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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 outline our domiciliary care organisation’s approach to Legionella prevention and water safety management, ensuring the protection of service users, staff, and visitors from Legionnaires’ disease and other waterborne illnesses. Legionella bacteria thrive in water systems, and effective management is crucial to maintaining a safe and compliant environment in line with Health and Safety Executive (HSE) guidelines and Care Quality Commission (CQC) requirements.

This policy establishes protocols for risk assessment, monitoring, maintenance, staff training, and incident response to mitigate the risks associated with Legionella contamination.

2. Scope

This policy applies to:

• Service users and their homes, where water systems may pose a risk.
• All employees, including care workers, office staff, and management.
• Third-party contractors, including plumbers, water treatment specialists, and facility managers.
• Local health authorities and regulatory bodies involved in Legionella risk management.

It covers:

• Legal and regulatory requirements.
• Risk assessments and monitoring procedures.
• Water system management and maintenance.
• Staff training and responsibilities.
• Emergency procedures and incident reporting.
• Compliance monitoring and continuous improvement.

In most cases, {{org_field_name}} does not own or control the service user’s water system. Our responsibilities are therefore to:

• identify and respond to risks created by our care activities (for example, where we run water, assist with bathing/showering, or use water-related equipment during visits);
• complete and document reasonable checks and provide information/advice to service users/families;
• escalate concerns promptly to the person who controls the premises (homeowner, landlord, housing provider, or managing agent) and to relevant professionals/agencies where required; and
• ensure that any premises we control (e.g., our office and any sites under our management) have suitable legionella controls in place.
  This approach supports safe care and treatment and meets our duty to make every effort to ensure environments/equipment used in care are safe and suitable.

3. Legal and Regulatory Framework

This policy aligns with the following legislation and guidance (as amended):

• Health and Safety at Work etc. Act 1974 – duty to protect employees and others affected by our work activities.
• Management of Health and Safety at Work Regulations 1999 – risk assessment and preventive/protective measures.
• Control of Substances Hazardous to Health (COSHH) Regulations 2002 – control of biological agents including Legionella.
• HSE Approved Code of Practice (ACOP) L8 (4th edition, 2013) – Legionnaires’ disease: The control of legionella bacteria in water systems.
• HSE HSG274 (2nd edition, published March 2024) – technical guidance for risk systems including hot and cold water systems.
• Water Supply (Water Fittings) Regulations 1999 – requirements for water fittings and backflow prevention.
• Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013 – reporting cases of legionellosis where linked to workplace exposure.
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (CQC Fundamental Standards), including:
  • Regulation 12 (Safe care and treatment) – assess risks and prevent avoidable harm.
  • Regulation 15 (Premises and equipment) – ensure equipment/premises used in care are safe; where the person’s own accommodation/equipment is used, the provider must make every effort to ensure it is clean/safe/suitable.
  • Regulation 17 (Good governance) – effective systems, audits, and accurate records.
• UK Health Security Agency (UKHSA) / local Health Protection Teams – public health notification and management of cases/clusters/outbreaks.

4. Risk Assessments and Monitoring Procedures

{{org_field_name}} will take a risk-based approach that reflects what we control and what we can reasonably influence in a person’s own home. We will:

4.1 Organisational premises under our control

• Ensure a suitable and sufficient legionella risk assessment is completed by a competent person for any premises and water systems we control (e.g., office).
• Maintain a written control scheme (see Section X “Written Scheme & Records”).

4.2 Service users’ homes (where we do not control the system)

• During assessment/initial visits, care staff will complete a Legionella & Water Safety screening check (visual/observational) for risk indicators relevant to our care delivery, such as: infrequently used outlets, signs of long-term stagnation, poor hot water delivery, persistent low hot water temperature, dirty/descaled showerheads, or vulnerable risk factors (e.g., immunosuppression).
• Where indicators are identified, we will record the concern, inform the service user/representative, and escalate to the person in control of the premises (landlord/housing provider/managing agent/homeowner) requesting review/repairs/risk assessment as appropriate.

4.3 Temperature control (where checks are within our role)

Where we are asked/authorised to check temperatures (or where our care plan requires it due to risk), we will use the following HSE/HSG274-aligned indicators:

• Hot water should reach at least 50°C at the outlet within 1 minute (unless thermostatic mixing controls are fitted at the outlet).
• Cold water should be below 20°C within 2 minutes.
• Where storage temperatures are within the provider/landlord’s control, hot water storage should typically be 60°C or higher and distributed to achieve safe outlet temperatures (with anti-scald controls where needed).

4.4 Flushing and outlet hygiene

• If the care plan includes flushing of little-used outlets, it will specify frequency (normally weekly) and safe method (to minimise aerosol).
• Showerheads/tap aerators will be cleaned/descaled on a risk-based schedule or in line with the household/provider’s arrangements, and care staff will record when tasks are completed.

4.5 Water sampling

Water sampling/testing will be used only where indicated (for example, following repeated control failures, credible risk indicators, or after a suspected case/outbreak), and will be arranged through competent contractors and/or the dutyholder for the premises

5. Water System Management and Maintenance

To maintain a safe water supply, we implement the following management procedures:

Plumbing System Inspections:

• All plumbing systems in service users’ homes are inspected periodically.
• Any dead legs or redundant pipework that could harbor Legionella bacteria are removed.
• Premises under our control:

• {{org_field_name}} will arrange periodic inspection/servicing through competent contractors in line with the legionella risk assessment and HSE guidance (ACOP L8 / HSG274).
• Service users’ homes (premises not under our control):

• {{org_field_name}} does not routinely inspect or alter domestic plumbing systems. Where concerns are identified, we will document them and escalate to the homeowner/landlord/housing provider/managing agent, and follow up to confirm actions taken where this affects safe delivery of care.
• We will not remove/alter pipework (e.g., dead legs) unless the organisation is the dutyholder for that system or we have explicit written agreement and competent contractor arrangements in place.
• Thermostatic mixing valves (TMVs) and scald prevention:
• Where TMVs are present and relevant to care delivery, we will record any signs of malfunction (e.g., unstable temperatures) and escalate promptly to the dutyholder/landlord for inspection/maintenance.

Preventative Maintenance:

• Routine servicing of water heaters, thermostatic mixing valves (TMVs), and storage tanks.
• Ensuring all pipework is insulated to prevent temperature fluctuations.

Emergency Water System Checks:

• If a service user reports discolored or stagnant water, an immediate site assessment is conducted.
• Water system disinfection procedures are activated if contamination is suspected.

6. Staff Training and Responsibilities

All employees involved in care delivery and maintenance receive mandatory Legionella awareness training.

Training includes:

• Identifying Legionella risk factors in domiciliary care settings.
• Procedures for water system flushing and monitoring.
• Incident reporting protocols in case of suspected contamination.
• Safe handling and storage of cleaning and disinfecting agents.

Training frequency and competence:

• Legionella awareness training will be completed at induction and refreshed at least annually (or sooner if guidance changes or incidents occur).
• Staff assigned tasks such as flushing, outlet cleaning, or temperature checks must be assessed as competent for those tasks and must follow the individual’s care plan and risk assessment.
• Training, competency sign-off and refresher dates will be recorded and audited as part of governance arrangements.

Roles and Responsibilities:

• Registered Manager:
  • Ensures that legionella risks are assessed and controlled for premises/systems under {{org_field_name}}’s control, and that effective arrangements are in place for risk identification, escalation, record keeping and follow-up in service users’ homes where we do not control the water system.
  • Oversees emergency response planning for Legionella outbreaks.
• Care Workers:
  • Monitor and report unusual water temperatures, stagnant water, or odor issues.
  • Educate service users on safe water usage and hygiene practices.
• Office Staff:
  • Document all maintenance activities and report compliance issues.

7. Emergency Procedures and Incident Reporting

In the event of a suspected or confirmed Legionella outbreak, our response includes:

• Immediate Reporting:
  • Any suspected Legionella contamination must be reported to the Registered Manager.
  • If required, escalate concerns to the UK Health Security Agency (UKHSA) / local Health Protection Team and cooperate with any public health investigation and control measures.
• Containment Measures:
  • Affected water systems are isolated to prevent further exposure.
  • Emergency water sampling and testing are conducted.
  • Service users in high-risk areas are provided with alternative safe water sources.
• Disinfection and Remediation:
  • Affected water systems undergo chemical treatment (e.g., chlorine shock treatment).
  • Maintenance teams carry out deep cleaning and pipe flushing.
  • Water temperature settings are reviewed and adjusted for optimal safety.
• Follow-up Monitoring:
  • Post-treatment water testing is conducted to confirm contamination has been eradicated.
  • Service users and staff are updated on safety measures and preventive actions.

Regulatory reporting/notifications:

• RIDDOR: Where an employee is diagnosed with legionellosis and there is reasonable evidence of occupational exposure relevant to our work activities, {{org_field_name}} will make a RIDDOR report to the enforcing authority.
• CQC statutory notifications: {{org_field_name}} will submit CQC statutory notifications when required (for example, where an incident results in a notifiable death/serious injury or other notifiable event connected to the regulated activity), in line with CQC notifications guidance.

8. Written Scheme of Control and Record Keeping

{{org_field_name}} will maintain a Written Scheme of Control proportionate to the systems we control and the tasks we deliver in service users’ homes. Records will be retained securely and be available for inspection.

8.1 Records for premises under our control (e.g., office)

• Legionella risk assessment(s) and review dates.
• Water system schematic/asset register (where applicable).
• Control measures and monitoring schedules (temperature checks, flushing regimes where relevant).
• Maintenance/service certificates (e.g., water heaters, TMVs where applicable).
• Any corrective actions and verification of completion.

8.2 Records for service users’ homes (where relevant to care delivery)

• Legionella/water safety screening checks completed as part of assessment/visit where applicable.
• Care plan tasks undertaken (e.g., flushing, outlet cleaning) including dates and staff initials.
• Escalations made to landlords/housing providers/homeowners and follow-up outcomes.

8.3 Audit and review

These records form part of {{org_field_name}}’s governance and audit programme to ensure risks are identified, escalated and managed without delay.

9. Compliance Monitoring and Continuous Improvement

To ensure ongoing compliance with water safety standards, {{org_field_name}}:

• Conducts quarterly audits of Legionella risk assessments.
• Reviews staff compliance with temperature checks and flushing routines.
• Collaborates with local health authorities to stay updated on best practices.
• Ensures service user feedback is incorporated into risk assessments and water safety measures.

Findings from audits (including legionella screening, escalations, and completion of care-plan water safety tasks) will be reviewed through our governance systems to ensure we assess/monitor/improve safety and maintain accurate, complete records.

 

10. Policy Review and Updates

This policy is reviewed annually or sooner if:

Feedback from audits or service users suggests improvements are required.

New or updated guidance is issued by the HSE (including updates to ACOP L8 / HSG274), UKHSA, or the CQC;

An incident occurs that necessitates changes to prevention protocols;

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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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