Water Safety Plan (Healthcare)

A risk-management approach to the safety of water that establishes good practices in local water distribution and supply. It will identify potential hazards, consider practical aspects, and detail appropriate control measures. A complex range of issues distinguishes healthcare environments from most other building types. One of the most important of these relates to the control of infection.

Do I need a Water Safety Plan?
In most cases companies, employers and organisational establishments are relying on a very basic ‘Legionella Risk Assessment’ carried out by a company who are normally offering additional remedial services on the back of their assessments. You have to ask yourself if the regulator inspected your site, would this document be enough to satisfy the inspectors and does it cover all aspects of water safety?

Am I a Healthcare Organisation?
Healthcare organisations are not simply NHS Hospitals or primary care providers. Anywhere where clinical assessment or surveillance or medical intervention for the quality of life etc has to be administered should be classed as Healthcare. Health care includes all forms of health care provided for individuals, whether relating to physical or mental health, and also includes procedures that are similar to forms of medical or surgical care but are not provided in connection with a medical condition. Some examples include Care homes, Nursing Homes, Respite Centres and Hospice’s

To assist with understanding and mitigating risks associated with waterborne hazards in distribution and supply systems and associated equipment, WIPC will work with you to develop and implement a WSP.

With Health Facilities Scotland and NHS Services Scotland pushing for NHS Boards to Adopt HTM04:01 and the cessation of SHTM 04 guidance, NHS Estates and Infection control must ensure that they seek appropriated consultancy from a qualified and experienced Authorising Engineer to help navigate and manage the significant changes required to move from simple Legionella control to holistic management of water borne pathogens and their clinical consequences.


Our water safety plan will:

Assess the risks that may be posed to patients (including those with particular susceptibility), staff and visitors.
Put into place appropriate management systems to ensure the risks are adequately controlled.
Clinical Governance arrangements.
A clinical risk assessment review to identify those settings where patients are at significant risk from waterborne pathogens.
An engineering and bacterial risk assessment of all water systems.
Operational monitoring of control measures and record-keeping methodology.
Information on the age and condition of the water distribution system and materials of construction (as different materials hold differing risks and react differently to chemicals).
Links to clinical surveillance.
Plans for the sampling and microbiological testing of water in identified at-risk units.
Adequate supervision, training and competency for all levels of staff including housekeeping staff and those employed by facilities management organisations.
Appropriate design, installation, commissioning and maintenance of all components and equipment.
Remedial actions to be taken to remedy high counts for P. aeruginosa and Legionella and other relevant pathogens where appropriate.
Adjustments to clinical practice until remedial actions have been demonstrated.
Specialist considerations for water used in clinical care such as Toxoplasma gondii risk in Maternity settings.
“To manage and monitor the prevention and control of infections effectively, the HCAI Code of Practice requires a WSG and a water safety plan (WSP) to be in place.”
Dept. Of Health HTM04:01 Part B