RQIA letter to All Care Homes and Independent Hospitals


January 2024


View the Original Document Here.  

For queries regarding this, please contact the LCA.


Our ref: CEx1343

By email only: Managers and proprietors of all regulated Residential Care, Nursing Homes, Independent Hospitals


Dear Sir/Madam,

Companies carrying out activities associated with the control of legionella bacteria in water systems in registered and regulated care homes and independent hospitals


The number of notifications that RQIA have received from registered and regulated services relating to detection of legionella bacteria in water systems has increased markedly over the past two years. Subsequently there has been significant activity in the sector by specialist companies undertaking the range of activities associated with legionella control.

Health & Safety Executive (HSENI) approved code of practice and guidance

The approved Code of Practice (ACOP) and guidance issued by The Health & Safety Executive ‘The control of legionella bacteria in water systems’ (L8) gives practical advice on how to comply with the respective health & safety law. Technical guidance HSG274 parts 1, 2 and 3 are also published separately alongside and in support of L8. These documents are freely available on the HSENI website www.hseni.gov.uk.

L8 and HSG274 both refer to the Code of Conduct administered by the Legionella Control Association (LCA) as the level of service that should be expected from contractors undertaking relevant activities.

The Legionella Control Association (LCA)

LCA is a voluntary organisation that operates a membership scheme for companies undertaking activities associated with legionella control. Members are audited by occupationally competent auditors prior to registration against a code of conduct.

This is to ensure they operate appropriate management systems for services they offer and they are required to summarise these in a ‘Statement of Compliance’. Annual audit of the management systems and procedures and a sample of the output from those procedures for compliance with the Code is an ongoing requirement of LCA membership.

LCA membership can be attained for various services including:

  • Risk assessment
  • Water treatment
  • Hot and cold water monitoring and inspection
  • Cleaning and disinfection
  • Independent consultancy
  • Training
  • Legionella monitoring
  • Plant and equipment.

Action by providers

RQIA believe that to achieve optimum water safety standards in registered and regulated premises, where the above services are carried out by third party companies, the companies should be members of LCA. Going forward, RQIA would encourage you to ensure that all outsourced services listed above are carried out by a company holding relevant membership category with the LCA.

A register of LCA members is available on their website www.legionellacontrol.org.uk

The LCA standards and guidance as well as a range of useful resources are also available on the website including a guide to selecting a competent service provider:

A-Buyers-Guide-to-Using-the-Code-of-Conduct-for-Service-Providors-702.19-09- 23.pdf (legionellacontrol.org.uk)

Services that providers choose to undertake ‘in-house’ should be carried out to comparable standards in order to achieve full compliance with L8.

Northern Ireland Health & Social Care Trusts (HSCTs)

HSCTs have in place Water Safety Groups (WSGs) comprising of expertise from the range of specialists to manage water systems in their estate.

Water systems in registered and regulated care homes and services operated by HSCTs coming under the scope of WSGs and their in-house HSCT Estates Departments may be managed to standards comparable to or exceeding LCA member companies and this correspondence may not be pertinent in these circumstances unless particular services are outsourced to third party companies.

I trust you will find this information helpful and that you will take appropriate action in respect of this communication. Should you have any queries please contact Phil Cunningham, Senior Estates Officer through our office.

Yours sincerely,



Briege Donaghy
Chief Executive, RQIA