Legionella Risk Assessment and Water System Checks Audit - Care Homes
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- Q1: Is there a current and comprehensive Legionella risk assessment carried out by a competent person or external contractor?
- Q2: Is the risk assessment reviewed annually or when significant changes to the water system occur (e.g., plumbing work, occupancy changes)?
- Q3: Is there a named person responsible for Legionella risk management within the service?
- Q4: Are written control measures in place, including temperature monitoring, flushing, and descaling schedules?
- Q5: Are hot water temperatures regularly checked and recorded at sentinel outlets (e.g., taps and showers)?
- Q6: Is the hot water consistently stored above 60°C and distributed at a minimum of 50°C at outlets?
- Q7: Are cold water temperatures monitored to ensure they remain below 20°C within two minutes of flow?
- Q8: Are infrequently used outlets (e.g., en suite sinks, showers in unused rooms) flushed weekly to prevent stagnation?
- Q9: Are all shower heads and hoses cleaned, descaled, and disinfected at least quarterly, with records kept?
- Q10: Is the cold-water storage tank regularly inspected for cleanliness, proper cover, insulation, and signs of contamination?
- Q11: Are thermostatic mixer valves (TMVs) maintained to ensure appropriate temperature control and reduce scald risk?
- Q12: Is the water system schematic diagram (layout of tanks, pipes, outlets) available and up to date?
- Q13: Is there a logbook or digital system to record all temperature checks, flushing, maintenance, and cleaning tasks?
- Q14: Are external contractors (if used) qualified and providing documented proof of works completed (e.g., calibration, inspection, water sampling)?
- Q15: Are records kept for at least five years in line with HSE guidance (e.g., ACOP L8, HSG274 Part 2)?
- Q16: Are water sampling and microbiological testing conducted where required due to higher risk or identified issues?
- Q17: Is risk from aerosol-producing equipment (e.g., showers, whirlpool baths, spa equipment) assessed and controlled?
- Q18: Are hot and cold water outlets checked at point of use, especially in areas serving vulnerable residents (e.g., low immunity, respiratory conditions)?
- Q19: Is water system maintenance included in the premises’ Planned Preventative Maintenance (PPM) schedule?
- Q20: Are all areas, including staff rooms, kitchens, laundry, sluice rooms, and storage spaces, included in the checks?
- Q21: Are control measures adapted for vacant rooms or areas to prevent water stagnation (e.g., flushing protocols)?
- Q22: Are staff aware of the signs and risks of Legionnaires’ disease and how to report concerns?
- Q23: Is there a contingency plan in place in case of a Legionella outbreak or water system failure?
- Q24: Is any refurbishment or plumbing work reviewed to ensure it does not increase Legionella risk (e.g., dead legs, cross-connections)?
- Q25: Are residents, staff, and visitors protected from scalding through appropriate use of temperature-limiting devices or safe design?
- Q26: Are audits of Legionella compliance undertaken internally or externally and used to inform safety improvements?
- Q27: Are any Legionella incidents, near misses, or water contamination concerns investigated and acted on promptly?
- Q28: Is evidence of compliance available and accessible for inspection (e.g., during CQC, HSE, or Environmental Health reviews)?
- Q29: Are relevant policies (e.g., Legionella, water safety, infection control) aligned and cross-referenced for consistency?
- Q30: Are changes in occupancy (e.g., resident admission/discharge, room rotation) factored into flushing and monitoring routines?
- Q31: Is there collaboration with property management (if leased) or landlords to ensure shared water systems are maintained to required standards?