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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 ensure that {{org_field_name}} effectively manages the risk of Legionella bacteria in water systems, safeguarding the health and well-being of service users, staff, and visitors. This policy ensures compliance with the Health and Safety at Work Act 1974, the Control of Substances Hazardous to Health Regulations 2002 (COSHH), the Approved Code of Practice L8 (ACoP L8) – Legionnaires’ Disease: The Control of Legionella Bacteria in Water Systems, and the Regulation and Inspection of Social Care (Wales) Act 2016 (RISCA).

Legionnaires’ disease is a serious lung infection caused by inhaling water droplets containing Legionella bacteria, which thrive in stagnant or untreated water systems. This policy outlines our approach to identifying risks, controlling Legionella growth, and ensuring water safety in domiciliary care settings.

2. Scope

This policy applies to all employees, workers, managers and other persons engaged by {{org_field_name}} in the provision of domiciliary support services and to any premises or water systems which are owned, occupied, managed or controlled by {{org_field_name}}.

In relation to an individual’s own home, {{org_field_name}} will identify and manage risks arising from the provision of care and support so far as those risks fall within the organisation’s responsibilities and control. The fact that staff provide care in an individual’s home does not, by itself, make {{org_field_name}} responsible for the design, maintenance, testing or management of the domestic water system.

Where responsibility for the water system rests with another person, including a landlord, housing association, property manager or homeowner, {{org_field_name}} will report identified concerns promptly to the appropriate person and will take reasonable action within its own control to protect individuals and staff while the concern is being addressed.

This policy covers:

• identification and assessment of Legionella and water-safety risks relevant to the delivery of the service;
• action to reduce risks to individuals and staff so far as reasonably practicable;
• safe use of water and water-related equipment where this forms part of the care or support provided;
• reporting and escalation of concerns about domestic water systems;
• staff information, instruction and training appropriate to their role;
• recording, monitoring and review of identified risks and actions; and
• arrangements for responding to suspected or confirmed Legionella contamination, Legionnaires’ disease or an infectious disease outbreak.

Nothing in this policy transfers the statutory responsibilities of a landlord, homeowner, housing provider, property manager or other person who owns, manages or controls a water system to {{org_field_name}} unless {{org_field_name}} has itself assumed responsibility or control for that system.

3. Identifying and Assessing Legionella Risks

Legionella bacteria thrive in water systems that are:

• Stored or stagnant between 20°C and 45°C.
• Poorly maintained, with scale or biofilm buildup.
• Inefficiently used, such as unused taps or showers.

3.1 Legionella Risk Assessments

{{org_field_name}} will ensure that Legionella and water-safety risks which are relevant to the provision of its regulated service are identified, assessed and reduced so far as reasonably practicable.

Where {{org_field_name}} owns, manages or controls premises or a water system, a suitable and sufficient Legionella risk assessment will be undertaken by a person who is competent to assess the particular system. The assessment will be reviewed when there is reason to believe that it is no longer valid, following significant changes to the water system, use of the premises or population at risk, or where monitoring, an incident or other information indicates that a review is required.

For care provided in an individual’s own home, staff are not expected to undertake a technical Legionella assessment of the domestic water system unless this has been specifically arranged and the person undertaking the assessment is competent to do so.

The provider assessment, personal plan and associated risk assessments will, where relevant to the care being provided, consider factors including:

• known problems with hot or cold water supplies;
• prolonged non-use or stagnation of water;
• showers, spray-producing equipment or other water equipment used by staff as part of care delivery;
• information supplied by the individual, representative, landlord, housing provider or other responsible person about the safety of the water system;
• the individual’s susceptibility to infection, where this is relevant to the safe provision of care; and
• any visible or reported defect or condition which may indicate that the water system is unsafe.

Staff must report any water-safety concern without delay to the Registered Manager or other designated person. Where responsibility for the water system rests with a landlord, housing provider, homeowner or other third party, the concern will be referred promptly to that person.

Where a significant risk cannot be adequately controlled, {{org_field_name}} will consider whether care activities involving the affected water supply need to be temporarily changed or suspended and will liaise with the individual, their representative where appropriate, the service commissioner and relevant professionals to ensure that care can continue safely.

4. Controlling Legionella Risks in Domiciliary Care

4.1 Water Temperature Management

Where {{org_field_name}} owns, manages or controls a hot and cold water system, Legionella control measures will be based on a suitable risk assessment and current Health and Safety Executive guidance.

Where temperature is used as the principal means of controlling Legionella:

• hot water should normally be stored at not less than 60°C;
• hot water should normally achieve at least 50°C at appropriate outlets within one minute, subject to any necessary point-of-use scalding controls;
• cold water should normally be maintained below 20°C; and
• monitoring arrangements and frequencies will be determined by the Legionella risk assessment and applicable guidance.

These system-control temperatures must not be interpreted as requiring water presented directly to an individual for bathing, showering, washing or personal care to be at 50°C or above.

The risk of scalding must be assessed separately. Where an individual is at increased risk of scalding, suitable engineering controls, including appropriately installed and maintained thermostatic mixing valves where required, must be used by the person responsible for the water system to provide a safe point-of-use temperature while maintaining appropriate Legionella controls elsewhere in the system.

Care staff must not alter boiler, calorifier, thermostatic mixing valve or other water-system control settings unless this forms part of their authorised role and they have been assessed as competent to do so.

Any concern about unsafe water temperatures, failure of a thermostatic mixing valve or other water-system defect must be reported promptly to the Registered Manager and to the person responsible for the property or water system.

4.2 Flushing Infrequently Used Outlets

Where a Legionella risk assessment identifies infrequently used outlets as a risk and {{org_field_name}} is responsible for controlling the relevant water system, an appropriate flushing programme will be implemented in accordance with the risk assessment and current Health and Safety Executive guidance. Infrequently used outlets will normally be flushed at least weekly unless the risk assessment specifies a different control measure or frequency.

Flushing must be carried out in a way that minimises exposure to aerosols and splashing. Showerheads and other spray-producing outlets must not be directed towards a person during flushing.

In an individual’s own home, care staff will only undertake flushing where:

• the activity has been identified as necessary through an appropriate assessment;
• responsibility for the activity has been agreed with the individual and, where relevant, the landlord, housing provider, representative or service commissioner;
• the activity is recorded in the individual’s personal plan or other authorised care documentation;
• staff have received appropriate instruction and understand how to carry out the activity safely; and
• the activity can be undertaken without exposing the individual or member of staff to an avoidable risk.

Care staff must not assume responsibility for a landlord’s, homeowner’s or housing provider’s water-system maintenance programme merely because they provide care at the property.

Where required as part of the care arrangement, flushing activity and any identified concerns must be recorded in accordance with {{org_field_name}}’s record-keeping procedures.

4.3 Cleaning and Descaling Fixtures

Where {{org_field_name}} owns, manages or controls the relevant water system, showerheads, hoses and other outlets liable to accumulate scale, sediment or biofilm will be inspected, cleaned and descaled at a frequency identified by the Legionella risk assessment and current Health and Safety Executive guidance. Where appropriate, this will normally include quarterly cleaning and descaling of showerheads and associated hoses, unless the risk assessment requires a different frequency.

In an individual’s own home, responsibility for maintenance and descaling of the domestic water system and its fixtures normally remains with the homeowner, landlord, housing provider or other person responsible for the property.

Care staff may assist with cleaning an outlet only where this is an agreed part of the individual’s care and support, has been appropriately risk assessed and can be carried out safely within the staff member’s role and competence.

Staff must report significant scale, contamination, defective showerheads or hoses, unusual discolouration, persistent water-quality concerns or other relevant defects to the Registered Manager so that the concern can be referred to the person responsible for the water system.

4.4 Safe Use of Water Equipment

• Hosepipes, whirlpool baths, and humidifiers should be cleaned regularly, and stagnant water must be drained after use.
• Staff must report any faulty plumbing, leaks, or signs of contamination immediately to the Registered Manager.

5. Managing Legionella Risks in Rented Properties

Where an individual receives domiciliary care in rented accommodation, responsibility for assessing and controlling Legionella risks within the property’s water system will normally rest with the landlord or other person who has responsibility for or control of the premises and water system.

{{org_field_name}} will not require an annual Legionella risk assessment or an annual Legionella certificate as a routine condition of providing domiciliary care, because health and safety legislation does not prescribe an annual or biennial Legionella risk assessment for domestic rented accommodation.

Where a water-safety concern relevant to the individual’s care is identified, {{org_field_name}} will:

• record the concern and any immediate action taken;
• inform the individual and, where appropriate, their representative;
• promptly notify the landlord, housing association, property manager or other person responsible for the property;
• take reasonable interim measures within the provider’s control to protect the individual and staff;
• review the individual’s relevant risk assessment and personal plan where the concern affects the way care and support can safely be delivered;
• inform the service commissioner or other relevant professional where the concern materially affects the individual’s care and support; and
• escalate unresolved concerns to the appropriate statutory or enforcement body where this is necessary to protect the individual or staff.

A landlord’s Legionella risk assessment should be reviewed when appropriate, including where there is reason to believe that the existing assessment is no longer valid or where there has been a relevant change to the water system, occupation or level of risk.

Where the individual owns their home, {{org_field_name}} will explain any identified concern to the individual or their representative and advise them to obtain appropriate advice or arrange inspection and remedial work by a competent person where required.

Where an unresolved water-safety risk prevents {{org_field_name}} from safely carrying out part of the agreed care, the Registered Manager will liaise with the individual, representative where appropriate, service commissioner and relevant professionals to agree alternative arrangements and ensure that essential care and support are not withdrawn without appropriate planning.

6. Staff Responsibilities and Training

All care staff, managers, and maintenance personnel are trained to:

• Recognise Legionella risks and symptoms of Legionnaires’ disease.
• Follow proper flushing, cleaning, and temperature control measures.
• Report any concerns related to water hygiene, including poor water pressure, discoloured water, or unusual odours.

Training is provided during induction and annual refresher courses, ensuring compliance with CIW and health and safety regulations.

7. Responding to Suspected or Confirmed Legionella Contamination or Legionnaires’ Disease

Where suspected or confirmed Legionella contamination presents a risk to an individual or member of staff, {{org_field_name}} will take immediate and proportionate action to protect those affected.

The Registered Manager or designated senior person will:

1. identify which care activities, outlets or equipment may be affected and prevent their use where continued use may present an unacceptable risk;
2. put appropriate alternative arrangements in place for essential care and support;
3. inform the individual and, where appropriate, their representative of the concern and the precautions being taken;
4. notify the person responsible for the water system, such as the landlord, housing provider, homeowner or property manager, without delay;
5. seek advice from an appropriately competent water-safety professional and/or the relevant public health or health protection service where required;
6. ensure that sampling, disinfection, remedial work or recommissioning of the affected water system is undertaken only by appropriately competent persons where such action is required;
7. review relevant risk assessments and the individual’s personal plan and record all decisions, actions and advice received; and
8. ensure that an affected water source or item of equipment is not returned to normal use until the person responsible for the water system has confirmed that it can be used safely.

CIW Notification

Where there is an outbreak of an infectious disease affecting the regulated service, {{org_field_name}} must notify Care Inspectorate Wales in accordance with Regulation 60 and Schedule 3 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

The notification must be made without delay, in writing and using the method required by CIW. In practice, notifications should normally be submitted through CIW Online as soon as possible and usually within 24 hours of the event.

A positive environmental Legionella result, in the absence of an outbreak, is not automatically an infectious-disease-outbreak notification. However, a notification to CIW must also be considered where the incident prevents, or could prevent, {{org_field_name}} from continuing to provide the regulated service safely or where another notification requirement under Regulation 60 and Schedule 3 applies.

The Registered Manager must ensure that the Responsible Individual is informed of any significant Legionella incident and that responsibility for making the required CIW notification is clearly allocated and recorded.

RIDDOR

Where an employee or other worker is diagnosed with disease and there is reasonable evidence that occupational exposure to Legionella or another biological agent was the likely cause, the responsible person must consider and, where the legal criteria are met, make a report under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013.

Illness in an Individual or Member of Staff

Legionnaires’ disease requires medical assessment and treatment. Where an individual or member of staff develops symptoms which may be consistent with Legionnaires’ disease and there is known or suspected exposure to Legionella, urgent medical advice must be sought and the healthcare professional must be informed of the possible exposure.

Emergency assistance must be requested through 999 where the person’s condition is immediately life-threatening, including severe breathing difficulty, collapse or another medical emergency. In other circumstances, appropriate urgent medical advice must be obtained through the person’s GP, NHS 111 Wales or other appropriate healthcare service.

Staff must not attempt to diagnose Legionnaires’ disease.

8. Monitoring and Compliance

{{org_field_name}} will maintain effective arrangements for monitoring compliance with this policy and for identifying, reviewing and reducing water-safety risks relevant to the regulated service.

The Registered Manager will ensure that:

• service-level and individual risk assessments identify relevant water-safety hazards where these may affect the delivery of care and support;
• actions required to address identified risks are allocated, recorded and followed through;
• staff report water-safety concerns promptly and those concerns are escalated to the person or organisation responsible for the water system where the system is not controlled by {{org_field_name}};
• records are maintained of water-safety checks, flushing or other control measures undertaken by staff where these activities form part of {{org_field_name}}’s agreed responsibilities;
• relevant information, reports or confirmations received from landlords, housing providers, competent contractors or other water-system dutyholders are retained where they are necessary to demonstrate how an identified risk has been managed;
• incidents and outbreaks are reviewed to identify learning and any required improvement;
• required notifications to CIW and other statutory bodies are made in accordance with applicable legal requirements;
• staff training, instruction and competency are reviewed where staff have duties under this policy; and
• identified improvements are implemented according to the level of risk.

{{org_field_name}} will not represent itself as having inspected, maintained, tested or certified a service user’s domestic water system unless it has actually undertaken or commissioned that activity and has responsibility for doing so.

Where {{org_field_name}} owns, manages or controls a water system, appropriate Legionella risk assessments, control measures, monitoring and records will be maintained in accordance with applicable health and safety legislation, the Approved Code of Practice L8 and relevant Health and Safety Executive technical guidance.

The Registered Manager will include significant findings, incidents, trends and unresolved risks within the organisation’s governance and quality assurance arrangements and will escalate matters to the Responsible Individual where appropriate.

This policy will be reviewed at least annually and sooner where there is a relevant change in legislation, statutory guidance, CIW requirements, Health and Safety Executive guidance, the nature of the service or following a significant water-safety incident.

9. Related Policies

This policy should be read alongside:

• Health and Safety at Work Policy (DCW16).
• Infection Prevention and Control Policy (DCW17).
• Risk Management and Assessment Policy (DCW18).
• Safe Care and Treatment Policy (DCW11).
• Emergency and Business Continuity Plan (DCW19).

10. Policy Review

This policy will be reviewed annually or sooner if legislation, CIW regulations, or best practices change. Updates will be communicated to all staff.

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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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