Legionella Risk Assessments for Care & Residential Homes, Dental and GP Practices

HSE ACOP L8 and Department of Health & Social Care HTM 04-01 Legionella Services

If you manage, run or own a health or care related site then you have a legal obligation under health & safety law and the Health & Social Care Act to have a valid and up to date Legionella Risk Assessment in place as well as carrying out other control & prevention measures.  In support of these legal requirements the HSE have issued the Approved Code of Practice for the Control of Legionella Bacteria in Water Systems commonly called "ACOP L8" and the Department of Health have also issued guidance in HTM 04-01 "Safe Water in Healthcare Premises" both of which states enhanced performance criteria for health & care sites such as increased hot water temperatures, more frequent monitoring and water testing.

A Legionella Risk Assessment is the first step to ensuring compliance with the HSE's ACOP L8 and the Department of Health's HTM 04-01.


In health & care sites Legionella Risk Assessments must be carried out to a very high standard and will almost certainly require specialist contractors. 


Not having an upto date risk assessment or failing to have one carried out competently could be seen by the courts as a breach of health & safety law.

Our risk assessors are certified by Trust Mark who work with Trading Standards.  Trust Mark is the only Government Endorsed Competent Person Scheme in the UK and operates under Government Licence from the Department of Business, Energy and Industrial Strategy so you can be assured of our competency.

Why choose Water Wise to carry out your Legionella Services?

  As well as being Trust Mark certified we are also City & Guilds accredited and certified by Stroma who are a Government approved provider of certification and training services.  Our team also includes City & Guilds and NVQ Level 2 & 3 qualified engineers.  Our services are designed to meet the requirements of the HSE's ACOP L8 for health & care sites and the Department of Health & Social Cares HTM 04-01.

Legionella Risk Assessments

UKAS Accredited Legionella Testing

CPD Accredited Training Courses

HSE Compliant Legionella Log Books

The Care Quality Commission

Have you been asked by a CQC inspector for a Legionella Test Certificate?  If so, they are not carrying out their inspection correctly.  CQC inspectors should ask to see your Legionella Risk Assessment and Legionella Log Book during every inspection.  This part of the inspection falls under "Infection Control".  It is the Legionella Risk Assessment which identifies what control and prevention measures are required for each site which includes if there is a need to carry out Legionella Testing.  And the Log Book demonstrates your compliance with the ACOP L8 and HTM 04-01.  A Legionella Test Certificate does not identify risks or demonstrate your compliance.  So why are CQC inspectors asking for a Legionella Test Certificate?  Basically because inspectors are not competent in dealing water hygiene issues.

The CQC are not only a regulator but following an agreement with the HSE they are also the lead investigatory body for Legionella failures in the health and care industry.  However, our experience shows that CQC inspectors are not competent to assess or support service providers in relation to Legionella or wider water hygiene issues and you can not rely on them to ensure your compliance.


In March 2019 following a death in a care home the Swindon & Wiltshire Coroner's office wrote to the CQC after identifying that inspectors are not sufficiently trained to deal with water hygiene and instructed the CQC to reply with a written response detailing how they will rectify the education & training of inspectors. 


The CQC replied to the coroners office stating that the training of inspectors will be improved and that the CQC inspect Legionella records during site visit.  However, this is not our experience and we regularly see instances where CQC inspectors have failed to identify compliance issues, have not inspected records, given the wrong advice to service providers and made the wrong recommendations.

Four Seasons fined £600,000 over legionnaires death.


“We accept that there were repeated failures to manage the implementation of procedures to safeguard people in the home, for which we sincerely apologise.  The home had engaged a specialist environmental services contactor to maintain the water systems and keep them free from bacteria, but we should have carried out checks to establish their level of technical expertise".

CQC Inspection slams Enham Trust Care Homes.


The CQC revealed low levels of legionella bacteria had been detected in the water system of Elizabeth House in late 2017 and actions had not been taken by February 2018 from the first assessment.  And inspectors discovered the service did not have “the right people, with the right qualifications and skills, in post to oversee this area of responsibility”.

BUPA fined £3,000,000 over legionnaires death & lack of training.


The court found those responsible had not been trained to the required standard.


Judge Emma Peters described that there were failings across the board from the care home operator and contractors.  In particular, she cited the lack of training and understanding regarding the control of legionella among the line manager and staff. 

Surgery facing closure after been rated inadequate.


A GP surgery in Forest Gate faces closure unless it improves the care offered to its patients within six months.  The most recent legionella risk assessment was dated May 2016, “staff told us every action to ensure patient safety had been taken but this was not the case and actions in response to a previous legionella risk assessment dated 2011 were insufficient.”

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