Why should you read this?
When something goes wrong in health and social care, the people affected and staff often say, "I don’t want this to happen to anyone else." These 'Learning from safety incidents' resources are designed to do just that. Each one briefly describes a critical issue - what happened, what CQC and the provider have done about it, and the steps you can take to avoid it happening in your service.
Unguarded hot surfaces can cause serious or fatal injuries.
Many people who use health and social care services may be vulnerable to injury from hot water or surfaces. Those at risk include:
- older people
- people with reduced mental capacity, reduced mobility, or a sensory impairment
- people who cannot react appropriately, or quickly enough, to prevent injury
Prosecution by CQC
In February 2017, CQC successfully prosecuted a care home provider. The provider failed to provide safe care and treatment resulting in avoidable harm to a person using services.
A 79-year-old woman suffered serious burns from prolonged contact with an uncovered radiator.
The woman was identified as being at a high risk of falls. Her risk assessment stated:
- there must be a sensor mat in place to alert staff when she was out of bed
- hourly checks at night were essential
When the incident took place in November 2015, there was no sensor mat and the woman was last seen over an hour before. She was found to have a large burn to her back and skin was visible on the uncovered radiator.
In 2014 a health and safety consultant had identified that uncovered radiators at the service posed a risk of burns and they needed to be covered. The provider made assumptions about which radiators needed covering. They did not consider the radiator in this woman’s bathroom.
The provider was ordered to pay:
- a £20,000 fine
- £4,500 costs
The provider has taken steps to improve
When CQC inspectors visited the care home in December 2015, they found concerns around the lack of risk assessments to keep people safe. Also there was no formal supervision to monitor staff practice. The service was rated as requires improvement for the three key questions about safe, effective and well-led.
At a follow-up inspection in June 2016, inspectors found that:
- assessments were in place to manage risk
- staff received regular supervision and felt supported
These measures helped demonstrate that the provider had carried out sufficient improvements. Therefore, the inspectors rated the safe and effective questions as good. The current rating is good overall.
What can you do to avoid this happening?
Unfortunately, this sort of incident is not uncommon and can cause fatalities but you can do something to reduce the risk.
In 2015 the Health and Safety Executive (HSE) prosecuted another care provider. A man suffered severe burns after becoming trapped between a wardrobe and a radiator. He died in hospital eight days later.