Legionella in Health & Care

in line with the HSE Approved Code of Practice ACOP L8

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If you manage, run or own a healthcare or care related premises then you have a legal obligation under Health & Safety Law & Regulation 12 of the Health & Social Care Act 2008 to have a valid and upto date Legionella Risk Assessment in place as well as carrying out other control and prevention measures.  


There are many myths and rumours about Legionella in the healthcare or care environment, most are due to a misunderstanding of the requirements of the ACOP L8, some of the confusion is even caused by the regulators themselves such as the CQC.


The HSE have issued an Approved Code of Practice for the Control of Legionella Bacteria commonly called ACOP L8, this is in effect a legal document.  The ACOP L8 gives guidance on how to comply with the law in relation to Legionella, it states increased performance criteria for care and residential homes and properties such as doctors and dental surgeries.  The increased performance criteria is designed to minimise the risk presented to the more susceptible groups of people found in the these environments.  Failure to meet the requirements of the ACOP L8 can lead to substantial fines, prosecution and even imprisonment.


So, what do I need to do?  The first step is simple, you need a Legionella Risk Assessment carried out by someone who is competent.  Given the increased risk found in the healthcare and care environment we would advise that whoever carries out the risk assessment needs formal qualifications.


Competency? The ACOP L8 explains in some detail that those involved in the Control & Prevention of Legionella need to be "Technically Competent" from the very start of the risk assessment right through to the regular control & prevention tasks, if there is a failing in competency then the potential for a worst-case scenario is increased, and they could find yourselves being prosecuted for a breach of health & safety law.


What happens next?  Once the risk assessment is complete you will have a list of recommendations ranging from weekly flushing to annual water testing.  Based on the recommendations you need to implement a written control scheme.  The control scheme is nothing more than who does what, when, how often and their competency to do the task.


Control & Prevention refers to carrying out & recording tasks to minimise (Prevent) legionella bacterial growth and control any levels of bacteria you may already have.  In the healthcare environment, the minimum level of regular control & prevention work you would expect to see if the risk was being managed correctly is flushing infrequently used outlets, monthly temperature monitoring, quarterly cleaning & descale of "spray" outlets, annual maintenance of TMV valves and annual Legionella testing.  Other "elaborate" control & prevention tasks maybe advised based on the risk assessment, these tasks may involve more regular reviews of the risk assessment, cleaning & disinfection of water storage tanks and an increased frequency of Legionella testing.

How do the CQC cause confusion?  Under "Safe" the CQC are to inspect a service to ensure it is safe for users.  The "Safe" part of the inspection should include the Legionella Risk Assessment.  The guidance that the CQC gives to its inspectors and providers is misleading as it gives the impression providers may not need to carry out any control and prevention measures.  For example, in section 27 of "Nigel's Surgery" the CQC gives general advice taken from the ACOP L8 but the information that they give is taken out of context for healthcare providers. 


Nigel's surgery states "A simple risk assessment may show that the risks are low and being properly managed.  In many cases the risk assessment will lead the practice to conclude that the risks are insignificant and are being properly managed to comply with the law.  In these instances, the assessment is complete, and no further action is required."  This has led many healthcare related premises to believe they can conduct the risk assessment themselves and not carry out any further control and prevention tasks.


However, further reading of the ACOP L8 2.152 to 2.168 is entitled "Special Consideration for Health Care and Care Homes".  This special consideration explains that you need to consider the people using the service and implement most if not all the guidance given in the ACOP L8.  A vastly different recommendation in comparison to the advice given by the CQC in "Nigel's Surgery".


The CQC have rated us as "Safe" so must be happy with what we are doing!


In June 2018 BUPA was fined £3,000,000 plus costs of £151,482 by Ipswich Crown Court for a Legionella related death & other failures including lack of training.  BUPA Care Homes (BNH) Ltd pleaded to breaching Section 3 (1) of the Health and Safety at Work Act 1974.  The investigation found that for more than a year, during which time major refurbishment works were carried out, BUPA Care Homes (BNH) Ltd failed to implement the necessary control and monitoring measures required to safely manage their hot and cold-water system.  It also found "failings across the board” and that those responsible for overseeing legionella had a lack of "training and understanding".  The court noted that those involved in taking crucial water temperature measurements had not been trained to the required standard. 


What is interesting here is that the CQC inspection prior to the Legionella related death rated the home as meeting the required standards for "Care and welfare for people who use services " and "Cleanliness and infection control".  It was only after the death did the CQC rate the home as "Requires Improvement" under Safe.  Unfortunately, this is not the only incident of this type we have seen, and no blame has attached itself to the CQC in these cases.  Ultimately you need to remember if there is a health & safety breach it is not the CQC that will find themselves in trouble, it's you.  Even if the CQC guidance is misleading health & safety is your responsibility.


The most common problem we find is the confusion between the requirements of the CQC's Safe Hand Washing Guidelines and the temperature monitoring requirements of the HSE's ACOP L8.  We often find providers recording temperatures as required by the CQC, but this is only a fraction of the work required under the ACOP L8.

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