Introduction to Legionella in Care Homes:
Care homes are highly complex businesses with complex legal requirements governed by the Care Quality Commission (CQC). The Health and Safety Executive (HSE), is the lead enforcement agency for serious accidents, while the CQC will often take a lead on all but the most serious of health and safety incidents.
Those who own, direct, or manage care home activities are legally responsible for the health, safety, and wellbeing of elderly and vulnerable residents who are often in receipt of personal care and support. Legionella is one of many risks in a care home, that can result in serious ill health if it is not managed and prevented.
In the UK, keeping Legionella under control, in an environment where a commercial service is being provided by the care provider, is a statutory obligation. Care home providers must comply with the Health and Safety at Work Act 1974 and the Control of Substances Hazardous to Health (COSHH).
The specific requirements for managing legionella, is set out in L8 (HSG 274) which is an Approved Code of Practice A failure to manage legionella can lead to severe enforcement action including, but not limited to legal notices, fines, and prosecutions. All of these can be reputationally, very damaging for most businesses. This article dives into what legionella is, why it’s a risk, and how care homes can protect their residents while meeting legal requirements.
1. What Is Legionella and why are Care Homes at Particular Risk?
Legionella bacteria are naturally found in freshwater environments, like rivers and lakes, where they don’t usually cause human harm. However, in residential water systems, like those found in care homes, legionella can become a significant risk. The legionella bacteria thrive and multiplies in warm, stagnant water, especially when temperatures hover between 20°C and 45°C. The risk of legionella is principally managed through temperature control, so if the water system and associated water temperature are not effectively controlled, this allows the legionella risk to crystallize. Legionella bacteria itself can spread through tiny droplets, like those from showers, taps, and even when flushing toilets.
Why Care Homes Face Higher Risks:
Legionella is normally contracted by inhaling tiny, airborne droplets containing viable legionella bacteria. Although everyone is susceptible to infection, the risk increases with age and some people are at a higher risk, such as people over 45, smokers, heavy drinkers, people suffering from chronic respiratory or kidney disease, diabetes, lung and heart disease and anyone with an impaired immune system. Residents of care homes are commonly regarded as vulnerable, due to their age, pre-existing health conditions and general wellbeing. This means that they are more likely to contract pneumonia (a form/symptom of legionellosis) and therefore, given their vulnerability, are more likely to be seriously affected.
Care homes typically have large, complex commercial water systems which commonly serves the whole building. Some of the water outlets and general plumbing may not be used as regularly are other areas, leading to water stagnation. It is this stagnation that creates an environment for bacterial growth. A common example of little used outlets, may be a guest room where the taps and shower are only used when the guest room is occupied.
HSE Guidance on Legionella and Legionnaires’ Disease provides essential recommendations for preventing these risks in water systems across facilities, including care homes.
2. The Health Impacts of Legionnaires’ Disease
Legionnaires’ disease is not just another illness. It’s a severe form of pneumonia that can be life threatening, especially for the elderly or those with weakened immune systems. In care homes, where many residents fit this description, an outbreak can turn into a major public health crisis. Symptoms can start mild with a slight fever, chills, or muscle pain but may quickly develop into something much more serious. Residents may develop a persistent cough, shortness of breath, chest pain, and in severe cases, organ failure or even death.
If a legionella outbreak is traced back to a care home, the Environmental Health Team, working closely with other enforcement agencies, will almost certainly temporarily close the home down, until the risk is remediated. This would inevitably require residents to be temporarily rehoused.
Treatment for legionnaires disease normally requires hospital admission, with patients receiving antibiotics and for the most serious of cases oxygen therapy. Recovery can be slow and challenging, especially for care home residents who have underlying health conditions.
3. Legal Duties and Responsibilities of Care Homes
Under the Health and Safety at Work Act 1974, care homes are required to manage the risk of legionella to protect both residents and staff. The Control of Substances Hazardous to Health (COSHH) Regulations govern the control legionella, making it mandatory for care homes to assess risks, put controls in place, and monitor these measures regularly.
Who’s Responsible?
In a care home setting, the “duty holder” is typically the owner or top management. This person holds the primary responsibility to ensure the risk of legionella is assessed and that formal control measures are identified, implemented and monitored for their effectiveness. Duty holders will often need to appoint the services of a competent person to assist them with understanding and discharging their responsibilities.
4. Key Legionella Control Measures in Care Homes
Managing the risk of legionella in care homes requires consistency and attention to detail. Effective legionella control typically centres around regulating water temperature, flushing unused outlets, and conducting regular maintenance.
Temperature Control and Regular Testing:
To prevent legionella, care homes must ensure that hot water is stored above 60°C, and cold water is stored below 20°C. Maintaining the storage of hot and cold water at these temperatures makes it harder for legionella bacteria to survive or multiply. Staff or your appointed water management contractor should perform checks of water temperature at various points of the water system. Any fluctuations should be recorded and notified to your water management contractor to investigate and remediate. It’s important to recognise that storing hot water at 60°C, seriously increases the risk of scalding. Consequently, this risk must be managed at the outlet by a thermostatic mixing valve (TMV) which regulates the water to a predefined temperature, thus lowering the risk of scalding.
Flushing Outlets Regularly:
In care homes, not every room or outlet is used daily. To avoid stagnant water, all little unused outlets, including guest rooms or storage areas, should be flushed weekly. This simple action can go a long way in reducing the risk of legionella. Ideally, flushing should be part of a weekly maintenance routine that’s logged and signed off to keep track.
Cleaning and Disinfection:
Showerheads, taps, and storage tanks need to be cleaned and descaled regularly to prevent the buildup of scale and biofilm, which create hiding spots for legionella.
5. Case Law and Real Implications
Care homes have faced serious consequences for failing to control Legionella, and there are several cases that highlight the implications of non-compliance.
1. Bupa Care Homes, 2015: Bupa was fined £3 million (later reduced to £1.5 million) after an 86-year-old resident contracted Legionnaires’ disease and died. The infection was linked to the care home’s inadequate water management following refurbishments.
2. Fordingbridge Care Home, 2017: Sentinel Healthcare, the operator of Fordingbridge Care Home, was fined £150,000 after 56-year-old resident Andy Clegg died from Legionnaires’ disease. The infection was traced back to Legionella bacteria in the care home’s water system, which had not been adequately managed to prevent bacterial growth. This case marked one of the first times the Care Quality Commission (CQC) prosecuted a provider for Legionella-related negligence, leading to additional costs of £17,500 and a victim surcharge of £170.
6. Proactive Staff Engagement and Training
Legionella control isn’t just a matter for care home managers; it requires the buy in and engagement of Senior Officers and the entire care home staff. Staff at all levels, including those who may not directly work with water systems, need a basic understanding of legionella risks. A well informed team is more likely to take responsibility for small but critical tasks, like noticing when an outlet isn’t used regularly or reporting issues with temperature controls.
Conclusion: Why Vigilance Matters in Legionella Control
For care homes, managing legionella risks is about creating a safe space for resident to live. With simple, consistent actions, daily checks, weekly flushes, and ongoing staff training care homes can reduce the risk of a legionella outbreak. If you require support on your legionella arrangements, contact SafetyRAC for a no obligation discussion.
