Legionella Services for health & care sites meeting the ACOP L8 & HTM 04-01

If you manage, run or own a health or care related site then you have a legal obligation under health & safety law and regulation 12 of 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 an Approved Code of Practice for the Control of Legionella Bacteria commonly called ACOP L8 which gives guidance on how to comply with the law in relation to Legionella.  The ACOP L8 and supporting technical guidance HSG 274 state enhanced performance criteria for health & care sites.  The enhanced criteria are in proportion to the increased risk of Legionella infection that can be found at these sites.  The Department of Health have also issued guidance in HTM 04-01 "Safe Water in Health Care Premises".  This guidance document is often referred to as NHS Estates Guidance, it is a legal requirement for health & care sites and expands on the increased performance criteria of the ACOP L8.

A Legionella Risk Assessment is the first step to ensuring compliance with the HSE's ACOP L8 and is a legal requirement under health & safety law.  Risk assessments need to be carried out by someone who is competent to determine the possible risk from Legionella bacteria.  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.


Simply not having a risk assessment or failing to have one carried out competently could be seen by the courts as a breach of health & safety law.  And, because of the increased risk and enhanced performance criteria required in health and care sites you will almost certainly need to use a specialist contractor like Water Wise.  A risk assessment is only valid for up to 2 years which is the maximum allowed by the ACOP L8, after 2 years a new assessment needs to be carried out.  During the 2 year period the assessment needs to be regularly reviewed along with the control & prevention measures to ensure the assessment is still up to date and the measures are being effective.  For that reason, our risk assessments come with a built-in review log and document control clearly stating the assessment date, when the assessment expires and how long the assessment needs to be retained for to meet the requirements of the ACOP L8.  Based on the recommendations of the risk assessment control and prevention measures then need to be implemented.

Why choose Water Wise to carry out your Legionella Services?

As well as being Trust Mark certified our risk assessors are also City & Guilds qualified and certified by Stroma.  Stroma is a Government approved provider of certification and training services for assessors and one of the UK's foremost certification bodies.


Our service team also includes City & Guilds and NVQ Level 2 & 3 qualified plumbers who hold accreditation or membership with the CIPHE, Water Management Society, Engineering Council, Water Safe Registered (a requirement of NHS Estates) and are Water Industry Approved holding "Approved Contractor" status under the Water Supply (Water Fittings) Regulations 1999.


Our risk assessments are designed to be straight forward and easy to understand.  We don't just give you an overall risk score for the site, we assess each item individually so you can see where any risk is coming from.  Unlike many of our competitors we recommend site specific control & prevention measures as required by section 28 of the ACOP L8 and do not just include a general table of measures and frequencies.  We can also carry out the required control and prevention measures and record keeping.  Our remote and wireless temperature monitoring system is also particularly effective in health & care environments.


"The service you have provided has been more usful than the previous "in-depth" survey provided 2 years ago that was confusing and as such did not focus on the practical improvements we could and should make.  Your report has allowed us a much better understanding and from this we will make the improvements you have suggested" - West Hallam Medical Centre

Legionella and the Care Quality Commission


Legionella assessment, control and prevention is a specialist area of work and you cannot rely on the CQC to ensure your compliance.  In March 2019 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.  As a result, service providers can expect a much more in-depth and robust CQC inspection of water hygiene issues. 


However, that does not mean the CQC will get it right, we still see cases where CQC inspectors are misinterpreting the requirements of the ACOP L8 and HTM 04-01, failing to identify risks and giving providers poor ratings because of the inspectors lack of competence.  The lack of competence can also increase costs for providers who in an effort to achieve CQC ratings carry out work based on the recommendations of inspectors which is not required, can be ineffective, increase the risk or even be against the official guidance.


We have even seen cases where CQC inspectors have fabricated information in their reports or failed to identify the risks altogether.  It is important to remember that it is you who will fined or prosecuted for Legionella failures and not the CQC regardless of what they have written in their reports.  There have been several cases where people have fallen ill or even died as a result of Legionella failures that have led to services providers been fined or prosecuted.  In a number of these cases the CQC inspection prior to the outbreak rated the service provider as good or outstanding under safe but after the outbreak the service provider is rated as requires improvement or inadequate despite doing nothing different.  In nearly all prosecution cases it was found that those involved were not suitably trained or competent.

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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