Legionella Management Policy

HAUS OF ÄSTHETIK

Legionella Management Policy

Effective Date: 1st June 2025

Review Date: 1st June 2026

Approved by: Managing Director


 

1. Policy Statement

Haus of Ästhetik is committed to the prevention of Legionnaires’ disease and ensures full compliance with Health and Safety Executive (HSE) Approved Code of Practice (ACoP) L8 – Legionnaires’ disease: The control of legionella bacteria in water systems. This policy outlines the clinic’s procedures for the assessment, control, and monitoring of legionella risks in its water systems, despite the clinic’s limited plumbing infrastructure.

Although the risk is low due to the nature and simplicity of the clinic’s water systems, appropriate control measures and regular reviews are essential to remain compliant with Save Face, Care Quality Commission (CQC), and Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

 

2. Scope

This policy applies to:

  • All water outlets and plumbing infrastructure within Haus of Ästhetik

  • All staff and third parties who may come into contact with water systems

  • All areas used for clinical care, handwashing, cleaning, or sterilisation

 

3. System Overview

  • One single tap at the reception used primarily for handwashing and occasional rinsing.

  • One shared sink between two client toilets.

  • Hot water is provided by a 15-litre under-sink electric instant water heater.

  • Cold water is supplied directly from the mains

  • No water storage tanks are present

  • No showers, baths, or large-scale water systems are used in the clinic

Given this simplified configuration, the risk of legionella growth is categorised as low, but ongoing vigilance is necessary.

4. Responsibilities

  • The Managing Director assumes responsibility for Legionella control and ensures policy implementation.

  • The Nominated Person (e.g. Clinic Manager or Responsible Person for Facilities) shall carry out weekly checks and maintain records.

  • External contractors may be used for periodic inspection and validation.

 

5. Risk Assessment

  • A formal Legionella risk assessment has been conducted in line with HSE ACoP L8 and will be reviewed annually or if the water system changes

  • Risk is considered low due to:

    • Absence of water storage

    • Minimal pipework

    • Regular usage of all outlets (no stagnant water)

    • Use of a thermostatically controlled water heater maintaining temperatures above 50°C

    • Mains-supplied cold water

     

6. Control Measures

  • Maintain hot water at ≥50°C and cold water at ≤20°C at the outlets

  • Ensure taps are run at least weekly if not regularly used

  • Flush all taps for 2 minutes after periods of non-use (e.g. holidays or closure)

  • Descale taps and outlets monthly to prevent biofilm formation

  • Use WRAS-compliant fixtures and fittings only

  • Avoid any dead legs or redundant pipework in plumbing installations

  • Clean and disinfect the water heater filter and outlet according to the manufacturer’s instructions every 6 months

 

7. Monitoring & Record-Keeping

  • Weekly water outlet flushing and temperature checks (hot and cold)

  • Monthly inspection and cleaning of taps, sink drains, and water heater casing

  • Quarterly written inspection by a competent person, with documentation logged

  • Annual review of this policy and the overall risk assessment

 

Records will be retained for a minimum of five years and include:

  • Dates and times of flushing

  • Temperature records

  • Descaling and cleaning logs

  • Any service or maintenance of plumbing or water heating systems

 

8. Training

  • All clinical and support staff will receive Legionella awareness training as part of induction and annual CPD refreshers

  • The Responsible Person will undergo specific water safety training

 

9. Emergency & Incident Management

In the unlikely event of suspected legionella contamination (e.g. notification of illness or poor water temperatures), the following steps will be taken:

  • Immediate isolation of affected taps or water systems

  • Notification to CQC and Public Health England (if required)

  • Engagement of an external water hygiene contractor for testing

  • Suspension of clinical use of water facilities until cleared as safe

 

10. Compliance References

  • HSE ACoP L8: Legionnaires’ disease: The control of legionella bacteria in water systems

  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

  • CQC Regulation 15 – Premises and Equipment

  • Save Face Clinical Standards – Infection Prevention and Environmental Hygiene

  • Water Regulations Advisory Scheme (WRAS)

 

11. Review

This policy will be reviewed annually or following any significant change to water systems, regulatory guidance, or premises usage.