1. What the regulation says
This policy is anchored to the Health and Safety at Work etc. Act 1974 and the Control of Substances Hazardous to Health Regulations 2002. It also engages Regulation 12 (safe care and treatment) and Regulation 15 (premises and equipment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, quoted verbatim below.
Care and treatment must be provided in a safe way for service users. (Reg 12(1) (the headline duty))
ensuring that the premises used by the service provider are safe to use for their intended purpose and are used in a safe way, (Reg 12(2)(d) (premises safety))
assessing the risk of, and preventing, detecting and controlling the spread of, infections, including those that are health care associated, (Reg 12(2)(h) (infection control))
Regulation 15 adds the premises duties that this policy operationalises:
All premises and equipment used by the service provider must be ... clean, secure, suitable for the purpose for which they are being used, properly used, properly maintained, and appropriately located for the purpose for which they are being used. (Reg 15(1): the six criteria)
The full text is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/12 and https://www.legislation.gov.uk/uksi/2014/2936/regulation/15. Where this policy and the regulation diverge, the regulation wins.
2. Plain-English summary
Care and treatment must be provided in a safe way. Regulation 12 lists the things you have to do, including assessing and mitigating risks, ensuring premises and equipment are safe and used safely, and assessing the risk of and controlling the spread of infection. Regulation 15 requires premises and equipment to be clean, secure, suitable for purpose, properly used and maintained, and appropriately located. Managing water safety, including Legionella, is part of keeping premises safe, controlling infection and running good governance.
3. Purpose
The purpose of this policy is to make sure that [Service Name] manages water safety risks, including Legionella, Pseudomonas aeruginosa, scalding and other water-related hazards.
Water safety is part of safe premises, infection prevention and control, and good governance. Even small services must understand their water system, assess risks, maintain controls, act on concerns and keep records.
This policy supports safe care and treatment, premises and equipment safety, infection prevention and control, health and safety duties and good governance.
4. Policy warning
The service must not assume that water systems are safe because the premises are small, modern, leased, serviced by a landlord or used only part-time.
The provider remains responsible for ensuring that premises used for regulated activity are safe for their intended purpose.
Where water safety controls fail, or where there is concern about Legionella, Pseudomonas, contamination, unsafe temperatures or scalding risk, the Registered Manager must act without delay and seek competent advice where required.
5. Scope
This policy applies to:
- hot and cold water systems
- taps
- showers
- sinks and wash-hand basins
- baths where relevant
- thermostatic mixing valves
- water storage tanks where relevant
- drinking water outlets
- dental waterlines where relevant
- clinical hand-wash basins
- treatment-room sinks
- sluice or dirty utility areas
- low-use outlets
- water used in cleaning, care or treatment
- contractor-managed water systems where used by the service
6. Key risks
The service must consider risks from:
- Legionella
- Pseudomonas aeruginosa
- other waterborne pathogens
- scalding
- stagnant water
- dead legs and low-use outlets
- poor temperature control
- poor flushing
- poor maintenance
- unsuitable sinks or splash risk
- contaminated outlets
- poor cleaning or descaling
- contractor failure
- lack of records
- vulnerable people using the service
7. Responsibilities
The provider is responsible for ensuring that safe water arrangements are in place.
The Registered Manager is responsible for implementing this policy, maintaining records, escalating concerns and ensuring that actions are completed.
A competent person or contractor must be used where specialist water safety assessment, maintenance, testing or remedial work is required.
All staff are responsible for reporting water safety concerns, such as unusual odour, discolouration, poor flow, unsafe temperature, damaged outlets, blocked drains or unclean sinks.
8. Water safety risk assessment
The service must have a water safety risk assessment proportionate to the premises and service type.
The assessment must consider:
- water system layout
- people who may be vulnerable to infection or scalding
- hot and cold water temperatures
- low-use outlets
- showers and aerosol-producing outlets
- clinical hand-wash facilities
- water storage
- thermostatic mixing valves
- maintenance arrangements
- flushing arrangements
- contractor responsibilities
- testing or sampling requirements
- records required
- actions needed
The assessment must be completed or reviewed by a competent person where the provider does not have the required knowledge.
9. Written control scheme
Where required by the risk assessment, the service must maintain a written water safety control scheme.
The control scheme should include:
- responsible person
- water system description
- outlet list
- flushing arrangements
- temperature monitoring
- cleaning and descaling schedule
- TMV checks where relevant
- contractor duties
- escalation limits
- action required when controls fail
- record-keeping requirements
- review date
The control scheme must be practical and understood by staff who have water safety duties.
10. Low-use outlets and flushing
The service must identify low-use outlets and manage the risk of stagnation.
Low-use outlets may include:
- rarely used taps
- showers
- treatment rooms used intermittently
- staff-only areas
- empty rooms
- temporary closed rooms
- seasonal or low-activity areas
Flushing must be carried out according to the risk assessment and recorded where required.
If an area is closed or unused, the Registered Manager must consider whether additional flushing, isolation, cleaning or recommissioning is needed before reuse.
11. Temperature control
The service must manage water temperature risks according to the risk assessment and competent advice.
The arrangements must consider:
- preventing Legionella growth
- preventing scalding
- vulnerable people
- outlet type and use
- thermostatic mixing valves
- temperature monitoring
- action where temperatures are outside expected limits
- documentation
Staff must escalate water that is too hot, too cold, fluctuating, discoloured, odorous or otherwise unusual.
12. Thermostatic mixing valves
Where thermostatic mixing valves are used, the service must ensure that they are:
- suitable for the outlet and risk
- installed correctly
- maintained
- checked
- cleaned or serviced as required
- included in the water safety records
- repaired or replaced where faulty
A faulty TMV may create scalding risk or infection-control risk and must be escalated immediately.
13. Cleaning and descaling
The service must clean, descale and maintain outlets according to the risk assessment.
This may include:
- taps
- shower heads
- hoses
- splash outlets
- strainers
- clinical sinks
- hand-wash basins
- other water fittings
Cleaning must not compromise infection prevention and control.
Staff responsible for cleaning or descaling must be trained and must use suitable products safely.
14. Clinical sinks and hand hygiene
Clinical hand-wash facilities must be suitable and kept clean.
Staff must report:
- blocked sinks
- slow drainage
- visible contamination
- damaged taps
- splashback concerns
- lack of hot or cold water
- unsuitable storage around sinks
- use of clinical hand-wash basins for disposal of fluids or inappropriate items
Hand-wash basins must not be used as storage areas.
15. Dental, specialist or high-risk water systems
Where the service uses dental waterlines, specialist equipment, decontamination equipment, hydrotherapy, pools, birthing pools, endoscopy-related water systems, augmented-care areas or other high-risk water systems, the provider must have additional service-specific procedures.
These procedures must follow relevant specialist guidance and competent advice.
The generic water safety policy is not enough for specialist water systems.
16. Contractor and landlord arrangements
Where water systems are controlled, maintained or partly managed by a landlord, building manager or contractor, the provider must still obtain assurance that water safety is being managed.
The service must retain evidence such as:
- risk assessment
- maintenance records
- flushing records where relevant
- temperature monitoring records
- sampling results where relevant
- remedial action records
- contractor competence information
- communication with landlord or building manager
The service must not assume that "the landlord deals with it" is enough for CQC evidence.
17. Water safety incidents
The following must be reported and escalated:
- suspected Legionella or waterborne infection risk
- failed temperature checks
- scalding or near miss
- contaminated outlet
- unsafe water appearance or odour
- blocked or damaged sink affecting clinical use
- failure to complete flushing
- missed contractor checks
- unsatisfactory sampling result
- loss of hot or cold water
- water outage affecting safe care
- contractor warning or remedial notice
The Registered Manager must consider incident reporting, risk register entry, external advice, service restriction, CQC notification, safeguarding or health protection advice where relevant.
18. Outbreak or suspected infection link
Where there is concern that illness may be linked to the water system, the Registered Manager must seek urgent competent advice and consider contacting relevant external bodies.
The service must:
- protect people from further exposure
- restrict affected outlets where needed
- preserve records
- follow public health or competent-person advice
- communicate appropriately
- complete incident records
- review duty of candour and notification requirements
19. Records
The service must keep water safety records, including:
- water risk assessment
- outlet list
- written control scheme where required
- flushing records
- temperature checks
- cleaning and descaling records
- TMV checks and servicing
- contractor records
- sampling results where applicable
- remedial actions
- incident records
- staff training
- audit records
Records must be clear enough to show what was checked, when, by whom, what was found and what action was taken.
20. Staff training
Staff with water safety duties must receive training appropriate to their role.
Training may include:
- recognising water safety concerns
- flushing procedure
- temperature checks
- cleaning and descaling
- reporting concerns
- infection-control links
- scalding risk
- record keeping
- contractor escalation
- action during water outage
General staff must know how to report water safety concerns.
21. Audit
The Registered Manager must audit water safety records at least quarterly.
The audit must check:
- current risk assessment
- flushing records
- temperature records
- missed checks
- contractor evidence
- outlet cleaning
- TMV records
- incidents or concerns
- remedial actions
- risk register links
- whether staff know escalation routes
Findings must be added to the action plan or risk register where required.
22. Related policies
This policy should be read with:
- Safe Care and Treatment Policy
- Premises and Equipment Policy
- Infection Prevention and Control Policy
- Health and Safety and COSHH Policy
- Clinical Waste and Sharps Safety Policy
- Risk Management and Risk Register Policy
- Incident Reporting, Investigation and Learning Policy
- Business Continuity and Emergency Preparedness Policy
- Record Keeping Policy
- Training, Competency and Mandatory Training Policy
23. Review
This policy will be reviewed annually, or sooner following a water safety incident, water risk assessment update, premises change, service change, contractor change, CQC finding, infection-control concern, water outage or change in national guidance.
24. Sources and further reading
This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.
- Health and Safety at Work etc. Act 1974 (https://www.legislation.gov.uk/ukpga/1974/37)
- Control of Substances Hazardous to Health Regulations 2002 (https://www.legislation.gov.uk/uksi/2002/2677)
- CQC Regulation 12: Safe care and treatment
- CQC Regulation 15: Premises and equipment
- HSE Legionella Approved Code of Practice and guidance (ACOP L8)
- HSE HSG274: Legionnaires' disease technical guidance, used alongside ACOP L8 where applicable
- HTM 04-01 Safe Water in Healthcare Premises
- Competent water risk assessor
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/12)
25. When to seek further advice
Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.
26. Document control
| Version | Date | Author | Changes |
|---|---|---|---|
| v1 | 2026-06-10 | Verivius (sample) | Initial sample template, conformed to the Verivius policy standard. |
This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.