ensure that services are fair and meet the needs of everyone, regardless of their background or current circumstances.
Sexual Offences Act 2003
This act modernised the law by prohibiting any sexual activity between a care worker and a person with a mental disorder while the relationship of care continues. A relationship of care exists where one person has a mental disorder and another person provides care.
It applies to people working both on a paid and an unpaid basis and includes:
- Doctors
- Nurses, including midwives
- Care workers in homes
- Workers providing services in clinics or hospitals
- Volunteers
The Mental Capacity Act 2005
In order to protect those who lack capacity and to enable them to take part as much as possible in decisions that affect them, the following statutory principles apply:
- You must always assume a person has capacity unless it is proved otherwise
- You must take all practicable steps to enable people to make their own decisions
- You must not assume incapacity simply because someone makes an unwise decision
- Always act, or decide, for a person without capacity in their best interests
- Carefully consider actions to ensure the least restrictive option is taken
Working Together to Safeguard Children 2010
The way that agencies and organisations should work together to carry out their duties and responsibilities under the 1989 Children Act and other legislation is set out in a document called Working Together to Safeguard Children.
It sets out the responsibilities of all agencies in the protection of children, and is aimed at staff in organisations that are responsible for commissioning or providing services to:
- Children, young people and adults who are parents/carers
- Organisations that have a particular responsibility for safeguarding and promoting the welfare of children and young people
UK law does not legislate for the rights of the unborn baby. In some circumstances, agencies or individuals are able to anticipate the likelihood of significant harm with regard to an expected baby. Although the law does not identify an unborn baby as a separate legal entity, this should not prevent plans from being made and put into place to protect the baby from harm both during pregnancy and after the birth. The National Service Framework for Children, Young People and Maternity Services (2004) recommends that Maternity Services and Children’s Social Care have in place joint working arrangements to respond to concerns about the welfare of an unborn baby and their future, due to the impact of the parents’ needs and circumstances.
The General Data Protection Regulations (GDPR) and the Data Protection Act 2018
Introduced new elements to the data protection regime, superseding the Data Protection Act 1998. Practitioners must have due regard to the relevant data protection principles which allow them to share personal information. However, the GDPR and Data Protection Act 2018 do not prevent, or limit, the sharing of information for the purposes of keeping vulnerable individuals safe.
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.
How Often Should Dental Nurses Renew Their Safeguarding Training?
Managers should assess dental nursing staff safeguarding knowledge annually, and run refresher training if needed. To help dental nursing staff 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).
