Legionella Risk Assessment and Water System Checks Audit - Care Homes

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