Water Hygiene Policy
1. Introduction and Objectives
1.1 As a landlord, MHS Homes and Heart of Medway must meet the legal obligations which require us to deal with the risks associated with legionella bacteria within the properties we own or manage. Legionella bacteria can cause a potentially fatal form of pneumonia called Legionnaires’ disease. People contract Legionnaires’ disease by inhaling small droplets of water containing the bacteria.
1.2 As far as is reasonably practicable, we must introduce measures to reduce and/or control exposure to legionella bacteria, including managing the conditions that support the growth of the bacteria in water systems.
1.3 The key objective of this policy is to ensure that our Board, Executive Team, employees, partners and customers are clear on our legal and regulatory water hygiene obligations. This policy provides the framework our staff and partners will operate within in order to meet these obligations.
1.4 This policy forms part of our wider organisational commitment to driving a health and safety culture amongst staff and contractors (as detailed within our Health and Safety Policy). It will be saved on our shared drive and distributed to all relevant members of staff.
2. Scope
2.1 This policy applies to the following property types:
Communal blocks.
Sheltered / independent living schemes.
Community Hubs.
Foyers.
2.2 Some aspects of this policy also apply to individual domestic properties (houses, flats bungalows, and so on). Applicable items will be clearly referenced.
2.3 This policy is relevant to all our employees, customers, contractors, stakeholders and other persons who may work on, occupy, visit, or use our premises, or who may be affected by our activities or services. Adherence to this policy is mandatory.
3. Roles and Responsibilities
3.1 The Board has overall governance responsibility for ensuring this policy is fully implemented to ensure full compliance with legislation and regulatory standards.
3.2 The Building Safety Task Force will formally approve this policy and review it every two years (or sooner if there is a change in legislation or regulation).
3.3 The Executive Team will receive bi-monthly performance reports in respect of water hygiene safety and ensure compliance is being achieved. They will also be notified of any non-compliance issue identified.
3.4 The Assistant Director of Asset Management has strategic responsibility for the management of water hygiene safety, and ensuring compliance is achieved and maintained. They will oversee the implementation of this policy.
3.5 The Contract Manager has operational responsibility for the management of water hygiene safety and will be responsible for overseeing the delivery of these programmes. The Head of Customer and Building Safety is the Responsible Person.
3.6 The Senior Compliance Manager is the Deputy Responsible Person who will provide cover to the Head of Customer and Building Safety (Responsible Person) in their absence.
3.7 Housing teams will provide support where gaining access to properties is difficult.
3.8 Under the requirements of the Social Housing (Regulation) Act 2023 we have appointed the Executive Director of Assets & Development as our Health and Safety Lead.
4. Legislation, Guidance and Regulatory Standards
4.1 Legislation - The principal legislation applicable to this policy is as follows:
The Health and Safety at Work Act 1974.
The Control of Substances Hazardous to Health Regulations 2002 (as amended) (COSHH).
This policy also operates within the context of additional legislation (see Appendix 1).
4.2 Approved Code of Practice (ACoP) – The principal ACoP applicable to this policy is:
ACoP L8 - Legionnaires’ disease: The control of legionella bacteria in water systems (4th edition 2013).
4.3 Guidance – The principal guidance applicable to this policy is as follows:
HSG274 - Legionnaires’ disease: Technical guidance Part 2: The control of legionella bacteria in hot and cold water systems (2014).
HSG274 - Legionnaires’ disease: Technical guidance Part 3: The control of legionella bacteria in other risk systems (2013).
INDG458 - Legionnaires’ disease: A brief guide for dutyholders (2012).
BS 8580-1:2019 Water quality, risk assessments for Legionella control – Code of practice.
4.4 Regulatory standards – We must ensure we comply with the Regulator of Social Housing’s regulatory framework and consumer standards for social housing in England; the Safety and Quality Standard is the primary one applicable to this policy.
The Social Housing (Regulation) Act 2023 changes the way social housing is regulated and may result in future changes to this policy.
4.5 Sanctions – Failure to discharge our responsibilities and obligations properly could lead to sanctions, including: prosecution by the Health and Safety Executive (the HSE) under the Health and Safety at Work Act 1974; prosecution under the COSHH Regulations; prosecution under the Corporate Manslaughter and Corporate Homicide Act 2007; and via a regulatory judgement from the Regulator of Social Housing.
5. Obligations
5.1 The Health and Safety at Work Act 1974 places a duty on us, as an employer and landlord, to ensure our employees and others affected by our undertakings (for example, customers), are not exposed to health and safety risks, including the risk from legionella.
5.2 We have a legal obligation under COSHH to prevent or control exposure to biological agents, including legionella.
5.3 MHS Homes is the ‘Duty Holder’ as defined by ACoP L8 and we must take necessary precautions to prevent, reduce or control the risks of exposure to legionella.
5.4 As the Duty Holder, we must:
Carry out a risk assessment for all hot and cold-water systems, cooling plant and any other systems that can produce water droplets to identify and assess potential risks.
Implement measures to either eliminate, reduce or control identified risks.
Appoint a Responsible Person to take managerial responsibility for:
Carrying out risk assessments.
Producing written schemes of control (a practical, risk management document used to control the risk from exposure to legionella).
Implementing the written scheme of control.
Appoint a Deputy Responsible Person who will provide cover to the responsible person in their absence.
Keep associated records for five years.
6. Statement of Intent
6.1 We acknowledge and accept our responsibilities and obligations under the legislation outlined in Sections 4 and 5.
6.2 We will review legionella risk assessments using a risk-based approach. Schemes will be assessed as high, medium or low risk.
6.3 Written schemes of control will be in place for all properties risk assessed as requiring controls to manage the risk of legionella exposure.
6.4 When properties become void, we will drain and flush the water system, including any shower loop, before undertaking any work. The water system will then be flushed and recommissioned before the property is let, and the shower head replaced or sterilised.
6.5 We will carry out checks to identify pipework ‘dead legs’ and remove them within void properties and any properties where we are carrying out adaptations or planned investment work.
6.6 When we acquire properties (existing or new build) we will follow the same process as for void properties, and we will ensure that there are no pipework ‘dead legs’ present when we take possession of the property.
6.7 We will operate a robust process for the management of immediately dangerous situations identified from the legionella risk assessment, water testing/monitoring regime or suspected legionella outbreak.
6.8 We will use the legal remedies available within the terms of the tenancy and lease agreement should any customer, leaseholder or shared owner refuse access to carry out essential water hygiene related inspection and remediation works. Where customer vulnerability issues are known or identified we will ensure we safeguard the wellbeing of the customer.
6.9 We will operate effective contract management arrangements with the contractors responsible for delivering the service, including; ensuring contracts/service level agreements are in place, conducting client-led performance meetings, and ensuring that contractors’ employee and public liability insurances are up to date on an annual basis.
6.10 We will establish and maintain a risk assessment for water hygiene management and operations, setting out our key water hygiene risks and appropriate mitigations.
6.11 To comply with the requirements of the Construction, Design and Management Regulations 2015 (CDM) a Construction Phase Plan will be in place for all repairs work to void and tenanted properties (at the start of the contract and reviewed annually thereafter), component replacement works and refurbishment projects. A CDM policy will be implemented during the lifetime of this policy.
7. Programmes
7.1 Communal blocks and other properties – We will ensure all communal blocks and other properties (supported or sheltered schemes/community hubs/foyers) that we own or manage are subject to an initial visit to establish whether a legionella risk assessment (LRA) is required.
7.2 If an LRA is required, the property will be included on the LRA programme. If an LRA is not required, we will record this on our core asset register.
7.3 For all properties on the LRA programme, we will undertake a risk-based approach to renewing the LRAs. This will be supplemented by an annual internal desktop review.
7.4 ACoP L8, states that a Legionella risk assessment should be reviewed regularly, and specifically whenever there is reason to suspect it is no longer valid LRAs will be reviewed in the following circumstances:
Change in building use.
Change in internal layout of water system.
Change in building occupation that increases the risk due to health.
After a confirmed or suspected outbreak of Legionella.
Following a water hygiene audit (if required).
7.5 Domestic properties – We will undertake an annual programme of five per cent sample legionella risk assessments in domestic properties. These will be prioritised according to the perceived level of risk (based on design, size, age and type of water supply).
7.6 Testing and monitoring - We will undertake testing and monitoring (for example, monthly temperature checks) as set out within any written schemes of control.
7.7 We will ensure there is a robust process in place for the management of any follow-up works required following the completion of an LRA or ongoing monitoring (where the work cannot be completed at the time of the assessment or check).
7.8 Properties managed by others - We will ensure that information on Water Hygiene is stored on the Asset Management system for all of our properties that are managed by a Managing Agent.
8. Data and Records
8.1 We will maintain a core asset register of all properties we own or manage, setting out which properties require an LRA. We will also set out which properties require ongoing testing and monitoring as prescribed by the written control scheme (for example, monthly temperature checks).
8.2 We will operate a robust process to manage all changes to stock, including property acquisitions and disposals, to ensure that properties are not omitted from water hygiene programmes and the programmes remain up to date.
8.3 We will hold LRA inspection dates, LRAs, and testing and monitoring records against all properties on each programme. These will be held in the Asset Management System.
8.4 We will keep water hygiene logbooks electronically (or securely on site where practical), for all properties on the LRA programme.
8.5 We will keep all records for at least five years or for the duration that we own and manage the property and have robust processes and controls in place to maintain appropriate levels of security for all water hygiene related data.
9. Resident Engagement
9.1 We consider good communication essential in the effective delivery of water hygiene programmes, therefore we will establish a resident engagement strategy and communication programme. This will support customers in their understanding of water hygiene and legionella risk, advised them of how they can manage the risks within their properties, and to encourage them to report any concerns about water safety.
9.2 We also aim to successfully engage with vulnerable and hard to reach customers. We will share information clearly and transparently and will ensure that information is available to customers via regular publications and information on our website.
9.3 We will display written schemes of control in communal areas of buildings to inform occupants how the risk of exposure to legionella bacteria is being managed and controlled.
10. Competent Persons
10.1 As we should appoint a Responsible Person (Head of Customer and Building Safety) and a Deputy Responsible Person (Senior Compliance Manager), together with the Contracts Manager, they should both be trained, instructed, and informed to the same level and should assist in the frequent monitoring of written control schemes. Therefore, they should hold a relevant qualification such as the BOHS P901 – Management and control of building hot and cold water services, Level 2 Award in Legionella Awareness (or equivalent), or Level 4 VRQ Diploma in Asset and Building Management. If they do not have these already, they will obtain them within two years of the approval of this policy.
10.2 Only suitably competent consultants and contractors, registered with the Legionella Control Association (or equivalent), will undertake LRAs, prepare written schemes of control and undertake works in respect of water hygiene and legionella control.
10.3 Only suitably competent consultants and contractors, registered with the Legionella Control Association (or equivalent), will undertake third party technical quality assurance checks.
10.4 We will check that our contractors hold the relevant qualifications and accreditations when we procure them, and thereafter on an annual basis; we will evidence these checks and each contractor’s certification appropriately.
11. Training
11.1 We will deliver training on this policy and the procedures that support it, through appropriate methods including: team briefings; basic water hygiene awareness training; and on the job training for those delivering the programme of LRAs and water hygiene testing and monitoring, as part of their daily job. All training undertaken by staff will be formally recorded.
12. Performance Reporting
12.1 We will report key performance indicator (KPI) measures for water hygiene safety that follow the requirements set out in the Tenant Satisfaction Measures (TSMs) which came into force on 1 April 2023 and must be reported to the RSH on an annual basis.
12.2 We will report the following water hygiene performance:
Report Recipient | Frequency |
|---|---|
Regulator of Social Housing | Annual |
Executive Team | Bi-Monthly |
Board | Quarterly |
Customers | Quarterly |
12.3 We will also report the following:
Data – the total number of:
Properties split by category (domestic, communal blocks/schemes, commercial/other).
Properties on the LRA programme.
Properties not on the LRA programme.
Properties with a valid and in date LRA.
Properties without a valid and in date LRA.
Properties due an LRA within the next 30 days.
Overdue follow-up works/actions (split by priority).
Narrative - an explanation of the:
Current position.
Corrective action required.
Progress with completion of follow-up works.
In addition:
The number of RIDDOR notifications to the HSE with regards to water safety.
13. Quality Assurance
13.1 We will ensure there is a programme of third-party quality assurance audits to 100 per cent of LRAs. Annual audits will be undertaken to all systems identified as a high risk.
13.2 We undertake internal desktop audits to 100 per cent of all certification.
13.3 We will carry out an independent audit of water hygiene safety at least once every two years, to specifically test for compliance with legal and regulatory obligations and to identify any non-compliance issues for correction.
14. Significant Non-Compliance and Escalation
14.1 Our definition of significant non-compliance is any incident which has the potential to result in a potential breach of legislation or regulatory standard, or which causes a risk to health or safety, and which needs to be managed as an exception to routine processes and procedures.
14.2 All non-compliance issues will be reported and escalated as soon as possible, and no later than 24 hours after the incident occurred, or of an MHS Homes employee becoming aware of it.
14.3 Any non-compliance issue identified at an operational level will be formally reported to the Responsible Person or Deputy Responsible Person in the first instance, who will agree an appropriate course of corrective action with the Assistant Director of Asset Management and report details of the same to the Executive Team.
14.4 In cases of serious non-compliance, Executive Team and Board will consider whether it is necessary to disclose the issue to the Regulator of Social Housing as required by their regulatory framework, or any other relevant organisation such as the Health and Safety Executive.
14.5 We will ensure there is a robust process in place to investigate and manage all RIDDOR notifications made to the HSE in relation to water hygiene safety and will take action to address any issues identified and lessons we have learned, to prevent a similar incident occurring again.
15. Glossary
15.1 This glossary defines key terms used throughout this policy:
BOHS: British Occupational Hygiene Society.
Duty Holder: the owner of the non-domestic premises or the person or organisation that has clear responsibility for the maintenance or repair of non-domestic premises, for example through an explicit agreement such as a tenancy agreement or contract.
Legionellosis: a collective term for diseases caused by legionella bacteria including the most serious Legionnaires’ disease, as well as the similar but less serious conditions of Pontiac fever and Lochgoilhead fever.
LRA: Legionella Risk Assessment – an assessment which identifies the risks of exposure to legionella in the water systems present in a premises and the necessary control measures required.
Principles
Equality statement
mhs homes has a duty to ensure that no person receives less favourable treatment from the organisation on the grounds of age, disability, gender reassignment, marriage, civil partnership, pregnancy, religion or belief, race, sex or sexual orientation.
Data protection
mhs homes will only share information that meets the requirements of the Data Protection Act 2018 and the UK GDPR. Confidentiality and impartiality will be exercised by mhs homes at all times.
Feedback
We welcome suggestions and comments from people who use or provide our services. We believe that this can provide some important lessons to help us ensure that the service is improved for everyone.
If you have something to say about this policy or the information that is provided, then please let us know. Please refer any comments to the author of this document.
Appendix 1
This policy also operates within the context of the following legislation:
The Defective Premises Act 1972
Landlord and Tenant Act 1985
Homes (Fitness for Human Habitation) Act 2018
The Occupiers’ Liability Act 1984
Public Health (Infectious Diseases) Regulations 1988
The Workplace (Health Safety and Welfare) Regulations 1992
The Management of Health and Safety at Work Regulations 1999 (the Management Regulations).
Water Supply (Water Fittings) Regulations 1999
Housing Act 2004
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR)
Construction (Design and Management) Regulations 2015
Water Supply (Water Quality) Regulations 2018
Data Protection Act 2018
Social Housing (Regulation) Act 2023
Approval details
| Date approved | 30/05/2025 |
| Implementation date | 01/02/2023 |
| Review date | 31/05/2027 |
| Approved by | DD&A |