CHW163-Legionella Prevention and Water Safety Policy
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Registration Number: {{org_field_registration_no}}
Legionella Prevention and Water Safety Policy
1. Purpose
The purpose of this policy is to outline the procedures and controls implemented by {{org_field_name}} to prevent the risk of Legionella bacteria and ensure safe water systems across the premises. This policy is written in accordance with the Health and Safety at Work etc. Act 1974, Control of Substances Hazardous to Health (COSHH) Regulations 2002, the HSE Approved Code of Practice L8 (“Legionnaires’ disease: The control of Legionella bacteria in water systems”), and the Regulation and Inspection of Social Care (Wales) Act 2016. As a regulated care home, {{org_field_name}} has a duty of care to protect the health and safety of residents, staff, visitors, and contractors by maintaining clean and safe water systems that prevent the growth and spread of Legionella.
2. Scope
This policy applies to all staff, external contractors, and maintenance personnel who work with or manage the water systems, fixtures, and equipment at {{org_field_name}}. It applies to all areas of the premises where hot or cold water is stored, distributed, or used, including but not limited to taps, showers, sinks, storage tanks, toilets, spa baths, laundry rooms, kitchens, and garden irrigation systems. It also covers associated infrastructure such as pipework, thermostatic mixing valves (TMVs), and water heaters.
3. Related Policies
This policy should be read in conjunction with the following:
- CHW11 – Safe Care and Treatment Policy
- CHW16 – Health and Safety at Work Policy
- CHW17 – Infection Prevention and Control Policy
- CHW18 – Risk Management and Assessment Policy
- CHW19 – Emergency and Business Continuity Plan
- CHW24 – Management of Accidents, Incidents and Near Misses Policy
- CHW25 – Notification of Other Incidents Policy
4. Policy Statement and Implementation
A. Responsibilities and Competent Persons
The Registered Manager has overall accountability for water safety and Legionella prevention at {{org_field_name}}. A designated Responsible Person is appointed to oversee the management, monitoring, and documentation of the water safety system. Where appropriate, a competent external specialist (Legionella Risk Assessor or Water Hygiene Contractor) is engaged to provide technical advice, conduct risk assessments, and carry out monitoring and remedial actions. All staff are made aware of who the Responsible Person is, and how to report any concerns relating to water safety or hygiene.
B. Legionella Risk Assessment
A comprehensive Legionella risk assessment is undertaken at least every two years or sooner if there are significant changes to the water system, the building use, or following an incident. This assessment is carried out by a qualified and competent assessor in line with HSE ACOP L8 guidance. The assessment identifies areas of potential risk, such as dead legs in pipework, low usage outlets, storage tanks, and areas where water temperatures could support Legionella growth. A written scheme of control is developed from the assessment findings and is regularly reviewed by the Responsible Person to ensure it remains up to date.
C. Water Temperature Monitoring and Controls
Water temperature is a key control measure in preventing Legionella. Hot water must be stored at a minimum of 60°C and distributed to outlets at no less than 50°C. Cold water must be maintained below 20°C. Thermostatic Mixing Valves (TMVs) are installed at outlets used by vulnerable individuals to prevent scalding while maintaining safe storage and distribution temperatures. Weekly temperature checks are carried out at sentinel points (the furthest and nearest outlets on each system) and results are recorded in the Water Safety Logbook. Any abnormal readings are reported immediately to the Responsible Person and appropriate corrective action is taken.
D. Flushing of Infrequently Used Outlets
All outlets that are infrequently used (e.g. spare bedrooms, disused toilets or taps) are flushed through weekly for at least two minutes to prevent stagnation. A flushing log is maintained and monitored. Any outlet unused for more than one week is treated as infrequently used and added to the flushing schedule.
E. Cleaning and Descaling of Showerheads and Taps
All showerheads, hoses, and removable tap parts are cleaned, descaled, and disinfected at least quarterly. This task is carried out by the maintenance team or trained staff, following a documented procedure and using appropriate cleaning agents. Disposable gloves and aprons are worn during the process to prevent cross-contamination. Cleaning dates are logged and verified by the Responsible Person.
F. Cold Water Storage and Hot Water Systems Maintenance
Cold water storage tanks and calorifiers are inspected annually to ensure they are clean, appropriately sealed, and structurally sound. Water samples may be taken and tested by external contractors where required. Hot water systems are maintained and serviced in line with manufacturers’ instructions and relevant legislation. This includes routine checks on expansion vessels, immersion heaters, and boiler systems.
G. Control of Contractors and Hot Work
All external contractors working on water systems are vetted to ensure they are competent, qualified, and aware of their responsibilities regarding water safety and Legionella control. Contractors must follow site-specific water hygiene protocols and provide risk assessments and method statements prior to commencing work. Any “hot work” involving alterations to the water system is authorised and monitored by the Responsible Person, with post-work flushing and disinfection undertaken where necessary.
H. Water Outbreak Response and Incident Reporting
In the event of a suspected Legionella case or water safety incident, the Responsible Person will immediately isolate affected areas, notify the Registered Manager and Public Health authorities, and implement the outbreak response plan. This includes undertaking water sampling, communicating with CIW if required, and coordinating any emergency disinfection or engineering work. Incidents are recorded and investigated thoroughly, with lessons learned incorporated into future prevention strategies. All incidents are reported in line with CHW24 and CHW25.
I. Staff Training and Awareness
All staff receive induction and refresher training on the importance of water safety, personal hygiene, and their role in preventing Legionella. Staff involved in water monitoring or maintenance receive enhanced training appropriate to their responsibilities. Awareness materials are displayed in staff areas, and the importance of reporting discoloured water, low pressure, or unusual odours is reinforced regularly.
J. Documentation, Monitoring, and Audit
A Water Safety Logbook is maintained on site and includes:
- Legionella Risk Assessments
- Water outlet flushing records
- Temperature monitoring records
- Showerhead cleaning logs
- System maintenance and servicing records
- Contractor certifications and work reports
- Training records and policy reviews
Regular audits are carried out by the Responsible Person to ensure compliance, and findings are shared during health and safety reviews. The Registered Manager oversees the governance of water safety and ensures that remedial actions are completed and documented.
5. Policy Review
This policy is reviewed annually or earlier if there are changes in legislation, CIW guidance, or following a significant water safety incident. The Registered Manager and Responsible Person for Water Safety are jointly responsible for ensuring that the policy remains accurate and effective.
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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