Legionella in care homes, schools and dental practices

The law on Legionella is the same for every workplace, but the risks aren't. A care home, a primary school and a dental surgery each have their own quirks, and a good risk assessment should reflect them. Here's what's different about each, and what tends to get looked at when an inspector or auditor comes round.

Mid-December is a useful moment to think about all three. Schools and many dental practices are about to close for Christmas, and care homes are heading into their busiest, most vulnerable time of year.

The common ground

All three are covered by the same legal framework: the Health and Safety at Work etc. Act 1974, COSHH and the HSE's Approved Code of Practice L8. Each needs a suitable risk assessment, a written scheme of control, a competent responsible person and proper records. For the hot and cold water systems themselves, HSG274 Part 2 is the guidance to follow, with hot water stored at 60°C or above, reaching outlets at 50°C or more, and cold water kept below 20°C.

Where they differ is in who uses the building, how the water's used and what else is plumbed in.

Care homes

Care home residents are often older, frail or living with health conditions that make them more vulnerable to Legionnaires' disease. That alone means the risk assessment needs to be thorough and the controls need to be well run. The HSE has published guidance specifically for health and social care settings, and in England the Care Quality Commission expects providers to manage risks to residents properly.

Things we pay particular attention to in care homes:

• TMVs everywhere. Residents need protecting from scalds, so baths, showers and often basins have mixing valves. Those valves need regular servicing and the warm water downstream needs managing. We wrote about that in TMVs and Legionella.
• Empty rooms. When a room is vacant between residents, its en-suite stops being used. It needs adding to the weekly flushing list straight away.
• Assisted baths and showers. Specialist equipment with hoses, spray heads and sometimes its own water reservoirs.
• Higher temperatures. Some care providers choose to adopt healthcare standards, such as distributing hot water at 55°C as HTM 04-01 recommends for healthcare premises. Whether that's right for your home is something the risk assessment should consider.
• Sampling. Routine Legionella sampling is far more likely to be appropriate in a care home than in an ordinary office.

Schools

Schools are generally less about vulnerable users and more about long periods of stagnation. Six weeks over summer, two at Christmas, two at Easter, plus half terms. That's a lot of water standing still.

• Holiday closures. The written scheme should say exactly what happens during and after each closure. Ideally outlets are flushed weekly through the holidays, then everything is run through and temperatures checked before pupils come back. Our guide on reopening a building after closure covers the steps.
• Sports changing rooms. Showers that see heavy use some weeks and none at all in others.
• Science labs and technology rooms. Sinks and emergency eyewash stations that are rarely run.
• Old buildings and add-ons. Lots of schools have grown in stages, leaving long pipe runs, oversized tanks and dead legs where blocks have been altered.
• Who's responsible. The employer is the duty holder, and in schools that depends on the type of school. It might be the local authority, an academy trust or the governing body. Day-to-day tasks often fall to the site manager, so the scheme needs to make the arrangements clear.

Dental practices

Dental surgeries have the usual hot and cold water system to manage, plus something extra: dental unit water lines, or DUWLs. These are the narrow tubes that feed water to the drills, scalers and three-in-one syringes. They're very prone to biofilm, and the spray from dental instruments sits right next to the patient's face and the dental team.

In England, HTM 01-05 is the main guidance on decontamination in primary care dental practices, and it covers DUWLs. In summary, it expects practices to:

• flush water lines at the start and end of the day and between patients, as it describes
• use suitable water for the units (often from independent bottles rather than straight from the mains)
• clean and disinfect the lines following the dental unit manufacturer's instructions
• keep records showing it's all being done

Practices also tend to have small water heaters under sinks, and often occupy converted houses or shops with older plumbing. And because many practices close at weekends and over holidays, little-used outlets and stagnation need thinking about too.

What inspectors and auditors tend to look for

Whoever comes knocking, whether that's an HSE or local authority inspector, a regulator, an insurer or a trust auditor, the questions are usually similar:

1. Is there a current risk assessment that matches the building as it is now?
2. Is there a written scheme, and does it say who does what?
3. Has a responsible person been appointed, and are they trained?
4. Are the actions from the assessment done, or at least planned?
5. Do the records show temperatures, flushing and servicing actually happening?

If you can open a folder and show all five, you're in a good position. If you can't, our guide on what's in a written scheme of control is a good place to start.

A typical scenario

Imagine a 30-bed care home where three rooms are empty after residents moved on in the autumn. The maintenance person has been busy, the empty rooms haven't made it onto the flushing list, and one TMV in a shared bathroom is running noticeably cooler than the rest.

The fixes are simple enough: add the empty rooms to the weekly list, service the TMV, check temperatures on that floor and consider sampling from those outlets. But it shows why care homes need a routine that adapts as quickly as occupancy changes.

How we can help

We carry out risk assessments tailored to how each building is actually used, and can back them up with TMV servicing and water sampling analysed by a UKAS-accredited lab. If you'd rather not run the routine checks in-house, we can take those on too.