Legionella Risk Assessment & Water Hygiene Checklist

Owned by the responsible person. Enter the date of the site survey on the first task: every due date counts from it in working days. Choose the country and type of premises, whether this is a first assessment or a review, and any other water systems, and the tasks for each answer appear.

• Set up the assessment: the premises, the systems, the dates and the people — the premises and address, the country and type of premises, whether this is a first assessment or a review, any cooling towers, spa pools or other risk systems, the date of the site survey, the assessor, and the people; later tasks are assigned from these fields
• Appoint the responsible person in writing — a person with sufficient authority, competence and knowledge of the installation to take day-to-day responsibility for controlling the risk, their deputy, and how they can be contacted at all times; ACOP L8 calls this person the responsible person
• Confirm the law and guidance that apply — the law and guidance for the country and type of premises on the first task; the note below shows them
• Read the last assessment, the written scheme and the records since — shown only for a review: the last assessment and its significant findings, the written scheme, the monitoring records since, remedial work still open and any change to the system or its use
• Record why the assessment is being reviewed — shown only for a review: a change to the water system or its use, a change to the use of the building, new information about risks or controls, checks showing the controls are no longer effective, a change of key people, or a case of legionellosis associated with the system, as ACOP L8 lists them
• Choose a competent assessor — you, someone in your organisation or an outside consultant with the training and experience to assess this system; check an outside assessor’s experience, qualifications and memberships before you book them
• Gather the drawings, asset lists and who uses the building — plumbing drawings, any asset register, the last schematic, maintenance and water treatment records, the hours the building is used, and anyone using it who may be more at risk
• Cooling towers: check the notification — shown when there is a cooling tower or evaporative condenser: in Great Britain, check the local authority has been told in writing where each one is, and tell them when one stops being used; in the US, check what your state or local health department requires

The survey happens on the date on the first task. Walk the whole system with the assessor, including parts out of use, take baseline temperatures, list the outlets nobody uses, and draw the schematic.

• Walk the whole system with the assessor — the incoming supply, cold water tanks, water heaters and calorifiers, pipe runs, outlets, showers, thermostatic mixing valves and any parts temporarily out of use, with an asset register of the plant
• Take baseline temperatures at the sentinel outlets — hot and cold temperatures at the outlets nearest to and furthest from each tank and cylinder, and at the calorifier flow and return, recorded with the time taken to reach them
• List little-used outlets and dead legs — every outlet not used for seven days or more, and every dead leg and blind end, with where it is and whether it can be removed
• Note who could be exposed and anyone at higher risk — employees, residents, visitors, patients or guests who use showers, taps and other outlets that make spray, and anyone more at risk because of age, illness or a weakened immune system
• Identify where legionella could grow and spread — water between 20 and 45 °C, stored or recirculated water, sources of nutrients such as rust, sludge, scale, organic matter and biofilms, places water stagnates, and anything that makes spray that people could breathe
• Draw or update the schematic diagram — the layout of the system, including parts temporarily out of use, easy to read without special training; it is not a formal technical drawing

The assessor’s report gives the significant findings and what to do about them. Check it covers the whole system, record the findings, and agree when the assessment will next be reviewed. The report task asks whether remedial work is recommended, which adds Phase 5.

• Receive the risk assessment report — the significant findings, the risk at each part of the system, the controls recommended and any remedial work, with the name of the competent person and a description of the system
• Check the report against the survey — every part of the system covered, parts not accessed listed with a plan to reach them, and each recommendation clear enough to act on
• Record the significant findings — the significant findings, any groups identified as particularly at risk and the steps taken to prevent or control the risk; employers with five or more employees must record them
• Agree when the assessment will next be reviewed — a review date and what to consider at it, plus the events that bring the review forward; ACOP L8 asks for an indication of when to review the assessment and what to consider to be recorded

Where the assessment finds a risk you cannot prevent, a written control scheme says how it is controlled. Write it, set the checks and limits, say what happens when a check fails, and brief everyone with a role. Healthcare premises add one task.

• Write the written control scheme — an up-to-date schematic, the correct and safe operation of the system, the precautions, the checks and how often, and the remedial action if the scheme is not effective, as ACOP L8 lists them
• Set the checks, limits and frequencies for each system — each check, where it is taken, how often and by whom, with the limit it must meet; the UK figures in this template are HSE’s, and in the US they are your program’s control limits
• Write what to do when a check is out of limits — for each check, the action to take, who decides and who is told, so a failed reading leads to the same response every time
• Agree what contractors do and check their competence — the water treatment or monitoring contractor’s tasks in writing, their competence checked, and the responsible person still answerable for the standard of their work
• Brief and train everyone with a role in the scheme — the significant findings and the precautions each person must take, training for those doing checks, refresher training, and a record of all of it
• Healthcare: brief the water safety group — shown for UK healthcare premises and care homes: the assessment and the scheme taken to the water safety group, which HSG274 Part 2 describes as a multidisciplinary group that develops the water safety plan; HTM 04-01’s addendum advises forming one, though it is not statutory under health and safety legislation
• CMS-certified facilities: check the program meets CMS’s expectations — shown for US hospitals, critical access hospitals and nursing homes: a facility risk assessment of where Legionella and other opportunistic waterborne pathogens could grow and spread, a program that considers ASHRAE 188 and the CDC toolkit, testing protocols and acceptable ranges for control measures, and results and corrective actions documented, as CMS’s memo QSO-17-30 sets out

Applies only when the assessment recommends remedial work. Give each item a priority and an owner, remove dead legs, complete the other works, and clean and disinfect where the works call for it.

• Prioritise the remedial works and give each an owner — shown when the assessment recommends remedial work: every recommendation from the report, its priority, its owner and a target date
• Remove dead legs and redundant pipework — shown when the assessment recommends remedial work: redundant pipework cut back as far as possible to a common supply, preferably removing the feeding tee, and the schematic updated
• Complete the other remedial works and record each one — shown when the assessment recommends remedial work: each item done, with the date of completion and who did it, as ACOP L8 asks to be recorded
• Clean and disinfect where the works call for it — shown when the assessment recommends remedial work: after new installation or refurbishment, new components, a long period without use or flushing, or where a tank inspection shows it is needed, as HSG274 Part 2 lists; certificates kept

The first three months of the scheme’s routine checks, logged as they happen: weekly flushing, monthly temperatures, quarterly showerheads, and the six-monthly and annual tasks booked. Any reading out of limits is dealt with before the review.

• Book the six-monthly and annual tasks — the cold water tank inspection, the tank temperature check, the calorifier inspection and cleaning, and the servicing of thermostatic mixing valves, each with a date and an owner
• Flush little-used outlets every week and log it — each outlet on the list run until the temperature stabilises and is comparable to the supply, purged to drain without releasing spray, weekly or as the risk assessment says
• Check sentinel outlet temperatures every month — hot outlets timed to reach temperature, cold outlets after running, the nearest and furthest outlets each month and a rotating selection of others; the note below gives the figures for your country and premises
• Check calorifier flow and return temperatures every month — the flow from each calorifier or water heater and the return on each loop, logged monthly; HSE gives at least 60 °C flow and a return not below 50 °C
• Clean and descale showerheads and hoses — showerheads, inserts and hoses dismantled, cleaned and descaled, quarterly or as the risk assessment says
• Deal with every reading out of limits — each reading that missed its limit, the action the scheme sets, who took it and when, and a re-check showing the limit is met

Decide whether this cycle needs sampling for legionella and act on the results. Cooling towers, spa pools and other risk systems ticked on the first task add their own routine checks here.

• Decide whether sampling for legionella is needed this cycle — whether the scheme or the assessor calls for sampling now, for example where there is doubt about the controls, temperatures are not consistently met, people at higher risk use the building, or the system is an open one such as a cooling tower or spa pool
• Take the samples through an accredited laboratory — shown when sampling is needed: samples from the outlets, tanks and cylinders the scheme names, taken and analysed as the guidance for your country says
• Record the results and compare them with the action levels — shown when sampling is needed: each result against the action level in the scheme, read by someone competent to interpret it
• Resample and review the controls and the risk assessment — shown when a result is above the action level: resample, and review the control measures and the risk assessment to find the remedial action needed, as the guidance for your country says
• Consider disinfecting the system, then retest — shown when a result is above the action level: disinfection decided by the competent person, and retesting a few days after it and at frequent intervals until control is shown, as HSG274 Part 2 describes for results above 1,000 cfu/l
• Cooling towers: run the checks the scheme sets — shown when there is a cooling tower or evaporative condenser: the weekly check of the biocide regime, legionella sampling at least quarterly, and a system out of use for more than a month drained and shut down, as HSG274 Part 1 says
• Spa pools: run the checks the scheme sets — shown when there is a spa pool or hot tub: the checks HSE’s spa pool guidance sets, with routine testing at least quarterly; in the US, the checks in your program
• Other risk systems: run the checks the scheme sets — shown when there are other systems that make spray: humidifiers, misters, fountains, vehicle washers, dental equipment and similar, each checked as HSG274 Part 3 or the manufacturer says

Look at the first three months as a whole, make sure the records are complete, update the assessment and scheme, and hand the routine checks on so they carry on whatever happens next. Then the dutyholder signs off the cycle. Nothing after the sign-off can be completed until it is done.

• Review the first three months of records — every check done on time, the readings, the flushing log, the remedial works, any sampling results and the actions taken
• Check the records are complete and kept for the right periods — the responsible people, the significant findings, the scheme and its implementation, whether each system is in use, and every check with its date; records kept while current and for at least two years after, and monitoring records for at least five years
• Update the assessment and the scheme with what the cycle showed — any change the checks, the works or the results point to, made to the assessment and the written scheme, with the date
• Hand the routine checks on to an ongoing schedule — weekly flushing, monthly temperatures, quarterly showerheads and the six-monthly and annual tasks carried on after this run, each with an owner, whatever the sign-off decides
• Dutyholder signs off the assessment cycle — the assessment, the written scheme, the remedial works, the first three months of checks and the records; nothing after this task can be completed until it is signed off
• Not approved: complete what is missing and bring it back — shown when the sign-off is not approved: finish the tasks or records the dutyholder named, keeping the weekly flushing, monthly temperature checks and the other routine checks going while you do, then change the decision on the sign-off, or un-complete it and complete it again

After the sign-off: meet any conditions, tell the people affected what they must keep doing, and file the records.

• Meet the conditions of the sign-off — shown when the sign-off is approved with conditions: each condition met and recorded, and the dutyholder told
• Tell the people affected what they must keep doing — staff, occupants or tenants told the controls they help keep, such as not changing the hot water temperature setting, cleaning showerheads and reporting hot water that is not hot
• File the records and diary the next review — the report, the scheme, the logs, certificates and sign-off filed, and the next review date from Phase 3 in the diary of the responsible person and the deputy