Last reviewed 20 February 2014

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 home 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?

Vulnerable people

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 care home 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.

Risk assessments

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

Service users must be protected from accidental burns caused by coming into contact with hot surfaces, such as water pipes or radiators.

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 and in HSG220 Health and Safety in Care Homes.

To comply with the guidance, care home managers should conduct risk assessments to identify the potential risks of burning from hot surfaces and to assess the vulnerability of residents. Action then needs to be taken based on the assessments to make safe any radiators and pipes that vulnerable residents may come into contact with.

Some residents will be at greater risk than others. Where a resident is unable to move away, eg if they fall against a radiator and cannot get up or they become trapped by furniture, then the result could be severe burns or even fatalities.

Action to reduce the risk of hot surfaces

Where a risk of burns is identified for any resident, then the care home manager should take action, such as:

  • ensuring that pipes and radiators are covered or that the surface temperatures of radiators, heaters and pipes is reduced to 43°C when the system is running at maximum output

  • ensuring that the surfaces of radiators, pipes and heaters have fitted guards around them to prevent contact

  • replacing radiators with low-surface temperature heat emitters, eg cool wall systems

  • locating sources of heat out of reach, eg at high level or under floors.

Radiator temperatures should 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 never enough to merely put furniture in front of hot radiators and think that is sufficient to prevent injury.

Scalding risks

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.

In care homes, wherever such risks are identified, and where hot water is kept at 60°C or above to maintain safety against Legionella infection, engineering controls should be fitted to ensure that water temperature is reduced to a safe level at outlets such as bath taps or showers.

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.

Safe hot water systems

The HSE guidance recommends fitting Type 3 thermostatic mixing valves (TMVs) or temperature-restricted instant water heaters or showers. It states that Type 3 TMVs should be installed when TMVs are replaced or where there are new installations.

Where TMVs are not fitted to baths or showers, the guidance states that other, equally effective, controls should be 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. Wherever possible, this should include certification of checks.

Both hot and cold outlet water temperatures should be checked on a regular basis, and managers should ensure that an effective regime of water temperature monitoring is in place, with records kept.

The HSE states that removing the hot tap head is not advisable as this may prevent water being flushed out regularly to control the risk from Legionella. Staff should:

  • be trained in the use of thermostatic mixers

  • report faults immediately

  • report if water from any tap exceeds 44°C

  • always check that the temperature of a bath or shower is safe and comfortable for the resident before helping them to enter the water.

All homes 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.