Health and Safety
Executive / Commission
Local authority circulars
To: Local Authority Health and Safety Enforcement Managers, Health and Safety Regulators, Regulators of Health and Social Care Services and Others
This circular provides advice to Health and Safety Regulators (for clarity and convenience referred to as Inspectors) who are involved in the regulation of health and social care activities. The circular addresses the number of serious burning incidents to people who use care service from hot surfaces in health and social care premises.
1. This circular addresses the specific risk in health and social care premises to service users from hot water temperatures. For consistency, the term ‘people who use care services’ has been used to describe patients, residents and any other clients in health and social care premises.
2. High water temperatures create a scalding risk to vulnerable people who use care services. Those at risk from scalding/burning include children, the elderly, those with reduced mental capacity, reduced mobility and anyone with sensory impairment , or who cannot react appropriately, or quickly enough, to prevent injury. They may be in hospitals, care homes, social services premises and special schools (ie. health and social care establishments). The risk of scalding/burning should also be assessed in community facilities such as hostels, staffed and sheltered housing for the elderly, the mentally ill, and those with learning difficulties.
3. In recent years the implementation of appropriate temperature control arrangements has meant that the frequency of reported fatal and major injury accidents to vulnerable people who use care services has reduced considerably. For the period April 2001 to March 2006 RIDDOR statistics identified 2 fatal incidents and 8 major injuries attributable to hot water scalds in health and social care premises.
4. One of the main reasons given for maintaining hot water temperatures (ie above 50oC) in health and social care premises is to control legionella bacteria which can be harmful. Those particularly at risk include the elderly and those with cancer, diabetes, chronic respiratory or kidney disease. Bacteria are usually found in water systems, whirlpool bathers and hydrotherapy baths.
5. It has been suggested that the need to control legionella bacteria and to prevent/control the risk of scalding may be in conflict with, and cause unnecessary burden to, health and social care providers. For example, some employers, particularly smaller care homes, have argued that water temperatures have been increased purely to combat the risk of legionella. However, an increase in the risk of scalding cannot be justified as a consequence of introducing precautions against legionella.
6. HSE and local authority inspectors carried out a survey of the patterns of hot water use and the control of scalding in 1996. The results indicated that less than 20% of homes were holding water above 60oC solely for the purpose of controlling legionella. Most homes had hot water for other reasons, such as for kitchen/laundry use, to cater for long pipe runs, to ensure proper boiler operation, or to provide enough hot water to bathe all people using care services.
7. The health and safety of people who use care services is covered by the general requirements of Section 3 of the Health and Safety at Work Etc Act 1974, (HSW s.3) and by the risk assessment requirements of the Management of Health and Safety at Work Regulations (Reg 3) (MHSWR reg.3). The Provision and Use of Work Equipment Regulations 1998 (PUWER) also set out requirements for work equipment including suitability and maintenance, and instruction and training. HSE and LA Inspectors enforce these requirements.
8. Regulation 3 of the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR) requires that where a person not at work suffers a major injury (as defined in Schedule 1 to the regulations) or fatal injury out of or in connection with work the injury must be reported to the relevant enforcing authority. Guidance on understanding the meaning of the phrase “Arising out of or in connection with work” is given in regulation 2(2)(c) of RIDDOR. Accidents involving service users and hot water will generally be classed as ‘arising out of or in connection with work’ and will be reportable if they meet the above criteria.
9. CSCI is the single, independent inspectorate for all social care services in England. Further information on their role with regard to health and safety of people who use care services can be found in SIM 07/2006/14 Better Regulation: Regulatory Bodies Inspecting Social Care [155kb] 
.
10. In Scotland, the Scottish Commission for the Regulation of Care (the Care Commission) was set up under the Regulation of Care (Scotland) Act 2001 to establish a unified system of registration and regulation for social care services in Scotland including early education and independent and private health care. The Care Commission (CC) carries out regular inspections (at least twice a year for 24-hour care providers and annually, as a minimum, for others) to make sure that services meet the required minimum standards. Both HSE and CC have legitimate interest in matters concerning regulation in the care sector. However, because workplace health and safety is a reserved matter, HSE/LA inspectors in Scotland remain responsible for the regulation of risks to people who use care services arising out of or connected with work. A protocol, which will clarify the roles and responsibilities of HSE and CC is being developed.
11. In Wales the Care Standards Act 2000 and The Children Act 1989 (as amended) provide the National Assembly for Wales with the authority to register and inspect establishments and agencies in Wales that provide social care. The Care Standards Inspectorate Wales (CSIW), an operationally independent part of the Assembly regulates social care, early years and private and voluntary health care services. CSIW conduct regular (usually annual) inspections measuring services against National Minimum Standards produced by the Welsh Assembly Government. The National Minimum Standards address patient safety issues as well as the health and safety of care staff. A memorandum of understanding between HSE, LA’s and CSIW is being developed. CSIW will take the lead in enforcement in relation to any issue relating to safety of people who use care services within the Care Standards Act and associated regulations; this will include the management of risks from hot water. Social Services Inspectorate for Wales will merge with CSIW to create the Care and Social Services Inspectorate (CSSIW) in April 2007.
12. Inspectors should look at the following elements of the risk management system:
13. A risk assessment should be carried out to identify potential scalding risks from hot water temperatures and to assess the vulnerability of all those who have access to bathing and washing facilities. Questions to be asked may include:
14. The results of the risk assessment may be recorded on individual care plans of those using the care service, which should include an assessment of capabilities and needs and should specify whether a person is able to wash themselves unsupervised.
15. Where the risk assessment warrants it, engineering controls should be provided that ensure either:
16. Where thermostatic mixing valves are not fitted inspectors may find that other steps, such as locking bathroom doors or removal of the hot tap head, have been taken. Because such precautions rely solely on adherence to a safe system of work, and have failed in the past, these measures are only acceptable in the interim, while thermostatic mixing valves are fitted.
17. It is particularly important that where thermostatic mixing valves (TMVs) are provided they are maintained to at least the standard recommended by the manufacturer. A documented maintenance schedule which takes into account local conditions (eg hard water) and the risk of valve failure, should be followed and recorded.
18. Adequate training and supervision should be provided to ensure that staff involved in bathing people who use care services understand the risks and precautions. This will include, in particular, filling the bath before the person gets into it and monitoring the outlet temperature of the bath/shower water using a bath thermometer. If it is necessary to add hot water whilst the person using the care service is in the bath, this should be done slowly and the water should be tested as it is added.
19. Staff should be instructed that water in excess of 44oC coming from a tap should be reported to a responsible person, and access to the bath/shower concerned restricted until repairs to the thermostatic mixing valve have been carried out.
20. Determining appropriate enforcement action requires HSE inspectors to reference the HSE Enforcement Management Model (EMM), Version 3.0 [133kb] . This is a fully open government document available at the HSE website.
21. A judgement of actual risk will need to be made based on the vulnerability of the population who may have access to bathing facilities and the control measures in place.
22. In a worst case scenario of vulnerable people having access to water capable of whole body immersion in water >44oC., there is a risk of serious personal injury with likelihood probable to single casualties.
23. Where there are vulnerable people and control measures are incomplete, there will always be a risk of serious personal injury with likelihood possible or probable, depending on the circumstances, from whole body immersion if water can be delivered at >44oC.
24. Where all elements of the risk control system are in place, the permitted level of risk of injury is nil or negligible.
25. The risk gap should be determined using Table 2.1 of the EMM.
26. The following standards have been identified as ‘Established’ using the criteria set out in Table 3 of the EMM:
27. NHS Estates Health Guidance Note (HGN) 'Safe' hot water and surface temperatures 1998 edition(file 357) (Scottish version is Scottish Health Guidance Note (1999) recommends how to meet employer’s legal duty of care in respect of the risk of scalding and burning from hot water. It applies in all healthcare premises and those premises registered under the Registered Homes Act 1984 (Registered Establishments (Scotland) Act 1987). It takes into account other NHS Estates guidance on water supply, storage and services, and the introduction of the new Model Engineering Specification (MES) D08 -Thermostatic mixing valves (healthcare premises). Relevant sections of MES D08 are reproduced in the HGN.
28. The guidance gives maximum hot water temperatures for a range of applications. These are shown in the table below. The guidance also specifies particular standards of thermostatic mixing valve (TMV) for different applications.
| Maximum set hot water temperatures | |
|---|---|
| Application | Maximum temperature oC |
| Bidet | 38 |
| Shower | 41 |
| Washbasin | 41* |
| Bath | 44 |
| Bath | 46** |
| Notes: | |
| * For washbasins, washing under running water is assumed. | |
| ** Bath fill temperatures of more than 44oC should only be considered in exceptional circumstances where there are particular difficulties in achieving an adequate bathing temperature. If a temperature of more than 44oC is to be used then a safe means of preventing access to the hot water should be devised to protect vulnerable people who use care services. | |
29. The Sector was consulted on the new guidance and argued for the retention of the 43oC limit. However, no convincing evidence of a significant increased risk, at the higher temperature of 44oC, could be produced.
30. The new standard for thermostatic mixing valves is supported by a testing system managed by the Water Research Council. The HGN recommends that TMVs used for baths and showers should have a certificate of testing under this 'TMV Scheme'. (BuildCert http://www.buildcert.com/tmv/default.asp currently provide an independent third party certification scheme for thermostatic mixing valves against the requirements of the NHS Estates Model Engineering Specification D 08 (TMV 3 approval).
31. HS(G)220 Health and safety in care homes - issued 12/01 (file 357) recommends that where vulnerable people are at risk from scalding during whole body immersion, water temperatures do not exceed 44oC. Blending and temperature control devises are unlikely to be needed in establishments such as rehabilitation areas, provided there is adequate supervision of staff who have received information and training on the risks of scalding and the safe procedures to be adopted. Labelling hot water outlets with ‘very hot water’ signs will help to prevent inadvertent scalding.
32. HS(G) 220 also recognises the need for establishments such as rehabilitation training areas, community houses, and some residential homes to promote and provide as near a domestic environment as possible. This may require people who use care services to be involved in some level of risk taking to enable the necessary skills associated with ‘ordinary living’ to be developed and/or maintained (this is known as elective risk) - SIM 7/2007/XX, Balanced decision making for people who use care services provides further guidance. A balance has to be made to ensure the health and safety of individuals is not put at risk and also that the independence of others is not unnecessarily curtailed.
33. Department of Health, Health Technical Memorandum (HTM) 04-01 (available electronically from the NHS knowledge and information portal): The control of Legionella, hygiene, “safe” hot water, cold water and drinking water systems Part A: Design, Installation and testing. This document is applicable to both old and new healthcare sites. Chapter 9 deals with the risk of scalding for vulnerable patients and states the need for a risk assessment approach. Table 4 on page 31 sets out the safe water temperatures and appropriate delivery devices (TMV’s) over a range of areas/activities. (Scottish equivalent is Scottish Health Technical Memo (SHTM) 2040 Control of Legionella in Health Care Premises – a Code of Practice and SHTM 2027 Hot and Cold Water Supply, Storage and Mains Services).
34. Initial enforcement expectation is derived from Table 5.1 using the risk gap and standards established.
35. Inspectors should take into account previous advice, including any from the relevant intermediaries.
36. The potential risks presented by whole body immersion in hot water to vulnerable service users are well known and publicised. There are public interest implications to consider when determining appropriate action. The Services Sector promotes strong enforcement action where failings of risk management systems give rise to significant risk to vulnerable people who use care service. Inspectors should also consider that enforcement action will have a positive impact on dutyholders in the industry in general.
37. There have been a number of highly successful prosecutions following accidents to vulnerable people, including one instance where a company was fined £30,000 for failure to fit TMVs to a bath.
38. The Sector is of the opinion that inspectors need not take enforcement action requiring different water temperatures, for different applications. Enforcement action should only be considered where there is a risk to vulnerable people of whole body immersion in water exceeding 44oC.
39. Unless there are exceptional circumstances, the Sector would not normally support enforcement action regarding hot water supplied to washbasins.
40. The Health and Social Care Services Unit would welcome information about any incidents, campaigns or initiates on this issue. Contact should be made using the general Health Services Communities email account: hscsu@communities.hse.gov.uk
41. See SIM 07/2007/10 - “Balanced decision making for people who use care services” (Due to be published shortly)