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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Legionella Prevention and Water Safety Policy

1. Purpose

The purpose of this policy is to set out how {{org_field_name}} prevents, controls and manages the risk of exposure to Legionella bacteria and other water safety risks within the care home environment. Legionella can cause Legionnaires’ disease, a potentially fatal form of pneumonia, usually contracted by inhaling small droplets of contaminated water.

{{org_field_name}} recognises that people living in care homes may be at increased risk because of age, frailty, long-term health conditions, respiratory illness, smoking history, reduced immunity or other vulnerabilities. The service will therefore maintain safe hot and cold water systems, ensure effective monitoring, keep accurate records and act promptly where risks or defects are identified.

This policy supports compliance with the Health and Safety at Work etc. Act 1974, the Control of Substances Hazardous to Health Regulations 2002, the Management of Health and Safety at Work Regulations 1999, HSE ACOP L8, HSG274 Part 2 for hot and cold water systems, and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. It supports CQC Regulation 12, Safe care and treatment; Regulation 15, Premises and equipment; Regulation 17, Good governance; Regulation 18, Staffing, where staff competence and training are relevant; and Regulation 20, Duty of candour, where a notifiable safety incident has occurred.

2. Scope

This policy applies to all care home premises, buildings, gardens, outbuildings and areas where {{org_field_name}} has control of, or responsibility for, water systems used in connection with the regulated activity. This includes hot and cold water systems, storage tanks, calorifiers, pipework, taps, showers, baths, assisted bathing equipment, thermostatic mixer valves, hoses, sluices, cleaning equipment, irrigation systems, decorative water features, humidifiers, pressure washers and any other equipment that may store, heat, cool, circulate or aerosolise water.

This policy applies to the registered provider, Registered Manager, nominated individual where applicable, maintenance staff, care staff, domestic staff, agency staff, contractors, visiting professionals and any other person whose work may affect water safety.

Where any part of the building, water system or maintenance arrangement is controlled by a landlord, managing agent or external facilities provider, {{org_field_name}} will still ensure that responsibilities are clearly documented, evidence of compliance is obtained, and risks to people using the service are assessed and managed.

3. Related Policies

• CH11 – Safe Care and Treatment Policy
• CH15 – Premises and Equipment Policy
• CH16 – Health and Safety at Work Policy
• CH17 – Infection Prevention and Control Policy
• CH18 – Risk Management and Assessment Policy
• CH19 – Emergency and Business Continuity Plan

• CH35 – Duty of Candour Policy
• Accident, Incident and Near Miss Reporting Policy
• Contractor Management Policy
• Maintenance and Repairs Policy
• Fire Safety Policy, where water systems, sprinklers or fire suppression systems are relevant
• Safeguarding Adults Policy, where neglect, unsafe premises or failure to act may place people at risk
• Training and Competency Policy
• Business Continuity and Emergency Preparedness Policy
• Infection Prevention and Control Policy, including outbreak reporting arrangements

4. Understanding Legionella Risks

Legionella bacteria are commonly found in natural water sources but can become a risk in man-made water systems where conditions allow bacteria to multiply. The main risk factors include water temperatures between 20°C and 45°C, stagnation, poor circulation, scale, sludge, biofilm, rust, dead legs, infrequently used outlets and equipment that creates water droplets or aerosols.

In a care home, higher-risk areas may include showers, assisted baths, taps, thermostatic mixer valves, spa or hydrotherapy equipment where present, humidifiers, hoses, sluices, cleaning equipment, irrigation systems and any water outlet that is not used regularly.

People at increased risk include older people, people with chronic respiratory disease, kidney disease, diabetes, cancer, weakened immune systems, smokers, people with alcohol dependency, and people who are frail or recovering from illness. Because the service supports people who may be clinically vulnerable, all water safety risks must be assessed and controlled in a timely and proportionate way.

The service will also manage the risk of scalding. Hot water must be hot enough to control Legionella within the system, while outlet temperatures used by residents must be controlled safely through appropriate engineering controls, such as correctly fitted and maintained thermostatic mixer valves, individual risk assessments and safe bathing procedures.

5. Roles and Responsibilities

The registered provider is the dutyholder for the premises and has overall legal responsibility for ensuring that Legionella and water safety risks are properly assessed, controlled, monitored and reviewed.

The Registered Manager is responsible for ensuring that this policy is implemented in day-to-day practice, that water safety arrangements are understood by staff, and that any concerns, defects or incidents are escalated and acted on promptly.

{{org_field_name}} will appoint a named Responsible Person for water safety. The Responsible Person must have sufficient authority, competence, training, knowledge and resources to manage the water safety control scheme. A deputy Responsible Person will also be appointed to provide cover during absence.

The Responsible Person is responsible for:

• Ensuring a suitable and sufficient Legionella risk assessment is in place.
• Maintaining a written scheme of control or Water Safety Plan.
• Ensuring water temperature monitoring, flushing, cleaning, disinfection and maintenance are completed as scheduled.
• Ensuring actions from risk assessments, audits and contractor reports are recorded, prioritised and completed.
• Escalating failures, unsafe temperatures, suspected contamination, resident illness or contractor concerns immediately to the Registered Manager.
• Keeping accurate records that are available for inspection by CQC, HSE, the local authority, UKHSA or other authorised bodies.
• Ensuring contractors are competent and provide suitable reports, certification and remedial action plans.

All staff must:

• Report water safety concerns immediately, including unusual water temperature, poor flow, discolouration, odour, damaged outlets, leaking equipment, unused rooms or equipment, and resident illness that may be linked to water exposure.
• Follow safe bathing, showering, cleaning and flushing procedures.
• Avoid using any water outlet or equipment that has been taken out of use.
• Record and escalate concerns in line with this policy.

External contractors may support risk assessment, monitoring, testing, cleaning, disinfection and maintenance, but responsibility for ensuring risks are managed remains with {{org_field_name}}.

5.1 Written Scheme of Control and Water Safety Plan

{{org_field_name}} will maintain a written scheme of control, also referred to as the Water Safety Plan, for each care home premises. The written scheme will be based on the Legionella risk assessment and will set out how water safety risks are controlled, monitored and reviewed.

The written scheme will include:

• A current description of the water system.
• Up-to-date schematic drawings showing hot and cold water systems, storage tanks, calorifiers, sentinel outlets, thermostatic mixer valves, showers, little-used outlets and other relevant equipment.
• The name of the dutyholder, Responsible Person, deputy Responsible Person and competent contractor.
• The control measures in place, including temperature control, flushing, cleaning, disinfection, inspection and maintenance.
• The monitoring schedule, including frequency, responsible person and acceptable limits.
• The action to take when temperatures or other checks fall outside safe limits.
• Arrangements for commissioning, recommissioning, refurbishment, maintenance, room closures and reoccupation.
• Record-keeping arrangements.
• Escalation procedures for suspected contamination, positive Legionella results, resident illness, outbreak concerns or failure of control measures.

The Water Safety Plan will be reviewed at least annually and whenever the Legionella risk assessment is reviewed, the water system changes, the resident population changes significantly, or monitoring identifies that control measures may not be effective.

6. Legionella Risk Assessments

A suitable and sufficient Legionella risk assessment will be completed for the care home by a competent person. The assessment will identify and evaluate foreseeable risks from hot and cold water systems and any equipment that may store, circulate, heat, cool or aerosolise water.

The risk assessment will be reviewed:

• At least every two years, or earlier where required.
• When there are changes to the water system, building layout, storage tanks, calorifiers, pipework, outlets, thermostatic mixer valves or water-using equipment.
• When rooms, wings or outlets are taken out of use or brought back into use.
• When monitoring shows temperatures or control measures are not being maintained.
• When there is a change in the vulnerability or number of people living at the service.
• After refurbishment, building works, plumbing works or contractor activity affecting the water system.
• Following a suspected or confirmed case of Legionnaires’ disease, a positive Legionella sample, water contamination concern or advice from UKHSA, HSE, the local authority or CQC.
• When there is reason to believe the current assessment is no longer valid.

The risk assessment will include:

• Identification of the dutyholder, Responsible Person, deputy and competent contractor.
• A description and schematic of the hot and cold water systems.
• Identification of cold water storage tanks, calorifiers, sentinel outlets, showers, thermostatic mixer valves, little-used outlets, dead legs and aerosol-producing equipment.
• Identification of people at increased risk, including residents with reduced immunity, respiratory conditions or other vulnerabilities.
• Assessment of temperature control, stagnation, water turnover, cleanliness, scale, biofilm, corrosion and system design.
• Review of monitoring records, previous remedial actions, incidents, test results and maintenance records.
• A prioritised action plan with named responsibility and timescales.

Findings will be documented, signed off by the Registered Manager and Responsible Person, and incorporated into the Water Safety Plan.

7. Control Measures, Monitoring and Maintenance

The service will use temperature control, good water turnover, cleaning, inspection, maintenance and remedial action to control the risk of Legionella.

The following control measures will be maintained:

• Hot water will be stored at 60°C or above, unless the risk assessment and competent advice specify a safe alternative control method.
• Hot water distribution temperatures will be maintained at 50°C or above, subject to safe outlet controls and scalding risk management.
• Cold water will be maintained below 20°C where reasonably practicable.
• Hot and cold water temperatures will be checked at sentinel outlets and other outlets specified in the Water Safety Plan.
• Water temperature checks will confirm that hot water reaches the required temperature within a reasonable time and cold water remains below the required temperature within a reasonable time, in line with HSE guidance and the site-specific risk assessment.
• Little-used outlets will be identified, labelled where appropriate, and flushed at least weekly or as specified by the risk assessment.
• Showerheads and shower hoses will be dismantled, cleaned, descaled and disinfected at least quarterly, or more frequently where indicated by the risk assessment.
• Cold water storage tanks will be inspected at least annually and cleaned or disinfected when required.
• Calorifiers, hot water cylinders and associated components will be inspected, maintained and flushed in line with the Water Safety Plan and competent contractor advice.
• Thermostatic mixer valves will be inspected, serviced and fail-safe tested in line with manufacturer guidance, risk assessment findings and maintenance schedules.
• Dead legs, redundant pipework and unused outlets will be removed where reasonably practicable. Where immediate removal is not possible, interim controls will be recorded and monitored.
• Rooms, bathrooms, en-suites or areas taken out of use will have a documented flushing and recommissioning plan before being used again.
• New plumbing work, refurbishment and replacement equipment will be assessed for Legionella and scalding risks before being brought into use.
• Water outlets used by residents will be assessed for scalding risk, particularly where residents have reduced mobility, reduced sensation, cognitive impairment or require support with bathing.

All monitoring will be recorded on water safety logs. Records must include the date, time, outlet, result, name and signature of the person completing the check, any action taken, escalation made and confirmation that remedial action has been completed.

Where monitoring shows temperatures outside the required range, poor flow, stagnation, contamination, defective equipment or other failure of control measures, the Responsible Person must escalate this immediately to the Registered Manager. Affected outlets or equipment must be taken out of use where necessary until safe.

Thermometers and other monitoring equipment will be suitable for use, maintained in good condition and calibrated or checked for accuracy in line with manufacturer guidance.

7.1 Flushing, Little-Used Outlets and Unoccupied Rooms

The Responsible Person will maintain a current list of little-used outlets, including outlets in unoccupied bedrooms, guest rooms, assisted bathrooms, sluices, external taps, staff areas and any other area where water may stagnate.

Little-used outlets will be flushed at least weekly, or more frequently where required by the risk assessment. Flushing must be carried out safely to minimise aerosol generation and avoid exposing residents, staff or visitors to water droplets.

Where rooms or areas are closed, refurbished or not used for a period of time, the Registered Manager and Responsible Person must ensure that a flushing plan is in place. Before the room or outlet is returned to use, the Responsible Person must confirm that appropriate flushing, cleaning, disinfection or testing has been completed where required.

Flushing records must be retained as part of the water safety records.

7.2 Scalding Risk and Thermostatic Mixer Valves

{{org_field_name}} recognises that water safety management must balance Legionella control with the prevention of scalding. Residents may be at increased risk of scalding due to frailty, reduced mobility, reduced sensation, cognitive impairment, medicines, illness or dependence on staff support.

Resident-accessible baths, showers and wash hand basins will be assessed for scalding risk. Where thermostatic mixer valves are fitted, they will be installed, inspected, serviced and tested in line with manufacturer guidance, the Water Safety Plan and competent contractor advice.

Staff supporting residents with bathing, showering or personal care must check water temperature before use and follow the resident’s care plan, moving and handling plan and any specific bathing risk assessment.

Any excessively hot water, unstable outlet temperature, faulty thermostatic mixer valve or resident scalding concern must be reported immediately. The outlet must be taken out of use where required until it has been checked and confirmed safe.

8. Contractor and Third-Party Management

Where external contractors are used for risk assessments, water monitoring, sampling, cleaning, disinfection, plumbing, maintenance or remedial works, {{org_field_name}} will ensure that they are competent for the work they undertake.

Before appointment and periodically thereafter, contractors must provide suitable evidence of competence, which may include qualifications, experience, professional registration, training records, insurance, risk assessments, method statements, health and safety documentation and, where applicable, membership of a recognised water hygiene or Legionella control scheme.

Contracts and service agreements must clearly state:

• The contractor’s responsibilities.
• The standards and guidance they will follow.
• Required monitoring, testing, maintenance and reporting arrangements.
• Emergency response arrangements.
• Timescales for urgent and routine remedial works.
• Requirements for written reports, certificates and action plans.
• How serious risks will be escalated immediately to the Registered Manager and Responsible Person.

Contractors must report any identified risk, defect, unsafe condition, failed control measure or urgent remedial requirement immediately. The Registered Manager remains responsible for ensuring that risks are assessed, actions are tracked and evidence is retained.

No plumbing alteration, refurbishment, installation or water system modification may take place unless the Legionella and scalding risks have been considered and the Water Safety Plan updated where required.

9. Resident Safety, Care Planning and Individual Risk

Water safety risks will be considered as part of the wider care planning and risk assessment process where relevant to the resident’s health, care and support needs.

Individual risk assessments must be considered for residents who:

• Are clinically vulnerable to infection.
• Have respiratory disease, reduced immunity or other conditions that may increase the risk of severe illness.
• Require staff support with bathing, showering or personal care.
• Are at increased risk of scalding due to reduced sensation, reduced mobility, cognitive impairment or communication needs.
• Use specialist bathing equipment, assisted baths, shower chairs or other water-related equipment.
• Are unable to report unsafe water temperatures, discomfort or environmental concerns.

Where a resident is identified as being at increased risk, the care plan must set out the support required to keep the person safe. Staff must follow the resident’s care plan and report any concerns immediately.

10. Responding to a Suspected or Confirmed Legionella Incident

A Legionella incident may include a suspected or confirmed case of Legionnaires’ disease, a positive Legionella sample, failure of control measures, unsafe water temperatures, suspected contamination, or advice from UKHSA, HSE, the local authority, CQC or a competent contractor that immediate action is required.

In the event of a suspected or confirmed Legionella risk, the Registered Manager and Responsible Person must ensure that the following actions are taken:

• Take immediate steps to protect residents, staff and visitors.
• Isolate or take out of use the suspected source, outlet, shower, bath, equipment or affected part of the water system where required.
• Seek urgent advice from the competent water hygiene contractor.
• Notify the local UKHSA Health Protection Team where a suspected or confirmed case of Legionnaires’ disease, outbreak or significant public health concern is identified.
• Co-operate fully with UKHSA, the local authority, HSE, CQC and any other authorised body.
• Notify CQC without delay where the incident meets statutory notification criteria, including serious injury, death, an event that stops or may stop the service running safely and properly, or another notifiable incident under the Care Quality Commission (Registration) Regulations 2009.
• Inform commissioners, safeguarding partners and relatives or representatives where required and appropriate.
• Apply Duty of Candour where a notifiable safety incident has occurred.
• Complete a full investigation, including review of the Legionella risk assessment, Water Safety Plan, monitoring records, maintenance records, contractor reports and staff actions.
• Arrange cleaning, disinfection, remedial works, sampling, retesting and recommissioning as advised by competent persons or enforcing authorities.
• Keep affected outlets or equipment out of use until they have been confirmed safe.
• Record all actions, decisions, communications, test results and remedial works.

Where a registered medical practitioner suspects a notifiable disease, reporting must not wait for laboratory confirmation. Urgent cases should be reported by telephone to the local UKHSA Health Protection Team within 24 hours.

11. Training, Competence and Awareness

All staff will receive water safety and Legionella awareness information appropriate to their role during induction and through refresher training. Training will include:

• What Legionella is and why it is a risk in care homes.
• Why older people and clinically vulnerable residents may be at increased risk.
• The importance of safe water temperatures, flushing, cleaning and reporting concerns.
• How to identify and report water safety concerns, including unusual temperature, poor flow, discolouration, odour, damaged outlets, leaking equipment and little-used outlets.
• Safe use of showers, baths, taps, hoses, cleaning equipment and assisted bathing equipment.
• Actions to take if an outlet or item of equipment is taken out of use.
• Scalding prevention and safe bathing procedures.
• Incident reporting, escalation and record-keeping requirements.

Staff with specific responsibilities for water temperature monitoring, flushing, cleaning showerheads, checking outlets, maintaining records or managing contractors must receive additional practical training and competency assessment.

The Responsible Person and deputy Responsible Person must have sufficient training, knowledge, authority and support to manage the Water Safety Plan and escalate concerns effectively.

Training records and competency assessments will be retained and reviewed through supervision, audit and governance processes.

12. Governance, Audit and Quality Assurance

{{org_field_name}} will maintain effective governance systems to ensure that Legionella and water safety risks are assessed, monitored and acted on.

The Registered Manager will ensure that:

• A current Legionella risk assessment is in place.
• A Water Safety Plan and written scheme of control are maintained.
• Water safety roles and responsibilities are documented.
• Monitoring schedules are completed.
• Missed checks, failed readings and defects are escalated and acted on.
• Contractor reports are reviewed and remedial actions are tracked to completion.
• Records are complete, accurate and available for inspection.
• Trends, incidents, concerns and audit findings are reviewed through governance meetings.
• Learning from incidents, near misses, audits and external inspections is used to improve safety.

Water safety audits will be completed at planned intervals and will include review of:

• Risk assessment status.
• Monitoring records.
• Flushing records.
• Showerhead cleaning and disinfection records.
• Thermostatic mixer valve servicing records.
• Tank inspection and cleaning records.
• Contractor reports.
• Outstanding remedial actions.
• Staff training and competency.
• Incidents, complaints, safeguarding concerns and Duty of Candour issues linked to water safety.

Any gap in compliance must result in a documented action plan with named responsibility, timescale, risk rating and completion evidence.

12.1 Records to be Kept

The following records will be retained and made available for inspection where required:

• Legionella risk assessments.
• Water Safety Plan and written scheme of control.
• Water system schematics.
• Responsible Person and deputy appointment records.
• Water temperature monitoring logs.
• Flushing records for little-used outlets.
• Showerhead and hose cleaning, descaling and disinfection records.
• Thermostatic mixer valve servicing and fail-safe test records.
• Cold water storage tank inspection and cleaning records.
• Calorifier inspection, maintenance and temperature records.
• Contractor reports, certificates and remedial action plans.
• Evidence of completed remedial works.
• Sampling and laboratory results, where sampling is undertaken.
• Staff training and competency records.
• Incident, investigation, notification and Duty of Candour records.
• Audit reports and governance meeting records relating to water safety.

Records must be accurate, legible, dated, signed or electronically attributable, and retained in line with the organisation’s records retention policy and legal requirements.

13. Legal and Regulatory References

This policy should be read alongside the following legislation and guidance:

• Health and Safety at Work etc. Act 1974.
• Control of Substances Hazardous to Health Regulations 2002.
• Management of Health and Safety at Work Regulations 1999.
• Health and Social Care Act 2008.
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
• Care Quality Commission (Registration) Regulations 2009.
• HSE ACOP L8: Legionnaires’ disease: The control of Legionella bacteria in water systems.
• HSE HSG274 Part 2: The control of Legionella bacteria in hot and cold water systems.
• CQC Regulation 12: Safe care and treatment.
• CQC Regulation 15: Premises and equipment.
• CQC Regulation 17: Good governance.
• CQC Regulation 18: Staffing.
• CQC Regulation 20: Duty of candour.
• UKHSA guidance on notifiable diseases and local Health Protection Team reporting.

14. Policy Review

This policy will be reviewed at least annually, or sooner where required. An earlier review will take place if:

• HSE, CQC, UKHSA, local authority or other statutory guidance changes.
• HSE ACOP L8 or HSG274 guidance is updated.
• The Legionella risk assessment is reviewed or identifies significant changes.
• There is a suspected or confirmed Legionella case, positive sample, outbreak or water safety incident.
• There are significant changes to the care home premises, water system, occupancy, resident vulnerability or service model.
• Monitoring, audit, contractor reports or incidents identify that current arrangements are not effective.
• Enforcement, inspection or safeguarding findings require changes.

The Registered Manager is responsible for ensuring that the policy remains current, implemented and understood by staff. Any changes will be communicated to relevant staff and contractors.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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