SUP 06 Management & control of Hot Water Unified procedures for use within NHS Scotland May 2015
Contents page Acknowledgements... 4 1. Preface... 5 1.1 Management guidance... 5 2. Introduction... 6 2.1 Domestic hot water systems - General... 6 2.5 Legal considerations... 6 2.6 Aim of the procedures... 7 3. Scope of the policy and procedure... 8 4. Roles and responsibilities... 9 5. Risk reduction strategies/procedures... 12 6. Operational arrangements... 13 6.1 Controlled... 13 6.2 Procedural Temperature Control (Nursing)... 13 7. Reporting and monitoring... 16 7.5 Audit... 16 References... 17 Appendix A: Warning sign exemplar... 19 Appendix B: Water temperature log sheet - exemplar... 20 Appendix C: Procedure for checking bath and shower temperatures.... 21 Draft Version 0.06: May 2015 Page 2 of 21 Health Facilities Scotland, a Division of NHS National Services Scotland
Disclaimer The contents of this document are provided by way of general guidance only at the time of its publication. Any party making any use thereof or placing any reliance thereon shall do so only upon exercise of that party s own judgement as to the adequacy of the contents in the particular circumstances of its use and application. No warranty is given as to the accuracy, relevance or completeness of the contents of this document and Health Facilities Scotland, a Division of NHS National Services Scotland, shall have no responsibility for any errors in or omissions therefrom, or any use made of, or reliance placed upon, any of the contents of this document. Draft Version 0.06: May 2015 Page 3 of 21 Health Facilities Scotland, a Division of NHS National Services Scotland
Acknowledgements This unified procedures guidance has been produced for NHS Boards to adopt or adapt and incorporates information made available by NHS Lothian which is gratefully acknowledged. This has been updated and converted to generic form for general use and editing where required. Note: This unified procedures guidance has been produced for NHS Boards to adopt or adapt to suit individual circumstances. Draft Version 0.06: May 2015 Page 4 of 21 Health Facilities Scotland, a Division of NHS National Services Scotland
1. Preface Management guidance 1.1 It is the responsibility of the owners and occupiers of properties, NHS Board Chief Executive Officers and Managers to ensure that their premises comply with all statutory requirements. 1.2 Employers have a duty under the Health & Safety at Work etc Act 1974, so far as is reasonably practicable, to ensure the health and safety of employees, residents and visitors to their premises. It is incumbent upon both owners and occupiers of premises to ensure that there is a management regime in place for the proper operational and risk management of plant, equipment and systems with particular concern for the provision and maintenance activities related to domestic hot water supplies. 1.3 All personnel should be made fully aware of their safety responsibilities, as required by statute and they should be given the necessary information and training properly to understand and carry them out. This also applies to organisations and individuals to whom work has been contracted. 1.4 Management should make available guidance on the safe operation and practice of all activities undertaken by themselves or others under contract. 1.5 This procedures guidance lays out the responsibilities and requirements of NHS Board Estates Managers and staff in order to protect all patients, employees, contractors, voluntary workers and visitors as well as members of the public from injury or harm from scalding, waterborne bacteria or pathogens which occur naturally in domestic hot water supply systems through ineffective management. 1.6 The management of domestic hot water systems within all NHS Board controlled and maintained properties requires systematic examination to ensure there is suitable and adequate protection against any individual(s) suffering from burning, scalding or searing. 1.7 The NHS Board recognises the particular need to have in place a risk assessment process to ensure that there are suitable and sufficient controls to prevent injury from burning and scalding when washing and bathing vulnerable patients. Draft Version 0.06: May 2015 Page 5 of 21 Health Facilities Scotland, a Division of NHS National Services Scotland
2. Introduction Note: The term scald as used in these procedures also encompasses burn and / or sear. The term hot water incident refers to an occurrence or event relating to hot water that caused or may have caused injury or harm to a person(s). The term full body immersion refers to the immersion of a patient by means of bathing or showering. Domestic hot water systems - General Duty to protect 2.1 The NHS Board has a duty to protect all patients, employees, contractors, voluntary workers and visitors as well as members of the public from infection risks from bacteria or pathogens which occur naturally in hot water supply systems. 2.2 The NHS Board also has a duty to protect all patients, employees, contractors, voluntary workers, visitors as well as members of the public from the risk of being scalded from hot water, hot water appliance(s) and equipment whilst within its premises. 2.3 This scalding may occur as a result of coming into direct contact with hot water or indirectly from surfaces containing hot water, such as unprotected radiators and pipe work. Those at risk 2.4 Those who should be considered at risk and vulnerable include: patients with suppressed immune systems; staff, students (where applicable), visitors and contractors; babies; children; the elderly; those with reduced mental capacity, reduced mobility; anyone with sensory impairment or who cannot react appropriately or quickly enough to prevent injury to themselves or find themselves unable to alert others to react on their behalf. Legal considerations 2.5 The legislative framework that underpins the NHS Board s obligation to manage its Domestic Hot Water policy and procedures are contained within: Draft Version 0.06: May 2015 Page 6 of 21 Health Facilities Scotland, a Division of NHS National Services Scotland
the Health and Safety at Work etc. Act 1974; the Workplace (Health, Safety and Welfare) Regulations 1992; the Provision and Use of Work Equipment Regulations 1998; the Management of Health and Safety at Work Regulations 1999; the NHS Reform (Scotland) Act; Water Byelaws (Scotland) 2004; SHTM 04-01 (all parts): Water safety; The Control of Legionella Bacteria in Water Systems Approved Code of Practice L8; Legionnaires Disease: The Control of Legionella bacteria in water systems Approved Code of Practice and Guidance (HSE ISBN:9780717617722). Aim of the procedures 2.6 The NHS Board attaches the greatest importance to the health safety and welfare of its employees and others who may be affected by its activities. In particular, the Board recognises the significance of the risks of injury associated with the management of hot water. These procedures set out how the NHS Board will ensure that such risks are eliminated or reduced to the lowest level in so far as is reasonably practicable. 2.7 The NHS Board recognises its responsibilities under health and safety legislation and its duty to provide, so far as is reasonably practicable, working environments that are safe and healthy for all patients, employees, contractors, students/pupils on placements, voluntary workers and visitors as well as members of the public. 2.8 The NHS Board will endeavour to protect all staff and other persons, to whom it has third party liability, from the effects of injury by scalding through the use of hot water within its premises. This shall be achieved by ensuring that there are effective and auditable processes and procedures in place for the management of hot water. Draft Version 0.06: May 2015 Page 7 of 21 Health Facilities Scotland, a Division of NHS National Services Scotland
3. Scope of the policy and procedure 3.1 A system of control has been established for the management of hot water that shall ensure the safety of those within the NHS Board s premises by putting in place both physical and procedural controls. These controls shall be systematically examined and monitored by the NHS Board s Estates Department and those with management responsibilities for clinical care. Note: This policy and procedure shall apply to all of the NHS Board managed and controlled premises where patients, staff, visitors and other users have access. Draft Version 0.06: May 2015 Page 8 of 21 Health Facilities Scotland, a Division of NHS National Services Scotland
4. Roles and responsibilities 4.1 NHS Board responsibilities providing full and effective implementation of this policy and procedure document; providing a safe working environment in line with health and safety legislation; ensuring arrangements for identifying, evaluating and managing risks associated with the use of facilities and appliances providing hot water; where applicable providing sufficient resources to train staff effectively; ensuring that incidents relating to scalding from hot water are monitored and reported through the relevant Health and Safety Committee(s). 4.2 Chief Executive responsibilities: ensuring that there are arrangements for identifying, evaluating and managing risk(s) associated with the management of hot water; ensuring resources are provided for the implementation of the policy and procedures; ensuring there are arrangements in place for the effective monitoring of any incident(s) involving hot water or hot water appliances. 4.3 Directors of Operations / General Managers: ensuring the risk control measures to control hot water and surface temperatures are implemented; ensuring the NHS Board s Health and Safety Committee is appropriately informed of the effectiveness of the control system and is made aware timeously of any problems being experienced in the operational procedures; ensuring operational arrangements are regularly monitored. 4.4 Head of Estates (Responsible Person): (where applicable) ensuring the effective maintenance of engineering controls installed for the purposes of controlling hot water temperatures; ensuring an Estates Operational Manager(s) or his nominated deputy is appointed as Authorised Person (Water) and assumes responsibility for the maintenance of all thermostatic temperature limiting valves (TLVs) forming part of hot water systems within hospitals and other NHS Board premises; ensuring all staff conducting maintenance are competent to do so; ensuring records are kept of all hot water systems as referred to in SCART questionsets including a log of all thermostatic temperature limiting devices Draft Version 0.06: May 2015 Page 9 of 21 Health Facilities Scotland, a Division of NHS National Services Scotland
giving locations, and recorded and maintained within the estates management system; ensuring that standards are maintained by regularly checking maintenance records; ensuring that written schemes and risk assessments are in place and reviewed regularly or when alterations have occurred; ensuring that any significant change which affects the technical aspects of procedures and or safe operation of the installed services is communicated to the Director of Operations and other relevant people; ensuring all surface temperatures of radiators and pipe work where patients, residents, visitors and staff have access does not exceed 43 C.(as per HSE OG SIM 07/2007/09). 4.5 The Estates Operational Manager(s): ensuring that all maintenance records are maintained and kept up to date; ensuring that standards are maintained by regularly checking maintenance records; ensuring all staff conducting maintenance are competent to do so. 4.6 The Estates Authorised Person (AP) (Water): ensuring that their responsibilities are implemented; ensuring all work is carried out in compliance with the estate department s procedures; compliance with the NHS Board s Estates Procedures for thermostatic temperature limiting devices; ensuring all work activity undertaken is done so by adopting a safe system of work, safe means of access and the wearing of any personal protective equipment required. 4.7 The Procurement Manager shall be responsible for: ensuring that all thermometers purchased meet the necessary measuring criteria and tolerances. 4.8 Senior Managers, Senior Charge Nurses and Senior Midwives shall be responsible for: ensuring that a risk assessment at ward/department level has been 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; ensuring that all risk control measures identified above are communicated to nursing staff; Draft Version 0.06: May 2015 Page 10 of 21 Health Facilities Scotland, a Division of NHS National Services Scotland
ensuring that all procedures relating to the management and control of hot water are fully implemented within the ward(s) and other departments for which they are responsible; ensuring that suitable calibrated thermometers are available at each location where hot water temperatures need to be taken. Any damaged or malfunctioning thermometers should be replaced immediately. Certificates of calibration should be available for checking; ensuring signage is displayed indicating the correct bathing / showering temperature(s); ensuring temperatures are measured and recorded prior to any full body immersion of a vulnerable patient; the reporting any incidents of excessive temperature readings through the NHS Board s incident recording system. Informing the estates department of any hot water temperature(s) greater than 2 C above the recommended temperature(s). Draft Version 0.06: May 2015 Page 11 of 21 Health Facilities Scotland, a Division of NHS National Services Scotland
5. Risk reduction strategies/procedures 5.1 Following any assessment of the risk, risk reduction strategies and procedures must be implemented where possible to reduce the likelihood and/or severity of incidents from scalding. 5.2 Risk Reduction strategies/procedures include: policy awareness and implementation; risk assessment both generic and specific; appropriate maintenance of internal systems and approved equipment; training; local cleaning procedure development; reporting and recording; evaluating effectiveness of risk reduction strategies/procedures; reviewing procedures in the light of experience; checking evidence of improvement by looking at incident investigation and inspection reports; discussing hot water risks with safety representatives; re-training staff if required, reading available policies, strategies and procedures; ensuring that a review of clinical and workplace risk assessments is carried out after reports of any scalding. Draft Version 0.06: May 2015 Page 12 of 21 Health Facilities Scotland, a Division of NHS National Services Scotland
6. Operational arrangements Note: All NHS Board patients, visitors and staff must be presumed to be potentially at risk. However, some are more vulnerable to scalds than others. The management of hot water temperature for the prevention of scalding can be divided into two engineering group types: uncontrolled hot water outlets and controlled hot water outlets. Controlled hot water systems must be in place where vulnerable patients are cared for. Controlled 6.1 The management of controlled water outlets can be divided further again into two distinct methods which are: procedural (Nursing); and physical (Estates) temperature controls. Procedural Temperature Control (Nursing) Vulnerable patients 6.2 Vulnerable at risk patient groups shall be supervised at all times and bathing temperatures taken and recorded prior to any full body immersion. These groups are defined as: babies and children (currently a child is defined as being up to their 16thBirthday); elderly; confused; mentally / physically impaired; patients with sensitive skin; where full body immersion takes place the maximum water temperature recorded in the bath or shower will be 38ºC. This temperature takes into consideration those patients whose skin maybe more sensitive. 6.3 All bath/shower thermometers must be of an approved design, with an accuracy of +/- 2ºC. The maintenance, calibration and testing of electronic thermometers shall be carried out by the NHS Board s medical physics department. This calibration shall be carried out annually, or in the event of irregular readings being obtained, with a record retained on the ward for audit purposes. Patients Less at Risk 6.4 Although the risk from scalding maybe reduced as some patients are able to bath and shower themselves without supervision it is important that hot water temperatures continue to be recorded on a monthly basis. Monthly checks will Draft Version 0.06: May 2015 Page 13 of 21 Health Facilities Scotland, a Division of NHS National Services Scotland
help determine the effectiveness of the hot water management control system and the detection of any thermostatic temperature limiting device not operating correctly. An example of a Water Temperature Log is shown in Appendix B. 6.5 The procedure for carrying out this check is described within the Procedure for checking Bath and Shower Temperatures (Appendix C). The temperature(s) are recorded and kept within the area for reference and auditing. Excessive Temperature Recordings 6.6 In all instances the nurse in charge must inform the Estates Department immediately following any temperature readings taken that are greater than 2ºC above the recommended hot water temperature for that appliance. The bath or shower facility must be removed from use until the Estates Department have confirmed that the TLV has been repaired and is operating correctly. 6.7 The failure of any TLV must be recorded within the NHS Board s Incident Recording System by the nurse in charge. Physical/Engineering Temperature Controls (Estates) 6.8 All hot water outlets that pose a risk of whole body immersion shall have a suitable Thermostatic Limiting Valve (TLV) installed with a log maintained of all TLV locations held by the Estates Department. 6.9 Maximum settings for hot water thermostatic limiting valves are: Source/Appliance ºC Bidet 38 Shower 41 Washbasin 41 * Bath 43 *For wash-hand basins, washing under running water is assumed. Note: Temperature Limiting Valves (TLVs) are also known as Thermostatic Mixing Vales (TMVs). They perform the same function. 6.10 All TLV s shall be tested and maintained on a six (6) monthly programme by trained staff as contained within the NHS Board Estates Procedure for Temperature Limiting Valves (TLV s). 6.11 All staff who have responsibility for an area, shall log all requests to estates personnel for checks to be carried out on TLV s whenever a higher than safe water temperature reading is obtained (+2 C greater than that recommended). This log must be kept within the ward / department area and be made readily available for reference to and auditing thereof. Draft Version 0.06: May 2015 Page 14 of 21 Health Facilities Scotland, a Division of NHS National Services Scotland
6.12 Estates staff shall check and repair or recalibrate all TLVs as soon as possible. The responsible person for the area must be informed by Estates staff once a reported TLV has been checked and is functioning to a satisfactory standard before it is reinstalled into normal service. This shall be logged by the responsible staff member and kept as a record within the ward/department area, which again shall be made available for reference to and for auditing purposes. 6.13 Any Estates Manager or appointed person who has responsibility for the maintenance of TLV s within specific premises shall be informed of all requests for TLVs to be checked and of the results of these checks Note: These requests shall be made via the Estates Department help line number. They shall ensure appropriate action is undertaken to address any problems arising out of the control system or from the manufacture or design of the TLVs. The Director of Facilities shall, through the Head of Estates, be informed by the local Estates Manager or appointed person of any significant issue in relation to the safe operation of any hot water control(s). Uncontrolled 6.14 Those outlets that are uncontrolled are those that are not governed by a Thermostatic Limiting Valve (TLV), and must be clearly identified as such. This shall be done by displaying a very hot water sign fitted adjacent to the water outlet for the attention of all users. These shall be supplied and fitted by the estates department. (Appendix A). Draft Version 0.06: May 2015 Page 15 of 21 Health Facilities Scotland, a Division of NHS National Services Scotland
7. Reporting and monitoring 7.1 All incidents (including near misses) must be reported using the NHS Board s incident reporting and recording system in line with the NHS Board s Incident Management Policy and Procedure. 7.2 Line managers must ensure that a review and investigation of a contamination incident which can be demonstrated as originating in a drinking water system is carried out and recorded. All hot water incidents that are graded orange or red shall be reviewed as a significant adverse event as per the Incident Management Policy and Procedure. 7.3 In order to ensure the implementation and effectiveness of these procedures all reports relating to hot water management should be reviewed regularly by the responsible manager. 7.4 All accidents and incidents are monitored by the local health and safety committees and any scalding incidents which are not deemed to have been managed appropriately shall be the subject to further investigation by the appropriate senior manager. Audit 7.5 The application and effectiveness of this policy, throughout the organisation, shall be monitored by an internal audit process. The policy will be reviewed and revised on a regular basis or as a result of any changes in legislation, standards and Healthcare Facilities Scotland guidance. Draft Version 0.06: May 2015 Page 16 of 21 Health Facilities Scotland, a Division of NHS National Services Scotland
References Related documents These procedures should be followed in conjunction with the following: NHS Board Policies and Procedures Policies and Guidance for all Employees. NHS Board Incident Reporting and Investigation Policy. NHS Board Incident Reporting Operational Procedure. NHS Board Estates Department Operating Policy for Managing the Control of Legionella. NHS Board Estates Procedure for Thermostatic Temperature Limiting Valves. SHTM 04-01: Water Safety (Parts A and B). Relevant SCART questionsets, particularly, Water Safety. CEL letter CEL 08 (2013) dated 3 May 2013 Water sources and potential infection risks to patients in high-risk areas revised guidance. National Services Scotland guidance for neonatal units (NNUs) (levels 1, 2, 3), adult and paediatric intensive care units (ICUs) in Scotland to minimise the risk of Pseudomonas aeruginosa infection from water. References Health and Safety Executive Guidance and Procedures The following references are relevant published by the Health & Safety Executive: The Control of Legionella Bacteria in Water Systems Approved Code of Practice L8. Legionnaires disease. The control of Legionella bacteria in water systems Approved Code of Practice and guidance (HSE ISBN:9780717617722) Scalding risks from hot water in Health and Social Care SIM OG 7/2007/08 Burning risks from hot water surfaces in Health and Social Care SIM OG 07/2007/09 HSG 220 Health and Safety in Care Homes (Supersedes HS (G) 104) Draft Version 0.06: May 2015 Page 17 of 21 Health Facilities Scotland, a Division of NHS National Services Scotland
British Standards BS EN 1287:1999; sanitary tap ware. Low Pressure Thermostatic Mixing Valves. General technical specifications Draft Version 0.06: May 2015 Page 18 of 21 Health Facilities Scotland, a Division of NHS National Services Scotland
Appendix A: Warning sign exemplar Draft Version 0.06: May 2015 Page 19 of 21 Health Facilities Scotland, a Division of NHS National Services Scotland
Appendix B: Water temperature log sheet - exemplar 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Month/ Date Room No. Shower temp Bath temp Person checking Comments Additional comments/notes by ward/department/estates staff (please sign and date) Draft Version 0.06: May 2015 Page 20 of 21 Health Facilities Scotland, a Division of NHS National Services Scotland
Appendix C: Procedure for checking bath and shower temperatures. Note: This procedure must be carried out prior to any full body immersion of a vulnerable patient. The hot water temperature results shall be logged by nursing staff as a local record. The records should be retained for three months for audit purposes. The procedure can also be used to check daily the hot water temperatures for patients who are less at risk and again records should be retained for reference. Appendix B provides a Water Temperature Log which may be used by wards and or departments. Baths The hot water tap only should be turned on and allowed to run for a minimum of one minute or until the water temperature stops rising. The bath thermometer should then be placed under the running water for 10 seconds or until the temperature reading stabilises and the water temperature read and recorded. The member of staff responsible for the immersion bathing of babies, children, or other vulnerable individuals, will measure the temperature of the water with a bath thermometer prior to the patient being immersed. This will ensure that the temperature of the water does not exceed 38 C. The temperature of the water will be documented in the nursing notes following the procedure. All members of staff must follow this procedure even when the mother of the baby or anyone else is carrying out the bathing of a patient. Showers The dial should be turned to the highest setting the water turned on and allowed to run for a minimum of 1 minute or until the water temperature stops rising. The thermometer should be placed in a suitable receptacle. This should then be held under the running water until the thermometer becomes immersed and the reading stabilises. The water temperature can then be read and recorded. Bidets The Hot Water tap only should be turned on and allowed to run for a minimum of one minute or until the water temperature stops rising. Draft Version 0.06: May 2015 Page 21 of 21 Health Facilities Scotland, a Division of NHS National Services Scotland