Water Safety Group Setup: A Practical Guide for England
A water safety group (WSG) is a small, multidisciplinary team that oversees your water safety plan from commissioning to review. In England, healthcare guidance expects the duty holder to appoint one. Schools, universities, surgeries and larger commercial estates can borrow the same model to keep Legionella control owned, documented and reviewed. To set one up, name a chair with real authority, bring in estates, infection control and the people who use the water, write terms of reference, meet at least quarterly and track every action to closure. We support groups through each of those steps with risk assessments, sampling, training and remedial works.
TL;DR
A WSG is the group that commissions, develops, implements and reviews your water safety plan, so that nobody carries Legionella risk alone.
Healthcare premises in England follow HTM 04-01, which tells the duty holder to appoint a WSG. Other organisations can adopt the structure as good practice.
The chair needs management responsibility, competence and the authority to get work done. Accountability stays with the duty holder and cannot be delegated.
Write terms of reference covering purpose, membership, quorum, meeting frequency, agenda and reporting lines, then meet at least quarterly with minutes.
The group’s core job is an action loop: risk assessment, control measures, monitoring data, remedial actions with deadlines, and review.
Table of Contents
What a water safety group is and when you need one
The Department of Health’s HTM 04-01 Part B defines the group as a multidisciplinary body formed to oversee the commissioning, development, implementation and review of the Water Safety Plan. Its aim is safe water for patients or residents, staff and visitors, and a lower risk of infection from waterborne organisms such as Legionella and Pseudomonas.
The same document says that to meet legal duties in a healthcare organisation, the duty holder should appoint a WSG. It adds a point every manager should absorb: you can delegate compliance tasks to staff or contractors, but you cannot delegate accountability.
Who does this apply to?
Healthcare premises in England, including hospitals, GP surgeries, dental practices and care settings. HSG274 Part 2 says water systems in high-risk locations such as healthcare premises, care homes and residential homes need particular consideration, and that healthcare premises should refer to HTM 04-01 in England and Wales.
Schools, colleges and universities, where several departments touch the water system: estates, catering, sports facilities, science labs, halls of residence and sometimes contracted facilities teams.
Commercial and multi-site estates, where responsibility is often split between a landlord, a managing agent, a facilities provider and the tenant.
The legal framework for non-healthcare workplaces is HSE’s ACOP L8. It requires the duty holder to identify and assess the sources of risk, prepare a written scheme to control it, implement and monitor precautions, keep records and appoint a competent person with sufficient authority and knowledge of the installation. A group is the practical way to make those duties work when more than one person or department is involved. If your site has a single simple system and one clearly competent person, a formal group may be more than you need. When responsibility is spread across teams, a group is how you stop gaps opening between them.
Who should sit on the group
HTM 04-01 Part B says membership would normally include representation from:
estates (operations and projects)
infection control
medical microbiology
nursing and augmented care
housekeeping and support services
the appointed Authorising Engineer
medical technical officers
specialist users of water, such as renal units and aquatic therapy departments
sterile services
The HTM 04-01 Addendum adds that the group may be a sub-group of the infection control committee or another relevant forum. A typical line-up is the director of infection prevention and control, the IPC team, a consultant microbiologist, the estates and facilities team including the Responsible Person (Water), and senior nurses from augmented care units.
Translating the list for a school, surgery or commercial site
You will not have a microbiologist or a renal unit. Keep the logic, not the job titles. Ask who:
Owns the building and its plant: estates manager, facilities manager or managing agent.
Owns the risk in law: the duty holder, usually a director, head teacher, practice owner or senior landlord representative.
Knows how the water is used: the head of catering, the sports centre manager, the practice manager, the dental nurse who runs the unit water lines.
Looks after vulnerable people: a safeguarding or health and safety lead, a school nurse, clinical lead or infection control lead.
Delivers the work: your competent contractor, risk assessor and remedial team, either as members or as standing invitees.
That gives you four to eight people. Add a named deputy for each, so that a holiday or a resignation does not stop the group meeting.
Rooms where risk is easy to miss
Groups often fail because the people who use the water in unusual ways are not in the room. Think of showers in changing rooms, rarely used outlets in science blocks, hydrotherapy or treatment areas, and spaces serving people who are more susceptible to infection. If you manage settings for older adults, this guide to adult day care safety checks shows the kind of day-to-day vulnerabilities your group should keep in view when it reviews risk.
The chair, and what competence means
The chair matters more than any other seat. HTM 04-01 Part B says the group should be led and chaired by someone with appropriate management responsibility, knowledge, competence and experience. The Addendum says the chair, whoever they are, is responsible for making sure the group identifies microbiological hazards, assesses risks, identifies and monitors control measures and develops incident protocols.
Scottish guidance, SHTM 04-01, goes further for NHS Boards in Scotland: the group is chaired at minimum by the Responsible Person (Water), who should have sound professional knowledge of Legionella and the authority to see that operational procedures are carried out effectively and in good time. That is Scottish NHS guidance, but it is a useful benchmark for any English organisation choosing a chair.
A local English example shows the pattern in practice. One acute trust’s governance policy has the Head of Estates chairing the group, with a named deputy from the estates team. Your own chair might be the estates manager, the head of facilities or a senior health and safety manager. What counts is that they can commit budget and tell contractors and departments what to do.
HSE puts the reason plainly. Its ACOP L8 says inadequate management, lack of training and poor communication all contribute to outbreaks, so the people assessing risk and applying precautions must be competent, trained and aware of their responsibilities. Training the chair and members is therefore part of setup, not an extra. Our Legionella awareness training is available on-site or online, so the whole group can start from the same baseline.
How to set up the group, step by step
1. Confirm the duty holder and appoint in writing
The duty holder carries the legal accountability. Write down who that is, then appoint the chair, the Responsible Person and their deputy. ACOP L8 says that where competence is not available in-house you may appoint externally, but you must be satisfied about competence and set out responsibilities and lines of communication clearly. Our guide to the responsible person for Legionella covers what that role involves.
2. Write the terms of reference
An NHS ambulance trust’s water safety policy states that the terms of reference define the group’s purpose, membership, meeting frequency, quorum, agenda, objectives and reporting arrangements, and identify accountability and communication pathways up to the chief executive and board. Use that as your checklist. A one- to two-page document is enough if every item is answered.
The terms should also say what happens when someone cannot attend. The same trust-level policy that sets a quorum says a nominated deputy should attend in their absence, and that individual responsibilities should not be held back by the need for formal meetings. In other words, a missed meeting never justifies a missed temperature check.
3. Set the quorum
A quorum is the minimum attendance for a meeting to make binding decisions. One English trust’s policy sets it as the Director of Infection Prevention and Control (or deputy), the Head of Estates (or deputy), the Head of Facilities (or deputy) and at least two other members. For a school or surgery, a sensible equivalent is the chair, the duty holder’s representative, the person who runs the building and one user of the water. The full policy is a good model to read.
4. Fix the reporting line
The HTM 04-01 Addendum says the group should be accountable to the Director of Infection Prevention and Control and report upwards, for example to the infection control committee. Whatever route you choose, accountability should demonstrate effective governance and assurance. Outside healthcare, that means a standing report to the board, trustees, governors or the senior leadership team.
5. Set the meeting rhythm
Scottish guidance asks the group to meet at least quarterly with formal minutes and to report quarterly to the board’s health and safety committee. The English trust policy above also convenes quarterly or as required, with meetings of about an hour and a half. Quarterly is a workable starting point for most English organisations. Add an extra meeting after any positive Legionella result, major system change or incident.
6. Commission the baseline
The group cannot oversee a plan that does not exist. Start with a competent Legionella risk assessment of every system, then build the plan from its findings. Our Legionella risk assessments start from £185 one-off. For an overview of what a good one contains, read our guide to water risk assessment for Legionella.
7. Build the action tracker
The tracker is the group’s working tool. Every finding gets an owner, a deadline, a status and a closure date. Review it at every meeting, and do not close an item without evidence, such as a certificate, a photograph or a result.
Responsibilities of the group
HTM 04-01 Part B paragraph 6.9 lists what the group does. In plain terms:
Responsibility | What it means in practice |
Review risk assessments | Read each assessment, agree priorities and confirm that every task has been allocated and accepted |
Keep the water safety plan under review | The plan is a working document, not a binder on a shelf |
Ensure maintenance and monitoring are in place | Temperature checks, flushing, descaling, TMV servicing and sampling happen on schedule |
Review monitoring data | Look at clinical and environmental data together and spot trends |
Agree remedial actions | Set deadlines and make sure an action plan exists |
Oversee water treatment | Where treatment such as disinfection is used, check operational control monitoring |
Maintain surveillance | Keep watching both clinical and environmental indicators |
HSG274 Part 2 is clear that water safety plans must be kept up to date and reviewed. The Addendum sets a floor of at least annual review of the plan by the group. Scottish guidance has the group ensure risk assessments are refreshed every two years and reviewed at its meetings. In practice, revisit the assessment whenever the building, its use or its pipework changes. Our post on reviewing a Legionella risk assessment explains the triggers.
Temperature control is the first thing to check
HSG274 Part 2 says hot water should be stored at 60°C or above and distributed so that it reaches 50°C within one minute at the outlets. In healthcare premises the figure at outlets is 55°C. Those numbers appear in the HSE technical guidance, and the group’s data review should start there. Where staff time is tight, automated water temperature monitoring gives the group continuous data to review rather than a monthly snapshot.
Risk assessor independence
One trust policy requires that risk assessments follow ACOP L8, HSG274 Parts 2 and 3 and BS 8580:2019, and that the assessor is competent and independent of any ongoing remedial work. Whether you adopt that rule is your call, but the group should decide it deliberately and record the decision.
Who does what: group, duty holder, responsible person and contractors
Role | Core job |
Duty holder | Legally accountable. Appoints the chair, the competent person and the group. Cannot delegate accountability |
Chair | Makes sure hazards are identified, risks assessed, controls monitored and incident protocols written |
Responsible Person | Day-to-day control of the water systems, with the knowledge and authority to see procedures through |
Site teams | Carry out checks, flushing and reporting, and raise faults promptly |
External contractors | Assess, test, clean, disinfect and repair, and report to the group with documentation |
In the Scottish guidance the Designated Person (Water) is the senior management link who makes the written appointments of the Authorising Engineer, the risk assessor, the Responsible Person and their deputy, and the group members. England’s HTM uses similar roles. Even if you do not use those exact titles, make the same appointments in writing.
Healthcare and other premises: what differs
In healthcare, the group is formal, tied to infection control governance and driven by HTM 04-01. Patients are more susceptible, so HSG274 asks that risk assessment weigh Legionella and scalding together, with special consideration for those exposed to the water systems. That is why thermostatic mixing valves (TMVs) are such a common agenda item: they limit scalding at the outlet, and they need servicing to keep working. We service them under our TMV servicing and remedial works offer.
In schools, colleges, offices and hospitality, the same logic applies with lighter governance. The group can be a standing agenda item at an existing health and safety committee, as long as the terms of reference, minutes and tracker exist. Our HTM 04-01 compliance guide is a good next read for clinical premises. Hotels, gyms and leisure sites can look at our hospitality and leisure compliance page.
Guidance changes to know about
HSE’s HSG274 Part 2 notes that the second edition has been reviewed and updated for Part 1 only (evaporative cooling systems). Parts 2 and 3 remain in their original editions, so the hot and cold water guidance you have been working to still stands. Always check HSE’s own page for the latest versions before you finalise your plan.
Our view: the group is only as strong as its evidence
We have seen the same pattern across the commercial, education, healthcare and housing sites we support: a group that has good intentions but no evidence behaves like no group at all. Our aim is to make compliance simple. For a water safety group, that means three things. First, an independent, site-specific risk assessment, so the group starts from facts about your buildings rather than assumptions. Second, a logbook and control programme that the site team can actually run, so the data coming to each meeting is complete. Third, ongoing consultancy and training, so the people round the table understand what the numbers mean. Each site is different, so we build the services around your organisation, not the other way round. We work in partnership with you to identify and minimise risk, and to expand your team’s knowledge as we go. A chair who walks into a meeting with clear data, a closed-out action list and a named contractor for every open item is a chair who can show the duty holder that accountability is being met. Sammi
Getting the group working with us
We provide the pieces a new group needs most: Legionella risk assessments, water sampling and analysis, awareness training, remedial works, TMV servicing, automated temperature monitoring and ongoing consultancy for sites across the UK. Water testing starts from £55 per sample. Pick the page that matches your next action: Legionella water testing and analysis, or get in touch through our main site to talk through a site-wide plan.
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If your group’s first meeting is approaching, bring the risk assessment, the current logbook and a list of known faults. Our team can help you prepare that pack, and then keep the action list moving through ongoing maintenance and disinfection.
FAQ
Is a water safety group a legal requirement?
The law places duties on the duty holder: assess the risk, write a scheme to control it, apply and monitor precautions, keep records and appoint a competent person. In healthcare, HTM 04-01 tells the duty holder to appoint a group to deliver this. Elsewhere, a group is a sound way to meet the same duties.
Who should chair the group?
The chair needs management responsibility, knowledge, competence and the authority to get work done. Many English trusts choose the head of estates. For a school or surgery, the estates manager, facilities manager or a senior health and safety lead are the usual choices.
How often should the group meet?
Quarterly is the benchmark in NHS guidance and policies, with formal minutes and a report to senior governance. Call an extra meeting after a positive sample, a significant system change or an incident.
Can a contractor sit on the group?
Yes, as a member or a standing invitee, because contractors carry out much of the work. The duty holder’s accountability stays with the organisation, so decisions and sign-off belong to the group and its chair.
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