Last reviewed 9 February 2022
In November 2021 a care home in England was fined more than £1m for corporate manslaughter after a 93-year old resident was scalded in a bath of hot water. The resident was in the bath for around 10 minutes and suffered burns to 12% of her body. She died in hospital three days later. The police investigation found that the bath used in the fatal accident was not fitted with the correct type of thermostatic mixing valve. In addition, the one fitted was not working correctly and had not been serviced, there was no proper bathing policy in place and staff were not adequately trained. As well as a large fine for the owner, the care home manager and the care staff concerned were given suspended jail sentences. Scalding incidents, like the one described here, are entirely avoidable in adult social care settings. Martin Hodgson looks at how care providers can ensure that their service users are safe from such painful injuries and discusses the control measures they should have in place.
Injuries from scalding water and hot surfaces
Burns are injuries to the skin caused by fire or a dry heat source, such as hot metal. Scalds are similar injuries caused by a hot liquid or by steam. In both cases the skin may peel and there may be blisters or swelling as well as intense pain. Where large areas of skin are affected the injuries can be life-threatening.
Over the years a number of tragic accidents have occurred where service users have been burnt or scalded while being provided with adult social care.
staff neglecting to check the temperature of bath water and lowering a service user into hot water
a service user falling against an unprotected radiator or hot water pipe and being unable to move away.
Serious injuries can result from such incidents and cases where care has been found to be negligent have been severely dealt with in the courts.
Hot water or unprotected hot surfaces can be particularly dangerous for vulnerable people such as the elderly, those with reduced mental capacity or mobility, those with sensory impairments or those who cannot react appropriately or quickly enough to prevent injury.
Most people react quickly if they have been scalded or burnt. They will immediately pull their hand away from a hot surface or hot water or cry out. However, for some service users in adult social care this is not always the case. They may be confused or suffer from sensory or cognitive impairments which prevent them from recognising the dangers of hot surfaces or hot water or feeling pain.
Those who lack mental capacity, such as people with dementia, may be particularly vulnerable, as are those with limited mobility who may have difficulty moving away from a heat hazard.
Legal requirements and guidance
Section 3 of the Health and Safety at Work, etc Act 1974 places a duty on employers to protect people other than those at work from risks in connection with their activities.
Key safety guidance is produced by the Health and Safety Executive.
Chapter 10 of HSG220 (2nd Edition) Health and Safety in Care Homes.
The Care Quality Commission have also published online learning from safety incidents, Burns from Hot Water or Surfaces.
Key to the prevention of injury from scalds and burns in adult social care is risk assessment.
In care homes a risk assessment of the premises should be carried out to identify what controls are necessary and how hot water and heating systems should be managed and maintained. HSE advise that the results of this general risk assessment should be taken into account when completing individual service user’s care assessments. These should cover questions such as the following.
Is the service user's sensitivity to temperature impaired?
Is their mental state such that they can recognise hot surface temperatures or hot water?
Can they bathe or shower unaided?
Are they liable to try and run a bath/add water when unattended?
Are there any potential trapping risks near heaters or hot pipes, eg bed rails, furniture?
Appropriate control measures should be introduced wherever a risk is identified.
Risk assessments should be recorded and kept under review.
Control measures for hot water
The HSE guidance states that there is an increased risk of serious injury or fatality if hot water used for showering or bathing is above 44°C. In settings such as care homes they therefore recommend that “engineering controls” are installed to ensure that water hotter than 44°C is not discharged from outlets which may be accessible to vulnerable people and where there is the potential for whole-body immersion.
HSE suggest that similar controls may be needed at other outlets if people are especially vulnerable (eg basins available to those with a skin sensitivity impairment).
Engineering controls recommended by HSE include:
thermostatic mixing valves (TMVs)
temperature-restricted, instant water heaters.
Thermostatic mixing valves should not be confused with standard mixer taps. A TMV is a device which limits the temperature of stored hot water to a safe output level by blending it with cold water before it reaches the tap or outlet. TMVs thus ensure a constant and safe water outlet temperature at all times and mitigate the risk of scalding. This is particularly important in settings such as care homes where hot water will usually be stored at 60°C and distributed at 50°C or higher in order to control Legionella bacteria.
Managing the Risks from Hot Water and Surfaces in Health and Social Care, refers to the standard contained in Health Technical Memorandum 04-01 Safe Water in Healthcare Premises, published by the Department of Health and Social Care, that Type 3 TMVs should be installed whenever another mixer valve is replaced or in new healthcare settings.
HSE state that, where TMVs are not fitted to baths or showers, other equally effective controls should be in place.
Where electric showers are fitted, these should be designed so that water cannot be delivered at a temperature that may cause scalding. The HSE warn that domestic electric showers will have temperature regulation features but water temperatures above 44°C may still occur if there are fluctuations in flow or pressure. For vulnerable people the HSE recommend “healthcare standard” showers are installed which include Type 3 TMVs. These are required in all healthcare settings.
In domiciliary care the requirement to fit TMVs and similar devices may not apply in private homes. In such cases, for vulnerable service users, the HSE recommend that home care providers seek agreement with the person receiving care or in control of the premises to ensure systems for reducing the risk of burns or scalding are in place.
All care providers, including home care agencies, should have a policy on preparing a bath or shower for a service user. The water temperature should always be checked before the service user enters. Staff should use a thermometer for bathwater and not rely on “touch” methods such as “dipping an elbow" to assess temperature. Staff should be advised to never add hot water to an occupied bath.
Service users who are physically frail or confused should never be left unattended in the bath or shower.
Control measures for hot surfaces
In addition to hot water, vulnerable service users should also be protected from accidental burns caused by hot surfaces, such as hot water pipes or radiators. Where these are over 43°C the HSE warn that prolonged contact can cause particularly serious injuries. Such contact can be caused if a frail service user falls against a radiator or pipe and cannot get up or becomes trapped by furniture.
As with hot water, appropriate risk assessments should be completed and used to inform care assessments. Where a risk is identified appropriate measures should be taken to safeguard the service user concerned.
Control measures recommended by the HSE in settings such as care homes include:
providing low surface temperature heat emitters
locating sources of heat out of reach
guarding the heated areas (eg providing radiator covers, covering exposed pipework, etc).
Flow temperatures can be reduced to below 43°C but care must be taken not to increase risks from Legionella. Where necessary expert advice should be sought.
Maintenance and monitoring
All devices such as TMVs should be fitted by qualified and experienced contractors. They should be subject to regular temperature checks, inspection and servicing, as recommended by manufacturers. A documented maintenance schedule should be followed and an effective regime of water temperature monitoring should be in place with records kept.
Radiator temperatures should also be regularly monitored. Priority should be given to those radiators where service users are most likely to sustain an injury, such as bedrooms and bathrooms.
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 not enough to merely lock bathroom doors or put furniture in front of hot radiators and think that is sufficient to prevent injury.
The HSE state that adequate training and supervision should be provided to ensure that staff who maintain premises or assist vulnerable people fully understand the risks and precautions involved in preventing scalding or burning injuries. In all cases staff should be trained to report faults immediately. This includes faults where water temperatures are too hot and cannot be controlled, etc.