The term ‘care home’ may describe a wide range of properties of varying size and complexity catering to people with a wide range of needs. Whilst care providers tend to specialise in a particular group or type of residents, the common factor is that these establishments provide residential accommodation in an environment that caters specifically for those who are less able to live independently and care for themselves. These include homes for the elderly, physically disabled, children with special needs and those with mental health needs. Nursing homes are a special type of care home that can provide more advanced medical care.
Care homes may be run independently or as part of a group. Many commercially run homes exist, but charities and local authorities also run homes. Often, care home managers are very specialised in the type of care provided; alternatively, they may also have a more generalist managerial skill set. They are unlikely to possess specialist knowledge in water systems safety.
Like other businesses and service providers, care home operators have a duty of care to protect residents, staff, visitors, and anybody else who may be affected by their undertaking from foreseeable risks to their health, safety, and well-being.
Legionella and Scalding risk with vulnerable residents
Due to the nature of care homes, residents are often vulnerable to various risks. This includes the risk posed by waterborne pathogens and scalding by hot water.
Legionnaires’ disease and other waterborne pathogens are more dangerous to older people and those with underlying health concerns.
With respect to scalding, the HSE's guidance tells us that “those at risk include children, older people, people with reduced mental capacity, reduced mobility, a sensory impairment, or people who cannot react appropriately or quickly enough.”
Complex Water Systems
Care homes often require bigger and more complex water systems than typical households due to the number of residents and the components and services needed, e.g., the size and complexity of the building, multiple en-suite facilities, assisted bathrooms, commercial-grade catering facilities, and a high rate of hot water consumption during periods of peak demand. Larger and more complex water systems can be more challenging to keep under control and represent a more significant potential for problems.
HSE ACoP L8
The HSE’s Approved Code of Practice [ACOP] “Legionnaires’ disease, the control of Legionella bacteria in water systems”, L8 [4th Edition], applies to all duty holders that own or operate equipment or systems where there is a reasonably foreseeable risk of exposure to Legionella bacteria. Due to the vulnerable populations and more complex water systems, the standards and control measures applied to care homes may need to be more involved than those applied to other establishments such as schools and offices.
HTM04-01
Of course, any organisation providing medical services or procedures should look to the specific healthcare guidance contained in the Department of Health’s Health Technical Memorandum [HTM] 04-01. However, it could be argued that most care homes occupy a middle ground between general-needs accommodation and healthcare.
How to control Legionella?
Regardless of the level of care or the standards to be applied, the key to managing the risk is the implementation of the following five steps, as advocated under the HSE’s Approved Code of Practice (ACOP) L8:
Identify and assess sources of risk (i.e. carry out Legionella risk assessments);- Appoint a competent person(s) to take day-to-day responsibility for controlling any identified risks (typically known as the Responsible Person);
- Prepare a Water Safety Plan to prevent or control risk;
- Implement, manage, and monitor the scheme of precautions;
- Keep records of the precautions.
We have looked at these requirements in previous blogs; please follow the links provided for more information.
The Legionella risk assessment identifies the level of risk and, therefore, informs the Legionella written scheme and the control measures defined within it. Therefore, the assembly of a competent risk assessment team is of paramount importance. The team should comprise both care professionals and water hygiene specialists to understand water system installation, the operational requirements, and the user profile.
What can go wrong?
A quick round-up of related news articles reveals that water hygiene problems are not uncommon in care home environments. The summary below links to some interesting articles and highlights the deficiencies reported in each case:
Failure to appoint a ‘Responsible Person’: Reports stated that the management at St Christopher’s Hospice in Sydenham had failed to appoint a competent person to manage the risk of Legionellosis. A patient died from Legionnaires’ disease, and a worker at the hospice who also contracted the disease spent 18 days in a coma. This is a poignant reminder that Legionnaires’ disease does not only affect the most vulnerable individuals.
Inadequate Risk Assessments: A water treatment company was prosecuted for providing inadequate Legionella risk assessments to care homes in Wales. Nursing homes were rated as low risk, and there was no evidence that regular temperature readings were taken. The water treatment company was fined £24,000 and ordered to pay full costs of over £17,000.
In another unrelated example, a care home failed to comply with an improvement notice that required a risk assessment. Mother Redcaps Care Home Ltd was ordered to pay over £40,000.
Devise, implement and manage a scheme of control measures: Following the death of a resident in an elderly persons’ care home run by Reading Borough Council, an HSE spokesperson indicated that the council’s failings were “systemic” and that “the control and management arrangements were not robust, and the legionella training of key personnel fell significantly below the required standard”.
Similarly, this report states that BUPA was fined £3m (later reduced to £1.5m after appeal) after failing to implement measures to monitor and control hot and cold water systems during refurbishment works.
Failing to provide safe care and follow Health & Safety Executive guidance, a care provider was ordered to pay £167,670 following the death of a 56-year-old man at a care home in 2020. This was the first time the Care Quality Commission has prosecuted against a care provider where a person has contracted Legionnaires’ disease.
Selecting and monitoring contractors: In this final example, Four Seasons Healthcare engaged a specialist contractor to maintain the hot and cold water systems. However, they admitted to not having undertaken any checks on the contractor's “level of technical expertise” and were fined £600,000 for safety breaches. Click here to read another article that provides further details.
If you would like help with Legionella risk assessments, the development of a Water Safety Plan, or to learn more about Legionella training options, please don’t hesitate to contact the Water Hygiene Centre by clicking here.
Links to articles on other websites are provided for information only. Water Hygiene Centre does not endorse or sell any products and services offered by third parties
Editors Note: The information provided in this blog is correct at the date of original publication - November 2018. (Revised February 2025)
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