Care homes: what CQC actually checks on legionella

A care home answers to two regulators on the same water system, and that is the thing homes most often get wrong. The person responsible is the registered provider or registered manager. The duty runs under the Health and Safety at Work etc Act, the way it does for any employer, and it runs in parallel under the care regulator. So a legionella failure in a care home is both an HSE matter and a CQC matter at once.

HSE's guidance for health services tells providers to carry out a full COSHH risk assessment of their hot and cold water systems, and notes that where a provider is registered with CQC and the premises are in England, CQC is the relevant regulatory body for patient safety matters. So the water system sits inside the care regulator's remit, not just the employer's health-and-safety file, and an inspector from either side can ask about it. The CQC hook is Regulation 12, safe care and treatment, with Regulation 15 on premises and equipment behind it, both of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, on top of HSWA, COSHH, ACoP L8 and HSG274 Part 2.

One water system, two inspectors

The dual duty sounds like twice the work. It isn't, because the same evidence answers both regulators. There is one water system, one risk assessment, one monitoring record, and it satisfies the HSE duty and the CQC one at the same time. What differs is who turns up and what they lead with.

A CQC inspector is not usually a legionella specialist. They will not quiz you on sentinel outlets, but they will ask to see that a competent risk assessment exists, that monitoring is happening, and that flagged problems get fixed, because that is the shape of safe care under their regulations. HSE, if it gets involved, comes at the same failure from the health-and-safety side and brings heavier enforcement. So the record you keep for one is the record you produce for the other. Build it once, keep it current, and you are ready for whichever door it comes through.

Why a care home is higher risk than the building suggests

The residents are the reason. Legionella risk assessments talk about the susceptible group, and a care home is where that group lives. Residents are older to begin with, and the population skews towards exactly the conditions that make Legionnaires' more likely and more severe: respiratory disease, diabetes, a suppressed immune system, a history of smoking. The same warm, poorly-flushed outlet that might give a healthy adult a bad week can kill a resident.

That is why the monitoring runs harder than in a low-occupancy office. Monthly sentinel temperature checks are standard HSG274 Part 2 practice, and in a care home the case for keeping to that rhythm is stronger than almost anywhere. If you want the full cadence, every task and how often, we put the whole HSG274 regime on one page.

What CQC actually looks at

An inspector is not going to climb into your plant room and sample the calorifier. What they ask for is evidence that the risk is assessed and controlled, and it comes down to a short list:

• A current legionella risk assessment for the premises.
• A written scheme setting out what is controlled and how.
• The monitoring record, showing the temperatures and flushing actually happened, with dates and who did them.
• Proof that anything the monitoring flagged was followed up and closed.

That last one is where homes come unstuck. A single out-of-range temperature reading is not, by itself, a failure. A reading that went out of range and has no follow-up against it is an open loop, and open loops are what turn a bad inspection into a prosecution. We went through why open remedial actions are the ones that get charged, and in a care home the same logic applies with the susceptible group on the receiving end.

The prosecution that shows the stakes

This is not hypothetical. CQC prosecuted Sentinel Health Care Limited, which operated Fordingbridge Care Home in Fordingbridge, Hampshire. Reports of the case record that Andrew Clegg was admitted as a resident in April 2017 and died in hospital on 5 November 2017, aged 56, from Legionella pneumonia, and that a coroner's inquest in March 2019 concluded he had contracted the bacteria at the home. The company pleaded guilty to two charges: failing to provide safe care and treatment resulting in avoidable harm to Mr Clegg, and failing to provide safe care and treatment exposing other service users to a significant risk of avoidable harm. It was fined £75,000 on each charge and ordered to pay £17,500 in prosecution costs and a £170 victim surcharge, a total of £167,670. Sentencing was at West Hampshire Magistrates' Court on 26 November 2020. CQC said this was the first time it had used its prosecution powers against a provider in a case where a person had contracted Legionella.

Read that back slowly. The regulator that inspects your home has brought a legionella prosecution under the safe-care regulations, and a first has a way of not staying a one-off. Regulation 12 is not an abstraction in a policy binder. It says care and treatment must be provided in a safe way, and under Regulation 22 a failure to comply is an offence where it causes avoidable harm or exposes someone to significant risk of it.

Getting the duty straight

The registered provider or manager holds the duty and cannot pass it to a contractor. You can, and most homes should, bring in a water hygiene firm to do the sampling and the temperature rounds. What you are buying is the competent work, not the responsibility. The registered person still answers to CQC and to HSE for whether it happened and whether the actions closed. Our guide to the responsible person versus the competent person draws that line, and in a dual-regulator setting it is worth being certain which side of it you sit on.

In practice the registered manager usually names a responsible person on site to hold water safety day to day, and brings in a contractor for the tasks the home cannot do itself. That is the right structure. What it does not do is move the accountability off the registered person. If the sampling lapses or an action sits open, the manager cannot point at the contractor and be done with it. The regulator's question is what the registered person did to assure themselves the work was actually happening. Delegation gets the work done; it does not relocate the duty.

For a contractor covering a run of care homes, the deliverable a manager actually needs at inspection is the monitoring record and the closed-out actions, held per site, produced on the day an inspector asks rather than reconstructed that evening. That is what BlueWave's compliance records hold: the readings, the flags, and the follow-up against each home, kept beyond the five-year duty. A single home with a conscientious manager and a good paper logbook can meet the standard too. The standard is the same either way, and it is the evidence, not the format, that CQC weighs.

So the stakes here are not really paperwork. In a care home, an unmonitored month or an unclosed action is the part of the record an inspector reads first, and CQC has already used its prosecution powers in a legionella case.