Legionella Risk Assessment and Water System Checks Audit - Care Homes

Evidence to check

• • Current Legionella risk assessment completed by a competent person or competent external contractor
• • Assessment covers hot and cold water systems, tanks, pipework, outlets, showers, thermostatic mixer valves and areas used by residents, staff and visitors
• • Assessment considers vulnerable residents, including those with respiratory conditions, reduced immunity or frailty
• • Recommendations are transferred into an action plan with named owners and timescales

Evidence to check

• • Review date is recorded and current
• • Risk assessment reviewed after plumbing works, refurbishment, changes in occupancy, room closures or system changes
• • Review considers whether control measures remain effective
• • Outdated assessments are replaced and staff are informed of changes

Evidence to check

• • Named responsible person and deputy are documented
• • Role responsibilities are clear, including monitoring, contractor oversight, records and escalation
• • Responsible person has appropriate training or evidence of competence
• • Water safety issues are reported to senior management where required

Evidence to check

• • Written control scheme or water safety plan is available
• • Temperature checks, flushing and cleaning schedules are clearly defined
• • Staff know what checks they are responsible for
• • Records show the control scheme is completed consistently and gaps are followed up

Evidence to check

• • Temperature monitoring log includes sentinel outlets
• • Checks are completed at the required frequency
• • Results are recorded accurately with date, time, outlet and person completing the check
• • Out-of-range results are escalated and corrective action is recorded

Evidence to check

• • Hot water storage temperature records show appropriate control
• • Outlet temperatures are monitored against the written control scheme
• • Scald risk is managed through thermostatic mixer valves, risk assessments and safe design
• • Any failure to reach required temperatures is investigated and corrected promptly

Evidence to check

• • Cold water temperature records are completed at required outlets
• • Records include whether temperature is achieved within the expected flow time
• • Warm cold-water results are investigated
• • Corrective action is recorded for insulation, stagnation or pipework concerns

Evidence to check

• • Flushing schedule identifies low-use outlets, vacant rooms, en suites, showers, sluices and staff areas
• • Weekly or required-frequency flushing records are completed
• • Flushing records include date, outlet and person completing the task
• • Missed flushing is escalated and risk assessed

Evidence to check

• • Shower head and hose cleaning or descaling schedule
• • Records show cleaning, descaling and disinfection dates
• • Showers are visually checked for scale, damage or poor water flow
• • Replacement or repair is arranged where cleaning is ineffective

Evidence to check

• • Tank inspection records are current
• • Tank is covered, insulated and protected from insects, debris or contamination
• • Water condition, sediment and temperature are checked where required
• • Cleaning, repair or remedial work is completed where concerns are found

Evidence to check

• • Thermostatic mixer valve servicing and maintenance records
• • Thermostatic mixer valve outlet temperatures are checked and recorded
• • Thermostatic mixer valves are cleaned, serviced or replaced according to the control scheme
• • Resident scald risk assessments link to thermostatic mixer valve use where relevant

Evidence to check

• • Water system schematic is available
• • Diagram reflects current building layout and water system
• • Changes from refurbishment or plumbing works are added promptly
• • Responsible person and contractors use the schematic for monitoring and risk assessment

Evidence to check

• • Water safety logbook or digital record is organised and current
• • Records include monitoring, flushing, descaling, contractor visits, faults and corrective actions
• • Gaps in records are identified and investigated
• • Records are reviewed by the responsible person

Evidence to check

• • Contractor competence, qualifications or service agreement evidence
• • Contractor reports include findings, readings, samples, recommendations and actions
• • Certificates, calibration records or service reports are retained
• • Responsible person reviews contractor reports and follows up actions

Evidence to check

• • Records are retained in line with health and safety guidance and organisational policy
• • Historical records are accessible for audits or inspections
• • Records include risk assessments, written scheme, monitoring, maintenance and remedial works
• • Records are stored securely and not lost when staff or contractors change

Evidence to check

• • Sampling plan or contractor recommendation is recorded where applicable
• • Sampling results are reviewed promptly
• • Positive or concerning results trigger immediate risk controls and escalation
• • Remedial action and re-testing are documented where needed

Evidence to check

• • Risk assessment includes aerosol-producing outlets and equipment
• • Cleaning, descaling and disinfection schedules are completed
• • Equipment is maintained according to manufacturer and water safety guidance
• • Staff know when equipment should be taken out of use due to water safety concerns

Evidence to check

• • Monitoring includes resident bedrooms, en suites, assisted bathrooms and clinical areas
• • High-risk resident areas are included in the control scheme
• • Out-of-range readings in resident areas are escalated promptly
• • Alternative arrangements are made where water safety cannot be assured

Evidence to check

• • Planned preventative maintenance schedule includes water temperature monitoring, flushing, thermostatic mixer valves, tanks, showers, calorifiers and remedial works
• • Tasks are completed within planned timescales
• • Overdue maintenance is escalated
• • Maintenance actions are linked to the Legionella risk assessment

Evidence to check

• • Outlet inventory includes all areas of the home
• • Non-resident areas are included in flushing and temperature checks where required
• • External taps or rarely used outlets are considered
• • Changes in room use are reflected in monitoring schedules

Evidence to check

• • Vacant room and low-use outlet register is current
• • Flushing is completed for vacant rooms and closed areas
• • Rooms brought back into use are checked before occupation
• • Occupancy changes are communicated to the person responsible for water safety

Evidence to check

• • Relevant staff have water safety or Legionella awareness training
• • Staff know how to report unusual water temperature, discolouration, low flow, scale, leaks or illness concerns
• • Clinical staff know to escalate respiratory illness clusters or suspected Legionnaires' disease
• • Water safety concerns raised by staff are recorded and acted on

Evidence to check

• • Contingency plan covers water failure, contamination, positive samples and outbreak response
• • Plan includes alternative water supplies, bathing arrangements, drinking water and communication
• • Escalation routes include senior leaders, contractors, public health, local authority or environmental health where required
• • Staff know immediate actions such as taking outlets out of use where instructed

Evidence to check

• • Records of plumbing works, refurbishment or system changes
• • Risk assessment reviewed after works
• • Dead legs, redundant pipework, cross-connections or stagnation risks are identified and removed where possible
• • Contractors provide evidence that works were completed safely

Evidence to check

• • Scald risk assessments are completed for residents at risk
• • Thermostatic mixer valves are fitted and checked where required
• • Hot water outlet temperatures are monitored
• • Excessively hot water is escalated immediately and controlled until resolved

Evidence to check

• • Internal or external Legionella audit records
• • Audit checks risk assessment, logbook, monitoring, flushing, contractor actions and staff knowledge
• • Actions have owners, timescales and completion evidence
• • Repeat gaps are escalated through governance

Evidence to check

• • Incident or exception records for water safety concerns
• • Immediate control actions are recorded
• • Root cause and remedial works are identified
• • Learning is shared and monitoring adjusted where needed

Evidence to check

• • Risk assessment, written scheme, monitoring records, contractor reports and action plans are easily accessible
• • Records are complete and up to date
• • Responsible person can explain the evidence confidently
• • Missing evidence is identified and corrected before inspection

Evidence to check

• • Relevant policies are cross-referenced and consistent
• • Water safety links to infection prevention, premises safety, COSHH, outbreak management and business continuity
• • Staff guidance does not conflict between policies
• • Policy updates are communicated to relevant staff

Evidence to check

• • System for notifying water safety lead of room occupancy changes
• • Vacant or low-use rooms added to flushing schedule promptly
• • Rooms are checked before being reoccupied
• • Monitoring schedule reflects current room use

Evidence to check

• • Written agreement or communication clarifies responsibilities
• • Landlord or property manager provides relevant risk assessments, servicing or remedial evidence
• • Shared system risks are reviewed and escalated where needed
• • The care provider does not assume compliance without evidence

Evidence to check

• • Audit includes spot checks of outlets, temperatures, flushing evidence and staff understanding
• • Records are compared with actual room use and water system risks
• • Out-of-range trends and repeated gaps are analysed
• • Actions from audits lead to safer water management and reduced risk