BrodexTrident was instructed to complete a Legionella risk assessment at a two-storey care home in the South West.
The site operated 24 hours a day and provided accommodation for vulnerable occupants. This made effective management of domestic water systems especially important, as care environments often include multiple outlets, showers, thermostatic mixing valves, stored hot water systems, and areas where water use may vary depending on occupancy and care needs.
The assessment reviewed the condition, operation, monitoring, and management arrangements for the hot and cold water services. Following the assessment, the site was given an overall High Risk rating, with the cold water system, hot water system, and management system all requiring attention.
Care homes have a heightened need for effective water hygiene management. Residents may be more vulnerable to infection, and the domestic water systems serving the building must be carefully controlled, monitored, and evidenced.
At this site, the assessment identified a combination of engineering and management issues. The cold water system was mains fed, with no cold water storage tanks present, but little-used outlets and flexible hoses still required control. The hot water system presented more significant concerns, particularly in relation to stored hot water temperatures, TMV management, expansion vessel purging, and showerhead cleaning records.
The assessment also identified gaps in the site’s management arrangements. A site-specific Written Scheme of Control was not available, and several key records were either incomplete or not available for review. This included records for temperature monitoring, TMV servicing, expansion vessel purging, little-used outlet flushing, showerhead cleaning, staff training, and task-specific competence.
These findings showed that the site needed both physical system improvements and stronger compliance evidence to demonstrate ongoing control.
BrodexTrident reviewed the site against recognised guidance and standards, including ACoP L8, HSG274, BS 8580-1:2019, BS 7592:2022, the Water Supply Regulations, and Legionella Control Association requirements.
The assessment included a review of:
The purpose of the assessment was not only to identify physical risks, but also to check whether the management system was suitable, documented, and being implemented effectively.
The cold water system was mains fed, with no cold water storage tanks present on site. However, the assessment still identified cold water risks that required management.
Little-used outlets were present and needed to be added to a suitable flushing regime, or removed if they were no longer required. Flexible hoses were also present and required review to confirm whether they were necessary, suitable, and not contributing to stagnation.
The cold water system findings highlighted that even mains-fed systems can present control issues where outlets are not used regularly or where fittings create unnecessary stagnation risk.
The hot water system was one of the main areas of concern. Stored hot water temperatures were recorded below the required control levels in several hot water systems, and hot water outlet temperatures were also identified as being below expected limits.
The assessment recommended that the water heaters be adjusted to achieve suitable stored water temperatures and that temperature performance should be monitored to confirm that the non-conformance had been resolved.
Further issues were identified with thermostatic mixing valves. There was no evidence of annual TMV servicing, some TMVs were inaccessible, and some had no local isolation. Post-TMV temperatures were also found to be outside specification. These findings meant that servicing, access, isolation, temperature checks, and fail-safe testing all needed to be addressed.
The assessment also identified no evidence of routine expansion vessel purging. Expansion vessels can create areas of stagnation if not flushed or purged as part of a suitable control regime, so a routine purge and record-keeping process was recommended.
In addition, showerhead and hose cleaning records were not available. The assessment recommended implementing quarterly dismantling, cleaning, descaling, and disinfection of showerheads and hoses, with records retained.
The management system was assessed as a high-risk area and was a significant driver behind the overall site rating.
The assessment identified that a site-specific Written Scheme of Control was not available. This meant the site could not clearly demonstrate defined responsibilities, assets, monitoring tasks, frequencies, control limits, corrective actions, and review arrangements.
Monitoring records were also found to be inadequate. The assessment identified no evidence of relevant records for the required retention period, no evidence of monthly temperature monitoring records, no evidence of TMV service records, no evidence of expansion vessel purge records, and no evidence of little-used outlet flushing records.
There was also no evidence of Legionella awareness training or task-specific training for staff carrying out monitoring duties. This created uncertainty around whether the relevant people had the knowledge and competence required to complete assigned water hygiene tasks correctly.
These findings highlighted the importance of the management system in Legionella control. Even where physical remedial works are completed, the site must also be able to demonstrate that control measures are being implemented, recorded, reviewed, and escalated where required.
BrodexTrident provided the duty holder with a clear prioritised action plan to help restore control and improve compliance evidence.
The recommended actions included:
The assessment gave the duty holder a clear understanding of where Legionella risk was present and what actions were required to improve control.
Rather than simply identifying defects, the report provided a practical action plan to help the care home strengthen its water hygiene management arrangements. The recommendations supported improvement in several key areas, including hot water temperature control, TMV management, showerhead cleaning, little-used outlet flushing, expansion vessel purging, staff training, and compliance record-keeping.
For care homes, this type of structured risk assessment is particularly important. Vulnerable occupants, multiple water outlets, regular use of showers and assisted bathing facilities, and the need for scald protection all make clear water hygiene management essential.
By identifying both engineering and management control gaps, the assessment helped the duty holder prioritise action, improve accountability, and work towards a more stable and demonstrable level of Legionella control.