Health and Safety Hot Surfaces Prosecution Case Study

Health and Safety Review April 2026

A care provider and manager have been ordered to pay £27,960 after causing avoidable harm to a resident living at a nursing home in Manchester.

The care provider pleaded guilty to failing to provide safe care and treatment to the resident, resulting in avoidable harm. This resulted in one offence under Regulation 22 (2)(a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The care provider operates a nursing home in Manchester, which provides accommodation and care for older people. At approximately 2 am on 17 June 2021, a resident of Oakland House Nursing Home was found at a planned check by staff, lying on the floor of their bedroom between the stand hoist used to help them in and out of bed and the radiator. The resident’s left thigh was leaning on the radiator pipe, which resulted in a substantial burn. The resident had last been checked on just after midnight.

Staff called an ambulance, and they were taken to the hospital, where they were admitted and treated.

CQC inspectors visited the home following the incident and found that, while the specific radiator pipe in this resident’s room had subsequently been covered, similar exposed pipes remained in communal bathrooms, lounges and some other people’s bedrooms.

An independent health and safety expert concluded that:

• The risk from hot pipes was foreseeable and should have been identified through a competent risk assessment
• Staff responsible for undertaking risk assessments were inadequately trained
• The risks posed by the resident’s specific mobility needs and behaviours not adequately considered

The care provider was fined £26,800. It was also ordered to pay a £464 victim surcharge and £17,692.33 costs.

The registered manager of the service also pleaded guilty to failing to provide safe care and treatment to the resident, resulting in avoidable harm. This resulted in one offence under 22(2) (a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The registered manager was fined £1,160 and also ordered to pay a £464 victim surcharge.

Alison Chilton, CQC’s Deputy Director of Operations in Greater Manchester, said: ’People receiving care and treatment have the right to expect that any risks to their safety will be effectively managed. This isn’t what happened when this resident was in the care of Oakland House Nursing Home.’

‘The failure of Equilibrium Healthcare Limited and Derek Stanley to manage the risks to this resident was unacceptable.’

‘The majority of care providers do an excellent job. However, when a provider puts people in its care at risk of harm, we will take action to hold them to account and to protect people.’

‘I hope the outcome of this prosecution reminds care providers of their duty to assess and manage all risks to ensure people are kept safe.’