DH HTM 0401 PART B Acc

Department
of Health
Health Technical Memorandum

04-01: Safe water in healthcare
premises
Part B: Operational
management
Health Technical Memorandum
04-01: Safe water in healthcare
premises
Part B: Operational
management
Health Technical Memorandum 04-01: Safe water in healthcare premises – Part B: Operational management
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ii Front cover photograph reproduced by kind permission of the Mid Yorkshire Hospitals NHS Trust
Contents
Executive summary....................................................................................................................iv
Acknowledgements....................................................................................................................vi
Glossary and abbreviations......................................................................................................vii
0 Policy and regulatory overview: water safety and the healthcare estate......................... 1
1 Introduction.......................................................................................................................... 7
2 Governance and management responsibility.................................................................... 9
3 Statutory requirements......................................................................................................12
4 Legionella: overview...........................................................................................................15
5 Pseudomonas aeruginosa and other waterborne pathogens: overview.........................19
6 Operational management.................................................................................................. 22
7 Description of systems, operational considerations and requirements......................... 38
8 Other operational considerations..................................................................................... 49
9 Microbiological monitoring............................................................................................... 53
10 Testing for Legionella........................................................................................................ 54
Appendix A Examples of the use of water within a healthcare facility and water quality
types......................................................................................................................................... 60
Appendix B Action in the event of an outbreak of legionellosis............................................ 64
Appendix C Exemplar temperature test sheets...................................................................... 65
Appendix D Testing for P. aeruginosa..................................................................................... 67
Appendix E Water sampling for P. aeruginosa........................................................................74
Appendix F Microbiological examination of water samples for P. aeruginosa..................... 77
References................................................................................................................................ 82
iii
Executive summary
Preamble This Health Technical Memorandum (HTM)

gives comprehensive advice and guidance to
This current review and update of HTM 04-01 healthcare management, design engineers,
is intended to move users of the document estate managers, operations managers,
towards a holistic management of water contractors and the supply chain on the legal
systems via Water Safety Groups (WSGs), requirements, design applications, maintenance
Water Safety Plans (WSPs) and other initiatives. and operation of hot and cold water supply,
This version draws together and updates storage and distribution systems in all types of
the previous guidance and includes healthcare premises. It is equally applicable to
recommendations for the safe management both new and existing sites.
of water systems, via the integration of the
principle of WSGs and WSPs (first introduced Aims of this guidance
in the HTM 04-01 P. aeruginosa addendum – The current review and update of HTM 04-01
published in March 2013), and how to manage is intended to move users of the document
and minimise the risks to health from various towards a holistic management of water
aspects, ranging from clinical risks, microbial systems via WSGs, WSPs and other initiatives.
and chemical contamination, changes to the
water system, resilience of the water supply etc. It has been written to promote good practice
It also introduces a stronger emphasis on staff for those responsible for the design, installation,
competencies and the implementation of water commissioning, operation and maintenance of
hygiene awareness training. water services in healthcare premises, by:
• highlighting the need for robust
Introduction governance and management;
The development, construction, installation, • outlining the remit of the WSG and how
commissioning and maintenance of hot and this relates to the provision of safe water
cold water supply systems are vital for public in healthcare premises;
health. Healthcare premises are dependent • outlining key criteria and system
upon water to maintain hygiene and a arrangements to help stop the ingress
comfortable environment for patients and staff, of chemical and microbial contaminants
and for treatment and diagnostic purposes. and microbial colonisation and bacteria
proliferation;
Interruptions in water supply can disrupt
• illustrating temperature regimes for
healthcare activities. The design of systems
sanitary outlets to maintain water hygiene;
should ensure that sufficient reserve
water storage is available to minimise the • ensuring the safe delivery of hot water;
consequence of disruption, while at the same • outlining how the correct selection of
time ensuring an adequate turnover of water system components and correct use by
to prevent stagnation in storage vessels and occupants can help preserve the quality
distribution systems. and hygiene of water supplies;
iv
Executive summary
• providing a point of reference to Because of the complexity of hot and cold

legislation, standards and other guidance water distribution systems and the difficulty
pertaining to water systems; of maintaining a temperature control regime
• providing a basic overview of possible in some healthcare facilities, this guidance
potential waterborne pathogens; suggests that additional chemical, physical
and other water control methods that have
• giving an overview of some of the different
been shown to be capable of controlling
water systems (including components)
microbial colonisation and growth may also be
and their safe installation, commissioning
considered.
and operation and maintenance;
• providing typical system layouts and
individual component location; Main changes from the 2006
• providing information on thermostatic edition of HTM 04-01
mixing valve configurations, appropriate
usage and maintenance requirements; • This 2016 edition of HTM 04-01 provides
comprehensive guidance on measures
• identifying key commissioning, testing to control waterborne pathogens
and maintenance requirements such as Pseudomonas aeruginosa
for referral by designers, installers, Stenotrophomonas maltophilia,
commissioners, operators and Mycobacteria as well as Legionella.
management.
• This edition has been updated to align
with the Health and Safety Executive’s
(HSE’s) recently revised Approved
Controlling waterborne pathogens Code of Practice for Legionella (L8)
The guidance gives comprehensive guidance and its associated HSG274 guidance
on measures to control waterborne pathogens. documents.
While Legionella control is, in the main,
associated with poor engineering configuration • The Addendum to HTM 04-01 published
and maintenance, with no evidence of in 2013 (and now Part C of HTM 04-01)
patient-to-patient or patient-to-outlet transfer, introduced the concept of WSGs and
P. aeruginosa may be transferred to and from WSPs. Part B of the HTM now includes
outlets and the water from both patients and updated guidance on the remit and aims
staff. Suspected P. aeruginosa waterborne of the WSG and WSP.
infections require additional investigations to • New guidance has been included on the
determine the source and interventions from hygienic storing and installation of fittings
infection control specialists and microbiologists. and components and on the competency
Therefore, a temperature control regime is the of installers/plumbers working on
traditional strategy for reducing the risk from healthcare water systems. The guidance
Legionella and for reducing the growth and also outlines that any person working on
colonisation of other waterborne organisms water distribution systems or cleaning
within water systems. To prevent growth of water outlets needs to have completed a
P. aeruginosa and other waterborne pathogens, water hygiene awareness training course.
controls are necessary to manage the water An example course outline is included.
system before and after the outlet. • Guidance on sampling techniques for,
testing for, and the microbiological
As with all control measures, temperatures
examination of Pseudomonas aeruginosa
should be monitored at regular intervals to
samples – originally in the HTM 04-01
verify effective control.
Addendum – is now included in Part
B to complement similar guidance on
Legionella.
v
Acknowledgements
The Department of Health would like to thank the Steering Group for their
advice and support, and all those who contributed to the consultation
phase of the document.
Christian Taylor-Hamlin Bathroom Manufacturers Association
David Way BEAMA
Davy Burns Health Estates, Northern Ireland
Elise Maynard Water Management Society
George McCracken Belfast Health & Social Care Trust
Graham Thompson Water Management Society
Ian Storrar Health Facilities Scotland
Jimmy Walker Public Health England
John Newbold Health & Safety Executive
Lorraine Medcalf Health & Safety Executive
Mark Gapper NHS Wales Shared Services Partnership
Mike Arrowsmith Arrowsmith and Associates
Mike Kelsey Whittington Hospital, London
Mike Weinbren Chesterfield Royal Hospital NHS Foundation Trust
Nick Hill Institute of Healthcare Engineering and Estate Management (IHEEM)
Paul Millard Water Regulations Advisory Scheme (WRAS)
Paul Taylor NSF/BuildCert
Paul Weaving Infection Prevention Society
Philip Ashcroft Department of Health
Reginald Brown BSRIA
Robert Pitchers WRc
Simon Benton Drinking Water Inspectorate
Susanne Lee Royal Society for Public Health
Tom Makin Envirocloud Ltd
Tom Makin senior Makin and Makin Consultancy Ltd
vi
Glossary and abbreviations
In addition to the definitions listed below, other b. those cared for in units where organ
definitions can be found in the Water Supply support is necessary, for example
(Water Fittings) Regulations 1999; BS 6100; BS critical care (adult paediatric and
8558; and BS EN 806. neonatal), renal, respiratory (may
include cystic fibrosis units) or other
Alert organisms: Alert organisms are intensive care situations;
microorganisms that have the potential to cause
harm and disease in individuals and which can c. those patients who have extensive
cause an outbreak of infection in a hospital breaches in their dermal integrity and
environment. An alert organism is identified by require contact with water as part of
the microbiology laboratory and referred to the their continuing care, such as in those
infection prevention and control (IPC) team for units caring for burns.
assessment of possible healthcare-associated
acquisition and to identify any possible Backflow – Flow upstream, that is in a
environmental/equipment sources. direction contrary to the intended normal
direction of flow, within or from a water fitting.
Augmented care units/settings – There is no
fixed definition of “augmented care”; individual Biofilm: A biofilm is a complex layer of
providers may wish to designate a particular microorganisms that have attached and grown
service as one where water quality must be on a surface. This form of growth provides
of a higher microbiological standard than that a niche environment for a wide range of
provided by the supplier. While this document microorganisms to interact and where the
provides broad guidance, the water quality secretion of exopolysaccharides by bacteria
required will be dependent on both the type will form an extracellular matrix for both
of patient and its intended use. Most care bacteria and other unicellular organisms such
that is designated as augmented will be that as amoebae and flagellates to remain in a
where medical/nursing procedures render the protected state.
patients susceptible to invasive disease from
environmental and opportunistic pathogens Colony forming unit: Unit that gives rise to
such as Pseudomonas aeruginosa and other a bacterial colony when grown on a solid
alert organisms. In broad terms, these patient medium; this may be a single bacterial cell or a
groups will include: clump of cells.
a. those patients who are severely Dead-leg – a length of water system pipework
immunosuppressed because of leading to a fitting through which water only
disease or treatment: this will include passes infrequently when there is draw-off from
transplant patients and similar heavily the fitting, providing the potential for stagnation.
immunosuppressed patients during
high-risk periods in their therapy;
vii
Flow straightener: A device inserted into the Waterborne pathogen: microorganism

spout outlet of a tap to modify flow, take out capable of causing disease that may be
turbulence and create an even stream of water. transmitted via water and acquired through
ingestion, bathing, or by other means.
Healthcare-associated infections (HCAI):
encompasses any infection by any infectious Water outlet: (In this document) refers mainly
agent acquired as a consequence of a person’s to taps and showerheads, but other outlets, as
treatment or which is acquired by a healthcare indicated by risk assessments, may be
worker in the course of their duties. considered important.
Healthcare facility/building – all buildings: Water Safety Group (WSG): A
infrastructure, equipment, plant, embedded multidisciplinary group formed to undertake the
systems and related items that support the commissioning and development and ongoing
delivery of healthcare and services of all types, management of the water safety plan (WSP). It
irrespective of their ownership or operation by also advises on the remedial action required
third parties. when water systems or outlets are found to be
contaminated and the risk to susceptible
Healthcare organisations: organisations that patients is increased.
provide or intend to provide healthcare services
for the purposes of the NHS. Water safety plan (WSP): A risk-management
approach to the safety of water that establishes
Legionellosis: a collective term for diseases good practices in local water distribution and
caused by Legionella bacteria including the supply. It will identify potential hazards, consider
most serious Legionnaires’ disease, as well as practical aspects, and detail appropriate control
the similar but less serious conditions of Pontiac measures.
fever and Lochgoilhead fever.
Water supply [to the healthcare facility]:
Manual mixing tap – a tap that controls both The water supplied can be via:
the flow and temperature of water delivered.
• the mains water supply from the local
Point-of-use (POU) filter: a filter with a water undertaker;
maximal pore size of 0.2 μm applied at the outlet,
• a borehole (operated by the healthcare
which removes bacteria from the water flow.
organisation as a private water supply);
Redundant pipework (also known as blind • a combination of mains water and
end): a length of pipe closed at one end borehole supply;
through which no water passes. • emergency water provision (bulk tankered
Remediation: Any process that reduces the water or bottled drinking water).
risk from harmful agents such as Water undertaker – the role of a water
microorganisms. undertaker is defined in a number of sections of
Thermostatic mixing tap: a tap that controls the Water Industry Act 1991.
the flow and by thermostatic means the Wholesomeness: standards of
temperature of water delivered. wholesomeness are defined in section 67 of the
Thermostatic mixing valve: valve with one Water Industry Act 1991. Separate legislation for
outlet, which mixes hot and cold water and public and private supplies sets out the
automatically controls the mixed water to a prescribed concentrations and values for water
user-selected or pre-set temperature. and are detailed in the following legislation: the
Water Supply (Water Quality) Regulations 2000
Transmission: Any mechanism by which an for water from a public supply; or the Private
infectious agent is spread from a person or Water Supplies Regulations 2009 for water from
environmental source to a susceptible person. a private supply.
viii
List of abbreviations
cfu – colony forming units
COSHH – Control of Substances Hazardous to

Health [Regulations]
CQC – Care Quality Commission
DWI – Drinking Water Inspectorate
EA – Environment Agency
EPDM – ethylene propylene diene monomer
HBN – Health Building Note
HSE – Health & Safety Executive
HSG274 Part 2 – The Health & Safety

Executive’s technical guidance on the control
of Legionnaires’ disease in hot and cold water
systems.
HTM – Health Technical Memorandum
MCA: milk cetrimide agar
MRD: maximum recovery diluent
POU – point-of-use
PWTAG – Pool Water Treatment Advisory

Group
SHTM – Scottish Health Technical

Memorandum
WRAS – Water Regulations Advisory Scheme
WSG – Water Safety Group
WSP – Water safety plan
ix
0 Policy and regulatory overview: water safety and the healthcare estate
0 Policy and regulatory overview: water safety

and the healthcare estate
Introduction Adhering to the guidance outlined in this HTM

will be taken into account as evidence towards
0.1 The National Health Service (NHS) has compliance with these legal requirements and
a corporate responsibility to account for the governance standards.
stewardship of its publicly funded assets.
This includes the provision, management
and operation of an efficient, safe estate that Compliance of the healthcare
supports clinical services and strategy.
estate
0.2 This corporate responsibility is carried 0.6 Principles related to the safety of
by all accountable officers, directors with healthcare estates and facilities are
responsibility for estates and facilities and their enshrined in the Health and Social Care
equivalents, chairs, chief executive officers and Act 2008 (Regulated Activities) Regulations
non-executive board members. Together they 2014, specifically Regulation 12(2)(h) and
have a responsibility to enact the principles Regulation 15 of the Act.
set out in this document, provide leadership
and work together to implement the necessary
Note
changes to provide a safe, efficient high quality
healthcare estate. There are numerous other statutes and
legal requirements that NHS organisations,
0.3 To achieve this, quality and fitness-for- supporting professionals, contractors and
purpose of the healthcare estate is vital. Health suppliers must comply with. These are
Technical Memorandum (HTM) 04-01 seeks to covered in the respective Health Building
set out the quality of, and standards for, water Notes (HBNs), Health Technical Memoranda
safety in the healthcare estate. (HTMs) and the NHS Premises Assurance
Model (NHS PAM).
0.4 A healthcare organisation’s Water Safety
Group (WSG) (see Part B) is pivotal in ensuring
that decisions affecting the safety and Health and Social Care Act 2008 (Regulated
integrity of the water systems and associated Activities) Regulations 2014
equipment do not go ahead without being 0.7 Regulation 12(2)(h) decrees that registered
agreed by them. This includes consultations providers must assess:
relating to decisions on the procurement,
design, installation and commissioning of water • the risk of, and prevent, detect and
services, equipment and associated treatment control the spread of, infections,
processes. including those that are health care
associated.
0.5 The quality and fitness-for-purpose of
the estate are assessed against a set of legal
requirements and governance standards.
1
0.8 Appropriate standards of cleanliness and ‘Guidance for providers on meeting the
hygiene should be maintained in premises used regulations’ explains how to meet regulations
for the regulated activity. DH (2015) issued 12(2)(h) and 15 outlined above.
‘The Health and Social Care Act 2008 Code
of Practice on the prevention and control of 0.11 Failure to comply with the Health and
infections and related guidance’ (the HCAI Social Care Act 2008 (Regulated Activities)
Code of Practice), which contains statutory Regulations 2014 and the Care Quality
guidance about compliance with regulation Commission (Registration) Regulations
12(2)(h) (see paragraphs 0.15–0.17). (2009) is an offence, and the CQC has a
wide range of enforcement powers that it
0.9 Regulation 15 of the Act states that: can use if a provider is not compliant. These
include the issue of a warning notice that
(1) All premises and equipment used by the requires improvement within a specified
service provider must be – time, prosecution, and the power to cancel a
provider’s registration, removing its ability to
a. clean, provide regulated activities.
b. secure,
Examples of governance and assurance
c. suitable for the purpose for which they mechanisms arising from primary legislation
are being used, (not exhaustive)
NHS Constitution
d. properly used,
0.12 The Health Act 2009 places a duty
e. properly maintained, and on bodies providing and commissioning
NHS services to have regard to the NHS
f. appropriately located for the purpose Constitution. The Health and Social Care
for which they are being used. Act 2012 further applied this duty to the new
bodies created by that Act or by amendments
(2) The registered person must, in relation to to the 2012 Act.
such premises and equipment, maintain
standards of hygiene appropriate for the 0.13 The NHS Constitution “sets out rights to
purposes for which they are being used. which patients, public and staff are entitled”.
It also outlines “the pledges which the NHS
Note is committed to achieve, together with
responsibilities that the public, patients and
The “registered person” means, in respect staff owe to one another to ensure that the
of a regulated activity, the person who is the NHS operates fairly and effectively”.
service provider or a registered manager in
respect of that activity. 0.14 It commits the NHS to ensuring “that
services are provided in a clean and safe
A “service provider” means a person environment that is fit for purpose, based
registered with the CQC under Chapter 2 on national best practice (pledge)”. In order
of Part 1 of the Health and Social Care Act to deliver on this pledge, the NHS should take
2008 as a service provider in respect of that account of:
regulated activity.
• the NHS Premises Assurance Model
(NHS PAM) – the NHS PAM identifies
Regulator requirements
where the NHS Constitution needs to
0.10 The CQC independently regulates all be considered and where assurance is
providers of regulated health and adult social required;
care activities in England. The CQC’s (2015)
2
• national best practice guidance for the

design and operation of NHS healthcare Figure 1 illustrates how DH estates and
facilities (such as HBNs and HTMs). facilities best practice guidance (such
as the NHS PAM and HTMs) aligns with
The HCAI Code of Practice the statutory and policy framework. This
guidance is fundamental to ensuring that
0.15 A complex range of issues distinguishes NHS trusts are able to deliver on their
healthcare environments from most other commitments under the NHS Constitution
building types. One of the most important and to comply with the CQC’s fundamental
of these relates to the control of infection. standards.
Infection prevention and control teams should
be consulted on any design decisions and a
risk analysis conducted on the many issues of Never events
design involving water systems (see HBN 00-
09 – ‘Infection control in the built environment’). 0.18 NHS England’s never events policy
To manage and monitor the prevention and framework defines “never events” as serious,
control of infections effectively, the HCAI Code largely preventable patient safety incidents that
of Practice requires a WSG and a water safety should not occur if the available preventive
plan (WSP) to be in place. measures have been implemented by
healthcare providers. On the list of never events
0.16 The information outlined in HBN 00- is scalding of patients. The risk of scalding
09 follows the general principles given in the for vulnerable patients (children and young
HCAI Code of Practice, which sets out criteria people, older people, and disabled people) is a
against which a registered provider will be particular problem in healthcare premises. HTM
judged on how it complies with Regulation 04-01 provides guidance on reducing the risk
12(2)(h) of the Health and Social Care Act 2008 of scalding.
(Regulated Activities) Regulations 2014 on the
prevention, detection and control of infections,
particularly waterborne infections in relation to Health and safety legislation
this document. 0.19 In the UK, the control of Legionellae
falls within the requirements of the Health and
0.17 The law states that the HCAI Code Safety at Work etc. Act. This Act also places
of Practice must be taken into account by duties on design teams, suppliers and installers
the CQC when it makes decisions about to ensure that articles or substances for use
registration against the cleanliness and at work are safe and without risks to health
infection control requirement. The regulations and that any information related to the article
also say that providers must have regard to or substance is provided. The Management of
the Code when deciding how they will comply Health and Safety at Work Regulations 1999
with registration requirements. Therefore, by provide a broad framework for controlling
following the Code, registered providers will be health and safety at work. The Control of
able to show that they meet the requirement Substances Hazardous to Health Regulations
set out in the regulations. However, the Code 2002 (COSHH) provide a framework of actions
is not mandatory. A registered provider may designed to assess, prevent or control the risk
be able to demonstrate that it meets the from bacteria like Legionella and take suitable
regulations in a different way (equivalent or precautions.
better) from that described in this document.
The Code aims to exemplify what providers 0.20 The Health & Safety Executive’s
need to do in order to comply with the (HSE) (2013) Approved Code of Practice
regulations. ‘Legionnaires’ disease: The control of
Legionella bacteria in water systems (L8)’
contains practical guidance on how to manage
3
and control the risks in water systems. The cold water services, new or extended, in any
HSE has published complementary technical healthcare premises should also comply with:
guidance in HSG274, which is split into three
specific areas: • the Water Supply (Water Fittings)
Regulations 1999;
• Part 1 – evaporative cooling systems; • Defra’s guidance to the Water Supply
• Part 2 – hot and cold water systems; and (Water Fittings) Regulations;
• Part 3 – other risk systems. • recommendations of the water suppliers
in the Water Regulations Advisory
0.21 In addition, under the Reporting of Scheme’s (WRAS) ‘Water Regulations
Injuries, Diseases and Dangerous Occurrences Guide’; and
Regulations (RIDDOR), there is a duty for
• any other requirements of the local water
employers to report any cases of legionellosis
undertaker.
in an employee who has worked on hot
and cold water systems that are likely to
be contaminated with Legionella. Cases of Water Supply (Water Fittings) Regulations
legionellosis are reportable under RIDDOR if: 1999
0.25 These Regulations set legal requirements
a. a doctor notifies the employer; and for the design, installation, operation and
maintenance of plumbing systems, water
b. the employee’s current job involves
fittings and water-using appliances. They
work on or near cooling systems that
have a specific purpose to prevent misuse,
are located in the workplace and
waste, undue consumption or erroneous
use water; or work on water-service
measurement of water and, most importantly,
systems located in the workplace
to prevent contamination of drinking water.
which are likely to be a source of
contamination. 0.26 These Regulations apply in all types of
premises supplied, or to be supplied, with
0.22 With regard to enforcement
water from a water undertaker. They apply from
responsibilities, the HSE will take the lead with
the point where water enters the property’s
regard to incidents involving Legionella. See
underground pipe, to where the water is used
the Health and Safety Executive/Care Quality
in plumbing systems, water fittings and water-
Commission/Local Government Association’s
using appliances. However they do not apply in
(2015) ‘Memorandum of understanding
premises that have no provision of water from
between the Care Quality Commission,
the public mains supply.
the Health and Safety Executive and local
authorities in England’.
Water Supply (Water Quality) Regulations
2000
Security 0.27 These Regulations cover the quality
0.23 Accessibility to all plant and equipment of water supplied by water undertakers
should be limited to authorised personnel only for public distribution which is intended for
(see NHS Protect’s (2012) ‘Guidance on the domestic purposes; these purposes include
security and management of NHS assets’). drinking, cooking, food preparation, washing
and sanitation. Water supplied meeting
these quality requirements is referred to as
Water regulations wholesome water.
0.24 As well as complying with the
recommendations outlined in this document,
the design and installation of the hot and
4
Private Water Supplies Regulations 2009

0.28 These Regulations cover private sources
of water intended for human consumption
including drinking, cooking, food preparation or
other domestic purposes, such as boreholes
and wells. Water meeting these quality
requirements is referred to as wholesome
water. These Regulations also place duties
for monitoring and control of the quality of
public water supplies where these are then
further distributed to other users on separate
premises by the water company’s bill payer
(this arrangement is often referred to as onward
distribution).
0.29 Local authorities are the regulators for

private water supplies and have a number
of statutory duties under the Private Water
Supplies Regulations.
5
PARLIAMENT
Secretary of State for Health
Legislation
LAW LAW LAW
Health and Social Health and Social CQC
Care Act 2012 Care Act 2008 Regulations
(Regulated Activities) 2014
CQC
Policy
drivers
Example governance and Guidance for

providerson meeting
assurance standards that The Health and Social Care

Act 2008
the regulations
Health and Social Care Act 2008 (Regulated
help to influence safe

Code of Practice on the prevention and control of Activities) Regulations 2014(Part 3) (as amended)
infections and related guidance Care Quality Commission (Registration)
Regulations 2009( Part 4) (as amended)
heathcare estates and March2015
facilities
for England
26 March 2013
July 2015
(not an exhaustive list)

NHS HCAI Code of CQC
Constitution Practice standards
DH estates best practice guidance

Health Building Note 00-10
Part D: Windows and
associated har dware
Health Building Note 00-10

The NHS Premises Part D: Windows and
associated har dware
Assurance Model (NHS PAM)
August 2013 Update
December 2013
Multimedia and
December 2013
August 2013
web applications (e.g. ADB) HBNs/HTMs

NHS PAM
IMPROVED PATIENT OUTCOMES
Safety Effectiveness Patient experience
Figure 1 How best practice guidance on the safety and quality of healthcare estates and facilities fits in with the legislative and policy
framework. (The statutes and mandatory requirements shown in this figure are not exhaustive. See Note after paragraph 0.6.)
6
1 Introduction
1 Introduction
1.1 This edition of HTM 04-01 – ‘Safe water General

in healthcare premises’ supersedes HTM
04-01 – ‘The control of Legionella, hygiene, 1.4 Current statutory legislation requires both
“safe” hot water, cold water and drinking “employers” and “employees” to be aware of
water systems’ published in 2006. It is also their individual and collective responsibility for
based on the guidance given in HTM 04-01: the provision of safe wholesome hot and cold
Addendum ‘Pseudomonas aeruginosa – advice water supplies, and storage and distribution
for augmented care units’. It has been revised systems in healthcare premises. Ultimate
to take account of revisions to the HSE’s (2013) responsibility for management will fall to the
Approved Code of Practice L8 and technical statutory duty holder of the premises (see
guidance HSG274. paragraph 1.8 for a definition of the statutory
duty holder).
1.2 This HTM gives comprehensive advice
and guidance to healthcare management, 1.5 Healthcare premises are dependent on
design engineers, estate managers, operations water to maintain hygiene and a comfortable
managers and infection control specialists on environment for patients, visitors and staff, and
the legal requirements, design applications, for clinical and surgical care.
installation, commissioning, maintenance and
1.6 Intelligent design, construction, installation,
operation of hot and cold water supply, storage
commissioning and maintenance of hot and
and distribution systems and associated
cold water supply systems to minimise the
equipment and systems in all types of
risks of waterborne illness are vital for public
healthcare premises. It is equally applicable to
health.
both new and existing sites.
1.7 Interruptions in water supply can disrupt
1.3 In its new form, the document is divided
healthcare activities. Procedures should be
in three parts. This part (Part B) covers
in place to minimise the consequence of
operational management, including the
disruption, while at the same time ensuring
control of Legionella, P. aeruginosa and
an adequate turnover of water to prevent
other important waterborne pathogens. This
stagnation in storage vessels and distribution
document should be read in conjunction with
systems (see paragraphs 2.16–2.17 in HTM
Part A which outlines the principles involved
04-01 Part A and also HBN 00-07 – ‘Planning
in the design, installation, commissioning and
for a resilient healthcare estate’).
testing of the hot and cold water supply, and
storage and distribution systems for healthcare
premises. Some variation may be necessary Duty holder
to meet the differing provision arrangements of
the various water undertakers and complexity 1.8 In this document, the statutory duty holder
of distribution systems. Part C covers water is either the employer or the person in control
safety in augmented care settings. of the healthcare premises. Typically these
could be the owner, chief executive, board of
7
directors, or other person who is ultimately applicability will need to be considered in each
accountable, and on whom the duty falls, for case.
the safe operation of healthcare premises.
1.13 This HTM does not cover wet cooling
Shared premises systems such as cooling towers. Guidance
on these systems is given in HSE’s Approved
1.9 In estate management, it is increasingly Code of Practice and guidance ‘Legionnaires’
common for there to be several duty holders in disease: The control of Legionella bacteria in
one building. In such cases, duties may arise water systems (L8)’ and HSG274 technical
where persons or organisations have clear guidance Part 1.
responsibility through an explicit agreement
such as a contract or tenancy agreement. 1.14 While some guidance on other water-
service applications is included, it is not
1.10 The extent of the duty will depend on intended to cover them fully. For:
the nature of that agreement. For example, in
a building occupied by one leaseholder, the • process waters used for laundries, see
agreement may be for the owner or leaseholder HTM 01-04 – ‘Decontamination of linen
to take on the full duty for the whole building in health and social care’;
or to share the duty. In a multi-occupancy • endoscopy units, see HTM 01‑06
building, the agreement may be that the owner – ‘Decontamination of flexible
takes on the full duty for the whole building. endoscopes’;
Alternatively, it might be that the duty is
shared where, for example, the owner takes • primary care dental premises, see HTM
responsibility for the common parts while the 01-05 – ‘Decontamination in dental
leaseholders take responsibility for the parts practices’;
they occupy. In other cases, there may be an • renal units, see HBNs 07-01 and 07-02,
agreement to pass the responsibilities to a the Renal Association’s guidelines, BS
managing agent. Where a managing agent is EN ISO 13959 and BS EN ISO 11663;
used, the management contract should clearly
specify who has responsibility for maintenance • sterile services departments, see HBN 13
and safety checks, including managing the risk – ‘Sterile services department’;
from waterborne hazards. • hydrotherapy pools, see the PWTAG’s
‘Swimming pool water: treatment and
1.11 Where there is no contract or tenancy quality standards for pools and spas’;
agreement in place or it does not specify
• spa pools, see HSE/PHE’s ‘Management
who has responsibility, the duty is placed on
of spa pools: controlling the risks of
whoever has control of the premises or part of
infection’;
the premises.
Note
Areas this HTM does not cover This document is currently being revised
1.12 Although many of this HTM’s and will become HSG274 Part 4 – ‘The
recommendations will be applicable, it does control of Legionella and other infectious
not set out to cover water supply for fire- agents in spa pool systems’.
fighting services nor water supply for technical,
industrial or other specialist purposes, other • birthing pools, see HBN 09-02 –
than to indicate precautions that should be ‘Maternity care facilities’ and PWTAG’s
taken when these are used in association with ‘Swimming pool water: treatment and
domestic water services. The point at which quality standards for pools and spas’.
a domestic activity becomes an industrial
process has not been defined, and the
8
2 Governance and management responsibility
• appoint a competent person with

Note sufficient authority and knowledge of the
Governance is concerned with how an installation to help take the measures
organisation directs, manages and monitors needed to comply with the law.
its activities to ensure compliance with 2.3 To implement the above legal duties in
statutory and legislative requirements while a healthcare organisation, the duty holder
ensuring the safety of patients, visitors and should appoint a WSG to undertake the
staff is not compromised. commissioning, development, implementation
and review of a WSP. The aim of the WSG is to
To help achieve this, healthcare ensure the safety of all water used by patients/
organisations need to ensure that sound residents, staff and visitors, and to minimise
policies are approved by the board of the risk of infection associated with waterborne
directors. These should: pathogens. This is supported by the HCAI
• ensure safe processes, working Code of Practice (see paragraphs 0.15–0.17),
practices and risk-management which recommends that management and
strategies are in place to safeguard all monitoring arrangements should ensure that a
their stakeholders and assets in order WSG and WSP are in place.
to prevent and reduce harm or loss;
2.4 The WSP should demonstrate that any
and
person on whom the statutory duty falls has
• be backed up with adequate fully appreciated the requirement to provide
resources and suitably qualified, an adequate supply of hot and cold water
competent and trained staff. of suitable quality. Though compliance with
this guidance may be delegated to staff or
2.1 This guidance should be applied to all undertaken by contractors, accountability
healthcare premises, however small, where cannot be delegated. The WSG should ensure
there is a duty of care under the Health and that appropriate expertise and competence
Safety at Work etc. Act 1974. is available to ensure the delivery of safe
water for all uses throughout the organisation.
2.2 To ensure governance with regard to This group should have clearly identified
water safety, the duty holder will: lines of accountability up to the CEO and
board. For membership of the group, see
• identify and assess sources of risk; paragraphs 6.5–6.6.
• if appropriate, prepare a written scheme
for preventing or controlling the risk; 2.5 The WSG should include persons who
are fully conversant with the design principles
• implement, manage and monitor and requirements of water systems and should
precautions; be fully briefed in respect of the cause and
• keep records of the precautions; effect all waterborne hazards.
9
2.6 The WSP is a holistic approach to 2.10 The risk assessor(s) should be given
manage water for all uses (including diagnostic access to competent assistance from the
and treatment purposes) so that it is safe client. This may be in the form of:
for all users including those most at risk of
waterborne infections as a consequence of • engineering and building expertise;
their illness or treatment (see paragraphs • as-fitted drawings and schematic
6.16–6.22). diagrams;
2.7 All regular tests and checks set out in • clinical expertise;
the WSP should be carried out even if they • knowledge of building occupancy and
cause minor disruption to healthcare services, use including vulnerability of patient
and comprehensive records should be groups;
maintained in accordance with the healthcare
organisation’s management policy. • bespoke equipment plus policies,
procedures and any protocols (for
2.8 A risk assessment forms an integral example cleaning of wash-hand basins
component of the WSP and is a legal and disposal of clinical effluent etc).
requirement to identify potential hazards (which
may be microbial, chemical or physical) in 2.11 In addition access should be made
the system, risks of infection to patients, staff available to all required areas (and associated
and visitors, and other indicators of water systems and equipment) unless deemed
quality (for example, taste, odour, flavour and inaccessible by legislation (for example areas
appearance if intended for drinking). See that contain asbestos).
paragraphs 6.23–6.26 for typical examples of
2.12 For Legionella risk assessments,
issues to consider in the risk assessment.
contractors should be able to demonstrate a
2.9 The risk assessment should be carried full understanding of, and work to, BS 8580.
out by a competent person or persons. If the In addition to guidance provided above, the
provision of risk assessments is contracted to documents below should also be referenced
an external organisation, it is recommended in relation to the specification, procedures and
that those engaged to carry out any risk general requirements for completing robust and
assessments associated with water safety fit-for-purpose water safety risk assessments:
should be able to demonstrate to the WSG
• HSG274 Part 2 (2014) – ‘The control of
their experience and competence in assessing
Legionella bacteria in hot and cold water
specific risks from microbiological, chemical
systems’.
and physical hazards on the specific healthcare
population. They should also be able to give • BS 8580 – ‘Water quality: risk
advice on how to manage the systems/ assessments for Legionella control –
equipment to minimise the risks etc. It is the Code of Practice’.
responsibility of the WSG to determine the • BSRIA’s (1999) FMS 4/99 – ‘Guidance
method of demonstrating this competence. and the standard specification for water
Core requirements including accredited training services risk assessment’.
and personal examples of recent water safety
risk assessments in the healthcare sector • BSRIA’s (2015) BG 57/2015 –
presented orally and/or by interview should be ‘Legionnaires’ disease – risk
considered options. Detailed knowledge and assessment’.
expertise requirements of the risk assessor(s)
2.13 Management procedures should ensure
are provided in the World Health Organization’s
that compliance is continuing and not notional.
(WHO) (2011) ‘Water safety in buildings’.
The prime purpose of the assessment is to be
able to demonstrate that the WSG is aware of
10
all the relevant factors that may pose a risk of

waterborne infection, that effective corrective or
preventive action has been implemented, and
that monitoring is in place to ensure the plans
are effective in controlling the risk.
2.14 Healthcare organisations should be aware

of the legal duty to notify the water undertaker
when it is proposed to carry out works on any
systems conveying water from the public water
supply (see the WRAS website).
Note
Water undertakers can carry out a fittings

inspection to ensure that work has been
properly carried out and that the public
water supply remains protected for work
carried out.
11
3 Statutory requirements
3.1 It is the responsibility of the duty holder The Management of Health and
to ensure that their premises comply with all
statutes.
Safety at Work Regulations 1999
3.5 These regulations provide a broad
3.2 Duty holders have an overriding general framework for controlling health and safety at
duty of care under the Health and Safety at work. They require every employer to make a
Work etc. Act 1974. Therefore, they should suitable and sufficient assessment of all risks
ensure that the water supply, storage and to health and safety of employees and the
distribution services are installed and operated public caused by work activities, and require
within the terms of the following legislation. employers to have access to competent help in
applying the provisions of health and safety law.
In addition to Legionella and other waterborne
Health and Safety at Work etc. Act pathogens, other risks from a hot and cold
1974 water distribution system include deterioration
3.3 Employers have a general duty under the of water quality, scalding at hot water outlets
Health and Safety at Work etc. Act 1974 to and danger due to pipe bursts at excessive
ensure, so far as is reasonably practicable, the pressures.
health, safety and welfare of patients, visitors
and staff and the public who may be affected Control of Substances Hazardous
by workplace activities.
to Health (COSHH) Regulations
3.4 These duties are legally enforceable, 2002
and the HSE has successfully prosecuted
employers including health organisations 3.6 These regulations provide a framework
under this statute. It falls upon owners and of actions designed to control the risk from
occupiers of premises to ensure that there a range of harmful substances including
is a management regime for the proper waterborne pathogens such as Legionella and
design, installation and maintenance of plant, the chemicals that may be used to control the
equipment and systems. Failure to have a growth of microorganisms in water supplies.
proper system of working and adequate control Employers have a duty to assess the risks from
measures can also be an offence even if an exposure to these substances to ensure that
outbreak of, for example, Legionnaires’ disease they are adequately controlled.
or other such incident has not occurred.
12
3 Statutory requirements
Public Health (Infectious Diseases) purposes. These regulations also place duties
for monitoring and control of the quality of
Regulations 1988 public water supplies where these are then
3.7 The Public Health (Infectious Diseases) further distributed to separate premises by the
Regulations 1988 require that a properly bill payer other than the water undertaker or
appointed officer inform the chief medical licensed water supplier (often referred to as
officer for England or for Wales, as the case onward distribution).
may be, of any serious outbreak of any disease
that to his/her knowledge has occurred in the
district. Food Safety Act 1990
3.10 The Food Safety Act 1990 covers water
Note used for food preparation or food manufacture
and also includes water used for drinking. The
Appendix 2.3 of HSE’s Legionella Food Safety and Hygiene (England) Regulations
technical guidance HSG274 Part 2 (2013) 2013 are also relevant.
contains further advice and guidance on
communication and cooperation with
the consultant in communicable disease The Health and Safety Executive’s
control (CCDC), and on arrangements for (4th edition) Approved Code of
support of the CCDC and for this person
to have access to provider units including Practice L8 2013
healthcare organisations. 3.11 The HSE’s (2013) Approved Code of
Practice L8 (4th edition) came into effect
on 7 November 2013 and is supported
Water Supply (Water Quality) by the technical guidance (HSG274 Parts
Regulations 2000 1–3). It replaced the earlier publication
entitled ‘Legionnaires’ disease: The control
3.8 The Water Supply (Water Quality) of Legionella bacteria in water systems –
Regulations 2000 apply to water supplied by Approved Code of Practice and guidance’ (L8
a water undertaker to any premises that are 3rd edition). The onus is on the duty holder to
used for domestic purposes such as drinking, demonstrate that procedures in place are as
cooking, personal hygiene, washing or food good as, or better than, those required by L8.
production.
3.12 The Approved Code of Practice L8 has a
Note special legal status. If a person or organisation
is prosecuted for a breach of health and safety
Two additional sources of advice on drinking law and it is proved that they did not follow the
water quality are: provisions of the Code, they will need to show
that they have complied with the law in some
a. the director of public health; other equally effective way or a court will find
b. WHO’s ‘Guidelines for drinking water them at fault. Health and safety inspectors seek
quality’. to secure compliance with the law and may
refer to this guidance.
3.13 Compliance with HSG274 will satisfy the

Private Water Supplies Regulations Approved Code of Practice L8.
2009
3.14 The health service, with responsibility
3.9 These regulations cover private sources
for the wider aspects of public health and the
of water such as boreholes and wells intended
operation of healthcare premises, is expected
for human consumption including drinking,
to be particularly vigilant.
cooking, food preparation or other domestic
13
3.15 The incidence of healthcare- British and European Standards

associated waterborne illness including
Legionnaires’ disease is relatively low, but • The BS EN 805 series covers design and
cases and outbreaks are considered to be installation requirements for systems and
avoidable. Management, operators and components outside buildings.
contractors should be aware that incidents • The BS EN 806 series covers installations
or outbreaks cause widespread concern, inside buildings conveying water for
especially if associated with healthcare human consumption.
premises. Investigation of these outbreaks • BS 8558 provides UK-specific
has shown that they are generally related to complementary guidance to the BS EN
poor training, flaws in system design, poor 806 series of standards, replacing BS
commissioning and risk assessments, defects 6700.
and breakdowns. However, by far the greatest
contributors to outbreaks of Legionnaires’ • BS 1710 is the British Standard
disease are poor or inappropriate maintenance specification for identification of pipelines
and control procedures and ineffective and services.
communication and systems management. • PD 855468 – ‘Guide to the flushing and
disinfection of services supplying water
for domestic use within buildings and
Water Supply (Water Fittings) their curtilages’.
Regulations 1999 • BS 8551 – ‘Provision and management
3.16 These regulations set legal requirements of temporary water supplies and
for the design, installation, operation and distribution networks (not including
maintenance of plumbing systems, water provisions for statutory emergencies).
fittings and water-using appliances. They Code of practice’.
have a specific purpose to prevent misuse,
• BS 8554 – ‘Code of practice for the
waste, undue consumption or erroneous
sampling and monitoring of hot and cold
measurement of water and, most importantly,
water services in buildings’.
to prevent contamination of drinking water.
These regulations are enforced by the local • BS 7592 – ‘Sampling for Legionella
water undertaker. bacteria in water systems. Code of
practice’.
3.17 These regulations apply in all types of
premises supplied, or to be supplied, with
water from a water undertaker. They apply from
the point where water enters the property’s
underground pipe, to where the water is used
in plumbing systems, water fittings and water-
using appliances. However they do not apply in
premises that have no provision of water from
the public mains supply.
3.18 These regulations are set out – along

with the Department for Environment,
Food and Rural Affairs’ (Defra) guidance
on the regulations and the water industry’s
recommendations for fulfilling these provisions
– in the ‘Water Regulations Guide’ published
by the Water Regulations Advisory Scheme
(WRAS).
14
4 Legionella: overview
Source of the bacteria products, trapped organic and

inorganic molecules supplied by the
4.1 Legionella bacteria are ubiquitous in flowing water and a range of surface
both the natural and constructed aquatic materials.
environment and are widespread in natural
freshwater including rivers, lakes, streams and Legionella are unable to grow in
d.
ponds and may also be found in damp soil. sterile water as they require other
microorganisms for growth. Legionella
4.2 Airborne dispersal may occur when
have also been shown to proliferate
aerosols or droplet nuclei are created. There
rapidly in association with some
is a strong likelihood of low concentrations of
waterborne protozoa including
Legionella existing in all open water systems
amoebae.
including those of building services; therefore,
the main emphasis should be on preventing e. Water fittings, pipework and materials
Legionella from multiplying in water systems in used in the construction of water
healthcare premises. systems can encourage the growth of
waterborne pathogens. Water quality
can deteriorate within the system
Ecology and in components such as terminal
4.3 The following factors have been found fittings, particularly when utilisation
to influence the colonisation and growth of is low. Pipework downstream of
Legionella: thermostatic mixing valves may pose
a particular problem as the lower
a. Water temperature between 20°C and temperature can encourage the
45°C will promote growth. growth of waterborne pathogens.
b. Areas of poor flow, stagnation or
inappropriate components. Epidemiology
c. Biofilms play an important role in 4.4 Legionnaires’ disease is often described
harbouring and providing favourable as an atypical acute pneumonia of rapid onset
conditions in which Legionella can often with gastrointestinal symptoms, which
grow. Biofilms in water systems are can confuse the diagnosis. Legionnaires’
heterogeneous and will consist of disease is predominantly caused by inhalation
bacteria, fungi, algae, protozoa, debris of L. pneumophila serogroup 1, which is the
and corrosion products. Nutrients commonest cause of Legionnaires’ disease
can be provided to the biofilm from accounting for around 85% of cases within
the incoming water, particularly where the EU (see the European Centre for Disease
there is increased turbidity and also Prevention and Control’s (ECDC) website).
from scale, sediment, corrosion However, other non-pneumophila species
have also been shown to cause disease in
15
hospitals. Pontiac fever is a self-limiting form Control measures

of legionellosis which usually requires no
treatment. Outbreaks of Pontiac fever have See also:
been associated with patients showering.
• paragraphs 5.11–5.16 on
4.5 The risk of healthcare-associated management of control;
legionellosis depends on a number of factors • Chapter 4 in Part A on water
such as: treatment and control programmes for
• the presence of Legionella in sufficient hot and cold water systems.
numbers (see also paragraph 4.15);
4.7 A temperature control regime is the
• conditions suitable for multiplication of traditional means of controlling Legionella in
the organisms (for example temperatures hot and cold water services. Hot and cold
between 20°C and 45°C); water systems should be maintained to keep
• source of nutrients (for example scale, cold water, where possible, at a temperature
sludge, rust, protozoa, and other below 20°C, and to keep hot water stored at
available organic carbon, bacteria and 60°C and distributed so that it reaches the
biofilms); outlets at 55°C within one minute. Owing to
the complexity of hot and cold water systems
• a means of creating and disseminating
found in healthcare facilities and the difficulty
aerosols (a typical droplet size of <5 µm
of maintaining a temperature control regime
can be inhaled deep into the lungs)
at all times, in all areas, chemical and other
that contain viable Legionella (potential
water treatments that have been shown to be
sources, for example, include showers
capable of controlling microbial colonisation
and most other water draw-offs that are
and growth may need to be considered as an
capable of creating an aerosol);
additional control measure.
Note 4.8 Validation of treatment systems is
Some cases of Legionnaires’ disease in important to ensure that the design and
healthcare premises have been associated operation of a new or modified system is
with aspiration of contaminated ingested effective. Ongoing verification by operational
water rather than inhalation of aerosols. monitoring is essential to ensure that the
control measures remain effective. The
• the presence of people who may have monitoring of treatment programmes should
compromised immune or respiratory demonstrate that they are working within
systems or have other risk factors that legislation and the established guidelines, and
increase their susceptibility to Legionella are effective in controlling the target waterborne
infection. pathogens. The frequency of monitoring and
test procedures will vary according to the
4.6 Many, if not all, of these factors are likely to method selected.
be encountered in healthcare premises.
4.9 The use of biocides requires meticulous
monitoring and their use can have an effect on
water quality including taste and odour.
16
4.10 Where biocides are used, risk Number of infectious bacteria

assessments (which have been agreed with
the WSG) should identify at-risk patient groups 4.14 The number of organisms that cause
(and/or equipment) to ensure there are no infection has not been reliably determined and
unforeseen consequences for patients (for is likely to vary from person to person.
example, patients in neonatal units and renal 4.15 Two factors determine the number of
units). bacteria deeply inhaled:
a. The concentration of bacteria in

Route of infection the air is determined both by the
4.11 The principal route of infection for concentration of bacteria in the water
Legionnaires’ disease is through inhalation of and by the amount of contaminated
the bacteria into the lungs via aerosols. The water dispersed into a given air
risk rises with increasing numbers of inhaled volume. The concentration of live
bacteria. Aspiration of contaminated drinking bacteria in the air reduces rapidly with
water into the airways has also been described distance from the source; however
as a mode of transmission of Legionnaires’ this depends on the humidity and
disease. Aspiration can be a significant source temperature.
of legionellosis in certain vulnerable patients
including those using nasogastric tubes, stroke b. The duration of exposure to the
patients, those taking sedatives and narcotics, contaminated air:
and those with motor neurone disease.
Sucking ice made from contaminated water i. e
xposure in a shower is usually
has been linked to some nosocomial cases of limited to a few minutes, while
Legionnaires’ disease. exposure in a bath is much longer;
ii. the risk increases with the

Aerosol generation number of Legionella in the air, the
respiratory rate of the individual
4.12 Contaminated water presents a risk
and the length of time the person
when dispersed into the air as an aerosol with
is exposed. The chances of
smaller aerosols (<5 µm diameter) remaining
Legionella infections occurring
airborne for longer, penetrating deeply into the
increase with the number and
lungs (alveoli). However, larger droplets can
susceptibility of people exposed.
evaporate and still contain several organisms.
Amoebic vacuoles, typically 3 µm, may contain
many Legionella and potentially provide an Susceptibility of individuals
infectious dose.
4.16 While previously healthy people may
4.13 Water services are capable of generating develop Legionnaires’ disease, there are a
aerosols from the process of water splashing number of factors that increase susceptibility:
on to wash-hand basins, sinks, and baths,
in shower cubicles and when flushing toilets. a. increasing age, particularly over the
Equipment that uses or is cleaned by water age of 50 (children are rarely infected);
should be assessed for its potential to produce
b. men are approximately three times
aerosols both in normal and abnormal (for
more likely to be infected than women
example during maintenance) operating
(this may change with altered smoking
conditions.
habits);
17
c. existing respiratory disease that makes

the lungs more vulnerable to infection;
d. illnesses and conditions such as

cancer, diabetes, kidney disease or
alcoholism, which weaken the natural
defences;
e. smoking, particularly heavy cigarette

smoking, because of the probability of
impaired lung function;
f. patients who are

immunocompromised as a result of
illness or treatment (for example, those
on immunosuppressant drugs that
inhibit the body’s natural defences
against infection).
18
5 Pseudomonas aeruginosa and other waterborne pathogens: overview
5 Pseudomonas aeruginosa and other

waterborne pathogens: overview
Ecology higher the potential for patient colonisation or

infection.
5.1 P. aeruginosa is a Gram-negative
bacterium, commonly found in wet or moist 5.4 Contaminated water in a healthcare setting
environments. It is commonly associated can transmit P. aeruginosa to patients through
with disease in humans with the potential the following ways:
to cause infections in almost any organ or
tissue, especially in patients compromised by • direct contact with the water through:
underlying disease, age or immune deficiency. – ingesting;
As a pathogen the significance of P. aeruginosa
is exacerbated by its resistance to antibiotics, – bathing;
virulence factors and its ability to adapt to a – contact with mucous membranes or
wide range of environments and nutrients. surgical site; or
5.2 P. aeruginosa thrives in relatively nutrient- – through splashing from water outlets or
poor environments such as water systems at basins (where the flow from the outlet
a range of different temperatures and can exist causes splashback from the surface);
as planktonic cells in water or as biofilms where • inhalation of aerosols from respiratory
mixed populations of bacteria are bound to equipment, devices that produce an
surfaces. Biofilms can become detached to aerosol or open suctioning of wound
contaminate the water phase or flow. irrigations;
• medical devices/equipment rinsed with
Transmission contaminated water;
5.3 P. aeruginosa is an opportunistic pathogen • indirect contact via healthcare
that can colonise and cause infection in workers’ hands following washing
patients who are immunocompromised or hands in contaminated water, from
whose defences have been breached (for surfaces contaminated with water or
example, via a surgical site, tracheostomy or from contaminated equipment such as
indwelling medical device such as a vascular reusable wash-bowls or refillable spray
catheter). In most cases, colonisation will cleaning bottles.
precede infection. Some colonised patients
will remain well but can act as sources for
colonisation and infection of other patients. Source
As a microorganism that is often found in 5.5 It is generally accepted in the case of
water, the more frequent the direct or indirect Legionella that the source of bacteria in hot
contact between a susceptible patient and and cold water systems is the incoming water
contaminated water, and the greater the supply and that it becomes a problem where
microbial contamination of the water, then the there is a failure of the recommended control
measures (for example, maintenance of
19
temperatures or water treatment regimes). Mycobacteria

In contrast to Legionella, the origin of
P. aeruginosa is less certain and its presence 5.8 Non-tuberculous mycobacteria have
is particularly evident within the last two metres been associated with healthcare outbreaks
before the point of discharge. worldwide. These outbreaks usually involve
sternal wound infections, plastic-surgery
5.6 Devices fitted to, or close to, the tap wound infections or post-injection abscesses.
outlet (for example mixing valves, solenoids
or outlet fittings) may exacerbate the problem 5.9 Mycobacterial infections in patients
by providing the conditions and nutrients undergoing dialysis treatment have also been
that support microbial growth (for example, reported. Other infections have been attributed
appropriate temperatures, a high surface- to the transmission of Mycobacterium chimaera
area-to-volume ratio or a high surface area for from contaminated heater cooler units used in
oxygenation of water, and leaching of nutrients theatre during cardiothoracic surgery (see also
from materials such as ethylene propylene paragraph 8.23).
diene monomer (EPDM)). The source,
therefore, could be: Stenotrophomonas
• the incoming water supply from the water 5.10 There are at least 14 species of
provider; Stenotrophomonas; the most important
• the water supply within the building waterborne pathogen is Stenotrophomonas
(both from the storage and distribution maltophilia. This is an emerging opportunistic
system), usually within biofilms; environmental pathogen that causes
healthcare-associated infections and is found
• the wastewater system (see Breathnach in aqueous habitats including water sources.
et al. 2012); or S. maltophilia is an organism with various
• via external retrograde contamination molecular mechanisms for colonisation and
from: infection, and can be recovered most notably
from the respiratory tract of cystic fibrosis
– clinical areas due to the discarding of patients with P. aeruginosa. Its habits within
patient secretions or where medical the healthcare environment are very similar
equipment may have been washed in to P. aeruginosa; however, it is more heat-
the wash-hand basin; sensitive and will not grow above 40°C.
– outlet users where hands may have Good temperature management should
been contaminated by P. aeruginosa; reduce the risk of colonisation. It has been
associated with the colonisation of taps/tap
– poor hygiene or processes during
water, sinks/sink traps, showers, hydrotherapy
cleaning, resulting in contamination
pools, ice-makers, disinfectant solutions,
from the drain or surrounding
haemodialysers, nebuliser chambers, humidifier
environment to the outlet fitting;
reservoirs, bronchoscopes and ventilator
– splashback from contaminated drains; circuits. S. maltophilia isolated from tap water
– contaminated cloths/mops etc. has been shown to be responsible for the
colonisation/infection of five neonates in a
5.7 Given this variety, the challenge for the neonatal intensive-care unit. Where clinical
WSG is to risk-assess operational practices in results indicate water may be a vector in the
an attempt to minimise contamination from any transmission of Stenotrophomonas spp., then
of these sources. water sampling should be carried out as per
P. aeruginosa (see Appendix E).
20
5 Pseudomonas aeruginosa and other waterborne pathogens: overview
paragraphs 1.21–1.26 in HTM 04-01 Part A).

Other emerging pathogens of concern There should be strict adherence to the
in healthcare recommendations in HSG274 Part 2.
Other organisms may have particular 5.14 The WSG should also ensure that infection
pathogenicity in certain circumstances. prevention and control (IPC) teams have
Specialist microbiological advice should be received adequate training and that there is
sought until their management and control compliance with national evidence-based
within heathcare can be documented more guidelines for preventing healthcare-associated
fully. infections. Best practice advice relating to
clinical wash-hand basins should be followed to
minimise the risk of contamination of surfaces,
Management of control outlets and drains due to waterborne pathogens
(see Chapter 3 in HTM 04-01 Part C).
5.11 Management of water systems to reduce
the risk of waterborne pathogens is vital to 5.15 IPC teams and WSGs should continue to
patient safety. It requires surveillance and monitor clinical isolates of waterborne
maintenance of control measures including pathogens including the presence of
temperature control, usage, cleaning and P. aeruginosa in risk-assessed augmented care
disinfection measures as identified within the units as an alert organism and be aware of
risk assessment and WSP for both hot and cold possible outbreaks or clusters of infection with
water systems. this microorganism.
5.12 To prevent the growth of waterborne 5.16 The HCAI Code of Practice sets out the
pathogens, controls are necessary to manage criteria against which a registered provider’s
the water system before and after the outlet. compliance with the requirements relating to
cleanliness and infection control will be
5.13 The WSG should ensure that estates and assessed by the Care Quality Commission. It
facilities staff have up-to-date accurate records also provides guidance on how the provider
and drawings/diagrams showing the layout and can interpret and meet the registration
operational manuals of the whole water system. requirement and comply with the law.
Estates and facilities staff should have received Regulations 12 and 15 state that providers
adequate hygiene training (see paragraphs should provide and maintain a clean and
6.29–6.30) and be fully aware of the extent of appropriate environment in managed premises
their responsibilities to prevent microbial that facilitates the prevention and control of
contamination of plumbing components (see infections (see paragraphs 0.15–0.17).
21
6 Operational management
Introduction pathogens. It provides a forum in which people

with a range of competencies can be brought
6.1 Healthcare organisations have an explicit together to share responsibility and take
duty under the Health and Safety at Work Act collective ownership for ensuring it identifies
etc. 1974 to assess and manage the risks water-related hazards, assesses risks, identifies
posed by water systems on their premises. and monitors control measures and develops
In accordance with the HCAI Code of Practice incident protocols.
(see paragraphs 0.15–0.17), the healthcare
organisation’s chief executive is responsible
for having systems in place to manage and Note
monitor the prevention and control of infection. Where estates and facilities provider
These systems should make use of WSPs and services are part of a contract (including
risk assessments to consider how susceptible PFI), it is essential that these providers
patients are at risk from their environment and participate fully in all those aspects of
from others. Ensuring these elements are in estate and facilities management that can
place will assist the organisation to fulfil its affect patients. This includes responding to
duties in relation to the provision of safe water specific requests from the IPC team and
systems. A programme of audit should be in WSG, which may be in addition to relevant
place to ensure that key policies and practices guidance and documentation.
are being implemented appropriately. This will
inform the organisation’s assurance framework.
6.4 The WSG should have clearly identified
6.2 Each healthcare organisation, through its lines of accountability up to the duty holder.
WSG and WSP, should be able to demonstrate The roles, responsibility and accountability of
that they have suitable governance, the WSG should be defined (see Chapter 2).
competence and accountability arrangements
6.5 The group should ensure that there is the
in place to deliver safe water in healthcare
appropriate expertise available to ensure that
premises.
all elements of the WSP are fully implemented.
This will require assurance from installers,
The Water Safety Group (WSG) maintainers and users with regard to the safety
of all water used by patients/residents, staff
6.3 The WSG is a multidisciplinary group and visitors, to minimise the risk of infection
formed to oversee the commissioning, associated with waterborne pathogens. The
development, implementation and review of WSG may typically comprise personnel who:
the WSP. The aim of the WSG is to ensure
the safety of all water used by patients/ • are familiar with all water systems and
residents, staff and visitors, to minimise the associated equipment in the building(s)
risk of infection associated with waterborne and the factors that may increase risk of
22
infection from Legionella, P. aeruginosa and departments offering aquatic therapy), and
and other waterborne pathogens (that is, sterile services departments (SSDs). See Figure
the materials and components, the types 2 for an example structure and see also the
of use and modes of exposure, together Note under paragraph 6.3.
with the susceptibility to infection of
those likely to be exposed); 6.7 As and when required, the local security
management specialist (LSMS) should provide
• have knowledge of the particular a security management input. The LSMS
vulnerabilities of the at-risk population should be consulted in any vulnerability and
within the facility; as part of its wider risk assessments being undertaken, to ensure
remit, the WSG should include that the security of the water systems is
representatives from areas where fully considered and proportionate security
water may be used in therapies, measures are implemented.
medical treatments or decontamination
processes where exposure to aerosols 6.8 The WSG should be led and chaired by
may take place. a person who has appropriate management
responsibility, knowledge, competence and
6.6 This would normally involve representation experience. Where required, it may appoint in
from estates (operations and projects), writing an independent professional adviser/
infection control, medical microbiology, Authorising Engineer (Water) with a brief to
nursing, augmented care, housekeeping/ provide services in accordance with this HTM
support services, an Authorising Engineer/ and the HSE’s technical guidance HSG274
independent adviser, medical technical officers, Part 2.
specialist users of water (such as renal units
Management
(e.g. Board, CEO, Duty
holder)
Water Safety Group Auditor

External
Infection Consultant
Microbiologist Prevention
& Control
Risk Assessors
Facilities Estates
Management Management
Water
Contractors
House Specialist Department Plumbers and

Keeping heads (e.g. Operatives
Dialysis, ICU, Nursing)
Figure 2 Example WSG structure
23
Remit of the WSG 6.10 Detailed minutes of the group meetings

should be recorded, distributed promptly and
6.9 The following is a typical list of tasks retained in accordance with the management
assigned to the WSG: policy to demonstrate good management,
• to work with and support the IPC team; appropriate and timely actions and good
governance.
• to ensure effective ownership of water
quality management for all uses; 6.11 The WSG should always act in an
• to determine the particular vulnerabilities appropriate and timely manner. Individual
of the at-risk population; responsibilities should not be restricted by the
need to hold formal meetings.
• to review the risk assessments;
• to ensure the WSP is kept under review 6.12 Episodes of colonisation or infection of
including risk assessments and other patients that could be related to the water
associated documentation; system should be referred by the IPC team to
the chair of the WSG for any additional action
• to ensure all tasks indicated by the risk to be determined.
assessments have been allocated and
accepted; 6.13 The WSG should review any proposed
• to ensure new builds, refurbishments, or existing developments associated with the
modifications and equipment are water supply and distribution system to ensure
designed, installed, commissioned that they:
and maintained to the required water • minimise the risk to patients/service-
standards; users, especially those treated in
• to ensure maintenance and monitoring augmented care settings;
procedures are in place; • are compliant with all extant legislation
• to review clinical and environmental and DH policy and guidance.
monitoring data;
6.14 All systems and equipment that use
• to agree and review remedial measures
water to which patients, staff and visitors could
and actions, and ensure an action plan is
be exposed should be approved by the WSG.
in place, with agreed deadlines, to ensure
When buying equipment, assurance should be
any health risks pertaining to water
sought from the manufacturer regarding safety
quality and safety are addressed;
for patients and service-users.
• to determine best use of available
resources; 6.15 The WSG will need to ensure that
decisions affecting the safety and integrity of
• to be responsible for training and
the water system do not proceed without its
communication on water-related issues;
agreement.
• to oversee water treatment with
operational control monitoring and to
provide an appropriate response to out- Water safety plans (WSPs)
of-target parameters (that is, failure to 6.16 To assist with understanding and
dose or overdosing of the system); mitigating risks associated with waterborne
• to oversee adequate supervision, training hazards in distribution and supply systems
and competency of all staff; and associated equipment, healthcare
organisations should develop a WSP, which
• to ensure surveillance of both clinical and provides a risk-management approach to the
environmental monitoring. safety of water and establishes good practices
in local water usage, distribution and supply
24
(see Figure 3). It will identify potential water- water safety. See paragraph 6.21 for a list of
related hazards, consider practical aspects elements that the WSP should incorporate.
and detail appropriate control measures. The
content of a WSP will depend on the size and 6.17 Those organisations with existing robust
complexity of the healthcare organisation’s water management policies for waterborne
water system. The plan will include governance hazards will already have in place much of the
arrangements related to the management of integral requirements for developing a WSP.
Description of water system
System risk assessments
Identification of potential hazards

Supportive training and review programmes
Determine existing control measures
Periodic review
Assess and prioritise risks
Identify additional or improved control measures
Controlling risks
Implement and maintain monitoring and

control measures
Define corrective actions
Verification and auditing
Figure 3 Documentation of management procedures (adapted from Figure 4.1 in WHO’s ‘Water safety in
buildings’)
25
6.18 The WSP is a living document. It should • operational monitoring of control

be kept under continual review and ensure the measures and record-keeping
adequate assessment and control of the risks methodology;
from a wide range of waterborne pathogens. • information on the age and condition
It should be a standing agenda item at WSG of the water distribution system and
meetings. materials of construction (as different
6.19 The first step in the development of a materials hold differing risks and react
WSP is to gain a comprehensive understanding differently to chemicals);
of the water system, including the range of • links to clinical surveillance;
potential hazards, hazardous events and risks • early warnings of poor or unsuitable
that may arise during storage, delivery and water quality (for example, taste, odour,
use of water. It may require an understanding flavour and appearance if intended for
of the quality and management of the water drinking);
as provided and how that water is used.
Fundamental to this and any subsequent • plans for the sampling and
investigation or review is the provision and microbiological testing of water in
availability of accurate records. Schematic identified at-risk units (see Chapter 10
diagrams are useful for assisting understanding and Appendices E and F);
of how entire water systems operate; however,
more advanced drawings (as-built) are often Note
needed in complex buildings. The WSP should
Appendix F has been developed to
also be cross-referenced to the healthcare
provide technical guidance for a range of
organisation’s security management strategy
laboratories, including NHS, Public Health
and business continuity plan.
England (PHE) and commercial laboratories
6.20 WSPs include the need to: that have the capability and capacity to
undertake water sampling and testing.
• assess the risks that may be posed to
patients (including those with particular • adequate supervision, training and
susceptibility), staff and visitors; competency for all levels of staff including
housekeeping staff and those employed
• put into place appropriate management
by facilities management organisations;
systems to ensure the risks are
adequately controlled; • communication and documentation;
• ensure there are supporting programmes, • appropriate design, installation,
including communication, training and commissioning and maintenance of all
competency checks. components and equipment;
• remedial actions to be taken to remedy
6.21 With respect to physical, chemical and high counts for P. aeruginosa and
microbiological hazards, the WSP should Legionella and other relevant pathogens
incorporate: where appropriate;
• a clinical risk assessment to identify • adjustments to clinical practice
those settings where patients are until remedial actions have been
at significant risk from waterborne demonstrated to be effective;
pathogens; • regular removal/cleaning/descaling or
• an engineering and bacterial risk replacement of the water outlets, hoses
assessment of all water systems; and thermostatic mixing valves (TMVs)
and other components where risk
assessment necessitates;
26
• amendments when changes are carried • clinical practice where water may come
out including new builds, refurbishments into contact with patients and their
and recently decommissioned clinical invasive devices;
departments or units; • the appropriate cleaning of the
• amendments made when changes are environment and equipment;
made at the annual review. • the disposal of blood, body fluids and
patients’ wash-water;
6.22 The WSP should identify potential alert
organisms and microbiological hazards caused • the maintenance and cleaning of wash-
by Legionella, P. aeruginosa and other relevant hand basins and associated taps,
pathogens, consider practical aspects and specialist baths and other water outlets;
detail appropriate control measures. • suitable siting and installation of wash-
hand basins including the appropriate
Risk assessments positioning of soap and antimicrobial
hand-rub dispensers;
6.23 The risk assessments that inform the
WSP should identify potential hazards caused • change in use (for example, clinical
by Legionella, P. aeruginosa and other relevant area changed to office accommodation
pathogens, chemicals, temperature and events or vice-versa) due to refurbishment or
that may arise during supply, storage, delivery, operational necessity;
maintenance and use of water in healthcare • other devices that increase/decrease
facilities. the temperature of water (for example,
ice-making machines, water chillers)
6.24 Once potential hazards and hazardous which may not be appropriate where
events have been identified, the severity of patients are at particular risk such as in
risk needs to be assessed so that priorities for augmented care settings;
risk management can be established. The risk
assessment needs to consider the likelihood • engineering assessment of water
and severity of hazards and hazardous events systems, including appropriate design,
in the context of exposure (type, extent and installation, commissioning, maintenance
frequency) and the vulnerability of those and verification of the effectiveness of
exposed. Although many hazards may threaten control measures (see also the Water
water quality, not all will represent a high risk. Supply (Water Fittings) Regulations
The aim should be to distinguish between high 1999);
and low risks so that attention can be focused • infrequently used outlets;
on mitigating risks that are more likely to cause • previous risk assessment, current control
harm (see BS 8580 for guidance on Legionella measures and documentation;
risk assessments). Typical examples of issues
to consider may include the following: • policies and procedures;
• the unnecessary use of flexible hoses
• governance and accountability; and any containing inappropriate lining
• the susceptibility of all who may be materials;
exposed to water (including ice) used for • sampling, monitoring and testing
diagnosis and treatment; programmes that needs to be put in
• scalding risk and the appropriate place;
installation of TMVs; • backflow protection;
• failure to maintain necessary hot and cold • safe access to equipment;
system supply temperatures;
27
• prevention of unauthorised access to Water hygiene training

equipment;
6.29 Individuals to whom tasks have been
• education and training. allocated (supervisors and managers as
well as operatives) need to have received
6.25 Situations will arise where venous adequate training in respect of water hygiene
catheter sites and surgical wounds may and microbiological control appropriate to
become contaminated from water outlets the task they are responsible for conducting.
such as showers. Similarly the practice of The training and competence assessment
soaking leg ulcers or syringing ears may require should be clearly defined and should include
consideration of the microbiological quality of those responsible for simple housekeeping
water used and will require local assessment. tasks such as outlet flushing and the cleaning
of wash-hand basins, through to maintenance
6.26 The likelihood of hazardous events is
staff and up to individuals who define strategy
influenced by the size and complexity of the
and develop procedures.
water system and can be exacerbated by
poor or overcomplicated design, construction, 6.30 It is important that any person working
commissioning, operation and maintenance. on water distribution systems or cleaning water
outlets should have completed a water hygiene
awareness training course so that they can
Staff training and competence gain an understanding of the need for good
6.27 The WSG should implement a hygiene when working with water distribution
programme of staff training to ensure that systems and water outlets, and of how they
those appointed to devise strategies, carry out can prevent contamination of the water supply
control measures and undertake associated and/or outlets.
monitoring are appropriately informed,
instructed and trained. They should also be
assessed as to their competency. It is also
essential that they have an overall appreciation
of the practices affecting water hygiene and
safety, and that they can interpret the available
guidance and perform their tasks in a safe and
technically competent manner.
6.28 The WSG should review the competence

of staff on a regular basis, and refresher training
should be given; records of training attendance
need to be maintained. Although training is an
essential element of ensuring competence,
it should be viewed within the context of
experience, knowledge and other personal
qualities that are needed to work safely.
Competence is dependent on specific needs
of individual installations and the nature of risks
involved.
28
Water hygiene training • the responsibilities of individuals to

prevent the contamination of the
As part of helping to ensure the delivery water distribution system and water
of safe wholesome water at all outlets and outlets and assisting in ensuring
preventing contamination, which may lead control measures in place are
to healthcare-associated infections, it is effective;
recommended that healthcare organisations
implement a water hygiene training scheme. • how the safety of water can be
maintained by good hygiene
Consideration should also be given to practices;
integrating a health screening element into • when not to work with water intended
the training to help ensure those undergoing for domestic purposes;
the training are not carriers of any
waterborne diseases on the date of training • system design;
and are aware of their responsibilities • components/accessories (taps,
towards the water supply. It is important TMVs);
that individuals are aware of their duty to
protect the health of patients, staff and • disinfection and cleaning equipment/
visitors and that they are responsible for materials;
ensuring that they inform their line manager • how to store and handle pipes;
if they come into contact with any disease • organisation-specific control
that has the potential to cause harm. measures;
The course should encompass the following • the impact of getting it wrong;
topics (not exhaustive):
• role of persons being trained;
• organisational governance • personal hygiene along with dealing
arrangements in relation to water with clothing, footwear, cleaning
hygiene and safety; equipment/materials, tools and
• familiarisation with local policies/ storage when considering water
procedures in relation to the hygiene (as applicable to each role).
management and provision of water
hygiene and safety;
Management of water safety risks
• information on prominent waterborne
pathogens and their consequences; and issues
• the ways in which water distribution 6.31 Identified water safety risks and
systems, water outlets, components issues should be assessed, prioritised and
and any associated equipment can included on a risk register for discussion and
become contaminated; management by the WSG and advice given
on when these should be escalated to senior
management/board level. Consideration should
also be given to the potential and known
threats from unauthorised access to the water
supply for malicious purposes (see also NHS
Protect’s (2012) guidance on the security and
management of NHS assets).
6.32 When the risks have been identified,

an action plan needs to be developed with
defined roles and responsibilities, and agreed
29
timescales to minimise these risks. The action 6.37 Before lowering or assisting patients
plan should include: into the bath, the water temperature must be
checked with a thermometer to ensure that it
• appropriate remedial actions, monitoring has fallen to a safe value.
details and schedules for validation that
show the remedial actions are effective
and subject to ongoing verification Utilisation
(completion dates should be defined); 6.38 One of the critical factors affecting the
• any training and competency issues quality of water within hot and cold water
required to ensure compliance with this distribution systems is the extent of utilisation.
guidance.
6.39 Where stagnation occurs or utilisation
Advice on exposure of augmented care is low, cold water temperature can increase
patients to P. aeruginosa is covered in HTM significantly and approach the range that
04-01 Part C. is conducive to the growth of a variety of
waterborne pathogens such as Legionella.
Where hot and cold water is mixed, further
Documentation opportunities arise for deterioration in water
6.33 All records pertaining to the risk quality.
assessment and action plan should be held
6.40 TMVs should not be installed in series
and managed by the WSG.
with mixing taps (thermostatic or manual) (see
also paragraphs 6.52–6.58 on maintenance
Safe hot water temperature practice).
6.34 See paragraphs 10.57–10.59 in 6.41 The WSG needs to ensure that there
HTM 04-01 Part A for guidance on safe water is good liaison between the estates officers/
temperatures and delivery devices. See also maintenance providers and clinicians to ensure
HSE’s ‘Managing the risks from hot water and that the water services are sufficiently used.
surfaces’.
6.42 HSG274 Part 2 recommends that
6.35 To reduce the risk of scalding, generally, for infrequently used outlets,
thermostatic mixing devices are required for flushing is carried out once a week but that
specific hot water outlets (see Table 2 in in healthcare facilities the risk assessment, as
HTM 04-01 Part A). A scalding risk assessment agreed by the WSG, may indicate a higher
is necessary to establish the need and type of frequency, and water draw-off should form part
device to be installed. of the daily cleaning process. The procedure for
such practice should be fully documented and
6.36 As with any safety device, routine covered by written instructions.
checks will be essential to ensure continued
satisfactory operation (see Chapter 11 of 6.43 Monitoring of water usage on a building-
HTM 04-01: Supplement – ‘Performance by-building basis can indicate when usage
specification D 08: thermostatic mixing valves falls and the risk increases. Reductions in
(healthcare premises)’). Such devices, however, normal usage patterns should be investigated
should not be a substitute for caution. For and remedial measures introduced following
example, when performing assisted bathing, investigations by the WSG.
it is often necessary to set the delivery
temperature to a higher level than that normally
considered safe to allow for the cooling effect
of large baths that are required.
30
6.49 For further guidance, see HTM 07-04 –

Note ‘Water management and water efficiency’.
Regular flushing applies to all infrequently
used outlets. The use of portable
temperature-monitoring devices may assist
Water treatment undertaken by the
in identifying where additional flushing is local water undertaker
necessary. 6.50 Local water undertakers use different
types of water treatment, which may
include the use of chloramine, and add
Temporary closure of wards/ additional compounds such as fluoride.
departments It is recommended that regular contact is
maintained with the local water undertaker to
6.44 During the temporary closure of wards
keep up to date with changes that may affect
or departments, a flushing regime should be
water quality or other operational changes
instigated to maintain system hygiene. Flushing
affecting the premises.
should be continued until stable temperatures
are achieved. Advice and guidance is also
provided in BSI’s PD855468. Energy management
6.45 Alternatively, when this is impracticable, 6.51 Efforts should be taken to minimise
or should the temporary closure become energy consumption without compromising
permanent, it should be disconnected from water safety management. An effective
the rest of the system, ensuring there are no maintenance plan will also contribute to this.
dead-legs. Before reconnecting, the system Further guidance is given in HTM 07-02 –
should be recommissioned and disinfected in ‘EnCO2de’.
accordance with Chapter 15 of HTM 04-01
Part A.
Maintenance practice
Leak detection/water conservation Note
6.46 It is essential to regularly check systems See also Chapter 11 in HTM 04-01:
and all components for signs of leakage; Supplement – ‘Performance specification
for example, a tap left dripping can waste D 08: thermostatic mixing valves (healthcare
in excess of 14,000 L of water each year. premises)’.
Particular attention should be given to WCs as
leakage appears as a dribble at the back of the 6.52 Healthcare organisations should ensure
pan, which often goes undetected. that all personnel that work on water systems
can demonstrate competence and have been
6.47 Consumption should be monitored; if inducted in local procedures, which should
it increases for no apparent reason, this may include safe water hygiene practices (see
indicate a leak. Wet or soggy patches of paragraphs 6.29–6.30).
ground may identify underground leaks, for
example areas of greenery that are more lush 6.53 There are legal, operational and economic
than their surroundings. reasons for introducing good maintenance
practice. There is a legal requirement under the
6.48 Where water conservation measures are Water Supply (Water Fittings) Regulations 1999
to be considered, a risk assessment should be to maintain water fittings to comply with the
undertaken to ensure there is no detrimental regulations. It sets a requirement to protect and
impact that may cause stagnation or low preserve water quality for the safety of patients,
water usage in the existing water or drainage staff and visitors. Complying with the law is
systems.
31
generally given the highest priority and is the b. How long can a breakdown of
minimum requirement that must be satisfied. particular plant be tolerated?
Chapter 3 lists specific statutes that must be
complied with. Additional advice is provided in c. What cost can be justified to avoid
BS EN 806-5 and BS 8558. breakdown of particular plant such as
standby pumps, dosing pumps etc?
Note d. The availability of suitable spares.
BS EN 806-5 and complementary guidance
6.57 If response to failure is critical for certain
in BS 8558 covers the operation and
items of plant, the maintenance organisation
maintenance of water systems, in which a
will require a planned strategy of calling out
number of aspects are covered:
skilled staff to achieve an agreed response
• operation; time and to minimise the interval between
breakdown and the diagnosis and repair of
• interruptions to operation and
the plant.
disconnection;
• resumption of supply; 6.58 The approach for healthcare premises
should be based on that of planned preventive
• damage and faults (change in water
maintenance (PPM) as any failure in the water
quality, insufficient water supply, noise
services would be seriously detrimental to the
emission);
provision of healthcare. The PPM programme
• alterations, extensions and and any subsequent amendments should
refurbishment; be agreed by the WSG (see also Chapter 5
• accessibility of installation on maintenance in HTM 00 – ‘Policies and
components; principles of healthcare engineering’).
• maintenance.
Maintenance responsibility
6.54 Regulations require notification to the 6.59 A maintenance manager should be given
water undertaker of any proposed changes responsibility for implementation of a risk-
and additions to the water supply system in the based operational maintenance strategy. These
premises. Before making any changes, a risk responsibilities will include:
assessment should be carried out and audited
by an independent assessor. Further details a. the provision of adequately trained
can be found on the WRAS website. and supervised labour (see also
paragraph 6.30 on water hygiene
6.55 Maintenance is required to achieve training);
optimum economic life and maintain maximum
operational efficiency of the plant. b. clear definitions of the equipment and
services to be maintained, together
6.56 There should be a risk assessment to with the procedures to be carried out
decide the appropriate type of maintenance (for on them;
example scheduled, corrective or condition-
based) for the different items of plant. The c. monitoring of the quality of the
following should be considered: work carried out to ensure that it is
consistently acceptable;
Would a breakdown of a particular
a.
service during working, or outside d. the identification of appropriate
normal, hours pose a risk to patient resources and the implementation of
safety and wellbeing? financial control procedures.
32
WIAPS) authorised through the Water Supply

Note (Water Fittings) Regulations 1999. In addition
The maintenance manager should ensure to plumbing installers, four schemes (Aplus,
that risk assessments have been carried Taps, WaterMark and WIAPS) operate sector
out for all maintenance activities, and memberships for specialist areas of work
be particularly aware of any specific covering external water services (below-ground
risks associated with hot and cold pipe etc), catering equipment and point-of-use
water installations (for example, hazards (chilled-water) equipment.
associated with gaining access to cisterns,
6.64 The WaterSafe register holds details from
the discharge of large volumes of hot
all seven Approved Contractors’ Schemes
water to enable the inspection of calorifiers
for businesses that have registered plumbing
and hot water storage vessels, and the
installers.
possibility that these may have become
colonised by Legionella). 6.65 A recognised benefit to using an
Approved Contractor (including sector
installers) is they can carry out some work
Contract maintenance without the need to provide advanced
6.60 The increasing complexity of building notification to the water undertaker, and their
services equipment has resulted in a growing work will be certified upon completion. A “work
reliance on contractors for the provision of completed” certificate issued by a WaterSafe-
maintenance services. The decision to use recognised plumber provides a defence for
either a contractor or in-house staff should be property owners who are challenged by a
taken in the light of local circumstances. water undertaker enforcing the Water Supply
(Water Fittings) Regulations 1999 or during
6.61 Contracts between contractors and legal proceedings.
healthcare organisations should clearly define
the responsibilities of both parties. See
Chapter 2 of HBN 00-08 – ‘(Estatecode) Part Maintenance brief
B: Supplementary information for Part A’ for 6.66 The maintenance manager requires a
further guidance. BSRIA’s BG3: ‘Maintenance brief that is in line with all the requirements of
for building services’ also provides advice the WSP and approved by the WSG. This will
on aspects to be considered when obtaining include (among others):
contract maintenance.
a. the scope of work;
6.62 All staff who work on or with water
systems should have the necessary b. budgeting – overall and single item
qualifications, regulatory knowledge, limits;
competence and experience needed to
complete safely and effectively their specific c. level of reliability;
tasks. Each individual should have a full
understanding of their role and the impact d. response time required to correct
of their actions on patient care (see also faults;
paragraph 6.30 on water hygiene training).
e. criteria for quality of service, works and
6.63 Only installers with the appropriate equipment;
qualifications, regulatory knowledge and
competence should be used to install and f. reporting procedure;
maintain water installations. There are seven
Approved Contractors’ Schemes (APHC, g. accountability and responsibility;
Aplus, CIPHE, Snipef, Taps, WaterMark and
h. energy-saving policy;
33
j. health and safety policy; h. the agreed standards, number of

staff, and number of visits are being
k. environmental and sustainability achieved;
factors.
i. plant is being operated to achieve
6.67 The above requirements are necessary optimum energy usage;
regardless of whether the work is carried out by
contractors or in-house staff. j. health and safety requirements are
being complied with;
Performance monitoring k. only agreed subcontractors with

6.68 This involves the regular inspection of the appropriate knowledge and
systems and records, which should be in such competence are being employed (see
detail as to enable the WSG to form an opinion paragraphs 6.60–6.65);
regarding compliance with the agreed criteria.
l. the client and typical users of the
6.69 If a contractor is commissioned to carry building are satisfied;
out maintenance but in-house expertise is
not available to monitor their performance, m. invoices accurately reflect the work
it may be necessary to seek advice from an carried out, including materials
independent professional adviser (this may expended;
be available from a neighbouring healthcare
n. breakdowns do not occur too often;
organisation). Using another maintenance
contractor in a monitoring role could lead to a o. adequate consideration is being given
conflict of interest. to the potential environmental impact
of contractors’ actions, for example
6.70 Performance monitoring should establish
disposal of lubricants, chemicals, worn
that:
parts etc that cannot be recycled.
a. the required level of service is met;
b. all the required plant is being Monitoring systems

maintained; 6.71 Where monitoring systems are provided
to assist in the management of hot and cold
c. system performance is being water systems, they should be subject to a
maintained (that is, by the routine maintenance and calibration regime.
implementation of microbial sampling Systems should be in place to ensure all set
and temperature/biocide-level- alarms should be responded to in a timely
monitoring regimes); manner.
d. maintenance is being carried out to
the agreed standard; Emergency action
e. correct replacement parts are being 6.72 Contingency plans should be available in
used; the event of the following:
f. the agreed spares stocks are being a. A power or energy interruption

held on site; or a plant failure resulting in the
temperature control strategy or the
g. records are being correctly maintained; delivery of effective control measures
being maintained as designed.
34
b. A water supply failure that could last

beyond the period for the designed Note
storage capacity. Under the Security and Emergency
Measures Direction, water suppliers should
Note liaise with healthcare authorities to develop
emergency plans to maintain supplies for
The WSG should ensure that plans are domestic purposes to healthcare premises.
in place for the supply and distribution
of alternative safe water for drinking to These plans may include:
vulnerable patients and those unable to
collect supplies from distribution points • Adequate storage cistern capacity
within the healthcare facility. This will include and distribution arrangements within
the use of sterile water if appropriate. the healthcare facility to provide
minimum volumes of water at the
c. Monitoring and sampling results outset of a major incident to maintain
that indicate patient safety may be hygiene and health for an initial period
compromised unless remedial action until other temporary arrangements
is undertaken with immediate effect. can be introduced.
• The provision of facilities to connect
d. Emergency action in the event of a to, and distribute water from,
case or an outbreak of a healthcare- temporary storage cisterns such as
associated waterborne infection (see pillow tanks at key locations within the
also Appendix B for action to take on site. Ground-level storage cisterns will
an outbreak of legionellosis). require provision of booster pumps to
either lift the water to existing storage
e. Tampering and sabotage of the water cisterns or distribute it directly through
supply which could impact on patient existing or temporary site water
and staff safety. mains.
6.73 Guidance on temporary supplies is • The provision of connection points to
provided in BS 8551. existing storage cisterns at suitable
locations for delivery of emergency
supplies of water, for example from
tankers.
• Plans for the supply and distribution
of alternative safe water for drinking to
vulnerable patients and those unable
to collect supplies from distribution
points within the healthcare facility.
35
Data management and record- As-fitted drawings

keeping 6.80 The availability of accurate as-fitted
drawings is essential for the safe operation
6.74 Given the amount of data that must
of hot and cold water service systems and
be managed to facilitate the effective
to inform the risk assessment. The drawings
management of large and complex water
will be necessary to perform the temperature
systems, it is recommended that electronic
control checks on the systems and will assist
data management tools be utilised to facilitate
in identifying any potential problems with poor
the intelligent use of data for the WSG to easily
hot water circulation and cold water dead-legs
monitor trends and analyse chemical and
where flow to infrequently used outlets can be
microbiological parameters.
low. Such information should identify all key
6.75 It is essential to have comprehensive components in the installations, for example
operational manuals for all items of plant that water meters, cisterns, filtration equipment
include requirements for servicing, maintenance (where fitted), calorifiers, and the location
tasks and frequencies of inspection. of isolating valves in the systems. Drawings
should be kept up to date and amended when
6.76 This information should be kept together any changes are made to the system.
with all commissioning data.
Schematic drawings
6.77 Documentation should also be drawn
up as part of the health and safety file for the 6.81 Separate schematic drawings should
healthcare facility. be prepared and displayed such that all plant
items, control valves etc can be identified.
6.78 As a minimum, the following items should A schematic diagram is an important tool to
be recorded: inform the risk assessment process. These
are not formal technical drawings and are
a. the names and positions of those intended to be easy-to-read without specialised
responsible for conducting risk training or experience. While providing only
assessments, and managing and an indication of the size and scale, they allow
implementing the WSP; someone unfamiliar with the layout of a system
to understand the positions and connections
b. the significant findings of risk of the relevant components quickly. Drawings
assessments; should be kept up to date and amended when
any changes are made to the system.
c. details of the procedures including
sufficient detail to identify that the work
was completed correctly and when the Note
work was carried out; and All drawings should be available to each
person working on the systems and while
d. results of any monitoring inspection,
conducting risk assessments.
test or checks carried out.
6.79 Records should be kept for at least five 6.82 In addition to drawings, there should
years unless they are required to be kept longer be comprehensive schedules of outlets, lists
by the organisation’s data management policy. of sentinel taps (outlets), other outlets to be
tested (frequency as per the WSP) and other
components in the system.
36
Asset register
6.83 The WSG should ensure that an accurate
record of all assets relating to the hot and
cold water distribution systems is set up and
regularly maintained. They should also ensure
that records of all maintenance, inspection
and testing activities are kept up-to-date and
properly stored.
6.84 The asset register should be designed to

provide the following information:
a. an inventory of plant and water-

associated equipment;
b. a basis for identifying plant details;
c. a basis for recording the maintenance

requirements;
d. a basis for recording and accessing

information associated with
maintenance;
e. a basis for accounting to establish

depreciation and the provision needed
for plant replacement;
f. information for insurance purposes.
6.85 When completing records, it is essential

that there is an audit trail in place indicating the
individual concerned and dates/times where
appropriate.
6.86 Further information on the monitoring of

performance and effectiveness in carrying out
maintenance tasks can be found in CIBSE’s
Guide M – ‘Maintenance engineering and
management’.
37
7 Description of systems, operational

considerations and requirements
Source of supply Where a BMS is used, it will be essential to

ensure that regular calibration and physical
7.1 See Chapter 2 in HTM 04-01 Part A for tests are performed in accordance with the
comprehensive guidance and information on manufacturer’s instructions.
sources of water supply.
7.5 More extensive use of automatic sensors
7.2 If supplies are taken from local boreholes and reporting systems should be considered
or wells etc, the water should be tested to for surveillance of systemic temperature
comply with the requirements of the Private profiling. Sensors should be located throughout
Water Supplies Regulations 2009. The results the whole hot and cold water systems to
of all analyses should be kept and recorded. ensure they give representative temperature
Private supplies should be registered with the values.
local authority.
Biocide regimes
Temperature control regime
7.3 A temperature control regime is the Note
traditional strategy to control Legionella and
other waterborne pathogens. This will require Any biocidal treatment is likely to adversely
monitoring on a regular basis. Frequencies are affect the lifecycle of the installation.
listed in Table 1.
7.6 In addition to maintaining a temperature
control regime, there may be occasions where
Note additional biocidal treatment is required for
The flow temperature of hot water out of the the effective control of Legionella and other
calorifier should be a minimum of 60°C. It waterborne pathogens. However, the selection
should be a minimum of 55°C on flow and of a suitable treatment is complex and depends
returns to all outlets and at the start of the on a number of parameters. Moreover the
hot water return. It should be a minimum of chosen biocide needs to be properly managed.
50°C at the final connection to the calorifier. This is particularly the case with cold water
services compared with hot water services
7.4 Whereas many of the checks will, where, with the benefit of circulation, water is
of necessity, require the use of separate returned to the calorifier/water heater and is
thermometric equipment, some of the then pasteurised. However, it should be taken
temperature checks can be carried out by into consideration that effective concentrations
continuous monitoring such as sensors of some biocides are difficult to achieve in
and reporting systems (optionally linked hot water systems due to gassing off. For
to a building management system (BMS)). water intended for consumption, the biocide
concentrations must not exceed prescribed
concentrations for drinking water.
38
7 Description of systems, operational considerations and requirements
7.7 The WSG should be actively involved 7.14 Meters should ideally provide a pulse
in the decision-making process and should output that can be monitored by a BMS, but if
involve consultation with the water undertaker not should be read on a regular basis (monthly)
to ensure the suitability of biocidal products for and consumption monitored. Data from
their intended application. the meter should be reviewed over time for
anomalies (typically low or high consumption
For further information on biocidal rates). Graphical methods may be beneficial.
treatment, see Chapter 4 of HTM 04-01 Where it is desirable to connect to the water
Part A. For ongoing checks, see HSG274 undertaker’s meter, its authorisation must be
Part 2. gained in advance.
7.15 Consumption should be checked

against the utility bill and any discrepancies
Metal contamination investigated.
7.8 See Chapter 5 in HTM 04-01 Part A.
Water storage
Water softening 7.16 For general information on water storage,
7.9 See Chapter 6 in HTM 04-01 Part A. see Chapter 8 in HTM 04-01 Part A.
7.17 The Water Supply (Water Fittings)

Filtration Regulations 1999 and relevant parts of BS
7.10 See Chapter 7 in HTM 04-01 Part A EN 806 and BS 8558 specify minimum
for guidance on point-of-entry filtration. See standards for cold water storage cisterns to
paragraphs 7.45–7.49 and paragraph D22(k) in ensure that the stored water is retained at a
Appendix D and also Chapter 4 in HTM 04-01 wholesome standard suitable for domestic
Part A for guidance on POU filtration. use. It is necessary to minimise stagnation and
stratification of the stored water. A nominal
12 hours’ total on-site storage capacity is
Metering recommended. The quantity of the water
stored should be carefully assessed in relation
7.11 Metered data should be logged and
to the daily requirement so that a reasonable
recorded by an automatic metering system
rate of turnover is achieved. The storage
(see also HTM 07-04 – ‘Water management
capacity should be reduced where it is known
and water efficiency’). Where water meters are
or established that it is excessive and where it
installed in below-ground meter chambers,
is practicable to do so.
the chambers should be kept clean of debris
and water; this will enable quick and accurate 7.18 All cold water storage cisterns and
reading of the meters. cold feed cisterns should be examined at
least annually or more frequently if the risk
7.12 Meters should be periodically checked to
assessment dictates, paying particular
ensure that they are operating and providing
attention to the presence of foreign objects,
accurate readings.
biological material and excessive corrosion.
7.13 Meters, other than the water undertaker’s On completion of the examinations, the
meter, should be removed at such intervals cisterns should be cleaned, if required, and
as recommended by the manufacturer for any remedial work carried out. Before the
cleaning and renewal of worn parts and should cisterns and system are put back into use,
be tested for accuracy and disinfected prior to they should be disinfected in accordance
replacement. with the procedure detailed in chapter 2 of
HSG274 Part 2. Where consideration is being
given to the removal of a storage cistern, a
39
full assessment of the downstream system is Pressurisation/supply pumps

needed to ensure any consequential impacts
are properly understood. These may include, 7.24 Where two or more pumps are installed
but not be limited to, changes in pressure for pressurising systems, automatic control
for pipes or equipment and any backflow should be provided to prevent stagnation.
prevention protection the cistern may have The automatic control should also ensure all
been providing. pumps are brought into operation at a regular
frequency (for example, weekly) as determined
7.19 Any chemicals or biocidal products used by the risk assessment.
in the cleaning or maintenance of cisterns
should be flushed from the cistern before it is 7.25 The maintenance carried out on this type
put back into use. See Chapter 4 in HTM of equipment should be in accordance with the
04-01 Part A. manufacturer’s recommendations.
7.20 Cistern insulation should be checked to

ensure that it is adequately positioned and in Cold water distribution system
good condition. 7.26 The design and installation of the cold
water distribution system should comply with
7.21 Float-operated valves should be checked the Water Supply (Water Fittings) Regulations
to ensure that they are securely fixed and set 1999 and relevant parts of BS EN 806-2 and
to achieve a correct water level in accordance BS 8558 (see Chapter 9 of HTM 04-01 Part A
with the Water Supply (Water Fittings) for further information).
Regulations 1999.
7.27 The control of water temperature in the
7.22 Overflow/warning pipes should be cold water service will essentially rely on good
checked to ensure that they maintain a steady insulation and water turnover. Maintaining
fall (which ensures they will drain freely) and regular movement of cold water in sections
that they are clear and correctly routed to prone to stagnation and guarding against
give an obvious visual alarm of an overflow excessive heat gain are effective control
condition. A weatherproof label fixed adjacent measures for Legionella and other waterborne
to the warning pipe identifying the tank and its pathogens. Special attention should be given
location, together with the person/department to the maintenance and monitoring of these
to be contacted in the event of a discharge, systems.
will contribute to a quick and accurate defect
report which could then be acted upon, so
minimising water wastage (consideration to the
provision of high- and low-level alarms linked
to the BMS should also be given – see Chapter
8 in HTM 04-01 Part A). When connected to
drain, they should comply with BS EN 1717.
7.23 A schematic drawing illustrating typical

piping and valve arrangements for dual-cistern
installations is shown in Figure 3 of HTM 04-01
Part A.
40
e. every water outlet complies with the

Notes backflow protection requirements
1. For the control of Legionella and other of the Water Supply (Water Fittings)
waterborne pathogens, 20°C is the quoted Regulations 1999.
upper value above which multiplication of
Legionella in particular begins to take place
(see Chapter 4). It should be noted that
Drinking water
during extremes of weather, environmental 7.30 If separate drinking water supplies
factors can influence the incoming water are provided, reference should be made to
temperatures, particularly where water is paragraphs 9.11–9.13 in HTM 04-01 Part A,
provided from surface-water sources. and subject to a risk assessment consideration
should be given to their removal.
2. Where automatic flushing of urinals is
used, their careful location and connection
Notes
to the water system can be effectively used
to assist in water turnover. When used, 1. Current guidance does not draw a
devices having a duty cycle should be set distinction between drinking and general
to flush as deemed necessary by the WSG. cold water services, and separate
Information from water quality programs systems are no longer recommended.
could be used to determine appropriate The installation of separate drinking water
timeframes. Note that automatic flushing supplies has been standard policy. But
devices should not be located in in many cases where such systems have
accommodation used by patients who may been installed, the quality of drinking water
become distressed by the noise. (particularly at infrequently used draw-offs,
for example wash-rooms) has generally
7.28 Schematic diagrams (or as-built been inferior to that of the general cold
drawings) of the system with numbered and water supply.
labelled valves reduce confusion and save time
in trying to identify appropriate isolating valves 2. Softeners using salt-regenerated ion-
and other system components. exchange resins increase the sodium
content of the water during softening, and
7.29 Checks and actions should be carried out this may be undesirable for children and
to show that: infants (including the making up of babies’
bottles) and anyone on strict salt-restricted
a. the system components show no sign diets.
of leakage or corrosion or limescale;
b. the system insulation is in good Hot water storage and distribution

condition;
7.31 Hot water services should be designed
c. the system filters have been changed and installed in accordance with the Water
and/or cleaned in accordance with Supply (Water Fittings) Regulations 1999 and
manufacturers’ recommendations. relevant parts of BS EN 806-2 and BS 8558.
Regularly check and clean strainers; The hot water system may be of either the
vented or the unvented type (see Chapter 10 of
d. all isolating valves have periodically HTM 04-01 Part A for further information).
been worked through their full range of
travel;
41
7.32 To control possible colonisation by • Where it is known or established that

waterborne pathogens including Legionella, it is gross over-capacity exists in a calorifier,
essential to maintain the temperature within the and where it is practicable to do so, it
hot water circulating system. To some extent, if should be replaced by a calorifier of the
properly maintained, the calorifier/water heater appropriate size.
will provide a form of barrier to microbial growth.
The minimum flow temperature of water leaving Note
the calorifier/water heater should be 60°C.
Full-flow (spherical/ball-type) isolating valves
7.33 The minimum water temperature at the should be specified to avoid clogging. The
connection of the return to the calorifier/water drain from the gully should be of sufficient
heater should be 50°C. To achieve the required size to take the flow from the calorifier drain.
circulating temperatures, it will be necessary to
maintain the balance of flows to individual pipe 7.35 Hot water circulating pumps should be of
branches and draw-off points. adequate performance to ensure a minimum
available temperature at draw-off points of
7.34 Calorifiers should be subjected to regular
55°C and an absolute minimum of 50°C at
procedures that include the following:
the return connection to the calorifier. It is
• Inspection, cleaning and maintenance at undesirable to have standby pumps owing
least annually, or as indicated by the rate to stagnation risks. If, however, an existing
of fouling. installation includes a standby pump and it
is impracticable to remove it from service, it
• Quarterly drain flushing to minimise the should be automatically controlled so that
accumulation of sludge. This may be each is regularly brought into operation as
extended to annual draining if, during determined by the risk assessment.
inspection, it is found that there is little
accumulation of debris. 7.36 It is not permissible to shut down the
• Whenever dismantled for statutory pumped circulation. To do so will lead to the
inspection, or every year in the case of loss of the required system temperatures.
indirect calorifiers, calorifiers should be
7.37 Electrical trace-heating is not
thoroughly cleaned to remove sludge,
recommended except for very small systems
loose debris and scale.
and those existing systems that would be
• Whenever a calorifier is taken out of difficult to rectify. Where it has been retained,
service, it should be refilled, drained, it should be checked routinely (at least
refilled again and the entire contents monthly) to ensure that it maintains the water
brought up to, and held at, the nominal temperature above 55°C. Care should be
operating temperature of 60°C for at taken to ensure there are no cool spots.
least an hour. Consideration should be given to monitoring
• The calorifier should remain isolated the temperatures by means of a BMS (sensors
until the procedure is completed. When should be located at the most distal points).
bringing calorifiers back on line, it is
important that service valves are opened Note
slowly to avoid any disturbance of
sediment debris. Calorifiers that are to be Dead-leg lengths should be as short as
taken out of service for more than a few practicable; that is, the trace-heating should
days should be drained and should not be taken up to the draw-off or mixing
be refilled until ready to return to service. device. The continuity of the trace-heating
The drain valve should be left open while should be monitored to avoid localised
the calorifier is out of use. failure.
42
Instantaneous water heaters for 7.41 It is essential to check the temperature

settings and operation of water mixing devices
single or multi-point outlets regularly (see manufacturers’ instructions,
7.38 These devices usually serve one draw-off the checklist at paragraph 7.53, and
only and are either electrically or gas-heated. In Chapter 11 in HTM 04-01: Supplement –
essence: ‘Performance specification D 08: thermostatic
mixing valves (healthcare premises)’). Other
a. the flow rate is limited and is maintenance, where required, should be
dependent on the heater’s hot water strictly in accordance with the manufacturer’s
power rating; instructions. Local water quality will influence
the maintenance frequency for any installation.
b. where restricted rates of delivery are
acceptable, the heater can deliver 7.42 All pipework supplying existing
continuous hot water without requiring thermostatic mixing taps should be inspected
time to reheat; to ensure that there is no preceding TMV
supplying water to the hot port of the tap (see
c. they are susceptible to scale Figure D3 in Appendix D).
formation in hard water areas where
they will probably require frequent
maintenance; Notes
1. In existing installations, it may be

d. this form of hot water heating
necessary to install inline strainers. See the
should only be considered for
checklist at paragraph 7.53 for maintenance
smaller premises or where it is not
checks.
economically viable to run hot water
distribution to a remote outlet; 2. When bathing, or assisting patients,
healthcare staff must always check the
e. they should be monitored to ensure water temperature with a thermometer.
they operate above 55°C (see Table 1).
Pressure and expansion vessels Showers

7.43 Disinfection of showerheads and angle-
7.39 Pressure and expansion vessels
valve strainers has only a short-lived effect on
should be subject to routine inspection
microbial colonisation and growth. Manual
and maintenance as recommended by the
cleaning to remove scale and other deposits or
manufacturer. Where practicable, these should
replacement of disposable showers should be
be flushed through with wholesome water and
carried out as based on the risk assessment.
purged to drain. If replaceable, bladders or
Traditionally this has been a quarterly task
diaphragms should be changed according to
but the water quality and evidence base
the manufacturer’s guidelines or as indicated
will influence the risk assessor’s decision of
by the risk assessment.
the actual frequency implemented. Regular
flushing of showers reduces microbial growth,
Safe hot water delivery devices but counts can significantly increase if regular
flushing should cease. The most effective
7.40 Thermostatic mixing devices should only management of showers will be achieved
be installed where a risk assessment indicates by the removal of unnecessary ones and
their need. For guidance on applications and the regular use of others. Where showers
for a list of the types of mixing devices used, are removed, it is important to cut back and
see Table 2 in HTM 04-01 Part A. remove all associated pipework (see paragraph
7.50 on the removal of redundant pipework).
43
7.44 It is important to note the distinction may require additional backflow protection or
between self-purging and self-draining showers. modification of the system. In addition, sufficient
Self-purging showers can be an effective activity space should be maintained to enable
Legionella control procedure, while self-draining the outlet to be used without contaminating the
showers can support the proliferation of filter.
Legionella.
7.48 Where filters are in place, follow
manufacturers’ instructions for cleaning, or they
Note should be wiped clean as part of the basin/sink
cleaning protocol as agreed by the WSG.
Adjustable showerheads are not
recommended in healthcare facilities. See 7.49 Where point-of-use filters are no longer
paragraph 10.61 in HTM 04-01 Part A. required, the outlet connection should be
flushed, cleaned and disinfected to remove any
accumulated biofilm.
Point-of-use filtration
7.45 Point-of-use (POU) filtration should be Removal of redundant pipework
considered and agreed by the WSG only as an and services
interim safeguard where control measures have
been ineffective, prior to and during engineering 7.50 In existing systems or during
remedial works, during periods of plumbing refurbishments, water systems should be
refurbishments and maintenance works, and inspected to identify redundant pipework (often
where additional protection is required for referred to as blind ends) or services. In such
vulnerable patients. Continuous long-term use cases, pipework should be cut back to the
of POU filters is not recommended, except connection point including replacing the
where there is no effective alternative. The WSG branch T with a straight coupling to ensure all
should review their continued use and ensure redundant pipework is removed and to
an action plan is created and enacted to make eliminate any opportunity for stagnation to
certain they are changed at the intervals occur.
specified by the manufacturer.
7.46 Where POU filters are installed as a

Cleaning and disinfection
temporary measure while appropriate remedial 7.51 At some stage during the occupancy and
work is carried out, they should be changed in use of a building, it is possible that the hot and
accordance with the manufacturers’ cold water systems could become
recommendations, typically at least once a contaminated with waterborne pathogens.
month. Once removed for whatever reason, a Should this be the case, the WSG may wish to
replacement filter should be fitted. When consider cleaning and disinfection of part of the,
changing filters, it is recommended that or the entire, system. Advice may be found in
sampling of water quality takes place at outlets HSG274 Part 2 and BSI’s PD855468. See also
identified as sentinel points before refitting a Chapter 4 in HTM 04-01 Part A for guidance on
replacement filter. It is essential to ensure that the impact of treated water on materials and
– where filters are to be used – they are components.
constructed of the appropriate materials (see
paragraph 3.1 in HTM 04-01 Part A).
Note
7.47 Where POU filters are to be used, the
Whenever disinfection is planned, liaison
backflow protection requirements need to be
with specialist departments (such as renal
maintained in accordance with the Water
units and neonatal units) should take place.
Supply (Water Fittings) Regulations 1999. This
44
Summary checklist for hot and cold

system water systems
7.52 A summary checklist for hot and cold
water systems is shown on the following
pages (adapted from HSG274 Part 2 by kind
permission of the HSE). For every operation
that is undertaken, a method statement needs
to be prepared and followed to ensure the
stages are completed safely and effectively.
7.53 In Table 1 the suggested frequencies of

inspecting and monitoring the hot and cold
water systems will depend on their complexity
and the susceptibility of those likely to use
the water, and are for guidance only. The risk
assessment should define the frequency of
inspection and monitoring depending on the
type of use and user and particularly where
there are adjustments made by the assessor
to take account of local needs. The water
quality and evidence base will influence the risk
assessor’s decision.
45
Table 1 Checklist for hot and cold water systems (adapted from HSG274 Part 2)
Frequency (see
Service Action to take paragraph 7.53)
Calorifiers Inspect calorifier internally by removing the inspection hatch Annually, or as indicated
or using a borescope, and clean by draining the vessel. The by the rate of fouling
frequency of inspection and cleaning should be subject to the
findings and be increased or decreased based on conditions
recorded
Where there is no inspection hatch, purge any debris in the Annually, but may be more
base of the calorifier to a suitable drain frequent as indicated
Collect the initial flush from the base of hot water heaters to by the risk assessment
inspect clarity, quantity of debris and temperature or result of inspection
findings
Check calorifier flow temperatures (thermostat settings should Monthly
modulate as close to 60°C as practicable without going below
60°C)
Check calorifier return temperatures (not below 50°C).
Hot water For non-circulating systems: take temperatures at sentinel Monthly
services points (nearest outlet, furthest outlet and long branches to
outlets) to confirm they are at a minimum of 55°C within one
minute
For circulating systems: take temperatures at return legs Monthly
of principal loops (sentinel points) to confirm they are at a
minimum of 55°C. Temperature measurements may be taken
on the surface of metallic pipework
For circulating systems: take temperatures at return legs of Quarterly (ideally on a
subordinate loops; temperature measurements can be taken rolling monthly rota)
on the surface of pipes, but where this is not practicable, the
temperature of water from the last outlet on each loop may be
measured, and this should be greater than 55°C within one
minute of running. If the temperature rise is slow, it should be
confirmed that the outlet is on a long leg and not that the flow
and return has failed in that local area
All HWS systems: take temperatures at a representative Representative selection
selection of other points (intermediate outlets of single pipe of other sentinel outlets
systems and tertiary loops in circulating systems) to confirm considered on a rotational
they are at a minimum of 55°C to create a temperature profile basis to ensure the
of the whole system over a defined time period whole system is reaching
satisfactory temperatures
for Legionella control
POU water Check water temperatures to confirm the heater operates at Monthly–six monthly, or
heaters (no 55°C, or check the installation has a high turnover as indicated by the risk
greater than assessment
15 litres)
Combination Inspect the integral cold water header tanks as part of the cold Annually
water heaters water storage tank inspection regime; clean and disinfect as
necessary. If evidence shows that the unit regularly overflows
hot water into the integral cold water header tank, instigate a
temperature-monitoring regime to determine the frequency, and
take precautionary measures as determined by the findings of
this monitoring regime
Check water temperatures at an outlet to confirm the heater Monthly
operates at 55°C
46
Frequency (see
Cold water Inspect cold water storage cisterns and carry out remedial Annually
storage cisterns work where necessary
Check the cistern’s water temperature remote from the Annually (summer) or
ball valve and the incoming mains temperature. Record as indicated by the
the maximum temperatures of the stored and supply water temperature profiling
recorded by fixed maximum/minimum thermometers where
fitted
Cold water Check temperatures at sentinel taps (typically those nearest to Monthly
services and furthest from the cold cistern, but may also include other
key locations on long branches to zones or floor levels). These
outlets should be below 20°C within two minutes of running
the cold tap. To identify any local heat gain, which might not be
apparent after one minute, observe the thermometer reading
during flushing
Take temperatures at a representative selection of other Representative selection
points to confirm they are below 20°C to create a temperature of other sentinel outlets
profile of the whole system over a defined time period. Peak considered on a rotational
temperatures or any temperatures that are slow to fall should basis to ensure the
be an indicator of a localised problem whole system is reaching
satisfactory temperatures
for Legionella control
Check thermal insulation to ensure it is intact, and consider Annually
weatherproofing where components are exposed to the
outdoor environment
Showers and Dismantle, clean, descale and disinfect removable parts, Quarterly or as indicated
spray taps heads, inserts and hoses where fitted by the rate of fouling or
other risk factors, e.g.
areas with high-risk
patients
POU filters Record the service start date and lifespan or end date and According to
replace filters as recommended by the manufacturer (bacterial- manufacturer’s guidelines
retention filters should be used primarily as a temporary control
measure while a permanent solution is developed, although
long-term use of such filters may be needed in some healthcare
applications)
Base exchange Visually check the salt levels and top up salt, if required. Weekly, but depends on
softeners Undertake a hardness check to confirm operation of the the size of the vessel
softener and the rate of salt
consumption
Service and disinfect Annually, or according to
manufacturer’s guidelines
Multiple-use Backwash and regenerate as specified by the manufacturer According to
filters manufacturer’s guidelines
47
Frequency (see
Infrequently Consideration should be given to removing infrequently used Weekly, or as indicated by
used outlets showers, taps and any associated equipment that uses water. the risk assessment
If removed, any redundant supply pipework should be cut back
as far as possible to a common supply (e.g. to the recirculating
pipework or the pipework supplying a more frequently used
upstream fitting) but preferably by removing the feeding ‘T’
Infrequently used equipment within a water system (i.e. not
used for a period equal to or greater than seven days) should
be included on the flushing regime
Flush the outlets until the temperature at the outlet stabilises
and is comparable to supply water and purge to drain
Regularly use the outlets to minimise the risk from microbial
growth in the peripheral parts of the water system, sustain and
log this procedure once started
TMVs Where integral, inspect, clean, descale and disinfect any Annually or on a
strainers or filters associated with TMVs. frequency defined by
To maintain protection against scald risk, TMVs require regular the risk assessment,
routine maintenance carried out by competent persons in taking account of
accordance with the manufacturer’s instructions. There is any manufacturer’s
further information in paragraphs 2.152–2.168 of HSG274 recommendations
Part 2.
Inline strainers Where fitted, inspect, clean, descale and disinfect any strainers Annually or on a
or filters associated with TMVs or other sensitive equipment. frequency defined by
the risk assessment,
taking account of
any manufacturer’s
recommendations
Pressurisation Where practical, flush through and purge to drain. Monthly–six monthly,
and expansion Where removable, bladders or diaphragms should be changed as indicated by the risk
vessels according to the manufacturer’s guidelines or as indicated by assessment
the risk assessment
Biocidal Check the dosing and control system operation including Weekly
treatment alarms
systems Measure the treatment parameters to establish the required Weekly
values are being achieved at representative outlets including
sentinel outlets
Note: Validation and calibration
Consider 24-hour automatic monitoring for biocidal treatment of the automatic
on large or complex systems monitoring system should
be carried out at the
frequencies recommended
by the manufacturer
48
8 Other operational considerations
8.1 The WSG need to identify other

waterborne hazards (the list below is not Note
exhaustive but provides examples). Proprietary water containers for water
dispensing machines should be returned to
8.2 Waterborne pathogens including Legionella
the supplier.
may colonise other areas where droplets
of contaminated water of a size suitable for
8.6 Ice machines should not be placed in
deep inhalation are generated. Such aerosol-
augmented care units. Where ice is needed for
generating plant and equipment should not
treatment purposes, it should be made using
be installed next to patient accommodation or
water obtained through a microbiological POU
air inlets. Some patients may be particularly
filter or boiled water in sterile ice trays or ice
susceptible to infection (see also HSG274
bags.
Part 3).
8.7 Ice should not be allowed to stagnate in an
Vending, chilled-water and ice- ice-making machine’s storage bin, but should
be changed frequently. Appropriate cleaning
making machines and hygienic procedures, agreed by the
8.3 See paragraphs 9.24–9.27 in HTM 04- 01 WSG, including the cleaning and disinfection
Part A for guidance on installation of this of scoops etc should be put in place. For
equipment. guidance on infection-control precautions with
regard to ice-making machines, see HBN 00-
8.4 Where equipment is hand-filled, there 09 – ‘Infection control in the built environment’.
should be clear instructions on the water
used; it should be hygienically collected and 8.8 Maintenance for ice-making machines
decanted into the equipment from a clean should be carried out in accordance with the
vessel. manufacturer’s recommendations. Care should
be taken to ensure that the water supply to the
8.5 Chilled-water drinking fountains normally ice-making machine is not subjected to heat
include a reservoir to assist in the cooling gain.
cycle; if machines are turned off, water quality
can deteriorate. Provision of bottle dispensers
should be approved only by the WSG. Where Portable/room humidifiers
carbon filters and/or UV are fitted, these should 8.9 Designs should not include the use of
be maintained as per the manufacturer’s “portable” or “room” self-contained humidifiers
instructions. Additional cleaning to ensure (having a water supply that is sprayed/atomised
adequate hygiene of nozzles etc should be put into the room space). In clinical/patient areas
in place as recommended by the WSG. the decision to use this type of humidifier
should rest with the IPC team. See also Safety
49
Notice NHSE SN(96)06 – ‘Evaporative type Lawn sprinklers and garden (or
cooling fan’.
similar) hoses
8.13 In certain conditions, lawn sprinklers
Non-wholesome water storage may retain stagnant water in the pipework/
8.10 Non-wholesome water is sometimes hose supplying the sprinkler head; they may
stored for emergency use (for example for fire- also produce an aerosol spray. The pipework
fighting purposes). These systems should have may be installed underground or via a flexible
an appropriate backflow prevention device hose over ground. In either case it is very
in accordance with the Water Supply (Water unlikely that they can be completely drained
Fittings) Regulations 1999. They should be down after use or when not required; at certain
considered by the risk assessment and the times in the year the retained water may be
WSG. at temperatures suitable for the colonisation
by, and multiplication of, Legionella and
P. aeruginosa. There is evidence linking cases
Deluge showers of Legionnaires’ disease with permanently
8.11 Deluge showers (sometimes called installed systems that use underground
emergency showers) are intended for use supply plumbing. Irrigation systems and
in an emergency where a staff member or hoses for these purposes should be supplied
a patient has suffered external chemical via backflow prevention devices giving fluid
contamination. Similarly, there may be other category 5 protection – typically an air gap
special outlets used for personal emergencies, of Type AA or AB, which requires a break
for example eyebaths. These should not be tank and booster pump to provide adequate
installed on the end of lines. They should be pressure to the irrigation nozzle or hose outlet.
dismantled, descaled and disinfected regularly A risk assessment should be undertaken prior
in accordance with the risk assessment, and to use to minimise the risk by implementing
should be flushed in accordance with the suitable control measures.
recommendations in HSG274 Part 3. 8.14 Hoses used for filling of remote
equipment or mobile units should be of
Trolley wash procedures materials suitable for use with wholesome
water systems and should be drained, capped
8.12 High-pressure hoses will generate between uses and kept in cool conditions.
aerosols and have been associated with They should be disinfected (by immersing in
causing cases and outbreaks of Legionnaires’ hypochlorite) before use.
disease. The contamination of the aerosol can
be reduced if the water supply is taken from a
wholesome water system via a suitable air gap Vehicle-washing plant
giving fluid category 5 protection – typically 8.15 Vehicle washing is carried out either
an air gap of Type AA or AB, which requires using a hand-held pressure spray or by a
a break tank and booster pump to provide frame wash that consists of a bay containing a
adequate pressure to the washing equipment. rectangular pipework frame fitted with several
Procedures should be put in place to flush to high-pressure sprays. In the latter case,
drain before use, and to disinfect them if they this equipment should be flushed regularly.
have been out of use for a prolonged period. Pressure washers and frame washers should
be supplied via backflow prevention devices
giving fluid category 5 protection – typically
an air gap of Type AA or AB, which requires
a break tank and booster pump to provide
adequate pressure to the outlets. See the
50
Water Management Society’s ‘Managing the Wet fire and automatic sprinkler
risk of legionnaires’ disease in vehicle-washing
systems W046-5’.
systems
8.20 Wet fire protection systems have been
8.16 Permanent hard-standing areas for implicated in outbreaks of legionellosis. All hose
vehicle-washing purposes should have an even reels, sprinkler systems and wet risers should
surface to avoid ponding and have a slope or be isolated from the potable water supply by a
dish to a suitable drain. method permitted by the Water Supply (Water
Fittings) Regulations 1999. Many fire authorities
are not in favour of local fire-fighting, preferring
Decorative internal and external early professional intervention. It may, therefore,
water features be possible to remove hose reels, thus avoiding
8.17 Internal ornamental water features (for their hazards. (Any redundant pipework should
example a water cascade in the main entrance be cut back to the connection point including
hall) are susceptible to airborne contamination replacing the branch ‘T’ with a straight
and are not recommended. coupling.)
8.21 Fire-fighting systems should be included

External water features within risk assessments. See FPA Technical
Briefing Note – ‘Legionella and firefighting
8.18 Ornamental fountains have been systems’ for further guidance.
implicated in cases of legionellosis. External
water features should not be situated under
trees where fallen leaves or bird droppings Patient contact equipment (for
may contaminate the water. Exposure to high example respiratory nebulisers,
winds should be avoided as they can disperse
spray beyond the immediate confines of the humidifiers)
basin/pond. The apex of the water column/jet 8.22 Patient contact equipment (such as
should not exceed the distance to the nearest respiratory nebulisers and humidifiers) should
edge of the basin/pond for the same reason. be used, drained, cleaned, rinsed, and dried
An overflow/outlet to a suitable drain should strictly in accordance with the manufacturer’s
be provided for easy emptying and cleaning. recommendations and agreed by the WSG.
Where possible, a permanently installed They should always be allowed to dry
freshwater supply pipe with topping-up device thoroughly before use. See also Chapter 3 in
should be provided. Their provision should be HTM 04-01 Part C, which should be applied to
subject to a risk assessment and approval by all healthcare settings.
the WSG, and appropriate action is required
to minimise the risk. Any top-up supply from a
wholesome water supply should be supplied Heater cooler units used in cardiac
via backflow prevention devices giving fluid surgery
category 5 protection – typically an air gap of
Type AA or AB. 8.23 Heater coolers units (HCU) are used in
cardiopulmonary bypass operations and for
8.19 A risk assessment should be extracorporeal membrane oxygenation or
undertaken prior to use to minimise the risk by extracorporeal life support, and their function
implementing suitable control measures. is to regulate the temperature of the blood
perfusing the patient using water in the HCU
tanks to indirectly raise or lower the patient’s
body temperature. There have been a number
of outbreaks and fatalities due to the presence
51
of Mycobacterium chimaera in the HCUs

that has resulted in endocarditis, surgical
site infection and disseminated infection
possibly via the aerosol route. HCUs should
be operated and decontaminated according to
the manufacturer’s instructions, and their use
should be subject to a risk assessment that
should be approved by the WSG.
Flowers and plants

8.24 Consideration should be given to
providing specific facilities for regularly
disposing of wastewater and compost outside
in-patient accommodation. This should not be
provided in dirty utilities.
Buried pipelines
8.25 Pipelines made of plastics are susceptible
to hydrocarbons such as fuels and oils. These
chemicals can permeate through plastic
pipes if they are nearby and contaminate the
water supply, and it may take days, weeks or
even months before a noticeable taste can
be detected in the water supply. Whenever
spills are reported, an assessment of services
within the area should be undertaken. See also
paragraphs 12.8–12.16 in HTM 04-01 Part A.
8.26 Where there is a risk of hydrocarbon

contamination of the supply, barrier pipe can
be used instead. This is a double-layer plastic
pipe with a barrier layer (usually aluminium) in
between.
Other risk systems

8.27 Further guidance on other risk systems is
given in Appendix 3.1 of HSG274 Part 3.
52
9 Microbiological monitoring
9 Microbiological monitoring
9.1 Where there are taste or odour problems,

microbiological monitoring for total viable
counts (TVCs) may be considered necessary.
However, routine microbiological monitoring for
TVCs is not recommended as there is no direct
association with TVCs and the presence of
waterborne pathogens.
9.2 If performed, TVCs may be used to

analyse trends. Counts taken before and
after disinfection (samples at least 48 hours
post-disinfection) can give an indication of the
efficacy of a disinfection procedure.
9.3 All microbiological measurements should

be by approved methods and/or be carried
out by United Kingdom Accreditation Service
(UKAS)-accredited laboratories for the method
being used. Dip slides are not acceptable on
hot and cold water systems.
See also the Standing Committee of

Analysts’ ‘Microbiology of drinking water –
Part 7’ for methods suitable for TVCs.
53
10 Testing for Legionella
10.1 Legionella monitoring should be carried b. In systems where the temperature
out where there is doubt about the efficacy of or biocidal control regimes are not
the control regime or where the recommended consistently achieved, weekly checks
temperatures, disinfectant concentrations or are recommended until the system
other precautions are not consistently achieved is brought under control, after which
throughout the system. The WSG should use the frequency of monitoring can be
risk assessments to determine when and reviewed.
where to test, which may include the following
circumstances: c. When a nosocomial outbreak is
suspected or has been identified.
a. When storage and distribution
temperatures do not achieve those d. Where there are at-risk patients with
recommended and systems are increased susceptibility.
treated with a biocide regime, testing
should be carried out monthly,
although that frequency may be
altered depending on the results
obtained.
Legionella bacteria Action required

(cfu/L)
Not detected or up to 100 The primary concern is protecting susceptible patients, so any detection of
Legionella should be investigated and, if necessary, the system resampled
to aid interpretation of the results in line with the monitoring strategy and risk
assessment.
>100 and up to 1000 Either:
If the minority of samples are positive, the system should be resampled. If similar
results are found again, a review of control measures and a risk assessment should
be carried out to identify any remedial action necessary, or
If the majority of samples are positive, the system may be colonised, albeit at a low
level. An immediate review of control measures and a risk assessment should be
carried out to identify any other remedial action required. Disinfection of the system
should be considered.
>1000 The system should be resampled and an immediate review of the control measures
and a risk assessment should be carried out to identify any remedial actions,
including possible disinfection of the system. Retesting should take place three
days following systemic chemical or thermal disinfection and at frequent intervals
thereafter until a satisfactory level of control is achieved as agreed by the WSG.
54
10.2 As a minimum, samples should be taken 10.3 Analysis of water samples for Legionella
as follows: should be performed in UKAS-accredited
laboratories with the current ISO standard
• from the cold water storage and the methods for the detection and enumeration
furthermost outlet from the tank; of Legionella included within the scope of
• from the calorifier flow, or the closest accreditation. These laboratories should
tap to the calorifier, and the furthermost take part in a water microbiology proficiency
tap on the hot water service circulating testing scheme (such as that run by PHE or
system; an equivalent scheme accredited to BS EN
ISO 17043). Alternative quantitative testing
• additional samples should be taken from methods may be used as long as they have
the base of the calorifier where drain been validated using BS EN ISO 17994 and
valves have been fitted; meet the required sensitivity and specificity.
• additional random pre- and post- The laboratory should also apply a minimum
flush samples may also be considered theoretical mathematical detection limit of ≤100
appropriate where systems are known to Legionella bacteria/litre sample.
be susceptible to colonisation in line with
BS 7592 guidance; 10.4 Action following Legionella sampling in
hot and cold water systems is given in the
• methods should be in accordance with following flowcharts (see Figures 4–6).
BS 7592.
Note
Figures 4–6 are given as examples of a

range of various methods that may be
used. Individual conditions will dictate which
procedure is appropriate and therefore the
charts can be adapted accordingly.
55
Results from Pre-flush samples Systemic results (Post-flush samples)

Legionella
Pre-flush samples tend to be an indicator of local conditions and if detected will
bacteria (cfu/l) Post-flush samples (or multiple positive samples) may be an indication that the
often require Post-flush samples in order to determine that the contamination is local
whole water systems is contaminated and that controls are not effective.
and not systemic.
Legionella not
detected Continue with current control scheme
Legionella From Action required

detection to 100 • The detection limit for Legionella by culture methods was historically 100cfu/L, at present laboratories may be able to report to levels of 20cfu/L or less. This can
cause confusion over what level should bring about corrective actions. The primary concern is protecting susceptible patients, so any detection of legionella should
be investigated and, if necessary, the system resampled to aid interpretation of the results in line with the monitoring strategy and risk assessment.
100- less than Action required Action required
1000 • Identify remedial actions, Investigate:– Whilst low numbers are unlikely to pose a risk to the general population,
o Usage frequency • Review immediately the system control measures and risk assessment
o Outlet for corrosion and scale • Identify remedial actions, Investigate: -
o local heat gain, o Check for any hot water backflow via the calorifier cold feed pipes
o Local Dead ends o Calorifier discharge via open vents to the cold tank.
o Cross flow between hot and cold and vice versa, o Failure of HWS to operate at target temperatures
o Localised failure of the HWS return o Over capacity or under usage
• It may be appropriate to immediately resample to indicate if initial remedial • Cleaning & Disinfection of the entire system should be considered
actions have been effective. The locations should then be resampled after 3 • It may be appropriate to confirm effective disinfection, any required
to 6 months to confirm any actions taken have remained effective. microbiological samples should be taken between two and seven days
In addition to the above, and if the outlet is served by a TMV: after the system is treated. (Samples taken immediately after a disinfection
• Review the need for the TMV taking into account the relative risks of process might give false negative results).
scalding. Remove the TMV if considered appropriate • The water system should then be resampled regularly to confirm any actions
• If the TMV is to remain, clean and disinfect the TMV, the outlet and the taken have remained effective.
strainers on both cold and hot feeds.
• Identify any flexible hoses (particularly after the TMV) and consider
replacement, avoiding the use of flexible hoses where practicable.
1000-10,000 Action required Action required
• In addition to the above • In addition to the above
• Review immediately the local control measures and risk assessment to • Cleaning & Disinfection of the entire system is likely to be required.
identify any required remedial action (dead ends etc) • To confirm effective disinfection microbiological samples should be taken
• Cleaning and Disinfection of the outlet should be undertaken – (especially between two and seven days after the system is treated. (Samples taken
showers and spray taps) immediately after a disinfection process might give false negative results).
• If a shower (spray outlet) cannot be taken out of use, consider installing point
of use microbiological filters on all affected showers.
• It is likely to be appropriate to resample, between two and seven days after,
to indicate if initial remedial actions have been effective.
• The locations should then be resampled (e.g. 1 to 3 months) to confirm any
actions taken have remained effective.
56
Results from Pre-flush samples Systemic results (Post-flush samples)

Legionella
Pre-flush samples tend to be an indicator of local conditions and if detected will
bacteria (cfu/l) Post-flush samples (or multiple positive samples) may be an indication that the
often require Post-flush samples in order to determine that the contamination is local
whole water systems is contaminated and that controls are not effective.
and not systemic.
>10,000 Action required Action required
• In addition to the above. • In addition to the above.
• Take immediate measures to prevent exposure from this outlet until remedial • Take immediate measures to prevent exposure from all outlets fed by the
measures are taken and shown to be effective. system until remedial measures are taken.
• If the outlet cannot be taken out of use, install a point of use microbiological • Clean & Disinfect the entire system as soon as possible.
filter on all affected outlets.
• Resample, between two and seven days after, to indicate if initial remedial
actions have been effective.
• The locations should then be regularly resampled to confirm any actions
taken have remained effective.
Figure 4 Action levels following Legionella sampling in hot and cold water systems. Example 1
57
Legionella result
Is this in high risk area?#
Any Count <100 cfu/t >100 sample <1000 cfu/L or repeat positive of <100 cfu/L >1000 cfu/L
Multiple +ve**** Place back into Multiple +ve****

Single +ve Single +ve
INFORM RP sampling routine INFORM RP Single +ve Multiple
(Or if repeat +ve +ves****
Inform RP) INFORM RP
Take R.A. nos 1-3 Take R.A. 1-4

(Consider P.O.U.) (Consider P.O.U.) Take R.A.
Take R.A. nos 1-3
– discuss with – discuss with no. 1-4 Resample outlet Consider P.O.U –
IPCT PICT as per NOTE** discuss with
Isolate outlet*** IPCNT, or isolate
outlet ***
Retest outlet Retest outlets Retest outlet Retest outlets
48 hrs after R.A. 48 hrs after R.A. 48 hrs after R.A. 48 hrs after R.A.
complete complete complete complete
-ve +ve Take Remedial
Actions 1-4
Take R.A. Nos. 1-3

-ve result +ve result -ve results +ve results Place back into and retest 48 hrs Retest outlets
-ve result +ve result -ve results +ve results sampling routine after R.A. 48 hrs after R.A.
complete complete
Take R.A. No.4 Take R.A. No. 5

Place back into Place back into
NOTE* Note* Take R.A. No.4 Take R.A. No. 5
sampling routine sampling routine Place back into Place back into -ve +ve -ve +ve
NOTE ^^^ Note ^^^ NOTE* Note*
sampling routine sampling routine
NOTE ^^^ Note ^^^
Place back Take R.A. No. 4 Place back Take R.A. No. 5
into sampling NOTE* into sampling NOTE*
NOTE routine NOTE^^^ routine NOTE^^^
# High risk area: haematology/oncology/neurosurgery/transplant units/accommodation for older people

* If all remedial actions are exhausted and there is no improvement in results, then take remedial action No. 6.
** Take additional samples pre and post from adjacent areas on same loop based on worst case scenario (Low usage outlets).
*** Remedial Action should occur 48 hours after isolation.
**** More than one positive on same loop in the system.
^^^ More frequent sampling is required
• Remedial Actions (R.A.)
1. Review control measures e.g. temperatures flow and return and local, CLO2 levels, investigate if outlets are being used and/or flushing regime in place
2. Consider changing outlet i.e. shower head and hose or tap as appropriate
3. WHB – TMV change/consider removal
4. Full investigation of the plumbing system including dead leg invesitgation, flexible connections, has there been remedial works in the area, has anything changed
5. Consider Installation of standalone CIO2 Unit
6. Consultation/inform WSG
RP = Responsible person
Figure 5 Action levels following Legionella sampling in hot and cold water systems. Example 2
58
Positive Legionella sample result
Single samples can cause

confusion as they may well be an Single Post-flush or
indication of outlet contamination sample taken from the multiple samples
but could also indicate systemic Yes water system? No Positive?
colonisation. Yes
No
Pre-flush samples tend to be an Sample collected

indicator of local conditions. Pre-flush?
Yes
No
Post-flush samples or multiple positive
Outlets from mixed hot and cold samples from the same water system
water incorporating showers or may be an indication that the whole
hoses or TMVs are not good Blended / TMV / water systems is contaminated and that
locations for systemic testing. Shower/ Hoses controls are not effective.
Yes No
Systemic colonisation
Outlet colonisation
suspected
suspected
Protecting highly susceptible patients requires the
Protecting highly susceptible patients requires the detection
detection of any legionella even very low levels to be
of any legionella even very low levels to be investigated.
investigated. and, if necessary, the system resampled to aid
and, if necessary, the system resampled to aid interpretation 100cfu/ltr or less interpretation of the results in line with the monitoring
of the results in line with the monitoring strategy and risk
assessment. Yes Yes strategy and risk assessment.
Identify remedial actions, Investigate: - Whilst low numbers are unlikely to pose a risk to the general
o Usage frequency
No population, (high risk patients may be at risk).
o Outlet for corrosion and scale Review immediately the system control measures (thermal
o local heat gain, and chemical) and risk assessment
o Local Dead ends Identify remedial actions, Investigate: -
o Cross flow between hot and cold and vice versa, Hot water backflow via the calorifier cold feed pipes,
o Localised failure of the HWS return Calorifier discharge via open vents to the cold tank, Failure
It may be appropriate to immediately resample to indicate if of HWS to operate at target temperatures, Over capacity or
initial remedial actions have been effective. The locations under usage.
should then be resampled after 3 to 6 months to confirm Cleaning & Disinfection of the entire system should be
any actions taken have remained effective. considered
Review the need for any TMVs taking into account the >100cfu/ltr It may be appropriate to confirm effective disinfection, any
relative risks of scalding. Remove the TMV if considered <1000cfu/ltr required microbiological samples should be taken between
appropriate. two and seven days after the system is treated. (Samples
Where TMVs remain, clean and disinfect the TMVs, the Yes Yes taken immediately after a disinfection process might give
outlet and the strainers on both cold and hot feeds. false negative results).
Consider removal / replacement of any flexible hoses No The water system should then be resampled regularly to
(particularly after the TMVs) avoiding the use of flexible confirm any actions taken have remained effective.
hoses where practicable.
In addition to the above
Review immediately the local control measures and risk
assessment to identify any required remedial action (dead
ends etc) Action required
Cleaning and Disinfection of the outlet should be In addition to the above
undertaken - (especially showers and spray taps) Cleaning & Disinfection of the entire system is likely to be
If a shower (or spray outlet) cannot be taken out of use, required.
>1000cfu/ltr
consider installing point of use microbiological filters on all To confirm effective disinfection microbiological samples
affected showers. should be taken between two and seven days after the
Yes Yes
It is likely to be appropriate to resample, between two and system is treated. (Samples taken immediately after a
seven days after remedial action, to indicate if the actions No disinfection process might give false negative results).
have been effective.
The locations should then be resampled (e.g. 1 to 3 months
later) to confirm any actions taken have remained effective.
In addition to the above.
Take immediate measures to prevent exposure from this
outlet until remedial measures are taken and shown to be
Action required
effective.
In addition to the above.
If the outlet cannot be taken out of use, install a point of use
Take immediate measures to prevent exposure from all
microbiological filter on all affected outlets.
outlets fed by the system until remedial measures are taken.
Resample, between two and seven days after, to indicate if
Clean & Disinfect the entire system as soon as possible.
initial remedial actions have been effective.
The locations should then be regularly resampled to confirm
any actions taken have remained effective.
File evidence of actions taken
Figure 6 Action levels following positive result
59
Appendix A Examples of the use of water

within a healthcare facility and
water quality types
A1. All water and water systems in healthcare A2. Examples of different categories of water
facilities should be risk-assessed according to for differing uses are shown in Table A1.
their intended use and patient immune status
taking into account any identified inherent Note
hazards within the facility and the quality of the
water supply to the systems being assessed. The hazards and their occurrence will
The assessment of risk should take account depend on the quality of source water.
of the most vulnerable population likely to be Therefore the associated risks should
exposed to each potential source. be calculated taking into account local
conditions.
60
Appendix A Examples of the use of water within a healthcare facility and water quality types
Table A1 Examples of water quality parameters for different applications in healthcare

Particular
hazards
(based on an
Physical, chemical or microbial Water quality parameters assessment for
Healthcare area Application quality indicators given in: each system) See also
All settings Wholesome water Physical: Odour, colour, taste Water Supply (Water Quality) DWI guidance and codes of
for drinking, Chemical: Heavy metals, Regulations practice
cooking, food nitrates, orthophosphates, http://www.dwi.gov.uk/ Details of recommended
preparation and pesticides, surfactants stakeholders/legislation/ sampling procedures are given
washing Biological: Coliform bacteria, wqregs2007cons.pdf in the Microbiology of Drinking
E. coli, enterococci tables A and B. Water https://www.gov.uk/
Where private water supplies government/uploads/system/
are also used, see The Private uploads/attachment_data/
Water Supplies Regulations file/316769/MoDW-2-232.pdf
2009 http://www.dwi.gov. and BS EN ISO 19458.
uk/stakeholders/legislation/
pwsregs2009.pdf
All settings Circulated hot Legionella spp.: colony counts HTM 04-01 Parts A, B and C Legionella spp., For Legionella, see Health
water systems per litre BS 7592 Sampling for Pseudomonas and Safety Executive (2014).
and cold water Legionella bacteria in water aeruginosa and Legionnaires’ disease
Pseudomonas aeruginosa
systems systems. Code of practice other waterborne HSG 274 Part 2. The control of
colony counts per 100 mL
pathogens Legionella bacteria in hot and
cold water systems.
Flexible Initial flush Hardness HTM 01-06 Decontamination
endoscope Intermediate flush Hardness of flexible endoscopes Part B
reprocessing – Design and installation
Water for diluting Hardness
units HTM 01-06 Decontamination
disinfectants and
of flexible endoscopes Part E
detergents
– Testing methods
Final rinse-water • Hardness
• Total organic carbon
• Electrical conductivity
• Appearance
• pH
• Total viable count
• P. aeruginosa
• Environmental
mycobacteria
61
Particular
hazards
(based on an
Renal units and Water for Total viable counts and • BS ISO 13959: Water • HBN 07-01 Satellite
satellite dialysis haemodialysis endotoxin concentrations for haemodialysis and dialysis units
units related therapies. • HBN 07-02 Main renal
• BS ISO 11663: Quality units
of dialysis fluid for
haemodialysis and
related therapies.
• BS ISO 13958:
Concentrates for
haemodialysis and
related therapies.
Augmented Pseudomonas aeruginosa: HTM 04-01 Part B and
care Colony counts per 100 mL Part C: Pseudomonas
units aeruginosa – advice for
augmented care units
Aquatic therapy pH, free residual halogen, total • See the PWTAG’s
pools and combined halogen and ‘Swimming pool water:
other treatment parameters. treatment and quality
Coliforms, E.coli, Pseudomonas standards for pools and
aeruginosa and TVCs spas’;
Spa pools and pH, free residual halogen and • See HSE/PHE’s
whirlpools other treatment parameters ‘Management of spa
pools: controlling the risks
of infection’;
Note
This document is currently
being revised and will
become HSG274 Part 4 –
‘The control of Legionella
and other infectious agents
in spa pool systems’.
62
Appendix A Examples of the use of water within a healthcare facility and water quality types
Particular
hazards
(based on an
Sterile services Final rinse Appearance: HTM 01-01 Part D Washer
departments • pH disinfectors
• Conductivity at 25ºC
• Total dissolved solids
• Total hardness
• Chloride, Cl
• Heavy metals, determined
as Lead, Pb
• Iron, Fe
• Phosphate, P2 O5
• Silicate, SiO2
• Total viable count at 22ºC
• Total viable count at 37ºC
• Bacterial endotoxins
Other stages • Total hardness
• Chloride, Cl
• Silicate, SiO2
Laundries Final rinse Hardness (total Ca2+/Mg2+) HTM 01-04 Decontamination Clostridium Textile Services Association’s
• pH of linen for health and social difficile (2008) “Target specification for
• Turbidity care: engineering, equipment Bacillus cereus recycled water to meet final
and validation rinse quality”.
• Colour
• Iron
• Manganese
• Copper
• Surfactant
• Bioburden (TVC)
Dental facilities Dental unit water Legionella spp.: colony Chapter 19 in HTM 01-05 Legionella spp.
lines and water counts per litre Pseudomonas Decontamination in primary Pseudomonas
systems aeruginosa colony counts per care dental facilities aeruginosa and
100 mL https://www.gov.uk/ other waterborne
government/uploads/system/ pathogens
uploads/attachment_data/
file/170689/HTM_01-
05_2013.pdf
63
Appendix B Action in the event of an outbreak

of legionellosis
B1. In England and Wales, Legionnaires’ B4. The HSE or local environmental health
disease is notifiable under the Health Protection officers (EHOs) may be involved in the
(Notification) Regulations 2010. Under these investigation of outbreaks, their aim being
regulations, registered medical practitioners to pursue compliance with health and safety
must report cases of Legionnaires’ disease legislation. The local authority, Proper Officer or
to the Proper Officer. These regulations also EHO acting on their behalf will make a site visit
require human diagnostic laboratories to to carry out a public health risk assessment,
notify PHE of cases of Legionnaires’ disease often with the relevant officer from the enforcing
identified by laboratory testing. authorities (the HSE or the local authority) for
health and safety reasons. Any infringements of
B2. An outbreak is defined as two or more relevant legislation may be subject to a formal
cases where the onset of illness is closely investigation by the appropriate enforcing
linked in time (weeks rather than months) and authority.
location and where there is epidemiological
evidence of a common source of infection, B5. There are published guidelines on the PHE
with or without microbiological evidence. website for the investigation and management
An outbreak control team should always be of incidents, clusters and outbreaks of
convened to investigate outbreaks. It is the Legionnaires’ disease.
responsibility of the Proper Officer to declare
an outbreak. The Proper Officer, appointed B6. If the hot and cold water system is
by the local authority, is often a consultant in implicated in an outbreak of Legionnaires’
communicable disease control (CCDC) within disease, the WSG may wish to consider
the local PHE centre health protection team. cleaning and disinfection of part of the, or
the entire, system. Advice may be found in
B3. The local PHE centre health protection HSG274 Part 2.
team has established incident plans to
investigate major outbreaks of infectious
diseases including legionellosis.
64
Appendix C Exemplar temperature test sheets
Appendix C Exemplar temperature test sheets
65
C1. A unique identification is required for each

outlet/mixing device as well as identification of
its type.
C2. At commissioning, hot and cold water

pressures also need to be measured and
recorded for each mixing device together with
all the test parameters from the in-service tests
in HTM 04-01: Supplement – ‘Performance
specification D 08: thermostatic mixing valves
(healthcare premises)’. This allows supply
conditions to be reassessed in the future if
outlet temperatures have changed.
66
Appendix D Testing for P. aeruginosa
D1. P. aeruginosa may be present within the D7. To maximise the recovery of these free-
water storage, distribution and delivery systems floating planktonic bacteria, water samples
and also in the water supplied to the healthcare should be taken:
facility.
a. during a period of, preferably, no
D2. The sampling protocol (Appendix E) is use (at least two hours or preferably
intended to help healthcare providers establish longer); or
whether the water in augmented care units is
contaminated with P. aeruginosa and, if it is, to b. low use.
help locate its origin and to monitor the efficacy
of remedial measures. D8. If water flows over a biofilm containing
P. aeruginosa located in the last two metres,
D3. P. aeruginosa contamination is generally planktonic bacteria arising from that biofilm
found in the last two metres of the point of will be diluted and a subsequent sample will
water delivery; therefore pre-flush samples give low bacterial counts. If contamination
should be collected to assess the highest risk is upstream in the system, this will not affect
to outlet users and at-risk patients. bacterial counts, which may actually increase.
D4. Biofilm will constantly be released D9. The sample obtained after allowing water
as clumps or free-floating individual cells to flow from an outlet is referred to as a “post-
(planktonic forms).The concentration of flush” sample (see paragraphs E12 and E13
planktonic bacteria will build up over time when in Appendix E). Comparison of counts from
the water is stagnant, but will be diluted as pre-and post-flush samples can help locate
water is used and flows through the pipework the source of the P. aeruginosa. If a pre-flush
or tap containing the biofilm. sample gives a high count, subsequent paired
pre- and post-flush samples should be tested
D5. Water outlets can give very different results to help locate the source of the contamination.
and may be negative if water from the tap has
been used before a sample is collected. D10. In order to be able to carry out the
appropriate microbiological examinations on a
D6. The first water to be delivered from the sample and provide a meaningful interpretation
outlet (pre-flush sample) should be collected to of test results, it is essential that samples
assess the microbial contamination in the last are collected in the correct manner using
two metres of pipework. the correct equipment and that the sampling
protocol in Appendix E is adhered to.
D11. Protocols for microbiological examination

of samples are provided in Appendix F.
67
Where to sample water outlets D17. If test results are not satisfactory
(>10 cfu/100 mL), further sampling along with
D12. The water outlets to be sampled should an engineering survey of the water system
be those that supply water which: could be used to identify problem areas and
modifications that may be implemented to
• has direct contact with patients;
improve water quality.
• is used to wash staff hands; or
• is used to fill or clean equipment that will D18. After such interventions, the water should
have contact with patients as determined be resampled (see Figure D1 for suggested
by risk assessment. frequencies).
Note
When and how to sample water
Figure D1 gives an example of sampling
outlets frequencies. Sampling may be undertaken
D13. The outlets identified above should more frequently according to the risk
be sampled to provide an initial assessment assessment. It is important that samples are
of contamination levels. There is no need to taken as described in Appendix E to avoid
sample all taps that are due to be sampled false negative results.
on the same occasion; samples can be taken
in batches on separate occasions. It may
assist the receiving laboratory if the sampling
schedule is agreed beforehand (see Figure D1
and also Appendix F).
Interpretation of P. aeruginosa test

results
D14. If test results are satisfactory (not
detected), there is no need to repeat sampling
for a period of six months unless there are
changes in the water distribution and delivery
systems components or system configuration
(for example, refurbishments that could lead to
the creation of dead-legs) or occupancy.
D15. However, the WSG could indicate

that water sampling is required within six
months if there are clinical evidence-based
suspicions that the water may be a source of
patient colonisation or infection (that is, with
P. aeruginosa or another potentially waterborne
pathogen).
D16. If tests show counts of 1 to 10 cfu/100

mL, the WSG should risk-assess the use of
water while simultaneously retesting the water
outlet (see Figure D1 and Note below).
68
Water sample (pre-flush)
Not detected 1–10 cfu/100 mL >10 cfu/100 mL
Risk-assess removing
outlet from service and
retest (pre-/post-flush)
+ve Remediation
Retest (pre-/post-flush)
(see paragraph D22)
Satisfactory:
+ve
–ve Retest at 3 days
no further action
required
–ve
Reinstate outlet and retest +ve

after an additional 2 weeks
–ve
Retest after an additional +ve

4 weeks
–ve
Sample every 6 months
Figure D1 Summary of suggested water sampling and testing frequencies
Interpretation of pre- and post-flush • If both pre- and post-flush samples from
a particular outlet are >100 cfu/100 mL
counts and other nearby outlets have no or low
D19. High counts in pre-flush samples but counts, this shows that the single outlet
with low counts or none detected at post-flush is heavily contaminated, despite the high
could indicate that areas/fittings at or near the post-flush count. This could be explored
outlets are the source of contamination (see by testing dilutions of pre- and post-
Table D1). flush water samples from this outlet or
by using an extended flush such as for
• A few positive outlets, where the majority five minutes prior to post-flush sampling
of outlets are negative, would also or by taking a post-flush sample after
indicate that the source of contamination disinfection of the outlet as occurs with
is at or close to the outlet. Legionella post-flush sampling.
69
Table D1 Interpretation of pre- and post-flush counts D20. If the sampling indicates that the water
High P. aeruginosa pre-flush Suggestive of a local water services are the problem, then most outlets
count (>10 cfu/100 mL) and outlet problem
low post-flush count would possibly be positive and other points
(<10 cfu/100 mL) in the water system could then be sampled
High P. aeruginosa pre-flush Suggestive of a problem not to assess the extent of the problem (see
count (>10 cfu/100 mL) and related to a local water outlet
high post-flush count but to a wider problem within
Table D1).
(>10 cfu/100 mL) the water supply system
D21. Figure D2 provides a summary of the
sampling procedure and interpretation of
Note results for P. aeruginosa.
Overlaying sample results onto schematic
drawings of the system may help to identify
the source of contamination and locations
for additional sampling.
Samples taken in accordance with agreed written

protocols, on behalf of the Estates & Facilities
department, and correctly stored (if appropriate)
and transported to a laboratory that is capable of
processing and testing.
Results returned to nominated Estates &

Facilities and IPC teams that are members of
the Water Safety Group.
Results requiring action are identified.

Nominated people informed.
Appropriate course of action per outlet is
implemented.
Not detected 1–10 cfu/100 mL >10 cfu/100 mL
No further action See paragraph See paragraphs

required D16 D17 and D18
Figure D2 Summary of sampling procedure and interpretation of results for P. aeruginosa
70
What to do if a contamination e. Hand-washing should be

supplemented with the use of an
problem is identified antimicrobial hand-rub.
D22. Should risk assessment or water testing
identify contamination with P. aeruginosa, f. To prevent water stagnation, check
the following risk reduction and preventive for infrequently used outlets – assess
measures should be considered. frequency of usage and if necessary
remove infrequently used outlet(s).
a. Inform the WSG and hold a focused For example, the provision of
incident control meeting (for example, showers in areas where patients are
IPC team, estates and clinical staff) to predominantly confined to bed, and
ensure patient safety is prioritised and the resultant lack of use, could lead to
to formulate an action plan. stagnation.
b. If a water outlet has been taken out of g. Check connections to mixing taps
service because of contamination with to ensure that the supply to the hot
P. aeruginosa, continue daily flushing connection is not supplied from
while the outlet is out of normal use an upstream TMV. In a hot water
to prevent water stagnation and service, a dead-leg will exist between
exacerbation of the contamination. the circulating pipework and hot
connection of a fitting such as a mixing
c. Where practical, consider removal tap. In the case of cold water services,
of flow straighteners. However, the sometimes there will be no draw-off
removal of flow straighteners may from any part of the system and the
result in splashing and therefore entire service is in effect a dead-leg. To
additional remedial action may need minimise the stagnation of water in a
to be taken. If they are seen to be cold water system, it can be beneficial
needed, periodically remove them and to arrange the pipework run so that
either clean/disinfect or replace them. it ends at a frequently used outlet. A
Replacement frequency should be dead-leg may also exist when a TMV
verified by sampling/swabbing. is installed upstream of a mixing tap
(see Figure D3). Depending on the
d. Splashing can promote dissemination activities of the room in which the tap
of organisms, resulting in basin outlets is located, cold water may never be
becoming heavily contaminated. If drawn through the pipe between the
splashing is found to be a problem, cold water connections of the mixing
investigate the causes. Example valve and mixing tap.
causes include:
h. Risk-assess the water system for
i. the tap’s designed flow profile is redundant pipework and dead-legs
incompatible with the basin; (for example, where water is supplied
to both the cold water outlet and a
ii. the tap discharges directly into the
TMV supplying an adjacent blended
waste aperture;
water outlet, as such cold water
iii. incorrect height between tap outlet outlets in augmented care units may
and surface of the basin; be infrequently used). When removing
outlets, the branch hot and cold water
iv. excess water pressure; pipes should also be cut back to the
main distribution pipework in order to
v. a blocked or malfunctioning flow eliminate redundant pipework.
straightener.
71
Hot water Hot water Cold water Hot water Hot water
return flow supply return flow
TMV Cold water

supply
TMV
Mixed safe hot

water supply Cold water
to tap supply to tap
Cold water
supply to tap
Manual mixing
tap
(a) (b)
In the case of (a), as the tap lever is moved progressively from
left to right, only cold water will be drawn through initially. When
fully to the right, cold water will cease to flow and water will flow
from the upstream TMV.
In the case of (b), if the lever remains in the fully hot position, as it
is raised to draw-off water, there may never be flow from the
direct cold-water pipe supplying the tap.
Figure D3 Dead-leg formed by the cold pipework when a TMV is installed upstream of a mixing tap
i. Assess the water distribution system is necessary as in installations such

for non-metallic materials that may be as rise-and-fall baths and hand-held
used in items such as inline valves, showers).
test points and flexible hoses. They
should be replaced according to the k. POU filters, where they can be fitted,
guidance in safety alert DH (2010) 03 – may be used to provide water free of
‘Flexible water supply hoses’. P. aeruginosa. Where fitted, regard
filters primarily as a temporary control
j. All materials in contact with water measure until a permanent solution
should have been assessed and is developed, although long-term
shown they are appropriate for the use of such filters may be required in
intended purpose (see paragraph 1.15 some healthcare applications. Where
in HTM 04-01 Part A) and should not POU filters are fitted to taps, follow
leach chemicals that provide nutrients the manufacturer’s recommendations
that support microbiological growth. for renewal and replacement and
Materials should also be compatible note that the outer casing of a POU
with the physical and chemical filter and the inner surface can
characteristics of water supplied to become contaminated (see also
the building. Flexible pipes should only paragraphs 7.45–7.49). There should
be used in exceptional circumstances be sufficient activity space once a
(for example, where height adjustment POU filter has been fitted.
72
l. In certain circumstances, the WSG i. removable taps;

may decide it is necessary to carry
out a disinfection of the hot and cold ii. taps that are easy to use;
water distribution systems that supply
the unit to ensure that contaminated iii. taps that can be readily dismantled
outlets are treated. See chapter 2 for cleaning and disinfection;
of HSG274 Part 2 for guidance on
how to carry out the disinfection iv. taps to which a filter can be
procedure. Note that with respect to attached to the spout outlet.
P. aeruginosa, hyperchlorination is not Note: Such taps can be used
effective against established biofilms. for supplying water for cleaning
Consider replacing contaminated incubators and other clinical
taps with new taps; however, there is equipment.
currently a lack of scientific evidence
to suggest that this will provide a long- Note
term solution. When replacing taps,
consider fitting: In the event of an outbreak or incident,
further advice on the management of P.
aeruginosa contamination in water systems
can be sought from PHE.
73
Appendix E Water sampling for P. aeruginosa
Note neutralise up to 5 mg/L of free chlorine). It

should be further noted that dosing a 1 L
These sampling methods will also be sample bottle with 180 mg of sodium
applicable if sampling for Stenotrophomonas thiosulphate (equating to 180 mg/L in the final
maltophilia and Mycobacterium spp. sample) will neutralise up to 50 mg/L free
chlorine or will neutralise up to at least 80 µg/L
Click here for an online video showing silver and 600 µg/L copper). Sterile bottles are
methods for obtaining water samples. normally purchased containing the neutraliser.
However, EDTA has been found to be totally
E1. Sampling should be undertaken by staff ineffective as a neutraliser for silver and
trained in the appropriate technique for taking therefore should not be used as such in any
water samples including the use of aseptic bacterial test including P. aeruginosa and
technique to minimise extraneous Legionella spp. Where other disinfectants are
contamination. The method used in this being applied to the water system, take advice
guidance may differ from the collection of on the appropriate neutralisers to use.
water samples for other purposes (for example,
for sampling Legionella, which should be E5. The tap should not be disinfected by heat
carried out to BS 7592). or chemicals before pre-flush sampling (see
paragraph E9) nor should it be deliberately
E2. Carefully label samples with the type of cleaned or disinfected immediately before
samples (pre- or post-flush) and outlet such sampling.
that the outlet can be clearly identified; system
schematics indicating each numbered outlet to E6. Label a sterile collection vessel (200–
be sampled can be helpful in this respect. 1000 mL volume) containing a suitable
neutraliser for any biocide the water may
E3. The main strategy for sampling is to take contain. The labelling information should
the first sample of water (pre-flush) delivered contain details of the tap location, sender’s
from a tap at a time of no use (at least two reference, pre- or post-flush (see paragraph
hours or preferably longer) or, if that is not E12), person sampling, date and time of
possible, during a time of its lowest usage. This sampling.
will normally mean sampling in the early
morning, although a variety of use patterns E7. If P. aeruginosa has been found in a
may need to be taken into account. preflush sample, take a second paired set of
samples. The first would be a pre-flush sample
E4. Disinfectants in the water, such as chlorine as before. Run the tap for two minutes and
or chlorine dioxide, will have residual activity take a second identical post-flush sample.
after taking the sample and may inactivate Bacteria in this second sample (termed
bacteria in the sample prior to its processing postflush) are more likely to originate further
and therefore the WSG should take advice back in the water system. A substantially higher
from the receiving laboratory. To preserve the bacterial count in the pre-flush sample,
microbial content of the sample, neutralise compared with the post-flush, should direct
oxidising biocides by dosing the sample bottle remedial measures towards the tap and
with 18 mg of sodium thiosulphate (equating to associated pipework and fittings near to
18 mg/L in the final sample, which will that outlet. A similar bacterial count in pre-
74
Appendix E Water sampling for P. aeruginosa
flush and post-flush samples indicates that

attention should focus on the whole water
supply, storage and distribution system. A
more extensive sampling regime should be
considered throughout the water distribution
system, particularly if that result is obtained
from a number of outlets.
E8. Although water sampling is the principal

means of sampling, there may be occasions
when water samples cannot be obtained
immediately for analysis. In the event of a
suspected outbreak, swabbing water outlets
(as per section 5.4 of the Standing Committee
of Analysts’ (SCA) ‘Microbiology of drinking
water – Part 2: practices and procedures for
sampling’) to obtain strains for typing may
provide a means of assessing a water outlet,
but this does not replace water sampling (see
paragraph E15 on swabbing).
Procedure for obtaining the

samples
E9. Pre-flush sample: Aseptically (that is,
without touching the screw thread, inside of the
cap or inside of the collection vessel) collect at
least 200 mL water in a sterile collection vessel Collect at least 200 mL water in a sterile collection vessel
containing neutraliser. Replace the cap and
invert or shake to mix the neutraliser with the E11. For separate hot and cold water outlets,
collected water. each outlet is individually tested with its own
collection vessel and outlet identifier. For
E10. Depending on the water distribution blended outlets (that is, where both hot and
system design and the type of water outlet, the cold water come out of the same outlet):
water feed to the outlet may be provided by:
• sample water with the mixing tap set to
• a separate cold water supply and hot the fully cold position using an individual
water supply to separate outlets; collection vessel and outlet identifier, and
note the temperature setting;
• a separate cold water supply and hot
water supply, which may have its final • sample the blended outlet set to
temperature controlled by the use of an the maximum available hot water
integral TMV within the outlet; or temperature using an individual collection
vessel and outlet identifier, and note the
• a separate cold water and a pre-blended temperature setting.
hot water supply that has had its
temperature reduced by a TMV prior to E12. Post-flush sample: where this is required,
delivery to the outlet. allow the water to flow from the tap for two
minutes (see above) before collecting at least
200 mL water in a sterile collection vessel
with neutraliser. Replace the cap and invert or
75
shake to mix the neutraliser with the collected

water. This sample, when taken together with
the pre-flush sample, will indicate whether the
tap outlet and its associated components are
contaminated or if the contamination is remote
from the point of delivery (see Table D1 in
Appendix D).
E13. If a sample from a shower is required,

then place a sterile bag over the outlet. Using
sterile scissors, cut a small section off the
corner and collect the sample in a sampling
container (see PHE’s (2013) ‘Guidelines for
the collection, microbiological examination
and interpretation of results from food, water
and environmental samples taken from A sterile swab should be rubbed on the inside surface of the tap
the healthcare environment’). Appropriate outlet or flow straightener
precautions should be taken to minimise

aerosol production as described in BS 7592.
E14. The collected water should be processed

within two hours. If that is not possible, then it
should be refrigerated within two hours, kept at
2–8ºC and processed within 24 hours.
E15. To take a swab sample, remove a sterile

swab from its container and insert the tip
into the nozzle of the tap or other designated
area. Care should be taken to ensure no other
surfaces come into contact with the tip of the
swab. Rub the swab around – that is, move it
backwards and forwards and up and down,
as much as possible, on the inside surface
of the tap outlet or flow straightener (see
photograph). Replace the swab carefully in its
container, again ensuring no other surfaces
come into contact with the tip of the swab.
Place the swab in a transport medium or
maximum recovery diluent (MRD) and send to
the laboratory.
76
Appendix F Microbiological examination of water samples for P. aeruginosa
Appendix F Microbiological examination of

water samples for P. aeruginosa
Notes Testing principle

F2. A measured volume of the sample or
This appendix has been developed to a dilution of the sample is filtered through a
provide technical guidance for a range membrane filter (≤0.45 µm) to retain bacteria
of laboratories (including NHS, PHE and and the filter is then placed on a solid selective
commercial laboratories) that have the and differential medium.
capability and capacity to undertake water
sampling and testing. F3. CN agar contains cetyl trimethylammonium
bromide and nalidixic acid at concentrations
Alternative water-testing methods other
that will inhibit the growth of bacteria other than
than filtration methods may be used as
P. aeruginosa. Other selective and differential
long as they have been validated using
agars are available and acceptable if validated.
BS EN ISO 17994 and meet the required
sensitivity and specificity such as those F4. The membrane is incubated on a selective/
identified in BS EN ISO 16266. differential agar and characteristic colonies are
An oxidase test alone is not sufficiently counted. Confirmatory tests are carried out
specific to identify P. aeruginosa. where necessary (see paragraph F15) and the
result is calculated as the colony count per
Methods approved by the Standing 100 mL of water.
Committee of Analysts and listed in the
‘Microbiology of drinking water – Part 8: the F5. P. aeruginosa usually produces
isolation and enumeration of Aeromonas and characteristic blue-green or brown colonies
Pseudomonas aeruginosa’ are allowed to be when incubated at 37°C for up to 48 hours.
used. Confirmation of isolates is by subculture
to milk agar supplemented with cetyl
trimethylammonium bromide (commercially
Definition available) to demonstrate hydrolysis of casein.
F1. P. aeruginosa are Gram-negative, oxidase-
positive bacteria that, in the context of this Sample preparation and dilutions
method, grow on selective media containing F6. Water samples should be received and
cetrimide (cetyl trimethylammonium bromide), handled as described in the SCAs’ ‘The
usually produce pyocyanin, fluoresce under microbiology of drinking water Part 8’ (currently
ultraviolet light 360 ± 20 nm, and hydrolyse under review). For example, samples should
casein. P. aeruginosa needs to be identified be examined as soon as is practicable on the
by the following methods – identification by a day of collection. In exceptional circumstances,
positive oxidase test alone is insufficient. if there is a delay, store at 2–8°C and do not
exceed 24 hours before the commencement of
analysis.
77
Filtration and incubation

F7. Aseptically measure and dispense 100 mL
of water sample into the sterile filter-holder
funnel. If the funnel is graduated to indicate
volume, this can also serve to measure the
volume.
F8. If high bacterial numbers are present

in water samples, it may be impossible to
count individual colonies accurately on the
filter membrane. Therefore, if high counts
are expected, a range of dilutions made in
sterile diluent (water, MRD or similar) can be Plate showing raised counts of pyocyanin-producing colonies of
processed in parallel with the undiluted sample. P. aeruginosa
An example of this would be a 1-in-10 and
a 1-in-100 dilution processed as well as an Processing of swabs
undiluted sample. Filtration of 10 mL rather
than 100 mL is an alternative to filtering 100 mL F13. Swabs can show presence of
of a 1-in-10 solution. P. aeruginosa but will not provide equivalent
quantitative results as water sampling. They
F9. Draw the water sample through the filter. can be used to show the presence or absence
of P. aeruginosa at the outlet.
F10. Aseptically place the membrane onto
the P. aeruginosa selective and differential F14. In the laboratory, use the swab to
agar (see paragraph F3) and incubate inoculate a portion of an agar plate that is
aerobically at 37°C. selective and differential for P. aeruginosa (see
paragraphs F2 and F3). Streak the inoculum on
the plate as for a clinical sample. Incubate as
Counting of colonies described for filter samples above. Alternatively,
F11. Examine plates after 22 hours ± 4 hours after sampling, place the swab in 10 mL MRD,
and 44 hours ± 4 hours of incubation. vortex, then plate out (using serial dilution) on
the appropriate media and incubate as above.
F12. Count all colonies that produce a green-
blue (demonstrating pyocyanin production)
or reddish-brown pigment and those which
Confirmatory tests
fluoresce under ultraviolet light (optional). F15. Colonies that clearly produce pyocyanin
Exposure of colonies to daylight for two-to- (green-blue pigmented) on the membrane are
four hours enhances pigment production. considered to be P. aeruginosa and require no
When there is a moderately heavy growth of further testing. Other colonies that fluoresce
P. aeruginosa and other organisms on the or are reddish-brown require confirmation. If
membrane, colonies adjacent to pyocyanin- more than one volume or dilution has been
producing colonies of P. aeruginosa can filtered, proceed if possible with the membrane
also appear green after 44 hours ± 4 hours yielding 20–80 colonies to enable optimum
of incubation, making the interpretation of identification and accurate enumeration of
the count difficult. Observing the plates after colonies. Where there is doubt, perform
22 hours ± 4 hours assists in the interpretation additional tests to yield reliable species
in these instances. identification.
78
F16. To confirm other colonies, subculture F19. It will then be the responsibility of the
from the membrane onto a milk cetrimide agar testing laboratory to ensure that these isolates
(MCA) plate and incubate at 37°C for 22 hours are supplied to the typing laboratory (for
± 4 hours. Examine the plates for growth, example, PHE at Colindale) when requested,
pigment, fluorescence and casein hydrolysis and this should be written into the contract for
(clearing medium’s opacity around the testing.
colonies). If pigment production is poor, expose
the MCA to daylight at room temperature
for two-to-four hours to enhance pigment Calculation of results
production and re-examine. F20. Express the results as colonies of
P. aeruginosa per 100 mL of the undiluted
F17. P. aeruginosa is oxidase-positive, sample, for example:
hydrolyses casein and produces pyocyanin
and/or fluorescence. Occasionally atypical non- • for 100 mL sample – the count on the
pigmented variants of P. aeruginosa occur. A membrane;
pyocyanin-negative, casein-hydrolysis-positive,
fluorescence-positive culture should be • for 10 mL of sample – the count on the
regarded as P. aeruginosa. Additional tests may membrane multiplied by 10;
be necessary to differentiate non-pigmented • for 1 mL of sample – the count on the
P. aeruginosa from P. fluorescens (such as membrane multiplied by 100.
growth at 42°C or resistance to C-390,
9-chloro-9-(4-diethylaminophenyl)-10-
phenylacridan or phenanthroline or more Reporting
extensive biochemical tests). See Table F1. F21. If P. aeruginosa is not detected, report as
“Not detected in 100 mL”.
Retention of P. aeruginosa isolates F22. If the test organism is present, report
F18. Where a clinical investigation is underway, as the number of P. aeruginosa per 100 mL.
inform the testing laboratory that the Reports should be specific to P. aeruginosa,
P. aeruginosa isolates and associated sampling and not generic Pseudomonas species.
location information should be retained for
a minimum of three months as they may be F23. The sample reference originally submitted
required for typing at a later date. should be reported with each result.
Table F1
Colony on CN agar Oxidase test Fluorescing on Caseinolytic on Confirmed
MCA MCA P. aeruginosa
Blue or green + NT NT Yes
Fluorescing and not + + + Yes

pigmented
Reddish-brown non- + +/– + Yes

fluorescing
NT = No testing necessary
79
Microbiological typing F29. It is important to recognise that there are

some types of P. aeruginosa that are relatively
F24. Water and/or tap-swab isolates being commonly found in the environment and
sent to PHE’s Antimicrobial Resistance and among patient samples globally. These include
Healthcare Associated Infections (AMRHAI) the PA14 clone and clone C; a match between
Reference Unit for molecular analysis of patient and water samples with these strains
P. aeruginosa should only be referred if is not necessarily evidence of transmission
the isolates have been confirmed to be between the two.
P. aeruginosa and if there is a possible link to
the outbreak strain under investigation. F30. If a contamination problem has been
identified, the remediation measures in
F25. Referrals of P. aeruginosa isolates for paragraph D22 of Appendix D should be
typing should only be sent after consultation followed.
with the typing laboratory.
F26. Where many taps are positive for

P. aeruginosa, send one colony of the
P. aeruginosa from each water sample. Save
the primary isolation plate for possible further
examination once the results of typing are
known and have been discussed with the
typing laboratory. Analysis of results to date
has consistently shown that multiple picks have
been representatives of the same strain; since
multiple taps are being sampled, an idea of the
extent of homogeneity or otherwise will still be
gained where only one colony is sent from each
water sample.
F27. If only two or three taps are positive for

P. aeruginosa, then send two separate colony
picks of confirmed P. aeruginosa from the
primary plate per water sample to AMRHAI
(taking the stipulations in paragraph F25 into
account). Label these clearly as being from
the same water sample (so that AMRHAI can
accumulate data on how common mixed
strains are seen in the same tap water).
F28. It is important that the request forms

have information about the links between tap
water and cases as illustrated in the following
examples:
a. water from tap in room “A” ref

patient “X”;
b. water from taps in dirty utilities;
c. tap water from room “C” with no

cases.
80
Flowchart showing the processing and enumeration of P. aeruginosa by membrane filtration
Maintain the cold chain during transport of the sample to the laboratory
Process within 2 hours. If not possible, refrigerate within 2 hours, keep at 2–8°C and process
within 24 hours
Make any necessary dilutions
Filter
Aseptically place the membrane onto the pseudomonas selective and differential agar and incubate at
37°C; examine after 22 hours ± 4 hours and 44 hours ± 4 hours
Count all colonies that produce a green/blue or reddish-brown pigment and those that fluoresce under
UV light (optional)
Subculture non-pyocyanin-producing (green/blue) colonies to MCA and incubate at 37°C for 22 ± 4 hours
Examine the plates for growth, pigment, fluorescence and casein hydrolysis. If pigment production is poor,
expose the MCA to daylight at room temperature for 2–4 hours to enhance pigment production and
re-examine
Calculate confirmed count and report as P. aeruginosa
81
Acts and regulations

Care Quality Commission (Registration) Regulations 2009. SI 2009 No. 3112. HMSO, 2009.
http://www.legislation.gov.uk/uksi/2009/3112/made
Control of Substances Hazardous to Health Regulations 2002, SI 2002 No 2677.

http://www.legislation.gov.uk/uksi/2002/2677/contents/made
Food Safety Act 1990.

http://www.legislation.gov.uk/ukpga/1990/16/contents
Food Safety and Hygiene (England) Regulations 2013.

http://www.legislation.gov.uk/uksi/2013/2996/made/data.pdf
Health and Safety at Work etc. Act 1974.
Health and Social Care Act 2008 (Regulated Activities) 2014. SI 2014 No. 000. HMSO, 2014.
http://www.legislation.gov.uk/ukdsi/2014/9780111117613/contents
Health and Social Care Act 2012.

http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted
Health Protection (Notification) Regulations 2010. SI 2010 No. 659.

Management of Health and Safety at Work Regulations 1999. SI 1999 No. 3242.
Private Water Supplies Regulations 2009 (as amended). SI 2009 No 3101.

http://dwi.defra.gov.uk/stakeholders/legislation/pwsregs2009.pdf
Public Health (Infectious Diseases) Regulations 1988. SI 1988 No 1546

http://www.legislation.gov.uk/uksi/1988/1546/made
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR).

Security and Emergency Measures (Water Undertakers) Direction 1998.

http://www.dwi.gov.uk/stakeholders/legislation/semd98.pdf
Water Act 2003.

http://www.opsi.gov.uk/acts/acts2003/20030037.htm
82
Water Industry Act 1991 (as amended).

http://www.opsi.gov.uk/acts/acts1991/Ukpga_19910056_en_1.htm
Water Resources Act 1991 (as amended).

http://www.opsi.gov.uk/acts/acts1991/Ukpga_19910057_en_1.htm
Water Supply (Water Fittings) Regulations 1999, SI 1999 No 1148.

http://www.opsi.gov.uk/si/si1999/19991148.htm
Water Supply (Water Quality) Regulations 2000. SI 2000 No 3184.

http://www.opsi.gov.uk/si/si2000/20003184.htm
Water Supply (Water Quality) Regulations 2010. SI 2010 No 991.

Note
See also Appendix 2 in HTM 04-01 Part A, which gives an overview of UK water legislation.
Department of Health publications

NHS Premises Assurance Model (NHS PAM).
https://www.gov.uk/government/publications/nhs-premises-assurance-model-launch
Health Building Notes

Health Building Note 00-07 – Planning for a resilient estate.
https://www.gov.uk/government/publications/resilience-planning-for-nhs-facilities
Health Building Note 00-08 – (Estatecode) Part B: Supplementary information for Part A.
https://www.gov.uk/government/publications/the-efficient-management-of-healthcare-estates-and-
facilities-health-building-note-00-08
Health Building Note 00-09 − Infection control in the built environment.

https://www.gov.uk/government/publications/guidance-for-infection-control-in-the-built-
environment
Health Building Note 07-01 − Satellite dialysis unit.

https://www.gov.uk/government/publications/accommodation-guidance-for-satellite-dialysis-unit
Health Building Note 07-02 − Main renal unit.

https://www.gov.uk/government/publications/guidance-for-the-planning-and-design-of-a-main-
renal-unit
Health Building Note 13 – Sterile services department.

https://www.gov.uk/government/publications/the-planning-and-design-of-sterile-services-
departments
83
Health Technical Memoranda

Health Technical Memorandum 00 – Policies and principles of healthcare engineering.
https://www.gov.uk/government/publications/guidance-policies-and-principles-of-healthcare-
engineering
Health Technical Memorandum 01-01 – Management and decontamination of surgical

instruments (medical devices) used in acute care. Part D: Validation and verification. 2016.
sterilization
Health Technical Memorandum 01-04 – Decontamination of linen for health and social care.
Engineering, equipment and validation. 2016.
sterilization
Health Technical Memorandum 01-06 – Decontamination of flexible endoscopes. Part B:

Design and installation. 2016.
sterilization
Health Technical Memorandum 01-06 – Decontamination of flexible endoscopes. Part E:

Testing methods. 2016
sterilization
Health Technical Memorandum 04-01 – Safe water in healthcare premises. Part A: Design,
installation and commissioning. 2016.
sterilization
Health Technical Memorandum 04-01 – Safe water in healthcare premises. Part C:

Pseudomonas aeruginosa – advice for augmented care units. 2016.
sterilization
Health Technical Memorandum 04-01: Supplement. Performance specification D 08:

thermostatic mixing valves (healthcare premises).
https://www.gov.uk/government/publications/hot-and-cold-water-supply-storage-and-distribution-
systems-for-healthcare-premises
Health Technical Memorandum 07-02 – Encode. 2015.

https://www.gov.uk/government/publications/making-energy-work-in-healthcare-htm-07-02
Health Technical Memorandum 07-04 – Water management and water efficiency. 2013.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/147948/HTM_07-
04_Final.pdf
Estates and Facilities Alerts

DH (2010) 03 – Flexible water supply hoses.
84
NHSE SN (96)06 – Evaporative type cooling fan.

http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/
Lettersandcirculars/Estatesalerts/DH_4120799
Other government publications

Department for Environment, Food & Rural Affairs (DEFRA) (1999). Water Supply (Water
Fittings) Regulations 1999 guidance document relating to Schedule 1: Fluid Categories and
Schedule 2: Requirements for Water Fittings [See Regulation 4(3)].
http://webarchive.nationalarchives.gov.uk/20130402151656/http://archive.defra.gov.uk/
environment/quality/water/industry/wsregs99/documents/waterregs99-guidance.pdf
Department of Health (2015). The Health and Social Care Act 2008 Code of Practice on the
prevention and control of infections and related guidance’.
British Standards
BS 1710. Specification for identification of pipelines and services. British Standards Institution,
2014.
BS 2486. Recommendations for treatment of water for steam boilers and water heaters. British
Standards Institution, 1997.
BS 6100-1. Glossary of building and civil engineering terms. British Standards Institution, 2010.
BS 7592. Sampling for Legionella bacteria in water systems. Code of practice. British Standards
Institution, 2008.
BS 8551. Provision and management of temporary water supplies and distribution networks (not
including provisions for statutory emergencies). Code of practice. 2015.
BS 8554. Code of practice for the sampling and monitoring of hot and cold water services in
buildings. British Standards Institution, 2015.
BS 8558. Guide to the design, installation, testing and maintenance of services supplying water
for domestic use within buildings and their curtilages. Complementary guidance to BS EN 806.
British Standards Institution, 2015.
BS 8580. Water quality. Risk assessments for Legionella control. Code of practice. British
BS EN 805. Water supply. Requirements for systems and components outside buildings. British
BS EN 806 [All Parts]. Specifications for installations inside buildings conveying water for human
consumption. British Standards Institution, 2005.
BS EN 1717. Protection against pollution of potable water in water installations and general
requirements of devices to prevent pollution by backflow. British Standards Institution, 2001.
BS EN ISO 11663. Quality of dialysis fluid for haemodialysis and related therapies. British
85
BS EN ISO 13958. Concentrates for haemodialysis and related therapies. British Standards
Institution, 2015.
BS EN ISO 13959. Water for haemodialysis and related therapies. British Standards Institution,
2001.
BS EN ISO 16266. Water quality. Detection and enumeration of Pseudomonas aeruginosa.

Method by membrane filtration. British Standards Institution, 2008.
BS EN ISO 17994. Water quality. Requirements for the comparison of the relative recovery of
microorganisms by two quantitative methods. British Standards Institution, 2014.
BS EN ISO/IEC 17043. Conformity assessment. General requirements for proficiency testing.

British Standards Institution, 2010.
PD 855468. Guide to the flushing and disinfection of services supplying water for domestic use
within buildings and their curtilages. British Standards Institution, 2015.
Other publications
Breathnach, A.S., Cubbon, M.D., Karunaharan, R.N., Pope, C.F. and Planche, T.D. (2012).
Multidrug-resistant Pseudomonas aeruginosa outbreaks in two hospitals: association with
contaminated hospital waste-water systems. Journal of Hospital Infection. September. Vol. 82
No. 1, pp. 19–24.
BSRIA. BG3 – Maintenance for building services. BSRIA, 2008.
BSRIA. BG 57/2015 – Legionnaires’ disease – risk assessment. BSRIA, 2015.
BSRIA. FMS 4/99 – Guidance and the standard specification for water services risk
assessment. BSRIA, 1999.
CIBSE. Guide M – Maintenance, engineering and management. CIBSE, 2014.
Fire Protection Association (FPA). Technical Briefing Note – Legionella and firefighting
systems. FPA, 1999.
http://www.riscauthority.co.uk/free-document-library/RISCAuthority-Library_detail.si-legionella-and-
firefighting-systems.html
Health and Safety Executive (2013). Approved Code of Practice and guidance on regulations.
Legionnaires’ disease: The control of Legionella bacteria in water systems (L8). (4th edition). Health
and Safety Executive, 2013.
Health and Safety Executive (2012). Health Services Information Sheet No 6. Managing the
risks from hot water and surfaces in health and social care. Health and Safety Executive,
2012.
http://www.hse.gov.uk/pubns/hsis6.pdf
Health and Safety Executive (2014). HSG274 Legionnaires’ disease – technical guidance.
Part 2: The control of legionella bacteria in hot and cold water systems. Health and Safety
Executive, 2014.
86
Health and Safety Executive (2014). HSG274 Legionnaires’ disease – technical guidance.
Part 3: The control of legionella bacteria in other risk systems. Health and Safety Executive,
2014.
http://www.hse.gov.uk/pubns/priced/hsg274part3.pdf
Health and Safety Executive/Care Quality Commission/Local Government Association (2015).

Memorandum of understanding between the Care Quality Commission, the Health and
Safety Executive and local authorities in England.
http://www.hse.gov.uk/aboutus/howwework/framework/mou/mou-cqc-hse-la.pdf
(The) NHS Constitution. The NHS belongs to us all.

http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documents/2013/the-
nhs-constitution-for-england-2013.pdf
NHS Protect (2012). Guidance on the security and management of NHS assets.
http://www.nhsbsa.nhs.uk/Documents/SecurityManagement/Property_and_assets.pdf
Public Health England. Guidelines for the collection, microbiological examination and
interpretation of results from food, water and environmental samples taken from the
healthcare environment (forthcoming).
Renal Association. Guideline on water treatment facilities, dialysis water and dialysis fluid quality for
haemodialysis and related therapies. Renal Association and Association of Renal Technologists.
Standing Committee of Analysts. The microbiology of drinking water. Part 2 – Practices and
procedures for sampling. Environment Agency.
https://www.gov.uk/government/publications/standing-committee-of-analysts-sca-blue-books
Standing Committee of Analysts. The microbiology of drinking water. Part 7 – Methods for the
enumeration of heterotrophic bacteria. Environment Agency.
Standing Committee of Analysts. The microbiology of drinking water. Part 8 – The isolation
and enumeration of Aeromonas and Pseudomonas aeruginosa by membrane filtration.
Environment Agency.
Water Regulations Advisory Scheme (WRAS) (2000). Water Regulations Guide. WRAS, 2000.
http://www.wras.co.uk
World Health Organization (WHO) (2011). Guidelines for Drinking-water quality. 4th edition.
http://apps.who.int/iris/bitstream/10665/44584/1/9789241548151_eng.pdf
World Health Organization (WHO) (2011). Water safety in buildings.

http://www.who.int/water_sanitation_health/publications/2011/9789241548106/en/
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washing systems W046-5.
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87
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Health Technical Memorandum

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Preamble This Health Technical Memorandum (HTM)

• providing a point of reference to Because of the complexity of hot and cold

Glossary and abbreviations

Flow straightener: A device inserted into the Waterborne pathogen: microorganism

COSHH – Control of Substances Hazardous to

CQC – Care Quality Commission

DWI – Drinking Water Inspectorate

EPDM – ethylene propylene diene monomer

HBN – Health Building Note

HSE – Health & Safety Executive

HSG274 Part 2 – The Health & Safety

HTM – Health Technical Memorandum

MCA: milk cetrimide agar

MRD: maximum recovery diluent

PWTAG – Pool Water Treatment Advisory

SHTM – Scottish Health Technical

WRAS – Water Regulations Advisory Scheme

WSG – Water Safety Group

WSP – Water safety plan

0 Policy and regulatory overview: water safety

Introduction Adhering to the guidance outlined in this HTM

• national best practice guidance for the

Private Water Supplies Regulations 2009

0.29 Local authorities are the regulators for

Secretary of State for Health

Example governance and Guidance for

assurance standards that The Health and Social Care

help to influence safe

heathcare estates and March2015

(not an exhaustive list)

DH estates best practice guidance

Health Building Note 00-10

web applications (e.g. ADB) HBNs/HTMs

IMPROVED PATIENT OUTCOMES

Safety Effectiveness Patient experience

1.1 This edition of HTM 04-01 – ‘Safe water General

2 Governance and management responsibility

• appoint a competent person with

all the relevant factors that may pose a risk of

2.14 Healthcare organisations should be aware

Water undertakers can carry out a fittings

3.13 Compliance with HSG274 will satisfy the

3.15 The incidence of healthcare- British and European Standards

3.18 These regulations are set out – along

Source of the bacteria products, trapped organic and

hospitals. Pontiac fever is a self-limiting form Control measures

4.10 Where biocides are used, risk Number of infectious bacteria

a. The concentration of bacteria in

ii. the risk increases with the

c. existing respiratory disease that makes

d. illnesses and conditions such as

e. smoking, particularly heavy cigarette

f. patients who are

5 Pseudomonas aeruginosa and other

Ecology higher the potential for patient colonisation or

0 Policy and regulatory overview: water safety

a. The concentration of bacteria in

ii. the risk increases with the

c. existing respiratory disease that makes

d. illnesses and conditions such as

e. smoking, particularly heavy cigarette

f. patients who are

5 Pseudomonas aeruginosa and other

j. health and safety policy; h. the agreed standards, number of

Performance monitoring k. only agreed subcontractors with

b. all the required plant is being Monitoring systems

f. the agreed spares stocks are being a. A power or energy interruption

b. A water supply failure that could last

a. an inventory of plant and water-

c. a basis for recording the maintenance

d. a basis for recording and accessing

e. a basis for accounting to establish

7 Description of systems, operational

e. every water outlet complies with the

b. the system insulation is in good Hot water storage and distribution