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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 {{org_field_name}}’s approach to preventing and controlling the risk of exposure to Legionella bacteria and ensuring water safety in all care environments we manage or operate in. Legionella is a potentially fatal form of pneumonia caused by inhaling small droplets of water contaminated with the bacteria. This policy complies with the Health and Safety at Work Act 1974, the Control of Substances Hazardous to Health (COSHH) Regulations 2002, and is consistent with the HSE’s Approved Code of Practice (ACOP) L8 and HSG274 guidance. It also supports CQC Regulation 15 (Premises and Equipment) and Regulation 12 (Safe Care and Treatment) to ensure that water systems are maintained safely and do not pose a health risk to the people we support, staff, or visitors.

2. Scope

This policy applies to all properties and service environments where {{org_field_name}} has a responsibility for water safety. This includes supported living environments, communal housing managed by the organisation, and any water systems directly used in the provision of regulated activities. It applies to all employees, contractors, maintenance staff, care workers, and managers who have a role in ensuring water systems are maintained and monitored safely. The policy also informs individuals working in the homes of people we support, particularly those who are vulnerable to infection due to age, illness, or reduced immunity.

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

4. Understanding Legionella Risks

Legionella bacteria are commonly found in natural water sources such as rivers and lakes but become a health risk when they multiply in man-made water systems including storage tanks, pipework, showerheads, and taps. Risk factors include water temperatures between 20–45°C, stagnant water, scale, sludge, or rust that support bacterial growth. People over 45, those with chronic respiratory or kidney disease, smokers, and those with weakened immune systems are most at risk. The primary risk of exposure in care settings is from aerosolised water droplets such as those from showers, taps, and humidifiers.

5. Roles and Responsibilities

The Registered Manager {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}} holds overall responsibility for ensuring compliance with Legionella prevention. A competent person or external contractor is appointed to act as the ‘Responsible Person’ for water safety. Their responsibilities include:

• Conducting Legionella risk assessments for all premises under our control
• Developing and maintaining a Water Safety Plan
• Implementing and monitoring control measures
• Ensuring remedial works are undertaken where risks are identified
• Maintaining accurate records of all checks, tests, and maintenance activities
  All staff have a duty to report concerns relating to water safety and must follow safe practices when using taps, showers, and cleaning equipment.

6. Legionella Risk Assessments

A comprehensive Legionella risk assessment is carried out every two years or sooner if:

• The water system changes
• There is evidence of water stagnation or contamination
• A person using the service is diagnosed with Legionnaires’ disease
  Assessments are conducted by a competent person and include:
• Identification of all water outlets and storage areas
• Temperature testing of hot and cold water
• Evaluation of water system design and condition
• Identification of potential sources of aerosol release
• Recommendations for control and maintenance
  Findings are documented, and the Water Safety Plan is updated accordingly.

7. Control Measures and Maintenance

To prevent Legionella growth, the following control measures are implemented:

• Hot water is stored at 60°C and distributed at 50°C or higher
• Cold water is maintained below 20°C
• Little-used outlets are flushed weekly
• Showerheads and hoses are cleaned and disinfected every 3 months
• Water tanks are inspected annually and cleaned as necessary
• Thermostatic mixer valves (TMVs) are serviced in line with manufacturer guidelines
• Dead legs or redundant pipework are removed promptly
  All water temperatures are recorded regularly using calibrated thermometers, and monitoring logs are maintained by the Responsible Person.

8. Contractor and Third-Party Management

Where external contractors are used for maintenance, risk assessments, or water testing, they must provide evidence of qualifications and follow HSE-approved practices. Contracts must include responsibilities for Legionella prevention, response times for faults, and reporting procedures. Work permits and risk assessments are required for any plumbing or water system modifications. Contractors must report any identified risks or defects immediately to the Registered Manager.

9. Water Safety in Service Users’ Homes

While {{org_field_name}} does not have direct control over private homes, staff must still remain alert to signs of water safety risks such as:

• Faulty or old showers and taps
• Infrequently used water outlets
• Water that is slow to heat or has a noticeable odour
  Where concerns arise, staff must inform the individual, family, landlord, or housing support provider and record the concern in the individual’s care plan. Staff may advise flushing of outlets and encourage good hygiene practices but must not undertake plumbing or maintenance unless trained and authorised.

10. Responding to a Legionella Incident

In the event of a suspected or confirmed Legionella case, the following actions must be taken:

• Immediate isolation of the suspected source (e.g., shower or water outlet)
• Notification to the local Health Protection Team {{org_field_outbreaks_support_local_health_protection_team_website}}
• Informing the Care Quality Commission (CQC) under Regulation 18 – Notification of Other Incidents
• Full investigation and review of the water system and risk assessment
• Communication with affected individuals, families, and staff in line with CH35 – Duty of Candour Policy
• Completion of any remedial work and retesting of water systems
  Records of the incident and all remedial actions are stored securely and used to inform future prevention strategies.

11. Training and Awareness

All relevant staff receive basic Legionella awareness training during induction and refresher training annually. This includes:

• Understanding Legionella and its risks
• How to report concerns about water safety
• Safe practices when cleaning, using water equipment, or assisting with bathing
  Staff involved in maintenance or facilities management receive specific training in water testing, temperature recording, and implementing control measures. Records of training are maintained within the staff training matrix and reviewed in supervisions.

12. Efficient Management at {{org_field_name}}

We ensure effective Legionella and water safety management through:

• Up-to-date Water Safety Plans reviewed annually
• Appointed Responsible Persons and external competent contractors
• Digital systems to log and monitor water testing results
• Centralised maintenance schedules and reminders
• Continuous monitoring and quick escalation of any deviations
  This structured approach supports compliance, reduces risk, and ensures a safe water supply for the people we support and our staff.

13. Policy Review

This policy will be reviewed annually, or sooner if guidance from the HSE or CQC changes, following a Legionella incident, or after significant changes to water systems. The Registered Manager is responsible for ensuring that the policy is kept up to date and that all staff are informed of its requirements and procedures.

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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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