Is your Water Safety Audit Fit for Purpose?

Managing water systems to ensure safe water for patients, staff, and the public is a complex task, especially within Healthcare, with multiple facets and potential risks to navigate. To ensure your water safety regime, including plans, policies, and protocols, is truly effective, a water safety audit conducted by an independent expert is an essential tool. It provides the assurance organisations need that their systems are fit for purpose and compliant with best practice.

Understanding the Role of Independent Audits

The HSE defines an audit as a key element of the Management of Health & Safety at Work Regulations (MHSWR) – 1999.

In a healthcare environment, HTM 00 (Health Technical Memorandum) – Policies and Principles of Healthcare Engineering states;

• 3.6 - The chief executive and board carry ultimate responsibility for a safe and secure healthcare environment. Aspects of that responsibility can be assigned or delegated to other senior executives, but an independent audit system should be in place to assure them that the responsibilities are being discharged properly.
  
  
• 3.13 This person (Designated Person) provides the essential senior management link between the organisation and professional support, which also provides independence of the audit-reporting process. The Designated Person (DP) will also provide an informed position at board level.
  
  
• 3.17 The Authorising Engineer (Water) (AE) will act as assessor and make recommendations for the appointment of Authorised Persons (APs), monitor the performance of the service, and provide an annual Water Safety Audit to the DP. To effectively carry out this role, particularly with regard to audit, the AE should remain independent of the operational structure of the healthcare organisation.
  
  

What a Comprehensive Water Safety Audit Should Cover

A Water Safety Audit carried out by an independent professional is effectively a strategic health check of your current water safety management systems, policies, and procedures. In order to gain a realistic and accurate assessment of your current water safety management system, the following should be included within your audit;

• Governance: Do your current policies, water safety plan, and Legionella written schemes of control align with current guidance?
  
  
• Lines of communication clearly defined
  
  
• Appointments to key roles and responsibilities: Are these in place?
  
  
• Training requirements: Have you carried out a Legionella training needs analysis for the roles required to deliver safe water in your organisation? Are the individuals in key appointments/roles suitably and sufficiently trained to carry out their role effectively? Is this training still in date/valid?
  
  
• Legionella Risk assessments: Are these in line with current guidance? – BS8580-1:2019 (Legionella) and BS8580-2: 2022 (Pseudomonas). Is there a plan in place to remediate or mitigate any recommendations from the current risk assessment(s)? Is this up to date? Are all risks identified As Low As Reasonably Practicable? (ALARP)?
  
  
• Design Control: Do you have plans and protocols in place for new build and refurbishment works to ensure that risk is reviewed, eliminated where possible, and mitigation plans are in place where the risk is inherent?
  
  
• Control and support schemes: Are your control measures and operational delivery protocols in line with current guidance – ACoP L8, HSG274, and HTM04-01?
  
  
• Operational and Performance records: Are your logbooks and water safety record-keeping systems suitable for their intended purpose? Are the monitoring records suitable, sufficient, and up to date?
  
  

On-Site Checks and Staff Interviews in Water Audits

It is important that when carrying out the audit, staff in key roles are made available for interview. This one-to-one interaction will yield first-hand feedback and give the auditor a clear indication of the interviewee's understanding as to what is required to carry out their role effectively, any shortfalls they identify, and where additional support may be needed.

Whilst on site, the auditor also has the opportunity to inspect the records kept for all water hygiene activities to corroborate and confirm that they are accurate, sufficient, and up to date. A site walkaround to observe and inspect key equipment will also add value to the audit findings.

The Importance of Design Control in Water Safety

Design Control is often overlooked or skimmed over and not given the attention to detail that it warrants. This may be because new buildings or major refurbishment works are few and far between, which can mean current policies (if any) are shelved and forgotten about until a new project emerges, whereby the policy is out of date due to changes in guidance.

A classic example would be the Healthcare sector NETB (NHS Estates Technical Bulletin)2024/3 – Designing Safe Spaces for patients at high risk of infection from Nontuberculous mycobacteria and other water borne pathogens – which was written to be used in conjunction with the existing HTM04-01. Has this addition been read, understood, and implemented in healthcare environments where and when the guidance is required? If you are a healthcare organisation, does your current Water Safety Plan include this guidance?

Why Annual Independent Water Audits Matter

An annual audit by an independent Authorising Engineer is designed to identify any shortfalls or omissions you may have in your current plans, policies, procedures, and output the recommendations required to rectify any such occurrences.

It is an objective – rather than subjective process, which is designed to identify the current level of assurance/compliance in your organisation's water safety management program. It is based on facts derived from the evidence presented at the time of the audit. A fantastic tool when applied correctly.

Does your current audit protocol meet these standards? If not, feel free to reach out with any questions or to consult with one of our water hygiene experts.

Editor's Note: The information provided in this blog is correct as of the date of original publication – April 2026

© Water Hygiene Centre 2026