Legionella Checks in GP Practices: A Practical CQC Compliance Guid
- Liam
- Aug 26
- 9 min read
Every GP practice must assess and manage the risk of Legionella bacteria within its water systems. However, this does not mean that every practice needs complicated water treatment arrangements or routine laboratory testing.
The controls required will depend on the building, its water system, the outlets in use and the vulnerability of the people who may be exposed.
A small GP surgery supplied directly by mains water, with regularly used taps and small point-of-use water heaters, may present a relatively low risk. A large health centre with stored water, showers, complex pipework and several infrequently used rooms is likely to require more extensive controls.
The important point is that the practice can demonstrate that risks have been assessed, responsibilities are clear, necessary checks are completed and any problems are acted upon.
What is Legionella?
Legionella is a type of bacterium that can grow in natural and purpose-built water systems. If contaminated water is released as fine droplets or aerosols, people may inhale the bacteria.
Legionella can cause Legionnaires’ disease, a potentially fatal form of pneumonia. Although anyone can become infected, some people are at increased risk, including:
People over 45
Smokers and heavy drinkers
People with chronic respiratory or kidney disease
People with diabetes, lung disease or heart disease
People with weakened immune systems
These groups will be represented within the population using most GP practices, making effective water safety management particularly important.
Legionella growth is more likely where:
Water temperatures remain between 20°C and 45°C
Water is stored or recirculated
Outlets are used infrequently
Dead legs or redundant pipework allow water to stagnate
Scale, rust, sludge or biofilm is present
Equipment produces water droplets or aerosols
The HSE Approved Code of Practice L8 sets out the principal framework for identifying and controlling these risks.
What does CQC expect from GP practices?
CQC GP Mythbuster 27 states that GP practices should be able to provide assurance that they have assessed risks associated with their premises and are managing those risks.
All relevant water systems require a risk assessment. However, CQC makes it clear that not every system needs elaborate control measures. A suitable assessment may conclude that the practice is low risk and that its existing arrangements are sufficient.
CQC’s newer Legionella risk assessment guidance for registration documents also provides a useful description of the information a comprehensive assessment may contain, including:
Identification and mapping of the water system
Taps, sinks, showers and other outlets
Water heaters, tanks and cylinders
Thermostatic mixing valves
Appliances that use water
Low-use outlets and areas of possible stagnation
Dead legs and redundant pipework
Temperature monitoring arrangements
Cleaning and descaling schedules
Control measures and maintenance arrangements
Records of checks and remedial work
Staff responsibilities and training
The registration page currently identifies particular service types that must submit the document with a new-provider application. GP practices should still follow the underlying legal duty to assess and control Legionella risk, even where the assessment is not listed as an application document for their service type.
CQC may consider Legionella arrangements in relation to:
Regulation 12: Safe care and treatment
Regulation 15: Premises and equipment
Regulation 17: Good governance
A practice should therefore have more than a certificate or report stored in a folder. It should be able to show that recommendations have been implemented and ongoing controls are working.
Who is responsible for Legionella control in a GP practice?
The dutyholder is normally the employer or the person who controls the premises or water system. In a leased or shared health centre, responsibilities may be divided between the landlord, NHS property organisation, building manager and individual healthcare providers.
The practice must establish exactly who is responsible for:
Completing the risk assessment
Maintaining the water system
Monitoring water temperatures
Flushing low-use outlets
Cleaning and descaling relevant fittings
Arranging repairs and remedial work
Reviewing the assessment
Retaining records
Escalating abnormal results
A contract or lease may allocate particular maintenance tasks to a landlord, but the practice should not simply assume that these tasks are being completed. It should obtain appropriate evidence and understand how concerns are reported.
HSE guidance confirms that employing a contractor does not remove the dutyholder’s responsibility. The practice should make reasonable enquiries about the contractor’s competence and check that the required work has been completed.
Does a professional company have to complete the assessment?
Neither CQC nor HSE specifies that a particular type of company must complete every Legionella risk assessment. The person carrying it out must be competent, with sufficient knowledge, training, skills and experience to assess the particular water system.
A relatively simple system may be assessed by a suitably competent person within the organisation. Specialist support is more likely to be needed where:
The building is large or has complex pipework
Water is stored in tanks or cylinders
There are several organisations sharing the building
There are showers or aerosol-producing devices
The system has repeatedly failed temperature checks
Legionella has previously been detected
There are known dead legs or areas of stagnation
Significant plumbing or building work is planned
The practice cannot confidently understand or manage the system
Whoever completes the assessment should clearly document their competence and the basis for their conclusions.
What Legionella checks should a GP practice complete?
The exact monitoring schedule must come from the practice’s Legionella risk assessment and written control scheme. The following are common controls drawn from HSG274 Part 2, but they should not be adopted without considering the design of the practice’s system.
Frequency | Typical check | Important qualification |
Weekly | Flush outlets that have not been used for seven days or more | Flush until the outlet temperature stabilises, or follow the risk assessment |
Monthly | Check cold-water temperatures at identified sentinel outlets | Cold water should normally fall below 20°C within two minutes |
Monthly | Check hot-water temperatures at identified sentinel points | In healthcare premises, hot distribution temperatures are generally expected to reach at least 55°C within one minute |
Monthly to six-monthly | Check small point-of-use water heaters | Frequency depends on turnover, design and the risk assessment |
Quarterly | Dismantle, clean and descale removable showerheads, hoses and spray-tap components | Increase or reduce frequency according to fouling and risk |
Annually | Visually inspect cold-water storage tanks, where present | Record condition and arrange remedial work where necessary |
Annually | Check the condition of accessible insulation | Repair damaged insulation or investigate heat gain |
Annually or risk-based | Inspect, maintain and service thermostatic mixing valves | Follow the risk assessment and manufacturer’s instructions |
As specified | Review actions and recommendations from the risk assessment | The responsible person should confirm that actions are completed |
These are indicative frequencies. The competent assessor may specify different or additional controls based on the practice’s water system and patient population.
A warning about hot-water measurements
Practices must balance Legionella control with the risk of scalding. Some outlets are fitted with thermostatic mixing valves, which blend hot and cold water before it reaches the user.
A temperature taken from the blended side of a thermostatic mixing valve will not demonstrate the temperature throughout the hot-water distribution system. The monitoring plan should identify where temperatures are to be measured and how this can be done safely.
Staff should not alter water-heater settings or remove scald controls simply to obtain a particular reading. Technical advice should be obtained if the required temperatures cannot be achieved safely.
Which outlets need weekly flushing?
Outlets that are not used for seven days or more should normally be considered for a flushing regime. Examples could include:
Taps in rarely used consulting rooms
Staff showers
Sinks in rooms temporarily taken out of use
Outlets in seasonal or part-time services
Rooms closed during refurbishment
Taps in areas used only by visiting clinicians
The practice should maintain an accurate list of low-use outlets. Each flush should be recorded, including:
Date
Outlet or room
Person completing the check
Confirmation that the outlet was flushed
Any concern identified
Action taken or person notified
Flushing should be completed in a way that reduces splashing and aerosol production. Staff should also be aware of the risk of hot water and should follow the practice’s safe procedure.
Where an outlet is no longer needed, permanent removal and elimination of the redundant pipework may be safer than maintaining an indefinite flushing schedule. This work should be planned and completed by a competent person.
Does a GP practice need routine Legionella water testing?
Routine microbiological sampling is not automatically required in every GP practice.
HSG274 explains that routine microbiological monitoring of mains-supplied domestic hot and cold water is not usually necessary unless the risk assessment or monitoring indicates a problem.
Legionella sampling may be appropriate where:
Required temperatures are not being consistently achieved
There is doubt about whether the control measures are working
Water is supplied from a private source
The system uses a chemical water-treatment regime
There are areas of persistent stagnation
The premises serves particularly susceptible patients
A case or outbreak may be connected to the premises
The competent risk assessor recommends sampling
Where sampling is required, it should be properly planned and analysed by an appropriately accredited laboratory. A negative sample does not replace the need for effective temperature control, maintenance, flushing and risk management.
Practices should be cautious about purchasing routine annual testing that has not been justified by the risk assessment. Testing a small number of outlets can create false reassurance if the wider water system is poorly controlled.
What records should the practice maintain?
Good records help the practice demonstrate that controls are not merely planned but are consistently implemented.
A practical Legionella file should contain:
The current Legionella risk assessment
A water-system schematic or outlet plan, where appropriate
Details of the dutyholder and appointed responsible person
The written control scheme
The current list of sentinel and low-use outlets
Weekly flushing records
Temperature-monitoring records
Cleaning and descaling records
Tank and water-heater inspection records
Thermostatic mixing valve maintenance records
Contractor reports and evidence of competence
Staff instructions or training records
A remedial-action log
Evidence that completed work has been checked
Previous assessments and review records
The findings should also connect with the practice’s wider governance arrangements. Significant risks, overdue actions or repeated temperature failures may need to be recorded on the practice risk register and discussed at an appropriate management meeting.
How often should a Legionella risk assessment be reviewed?
HSE does not prescribe a universal expiry date for every Legionella risk assessment. It says assessments should be reviewed regularly and whenever there is reason to believe that the existing assessment is no longer valid.
CQC’s current registration-document guidance refers to an annual review, or an earlier review following relevant changes. A documented annual management review is therefore a sensible way for a practice to confirm that the assessment, responsibilities and controls remain current. This does not necessarily mean paying for a completely new external assessment every year.
An earlier review should be considered following:
Changes to the water system
Building alterations or refurbishment
Installation or removal of outlets
Changes in how rooms are used
A prolonged period of closure
Significant changes in occupancy
Repeated failures of control measures
Evidence of contamination
A suspected case of Legionnaires’ disease
Changes in responsibility for the premises
New information about risks or control measures
The review should be documented, even if the practice concludes that the original assessment remains suitable.
What should happen if a check fails?
A failed check should not simply be initialled and filed. Staff should follow a clear escalation process.
Depending on the nature of the failure, actions may include:
Recording the result accurately.
Repeating the check to rule out an error.
Informing the responsible person.
Checking whether other outlets are affected.
Reviewing recent flushing and maintenance records.
Restricting use of an outlet if there may be an immediate risk.
Obtaining advice from a competent water-safety professional.
Arranging repairs, cleaning, disinfection or sampling where advised.
Recording the remedial action and completion date.
Reviewing the risk assessment and control scheme.
The response should be proportionate to the risk. Persistent or widespread temperature failures require more than repeated monitoring because they may indicate a problem with system design, heater performance, insulation or water circulation.
Common Legionella mistakes in GP practices
Common weaknesses include:
Having no documented risk assessment
Keeping an assessment that does not reflect the current building
Assuming the landlord has completed every required action
Failing to identify rarely used outlets
Completing flushing inconsistently
Recording temperatures without knowing which outlets are sentinels
Taking hot-water readings after a mixing valve
Ignoring repeated results outside the expected range
Paying for routine sampling without understanding why it is needed
Failing to complete recommendations made by the assessor
Having checks completed by staff who have not received instructions
Keeping records without reviewing or auditing them
A professional-looking assessment is not enough if the recommended actions remain outstanding.
A simple Legionella compliance checklist for GP practices
Your practice should be able to answer yes to the following:
Is there a current and suitable Legionella risk assessment?
Is there a named responsible person?
Are landlord and practice responsibilities documented?
Has the complete water system been considered?
Are low-use and sentinel outlets clearly identified?
Is there a risk-based written control scheme?
Are required flushing and temperature checks completed?
Are abnormal results escalated and investigated?
Are cleaning, descaling and maintenance tasks recorded?
Have all recommendations from the risk assessment been completed?
Are staff completing checks suitably instructed?
Is the assessment reviewed after changes or concerns?
Can the practice produce its records promptly if requested?
Final thoughts
Legionella compliance in a GP practice should be proportionate, practical and based on the actual water system.
Most practices do not need unnecessarily complicated testing arrangements. They do need a suitable assessment, a competent responsible person, clearly allocated duties, reliable monitoring and evidence that identified risks are being controlled.
The strongest evidence is not simply a Legionella certificate. It is a complete trail showing that the practice understands its water system, completes the checks required by its assessment and acts promptly when something goes wrong.
If your practice needs support reviewing its environmental risk assessments, preparing for CQC registration or checking its compliance systems, visit our CQC compliance support page to learn more.
This article provides general information and is not a substitute for a site-specific Legionella risk assessment or advice from a competent water-safety professional.
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