Burns and scalds are painful and can range from minor blisters to life-threatening injuries where large areas of skin are affected. Martin Hodgson reports.
In adult social care there have been a number of tragic cases where service users have died from these injuries. Care managers should ensure that their staff appreciate the severe dangers of burns and scalds to service users, and take the necessary precautions. Incidents where service users have been badly burnt or scalded, due to accidents where care has been negligent, have been severely dealt with in the courts with large fines.
Why, then, are scalds and burns a particular problem in adult social care and what can be done to prevent them?
Most people are aware of when they have been scalded or burned. If burned on the hand, they will quickly pull their hand away from the heat source. To test whether their bath water is too hot, they will quickly dip their toe in.
For some service users, this is not always the case. Some are vulnerable because they are confused or suffer from sensory impairments by which they do not recognise the dangers of hot radiators or scalding water. Those who lack mental capacity, such as people with dementia, may also be vulnerable, as are those who have limited mobility, as they will find it more difficult to move away from a heat source.
In order to identify service users at risk, care home managers should conduct appropriate risk assessments, which might include the following questions.
Is the service user’s sensitivity to temperature impaired in any way?
Is his or her mental state such that he or she can recognise hot surface temperatures or hot water?
Is the service user capable of summoning assistance if needed?
Are there any potential trapping risks near heaters or hot pipes, eg bed rails, furniture?
Can he or she bathe, shower and/or wash unaided?
Will any lifting or other aids limit the service user's mobility in the bath?
Is the person liable to try and run a bath/add water when unattended?
Some of these issues will be particularly relevant for confused service users and those with dementia.
The results of risk assessments should be recorded and records kept. Where no risk is determined, it would be appropriate to allow service users the freedom of choice to access the water conditions. However, they should be monitored to ensure that no potentially vulnerable person has access to water that could scald them.
Pipes, radiators and hot surfaces
While radiators and hot surfaces such as boilers, cookers and fires are an essential part of people’s lives and help them to live in comfort, for vulnerable people they are also a danger. For example, where a person has a sensory problem which leads them to fail to perceive heat they might lean up against a hot surface and suffer a burn. Others might be unable to move away if they fall against a radiator and cannot get up or become trapped by furniture. In such cases the result could be severe burns or even fatalities.
Where reasonably practicable, service users in domiciliary care should be protected from accidental burns caused by coming into contact with hot surfaces, such as water pipes or radiators. Domiciliary care managers should conduct a risk assessment and, where a risk is identified for any service user, a suitable plan of care should be put into place to safeguard them.
Action might include:
working with the service user, their family or their landlord to reduce the temperature of dangerous pipes or radiators or to have covers or guards fitted; when a heating system is running at maximum output, 43°C is considered to be a safe surface temperature for radiators, heaters and pipes
relocating furniture so it is not possible for service users to become trapped against a hot surface if they fall
ensuring service users have a means of summoning help if they do fall, such as a telecare alarm system.
Good practice in this area is identified by the Health and Safety Executive (HSE) in its Health Services Information Sheet HSIS6, Managing the Risks from Hot Water and Surfaces in Health and Social Care. While this is predominantly aimed at the care home sector, some aspects of the advice are relevant to home care and settings such as sheltered housing.
In the event of an incident, inspectors will expect to see evidence of risk being properly assessed and of suitable control measures being put into place to minimise that risk. It is never enough to merely put furniture in front of hot radiators and think it is sufficient to prevent injury.
Scalding risks are most apparent when a service user is bathed, showered or washed. Over the years, a number of tragic accidents have occurred where care staff have neglected to check the temperature of bath water, for instance, and people have been lowered into scalding water.
It is generally accepted that temperatures of 50°C and over present a considerable scalding risk, while temperatures between 45°C and 50°C have also been associated with scalds, especially with prolonged exposure for the elderly or the young.
Managing the Risks from Hot Water and Surfaces in Health and Social Care states that, where a risk assessment indicates a possible risk of scalding, water should be prevented from being discharged at more than 44°C from bath, sink or shower taps that are accessible to vulnerable service users, especially in areas where there is the potential for whole-body immersion.
The HSE guidance recommends fitting Type 3 thermostatic mixing valves (TMVs), temperature-restricted instant water heaters or showers or some other, equally effective, controls. However, the guidance acknowledges that such a requirement would not necessarily apply to all private domestic premises. It suggests that providers try to seek agreement with the person receiving care or in control of the premises where care is provided to put such safeguards in place.
All such devices should be fitted by qualified and experienced contractors and be subject to regular servicing, as recommended by manufacturers. A documented maintenance schedule that takes into account local conditions (eg hard water) should be followed and recorded.
be trained in the use of thermostatic mixers where these are fitted
report faults immediately.
All services should have a policy or protocol for preparing a bath or shower for a service user and this should be read by all care staff. The water temperature should always be checked before the service user enters. Staff should use a thermometer and not rely on “touch” methods to assess water temperature, such as dipping an elbow.