Legionella control and effective Legionella testing in care homes

Andrew Clegg tragically died of Legionnaires’ Disease in Fordingbridge Care Home, Hampshire in 2020. The care provider failed in its Legionella control duty to protect Mr Clegg and was subsequently prosecuted in a case brought by the Care Quality Commission. The £75,000 fine pales in insignificance compared to the untimely death of a vulnerable care home resident. To prevent future tragedies like this, Legionella testing in care homes is paramount.

What are Legionnaires’ Disease and Legionella bacteria?

Legionnaires’ disease is a severe form of pneumonia, an infection that causes inflammation of the small air sacs in the lungs (alveoli) and their associated tissues. It is caused by people inhaling legionella bacterium.

Legionella bacteria live in natural water sources such as lakes, reservoirs, rivers, and streams. However, they become a real cause for human concern when they grow in artificial water systems, including

• Hot and cold water systems
• Large, complex plumbing systems
• Cooling towers
• Showerheads and sink faucets

Why are care home residents more vulnerable to Legionnaires’ Disease?

Although everyone is susceptible to Legionnaires’ Disease, men are around three times more likely to contract the disease than women. Moreover, it is a particularly dangerous and potentially fatal disease for at-risk groups. Care homes, nursing homes, and other residential care facilities are particularly vulnerable to Legionella disease as they often house residents with one or several risk factors:

• People over 50 
• People suffering from chronic respiratory or kidney disease
• People who suffer from diabetes or heart disease
• People with chronic lung disease (such as chronic obstructive pulmonary disease or emphysema)
• People with underlying illnesses such as diabetes, kidney failure, or liver failure
• People with cancer
• Anyone with a compromised immune system
• People with organ transplants
• Anyone taking corticosteroid medicines

Regulation and legal compliance 

Given residents in care homes and nursing homes vulnerability to contracting Legionnaires’ disease, the care service providers must understand the risks associated with Legionella bacteria in water systems and their legal requirements to do to avoid tragedy and legal prosecution.

The following legislation is responsible for legally enforcing how the risks associated with legionella should be managed in care homes:

• Health & Safety at Work Act 1974
• Control of Substances Hazardous to Health Regulations 2002
• Management of Health & Safety at Work Regulations 1999

The following documents contain supporting information on the risks of legionella and legionella testing in care homes:

• Health & Safety Executive: HSG274 Legionnaires’ disease: Technical guidance
• Department of Health Estates and Facilities Division, Health Technical Memorandum 04-01: The control of Legionella, hygiene, “safe” hot water, cold water and drinking water systems (HTM 04-01).
• The Health and Safety Executive (HSE) Approved Code of Practice ACoP L8 "Legionnaires Disease: The Control of Legionella Bacteria in Water Systems"

To ensure compliance, ACoP L8 is the most important document for care and nursing home providers. It provides six crucial pieces of advice:

1. A Legionella risk assessment should be carried out to evaluate risks associated with legionella bacteria and Legionnaires’ disease.
2. A Responsible Person should be designated to take responsibility for compliance and procedures.
3. Records are mandatory and must cover every aspect of the Code of Practice and its recommendations (records should be kept for five years).
4. The Responsible Person should ensure water monitoring and testing are carried out.
5. If required, a water treatment system should be adopted to ensure safe levels of legionella bacteria.
6. If legionella bacteria is found, it should be reported immediately. 

Effective control and management of legionella in care homes

Care home providers have a legal duty to protect residents; however, there are always budget and time constraints. By working with a water treatment provider to devise and implement a water safety plan that maintains water hygiene, you can achieve these essential goals and reduce the cost of doing so.

Here are five tips that can help you prioritise safety whilst improving efficiency.

1. Carry out a Legionella risk assessment

The legionella risk assessment is the first place to start. It should be performed by a competent individual who has intimate knowledge of the risks of legionella as well as how such risks can be mitigated. It should also be regularly reviewed, especially if vulnerable people are involved. The legionella risk assessment must be made available when the care facility is inspected by the Care Quality Commission (CQC), the Local Authority, or the Health and Safety Executive.

2. Effectively manage risks

After carrying out a legionella risk assessment, a system must be in place to manage any identified risks. This may involve temperature monitoring and control, cleaning routines, and water sampling for legionella bacteria. All care homes are different, so each one must develop its own system; however, care homes will generally need to implement correct water system management and control of bacteria levels.

3. Use the right level of chemical dosing

Legionella thrives in poorly maintained or faulty water systems at temperatures between 20–45°C. If control measures, such as temperature, are not working on your particular site, the right answer is to engineer the correct solution. This may mean insulating pipework or even increasing the size of the hot water storage. However, in some cases, this is not practical, can be costly, or may take a significant amount of time. In these cases, alternative defence strategies could be worth considering.

One of the most popular measures for controlling Legionella, microorganisms, biofilm, and other harmful pathogens in water systems that cannot be controlled by temperature, is through chemical dosing, typically using Chlorine Dioxide (ClO2) or hypochlorous acid. Ideally, this should be delivered automatically using proportional dosing by systems controlled by software with appropriate safeguards. These types of systems ensure that the dosing is delivered at optimum levels—underdosing will not be effective, compromising patient safety, and overdosing will waste expensive chemicals and potentially cause issues for users. Using a system that delivers the perfect dose will ensure the water is still safe for human consumption as well as being cost-effective.

Some types of systems can log the treatment details, which helps comply with the legal requirements. All these measures should be part of a comprehensive water safety plan.

Additionally, removing potentially harmful agents will also help with the boiler's efficiency, reducing the energy it uses and, therefore, the running costs. 

4. Run an efficient hot water system

Hot water efficiency is another area where you could achieve savings. By installing a  pre-treatment plant, the system can be optimised to reduce scale in the system, which will result in less energy use to maintain a constant temperature and heat cold water entering the cylinder. You may also wish to consider solar pre-heating or ground/air source heat pumps, but be aware that Legionella is not killed instantly with temperature, so you need to ensure sufficient dwell time at the right temperature. 

5. Optimise the efficiency of the system

Cost savings can also be made by ensuring your system is as efficient as possible through regular system assessments. A thorough inspection can be carried out by your water treatment provider, who will be able to identify any problems such as leaks, faults, or potential future issues. They should also advise when elements of the system should be replaced to make them more water-efficient or less prone to a potentially expensive failure.

If you have on-site maintenance staff, they can undertake regular checks for drips and other tell-tale signs of water or energy wastage. Once identified, these should be dealt with—if not in-house—then by your water treatment provider.

Conclusion

Ensuring the safety of all residents in care homes is both a moral and legal requirement. The safest course of action for care home providers to take is to contract a specialist water treatment provider, which will be able to ensure water hygiene and system efficiency and ensure compliance.

The right provider can offer training for your on-site maintenance staff, carry out Legionella risk assessments, offer ongoing monitoring and reporting to show compliance, and undertake any required work.

Editor's note: This blog was originally published in March 2020 but has be republished for relevance and accuracy.