Water Safety Policy

1. Introduction and objectives

1.1 As a landlord, Gateshead Council must meet the legal obligations which require us to deal with the risks associated with legionella bacteria within the properties we own or manage. Legionella bacteria can cause a potentially fatal form of pneumonia called Legionnaires' disease. People contract Legionnaires' disease by inhaling small droplets of water containing the bacteria.

1.2 As far as is reasonably practicable, we must introduce measures to reduce and/or control exposure to legionella bacteria, including managing the conditions that support the growth of the bacteria in water systems.

1.3 The key objective of this policy is to ensure that our Cabinet, Senior Management Team, employees, partners, and tenants are clear on our legal and regulatory water safety obligations. This policy provides the framework our staff and partners will operate within to meet these obligations.

1.4 This policy forms part of our wider organisational commitment to driving a health and safety culture amongst employees and contractors (as detailed within our Health and Safety Policy). It will be saved on our shared drive and distributed to all employees.

1.5 This policy should be read in conjunction with the following related policies and procedures:

Water Safety Operating Procedure
WHO - water safety planning (opens new window)
Legionella Control - Written Scheme of Control (opens new window)
Legionella Risk Assessments (opens new window)
Gateshead Council Tenancy Agreement

2. Scope

2.1 This policy is relevant to all our employees, tenants, contractors, stakeholders, and other persons who may work on, occupy, visit, or use our premises, or who may be affected by our activities or services.

2.2 The policy should be used by all to ensure they understand the obligations placed upon Gateshead Council to maintain a safe environment for tenants and employees within the home of each tenant, and within all communal areas of buildings and other properties we own and/or manage. Adherence to this policy is mandatory.

2.3 The policy applies to all Council employees, tenants, contractors and other persons or other stakeholders who may work on, occupy, visit, or use our buildings, or who may be affected by our activities or services.

3. Roles and responsibilities

3.1 The Cabinet has overall governance responsibility for ensuring this policy is fully implemented to ensure full compliance with legislation and regulatory standards. As such, the Cabinet will formally approve this policy and review it every two years (or sooner if there is a change in legislation or regulation).

3.2 For assurance that this policy is operating effectively in practice, the Cabinet will receive regular updates on its implementation, water safety performance and non-compliance.

3.3 The Senior Management Team (SMT) will receive monthly performance reports in respect of water safety and ensure compliance is being achieved. They will also be notified of any non-compliance issue identified.

3.4 The Strategic Director has strategic responsibility for the management of water safety, and ensuring compliance is achieved and maintained. They will oversee the implementation of this policy.

3.5 The Service Director and Service Manager are the Responsible Person(s) and have operational responsibility for the management of water safety and will be responsible for overseeing the delivery of these programmes.

3.6 Housing teams will provide support where gaining access to properties is difficult.

3.7 The Section Manager is the Deputy Responsible Person who will provide cover to the Service Manager (Responsible Person).

3.8 Housing teams will provide support where gaining access to properties is difficult.

3.9 Service Director is designated as the health and safety lead as defined by the The Social Housing Regulations Act 2023 (opens new window).

4. Regulatory standards, legislation and approved codes of practice

4.1 Regulatory Standards

Regulatory standards for landlords (opens new window) - We must ensure we comply with the Regulator of Social Housing's regulatory framework and consumer standards for social housing in England. The new consumer standards were introduced on 1 April 2024 and detail the four consumer standards which landlords are required to comply with, including:

The Safety and Quality Standard (opens new window) - which requires landlords to provide safe and good quality homes and landlord services to tenants. This includes stock quality; decency; health and safety; repairs, maintenance, and planned improvements; and adaptations.

The Transparency, Influence and Accountability Standard (opens new window) - which requires landlords to be open with tenants and treat them with fairness and respect so that tenants can access services, raise complaints when necessary, influence decision making and hold their landlord to account. This standard incorporates Tenant Satisfaction Measure (TSM) requirements.

The Neighbourhood and Community Standard (opens new window) - which requires landlords to engage with other relevant parties so that tenants can live in safe and well-maintained neighbourhoods and feel safe in their homes.

The Tenancy Standard (opens new window)- which sets requirements for the fair allocation and letting of homes and for how those tenancies are managed and ended by landlords.

The Social Housing Regulations Act 2023 (opens new window) will change the way social housing is regulated and may result in future changes to this policy.

4.2 Legislation

The principal legislation applicable to this policy is as follows:

Health and Safety at Work Act 1974 (opens new window)

The Management of Health and Safety at Work Regulations 1999 (opens new window)

Control of Substances Hazardous to Health Regulations (as amended) 2002 (COSHH) (opens new window)

This policy also operates within the context of additional legislation (see Appendix 1).

4.3 Approved Code of Practice (ACoP)

The principal ACoP applicable to this policy is:

ACoP L8 - Legionnaires' disease: The control of legionella bacteria in water systems (4th edition 2013).

4.4 Guidance

The principal guidance applicable to this policy is as follows:

HSG274 - Legionnaires' disease: Technical guidance Part 1: The control of legionella bacteria in evaporative cooling systems (2013).
HSG274 - Legionnaires' disease: Technical guidance Part 2: The control of legionella bacteria in hot and cold-water systems (2014).
HSG274 - Legionnaires' disease: Technical guidance Part 3: The control of legionella bacteria in other risk systems (2013).
INDG458 - Legionnaires' disease: A brief guide for duty holders (2012).
BS 8580-1:2019 Water quality, risk assessments for Legionella control - Code of practice.

4.5 Sanctions

Failure to discharge our responsibilities and obligations properly could lead to sanctions, including prosecution by the Health and Safety Executive (the HSE) under the Health and Safety at Work Act 1974 (opens new window); prosecution under the COSHH Regulations; prosecution under the Corporate Manslaughter and Corporate Homicide Act 2007 (opens new window); and via a regulatory notice from the Regulator of Social Housing.

5. Obligations

5.1 The Management Regulations and the Health and Safety at Work Act 1974 (opens new window) place a duty on us, as an employer and landlord, to ensure our employees and others affected by our undertakings (for example, tenant(s), are not exposed to health and safety risks, including the risk from legionella.

5.2 We have a legal obligation under COSHH to prevent or control exposure to biological agents, including legionella.

5.3 Gateshead Council is the 'Duty Holder' as defined by Approved Code of Practice L8 (ACoP) and we must take necessary precautions to prevent, reduce or control the risks of exposure to legionella.

5.4 As the Duty Holder, we must:

Carry out a risk assessment for all domestic properties hot and cold-water systems, cooling plant and any other systems that can produce water droplets to identify and assess potential risks.
Implement measures to either eliminate, reduce or control identified risks.
Appoint a Responsible Person to take managerial responsibility for:
- Carrying out risk assessments.
- Producing written schemes of control (a practical, risk management document used to control the risk from exposure to legionella); and
- Implementing the written scheme of control.
Appoint a Deputy Responsible Person who will provide cover to the responsible person in their absence.
Keep associated records for five years.

6. Statement of intent

6.1 The Council acknowledges and accepts its responsibilities in accordance with the regulatory standards, legislation and approved codes of practice and that failure to discharge these responsibilities properly could lead to a range of sanctions including prosecution by the Health & Safety Executive under the Health and Safety at Work Act 1974 (opens new window), prosecution under the Corporate Manslaughter and Corporate Homicide Act 2007 (opens new window); prosecution under any of the principal legislation listed in Section 4.1; and via a regulatory notice from the Regulator of Social Housing.

6.2 We will review legionella risk assessments based on the level of risk, as follows, or more frequently where a water system is likely to undergo change and is therefore a higher risk. Schemes will be assessed as high risk (sheltered accommodation) on an annual basis, medium risk (homes within communal blocks) will be assessed every three years, or low risk (homes within communal blocks) will be assessed every five years.

6.3 Written schemes of control will be in place for all properties risk assessed as requiring controls to manage the risk of legionella exposure.

6.4 When properties become void, we will isolate the water and keep the system pressurised. The water system will then be flushed and recommissioned before the property is let, and the shower head replaced or descaled.

6.5 We will carry out checks to identify pipework 'dead legs' and remove, if reasonably practicable, within void properties and any properties where we are carrying out adaptations or planned investment work.

6.6 When we acquire properties (existing or new build) we will follow the same process as for void properties, and we will ensure that there are no pipework 'dead legs' present when we take possession of the property.

6.7 We will operate a robust process for the management of high risk, or dangerous situations identified from the legionella risk assessment, water testing/monitoring regime or suspected legionella outbreak. In the event of a legionella outbreak we will follow the safety procedures as per the risk assessments and operating procedures.

6.8 We will use the legal remedies available within the terms of the tenancy and lease agreement should any tenant, leaseholder, or shared owner refuse access to carry out essential water safety related inspection and remediation works. Where tenant vulnerability issues are known or identified we will ensure we safeguard the wellbeing of the tenant, whilst ensuring the organisation can gain timely access to any property to be compliant with this policy.

6.9 We will operate effective contract management arrangements with the contractors responsible for delivering the service, including ensuring contracts/service level agreements are in place, conducting client-led performance meetings, and ensuring that contractors' employee and public liability insurances are up to date on an annual basis and that Gateshead Council hold copies of this information.

6.10 We will establish and maintain a risk assessment for water safety management and operations, setting out our key water safety risks and appropriate mitigations.

6.11 To comply with the requirements of the Construction (Design and Management) Regulations 2015 (opens new window) a Construction Phase Plan will be in place for all repairs work to void and tenanted properties (at the start of the contract and reviewed annually thereafter), component replacement works and refurbishment projects.

6.12 We will ensure there is a robust process in place to minimise any potential non-compliance by ensuring processes are effective and have appropriate control measures in place to mitigate any risks. We will analyse any non-compliance that do occur, and take action to prevent recurrence . For example, we will investigate and manage all RIDDOR notifications made to the HSE in relation to electrical safety and take action to address any issues identified and lessons learned, to prevent a similar incident occurring again. This includes amending our processes to reflect best practice and ensure that service improvements are implemented.

6.13 The document will be strictly controlled in accordance with ISO 9001 (Quality Management) and maintained by the Service Manager Building Safety, in conjunction with the Quality Manager.

7. Programmes

7.1 Communal blocks and other properties - We will ensure all communal blocks and other properties (supported schemes/offices/shops/depots) that we own or manage are subject to an initial visit to establish whether a legionella risk assessment (LRA) is required. Thereafter, if an LRA is required, the property will be included on the LRA programme. If an LRA is not required, we will record this on our core asset register C365.

7.2 For all properties on the LRA programme, we will undertake LRAs and review the LRA every year for a high risk, three years for medium risk and five years for low risk, or more frequently where a water system is likely to undergo change and is therefore a higher risk.

7.3 LRAs will also be reviewed in the following circumstances:

Change in building use.
Change in internal layout of water system.
Change in building occupation that increases the risk due to health.
After a confirmed or suspected outbreak of Legionella.
Following a water safety audit (if required).
A change in management structure.

7.4 Domestic properties - We will undertake an annual programme of five per cent sample surveys in domestic properties. These will be prioritised according to the perceived level of risk (based on design, size, age, and type of water supply).

7.5 Testing and monitoring - We will undertake testing and monitoring (for example, monthly temperature checks) as set out within any written schemes of control.

Control measures

7.6 The control measures required for each property or property type will be determined by the risk assessment for that particular property only and will be implemented under the control of the Responsible Person.

7.7 A written scheme for controlling measures will be prepared by Gateshead Council and implemented and managed by the Responsible Person.

7.8 The control regime will include as appropriate:

Good design - for avoidance of water stagnation and low flow. Also, avoiding use of materials in the water system that may harbour and encourage growth of bacteria or other nutrients.
Temperature control - monitoring, inspection, and flushing.
Correct and safe operation of equipment and plant - including maintenance requirements and frequencies.
Testing of water quality - as required.

7.9 To ensure the control measures implemented remain effective, the condition and performance of the system will be monitored; the frequency and extent of the routine monitoring will depend upon the operating characteristics of the system identified by the risk assessment.

7.10 As a minimum, or in the absence of a suitable and sufficient risk assessment, the control measures and inspection programmes as given in table 2.1. of HSG 274 Part 2 The Control of Legionella Bacteria in Water Systems will apply.

7.11 When Legionella sampling is undertaken the samples are to be analysed at a laboratory accredited by the United Kingdom Accreditation Service (UKAS) in accordance with the Approved Code of Practice L8. The samples are to be taken in accordance with BS 7592:2022 Sampling for Legionella Bacteria in Water Systems. The actions required for any positive water analysis results is described in the Legionella Risk Assessment and supporting operating procedures.

Action to be taken on suspicion of an incident or outbreak

7.12 An outbreak is defined as two or more cases where the onset of illness is closely linked in time and location, where there is suspicion of, or evidence of, a common source of infection, with or without microbiological support.

7.13 The nominated Responsible Person(s) will inform the Environmental Health Officer/Health and Safety Executive and ask for their immediate advice and assistance. It is normal for them to send in a team to investigate and rectify the problem. It is important for them to be able to trace where the disease has come from.

7.14 The Responsible Person will ensure that any systems are safely isolated until a course of action has been agreed making sure that the system is not drained or disinfected before samples have been taken.

8. Follow up work

8.1 We will ensure there is a robust process in place for the management of any follow-up works required following the completion of an LRA or ongoing monitoring (where the work cannot be completed at the time of the assessment or check). This will also include any issues identified during a void period.

8.2 We will ensure there is a robust process in place for the management of any follow-up works required following the completion of a Water Risk Assessment (WRA) or ongoing monitoring. This will also include any issues identified during a void period.

8.3 We will use the date the WRA is received from our Assessors, to ensure that it has been through a quality assurance and validation process, as our timeframe to start completing WRA remedial actions.

8.4 WRA remedial actions identified will be carried out as soon as reasonably practicable, in line with the maximum timescales indicated below:

Critical - within 24 hours
High - within one month
Medium - within six months
Low - within 12 months

9. Data and records

9.1 We will maintain a core asset register of all properties we own or manage, setting out which properties require a Legionella Risk Assessment (LRA). We will also set out which properties require ongoing testing and monitoring as prescribed by the written control scheme (for example, monthly temperature checks).

9.2 We will operate a robust process to manage all changes to stock, including property acquisitions and disposals, to ensure that properties are not omitted from water safety programmes and the programmes remain up to date.

9.3 We will hold LRA inspection dates LRAs and testing and monitoring records against all properties on each programme. This information will be held in NEC, GP2, C365 and our document management system.

9.4 We will hold LRA inspection dates, LRAs, and testing and monitoring records against all properties on each programme. These will be held in the Orchard Housing Management system for the applicable dates and a shared drive for the physical LRAs and records.

9.5 We will keep water safety logbooks electronically (or securely on site where practical), for all properties on the LRA programme.

9.6 We will keep all records for at least five years or for the duration that we own and manage the property. This will be in line with our document retention policy and have robust processes and controls in place to maintain appropriate levels of security for all water safety related data.

10. Tenant engagement

10.1 We consider good communication essential in the effective delivery of water safety programmes, therefore we will establish a tenant engagement strategy and communication programme. This will support tenants in their understanding of water safety and legionella risk, advised them of how they can manage the risks within their properties, and to encourage them to report any concerns about water safety.

10.2 We will make reasonable adjustments in how we deliver the service to customers homes where a vulnerability would prohibit the service being carried out without adjusting the service. We will also make reasonable adjustments to how we communicate with customers based on their vulnerabilities.

10.3 We also aim to successfully engage with vulnerable and hard to reach tenants. We will share information clearly and transparently and will ensure that information is available to tenants via regular publications and information on our website.

10.4 Upon request we will provide written schemes of control in communal areas of buildings to inform occupants how the risk of exposure to legionella bacteria is being managed and controlled.

11. Competent person

11.1 As we must appoint a Responsible Person and a Deputy Responsible Person, they should both be trained, instructed, and informed to the same level and should assist in the frequent monitoring of written control schemes. Therefore, they should hold a relevant qualification such as the BOHS P901 - Management and control of building hot and cold-water services, Level 2 Award in Legionella Awareness (or equivalent), or Level 4 VRQ Diploma in Asset and Building Management. If they do not have these already, they will obtain them within 12 months of the approval of this policy.

11.2 Only suitably competent consultants and contractors, registered with the Legionella Control Association (or equivalent), will undertake LRAs, prepare written schemes of control and undertake works in respect of water safety and legionella control.

11.3 Only suitably competent consultants and contractors, registered with the Legionella Control Association (or equivalent), will undertake third party technical quality assurance checks.

11.4 We will check that our contractors hold the relevant qualifications and accreditations when we procure them, and thereafter on an annual basis; we will evidence these checks and each contractor's certification appropriately.

12. Implementation and training

12.1 We will deliver training on this policy and the procedures that support it, through appropriate methods including team briefings; basic water safety awareness training; and on the job training for those delivering the programme of Legionella Risk Assessments (LRA) and water safety testing and monitoring, as part of their daily job. All training undertaken by staff will be formally recorded via the Learning Hub.

12.2 We will ensure that all staff that are actively engaged in the delivery of this Water Safety Policy, inspections, assessments and remedial actions are suitably trained and have the relevant professional qualifications. All training undertaken by staff will be formally recorded and appropriate refresher training provided as required.

13. Performance reporting

13.1 We will report robust key performance indicator (KPI) measures for water safety that follow the requirements set out in the Tenant Satisfaction Measures (TSMs) which are reported to the Regulator on an annual basis. We will report internally monthly to Senior Management Team and Cabinet. The relevant TSM for water safety is defined as follows:

BS04 - Water Safety Checks: Proportion of homes for which all required legionella risk assessments have been carried out.

13.2 This measure ensures that all individual homes that may be at risk because of any non-compliance are identified.

13.3 We will also report the following:

Data - the total number of:

Properties - split by category (domestic, communal, commercial and others).
Properties on the Legionella Risk Assessment (LRA) programme.
Properties not on the LRA programme.
Properties with a valid and in date LRA.
Properties without a valid and in date LRA.
Properties due an LRA within the next 30 days; and
Overdue follow-up works/actions arising from the programme.

Narrative - an explanation of the:

Current position.
Corrective action required.
Anticipated impact of corrective action; and
Progress with completion of follow-up works.

In addition:

The number of RIDDOR notifications to the HSE with regards to water safety.

13.4 The full detail of our performance measures for water safety will be outlined in a KPI Definition Document which includes the relevant data sources used for each calculation, the calculation methodology, any exclusions, and the accountable roles for producing and managing the KPIs.

14 Quality assurance

14.1 We will ensure there is a programme of third-party quality assurance audits to five per cent of Legionella Risk Assessments. Annual audits will be undertaken to all systems identified as a high risk.

14.2 We undertake internal desktop audits to 100% off all certifications.

14.3 We will carry out an independent audit of water safety at least once every two years, to specifically test for compliance with legal and regulatory obligations and to identify any non-compliance issues for correction.

15. Significant non-compliance and escalation

15.1 Our definition of significant non-compliance is any incident which has the potential to result in a potential breach of legislation or regulatory standard, or which causes a risk to health or safety. All non-compliance issues will be reported and escalated as soon as possible, and no later than 24 hours after the incident occurred, or of a Gateshead Council employee becoming aware of it.

15.2 Any non-compliance issue identified at an operational level will be formally reported to the Service Director in the first instance, who will agree an appropriate course of corrective action with the Service Manager and report details of the same to the Senior Management Team (SMT).

15.3 In cases of serious non-compliance, the Service Manager will inform the Service Director, SMT and Cabinet to consider whether it is necessary to disclose the issue to the Regulator of Social Housing as required by their regulatory framework, or any other relevant organisation such as the Health and Safety Executive.

16. Approval

Strategic Lead

Service Director Repairs and Buildings Maintenance

Name: Ian McLackland

Date signed and approved:

Strategic Lead

Service Manager Building Safety

Name: Darren Burton

Date signed and approved:

17: Glossary

This glossary defines key terms used throughout this policy:

BOHS: British Occupational Hygiene Society.
Duty Holder: the owner of the non-domestic premises or the person or organisation that has clear responsibility for the maintenance or repair of non-domestic premises, for example through an explicit agreement such as a tenancy agreement or contract.
Legionellosis: a collective term for diseases caused by legionella bacteria including the most serious Legionnaires' disease, as well as the similar but less serious conditions of Pontiac fever and Lochgoilhead fever.
LRA: Legionella Risk Assessment - an assessment which identifies the risks of exposure to legionella in the water systems present in a premises and the necessary control measures required.