Standards › Standard 2B › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · WAT-SOP-001 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2B.3
At a glance
- Test the water on the schedule the committee sets, at the points listed in the schedule.
- Record every result on WAT-FRM-001 with the date and who tested.
- If a result is outside the limit, act at once: isolate the outlet, inform the infection prevention lead, and retest.
- Keep records for the last 3 months available for audit.
- Stop and get help straight away if: a result is outside the limit for a clinical outlet, or the supply is interrupted for patient care areas.
1. Purpose
To make sure water used for drinking, washing, dialysis, sterilisation and clinical care is safe, tested on a schedule, and that interruptions are managed [EC].
2. Scope
| Applies to | Facilities, infection prevention, laboratory and clinical staff who use water |
| Locations | All water outlets and storage tanks at the facility |
| When | On the test schedule, after any repair or interruption, and after any abnormal result |
| Does not apply to | Dialysis water, which has its own standard (SOP-105 and the dialysis service) |
3. Definitions
| Term | Meaning |
|---|---|
| Outlet | Any tap, shower or dispensing point |
| Water test | A test for microbiological and chemical quality as the schedule sets |
| Limit | The value set by the national standard or the committee (EC) above which action is needed |
4. Background
Municipal supply is not automatically safe inside a building. Pipes, tanks and stagnant outlets can introduce contamination, including Legionella and other organisms. Criterion 2B.3 requires testing on a schedule and a plan for interruption.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Facilities manager | Owns the schedule; arranges sampling and repairs; keeps the plan | Facilities and water systems competence |
| Infection prevention lead | Advises on results; decides on outlet isolation with the facilities manager | Infection prevention competence |
| Laboratory (or accredited external lab) | Tests samples and reports results within the agreed time | Accredited testing |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Sampling kit | Sterile bottles and labels, supplied by the testing lab | In date |
| Water test schedule (WAT-PLN-001) | Current | Available to facilities |
| Water test record (WAT-FRM-001) | Current | Used for each result |
7. Safety
- Wear gloves when sampling. Wash hands before and after.
- Do not use a tap that is isolated or flagged as unsafe.
- Keep disinfectant and cleaning products away from sampling points.
8. Before you start
- Check the schedule for the day.
- Check the sample bottles are sterile and labelled.
9. Procedure
Step 1. Take the sample on schedule.
- Sample from the points on the schedule, using the sampling method of the lab.
- Label with date, time, point and sampler.
- Send to the lab within the time the lab requires.
Key point: A sample from the wrong point or after flushing the tap gives a false result.
Step 2. Record the result.
- Enter each result on WAT-FRM-001 when received, with the limit and the status (within limit or not).
- File the lab report.
Key point: The record must match the lab report.
Step 3. If a result is outside the limit.
- Inform the infection prevention lead and the facilities manager the same day.
- Isolate the outlet and label it “do not use for drinking or clinical use”.
- Flush and disinfect the outlet as the plan says, then retest.
- Record each step and the time.
Key point: An isolated outlet is safer than a suspicious one still in use.
Step 4. Respond to interruptions.
- Follow the contingency plan (WAT-PLN-001): tell the clinical teams, use the stored water supply, and restrict use to essential purposes.
- Record the start and end of the interruption and the actions.
Key point: The plan is what keeps patients safe while the supply is off.
Step 5. Review the results.
- Review all results each quarter with the infection prevention lead.
- Look for trends and repeated failures at the same point.
Key point: A repeated failure at one point means the pipework or the outlet needs fixing, not just retesting.
10. Decision points
- If a result is outside the limit for a patient care outlet, the outlet is out of use until retested within limit.
11. Special situations
| Situation | Action |
|---|---|
| After any repair or new plumbing | Test before use, using the post-repair test (EC). |
12. Escalation
- Out-of-limit results and interruptions go to the infection prevention lead and the chief executive the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Tests done on schedule | 100% | Monthly | Facilities manager | Escalate to chief executive |
| Out-of-limit results acted on the same day | 100% | Each result | Infection prevention lead | Review with chief executive |
| Interruptions with plan followed and recorded | 100% | Each event | Facilities manager | Review of plan |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| WAT-FRM-001 Water Test Record | Facilities file | At least 3 months on site, then archived for the period set by the facility’s records policy years |
| Lab reports | Facilities file | the period set by the facility’s records policy years |
15. Training
- Facilities staff are trained in sampling and in responding to results (EC).
- Clinical staff are briefed on the interruption plan.
16. Related documents
| ID | Title | Use |
|---|---|---|
| WAT-PLN-001 | Water Interruption Contingency Plan | Used in step 4 |
| WAT-FRM-001 | Water Test Record | Used in step 2 |
| SOP-037 | Infection Prevention and Control Procedure (generic) | Hand washing with safe water |
| SOP-105 | Dialysis Water Testing Standard (generic) | Separate standard for dialysis |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | ASF Expert Committee consensus. Test parameters, frequency and limits must be set against national drinking water and healthcare water standards before approval. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | Approved by the ASF Expert Committee |
| 1.1 | the date of approval | Internal quality review: corrected cross-references, status wording and document control | Approved by the ASF Expert Committee |
E-learning for this document
- Water Source Testing & Documentation (WATER-01)
- Legionella Prevention & Hot Water Systems (WATER-03)
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)