Priorities for water safety in private healthcare

The private or independent healthcare sector is largely made up of hospitals and clinics run independently of the NHS. These healthcare facilities are normally run by a commercial company, although some are also run by charities or other non-profit organisations. Private healthcare sites may also include mental healthcare facilities, rehabilitation centres, care homes, and many other types of site-specific facilities.

Although Pseudomonas aeruginosa, Nontuberculous mycobacteria (NTM), and other waterborne pathogens continue to come to the fore, Legionnaires’ Disease and Legionellosis prevention must remain a key concern for private healthcare providers.

As applies equally to all healthcare businesses, private healthcare operators have a duty of care to protect their residents, staff, visitors, and anybody else who may be affected by their day-to-day risk management undertakings, from foreseeable risks to their health, safety, and wellbeing.

All healthcare estates are assessed against a set of legal requirements and governance standards — and the associated principles of health and safety are enshrined within the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and specifically Regulations 12[2][h] and 15 of the Act. Failure to comply with the aforementioned ‘Regulation’ or ‘Act’ is an offence, and as such the Care Quality Commission has ‘enforcement powers’ to ensure compliance with accepted standards. Such enforcement powers include: issuing time-defined warning notices, prosecution, and cancelling a provider’s registration to provide healthcare services — removing its ability to provide regulated activities.

Extensive guidance on offer

Despite Legionella risks being ever-present for providers, extensive guidance is available. The Department of Health’s Health Technical Memorandum 04-01 sets out the standards for water safety within health estates by acknowledging within its three parts — A, B and C — the regulatory requirements of the Health and Social Care Act, as well as the role of the Health and Safety Executive (HSE) for the safe management of healthcare estates.

There are many commercially run private healthcare sites, and the skills and competencies of staff within these varying sites may well be adequately specialised and relevant to ensure that good water hygiene management practices are implemented. Alternatively, staff may 
also have a more general managerial skillset, and be unlikely to possess the requisite knowledge in water system safety.

A checklist to provide assurance

So, can we simply identify the measures within a checklist to provide assurance both individually at site level, and at a more strategic level? Regardless of the level of care or the standards to be applied, the key to managing Legionella risk is the implementation of the following five steps, as advocated under the HSE’s Approved Code of Practice (ACoP) L8:

1. Appoint a manager to be responsible for others;

2. Identify and assess sources of risk (i.e. carry out Legionella risk assessments];

3. Prepare a scheme to prevent or control risk (i.e. a Water Safety Plan);

4. Implement, manage, and monitor, the scheme of precautions;

5. Keep records of the precautions.

In their most skeletal form, the aforementioned five steps are no less fundamental to an individual property or organisation’s safe operation today than when initially documented in earlier editions of ACoP L8. The document elaborates on these points whilst also detailing specifically the nature and make up of a ‘Written Scheme’ — or in healthcare parlance — the ‘Water Safety Plan’, for:

• Preventing or controlling the risk from exposure;
• Ensuring proper implementation and management;
• Specifying measures undertaken to ensure that it remains effective.

BS8680:2020 Water Quality

More recently, BS8680:2020 Water Quality — Water Safety Plans — Code of Practice has been issued to provide unequivocal recommendations and guidance on the development of a Water Safety Plan (WSP). The standard is intended to be used as a code of practice to demonstrate current good practice and compliance, and private healthcare providers should now be looking to integrate the document’s evolutionary approach into their own water compliance system.

Private healthcare providers may also follow a basic checklist for reducing the risk from Legionella (and other waterborne pathogens) in association with the aforementioned HSE and DoH guidance. The key steps are as follows:

1. Having specifically appointed person(s) responsible for Legionella (water safety) control in place;

2. Ensuring that the current water risk assessment is available at local level, understood by the appropriate manager(s), and with a management plan in place to act on any findings;

3. Ensuring a logbook system is in place detailing the site’s communication pathway, and planned preventative maintenance tasks undertaken and frequencies — including records, contingency measures, and any other relevant information. Note: the logbook system should be appropriate to the site it concerns;

4. Ensuring that all identified relevant person(s) have sufficient Legionella training and experience to be able to carry out the role competently, and that the relevant staff are trained to be aware of the importance of their role in controlling Legionella;

5. Keeping hot water hot at the appropriate level, and circulating at all times, at 55°C-60 °C throughout the entire hot water system;

6. Keeping cold water cold at all times. It should be maintained at temperatures below 20 °C throughout the system to all outlets. (This may not be possible when the ambient temperature is high, but every effort should be made to ensure that cold water entering the premises and in storage remains as cold as possible);

7. Running all outlets, including showers in all areas (healthcare or otherwise), for several minutes to draw through water (until it reaches the temperatures stated in points 5 and 6) at least twice a week, and dependent on risk assessment findings (or daily if in an augmented care area) if rooms are unoccupied, and always prior to occupation;

8. Keeping shower heads/hoses, taps, and other facilities dispensing water, clean and scale-free;

9. Implementing cleaning, draining, and disinfection of hot water (storage) generators on an annual basis;

10. Cleaning and disinfecting all water filters regularly, as directed by the manufacturer, at least every three months;

11. Inspection of water storage tanks and visible pipework routinely. Ensure that all coverings are intact and firmly in place, and disinfect with 50mg/l of sodium hypochlorite or similar, and clean based on condition;

12. Ensuring that any TMVs installed are suitably inspected and maintained on a six-monthly basis;

13. The identification of any ‘other’ system via the current water risk assessment, and ensuring that all pertinent PPM tasks are implemented;

14. When carrying out system modifications or new installations, ensuring that they do not create pipework with intermittent or no water flow, and disinfecting the system following any work;

15. Keeping records of all water system readings, such as temperature, pH, and chlorine concentrations, and ensuring that they are checked regularly by the appropriate manager;

16. Consideration of, and undertaking, microbiological samples to aid demonstration of monitoring compliance and safe water systems.

*The aforementioned checklist is not exhaustive, and is more appropriate for smaller sites. Healthcare sites of significant size would require a significantly more detailed approach.

In summary, we may ask ourselves if we have learnt our lesson since the mid-1970s, when Legionnaires’ Disease first came into public consciousness. Simply put, despite the wealth of straightforward health and safety advice —from regulators such as the Health and Safety Executive, learned societies, and other healthcare industry bodies, this largely avoidable disease continues to be a concern for estates and facilities managers and occupiers alike.