WATER MANAGEMENT & CONTROL OF LEGIONELLA POLICY Policy PROV 53 July 2010

Transcription

1 WATER MANAGEMENT & CONTROL OF LEGIONELLA POLICY Policy PROV 53 July 2010

2 Document Management Title of document Water Management and Control of Legionella Policy Type of document Policy PROV 53 Description Target audience To define the strategy for managing and controlling water systems and Legionella within NHS Northamptonshire and the required actions to ensure that a robust management system operates across all areas of the Trust; addressing all Corporate Objectives. All staff Author Department Directorate Interim Head of Estates and Facilities Estates and Facilities Finance Approved by Date of approval Version Number Next review date Related documents Superseded documents Internal distribution External distribution Availability Contact details (of main contact for this document) NHSN EMT 29 July Annually from approval date July 2011 All staff Yes, after approval and/ or relevant contractors All ratified policies, strategies, procedures and protocols are published on the Public Website. Name: Head of Estates and Facilities Address: Bevan House, Kettering Parkway South, Venture Park, Kettering, NN15 6XR Tel:

3 Table of Contents 1 Introduction Policy Statement Legislation and Regulation The Control of Legionella bacteria in water systems Approved Code of Practice & Guidance L8 (ACoP L8) Health and Safety at Work etc. Act Control of Substances Hazardous to Health Regulations 2002, Regulation 6 (COSHH) The Public Health (Infectious Diseases) Regulations The Water Supply (Water Fittings) Regulations BS 6700:1997 Specification for Design, installation, testing and maintenance of services supplying water for domestic use within buildings and their cartilages Scope Aims and Objectives Purpose Related Policies Roles and Responsibilities Chief Executive Director of Operations and Policy Provider Services Associate Director Estates (Responsible Person) Head of Estates (Deputy Responsible Person) Consultant/Contractor Service Providers Estate Staff Project Managers General Users Health & Safety Manager Processes and procedures Standards Managing and Controlling Legionella

4 9.3 Risk Assessment Record Keeping Training Monitoring effectiveness and compliance APPENDIX 1 Policy Guidance

5 1 Introduction This document sets out NHS Northamptonshire s (hereafter referred to as the Trust ) Policy for managing and controlling water systems and Legionella. Through this policy, the Trust aspires to provide a safe, high quality healthcare Environment for its patients, staff and visitors. This is partially achieved by ensuring that Trust premises are maintained to a high standard, comply with statutory and mandatory requirements and best practice as set out in Health Technical Memorandums and other DoH guidance. This document is intended to and must be read in conjunction with the Procedure Manual for the Management and Control of Legionellosis for the Trust. It is the responsibility of the Trust; under the Health and Safety at Work Act 1974 etc. (Section 16) and the Control of Substances Hazardous to Health 2002, to take all reasonable precautions and to follow approved codes of practice for managing and controlling risks. The guidance issued for the control of Legionella Bacteria in Water Systems is for most circumstances, The Approved Code of Practice L8 The Control of Legionella Bacteria in Water Systems ( ACoP L8 hereinafter) and also for NHS Trusts in England and Wales HTM The Trust accepts its responsibility for the Management and Control of Legionellosis including Legionnaires Disease under The Health and Safety at Work Act 1974 (section 16) and the Control of Substances Hazardous to Health 2002 and ACoP L8. This Policy sets out the control measures and the Management Systems utilised by The Trust (known also as the written Scheme of Precautions), to Manage and Control the risk of Legionellosis and Legionnaires Disease and complies with the ACoP L8. This document forms the written Scheme of Precautions detailed in ACoP L8 Part 1 paragraph 52 and 53 which state: Where the Assessment shows that there is a reasonably foreseeable risk, the use of the water systems, parts of the water systems or systems of work that lead to exposure has to be avoided so as far as reasonable practicable. Where this is not reasonably practicable, there should be a written scheme for controlling the risk from exposure which should be implemented and properly managed. The aim of this Policy is to provide for The Trust s employees, a structured approach for the Management and Control of Legionellosis including 5

6 Legionnaires Disease, detailing all the requirements of The Trust to comply with the ACoP L8 and HTM As laid down in The Health and Safety Commission's Approved Code of Practice L8 to comply, The Trust will undertake to: a) Identify and assess sources of risk b) Prepare a scheme for preventing, reducing or controlling the risk c) Implement and manage precautions d) Keep records of the precautions implemented e) Appoint a person to be managerially responsible The scope of the Policy extends to all of the properties currently owned or occupied by The Trust and those properties that may come into ownership or occupation of The Trust. The policy also describes the roles and responsibilities of various individuals in the Trust who are involved it the design, management, operation, maintenance and testing of systems. The Policy also describes the key activities which must be undertaken and a process for assurance. 2 Policy Statement The Trust recognises and accepts its responsibility under the Health and Safety at Work etc. Act 1974, the Control of Substances Hazardous to Health 2002 and guidance document ACoP L8, to sufficiently manage and control the associated risk from Legionella bacteria that may be present in the water systems operated by The Trust and the potential for distribution of the bacteria in aerosols or water droplets. It is the Policy of The Trust to implement and operate this scheme of precautions in recognition of the identified risks from Risk Assessments to all of the properties and continually manage the program of works and maintain all records. The Trust will also appoint a Responsible Person who will influence the scheme of precautions and manage the day to day operations. All properties currently occupied and owned and properties that become occupied or owned by The Trust shall be included in the scope of this policy. The Trust shall undertake to Manage and Control Legionella bacteria using the methods discussed in the ACoP L8 including thermal disinfection, ionisation using silver and copper, disinfection using and sufficient management as described later in this document. 3 Legislation and Regulation The Trust will utilise the following guidance and Approved Code of Practice to manage the associated risks within its premises: 6

7 a) The Control of Legionella bacteria in water systems Approved Code of Practice & Guidance L8 (2001). b) Health and Safety at Work etc. Act 1974, Sections 2, 3 and 4. c) Health Technical Memorandum d) Control of Substances Hazardous to Health Regulations 2002, Regulation 6. e) The Public Health (Infectious Diseases) Regulations f) The Water Supply (Water fittings) Regulations g) BS 6700: Specification for Design, installation, testing and maintenance of services supplying water for domestic use within buildings and their curtilages. h) Food Act The Control of Legionella bacteria in water systems Approved Code of Practice & Guidance L8 (ACoP L8) This Approved Code of Practice gives practical advice on the requirements of the Health & Safety at Work etc. Act 1974 in particular sections 2, 3, 4 and 6 (as amended by the Consumer Protection Act 1987) and regulations 6, 7, 8, 9 and 12 of the Control of Substances Hazardous to Health Regulations 1999 (2002). The main obligations under the ACoP L8 are to: Appoint a Managerially Responsible Person Undertake Risk Assessments Devise a Scheme of Precautions Implement that Scheme of Precautions Keep sufficient records 3.2 Health and Safety at Work etc. Act 1974 Under the 1974 Act, it is the general duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees. In particular, so far as is reasonably practicable, the employer has to provide a safe system of work; make arrangements for ensuring safety and absence of risk to health connected with the use, handling, storage and transport of articles and substances; provide information, instruction, training and supervision necessary to ensure health and safety at work; provide safe access to and from the workplace; and provide a working environment that is safe, without risk to health, and adequate as regards facilities and arrangements for welfare at work. As laid out in the ACoP L8, duties under the HSWA extend to risks arising from Legionella bacteria which may arise from work activities. Such duties are legally enforceable and the Health and Safety Executive hold responsibility for enforcement of the law. Responsibilities fall upon both owners and occupiers of premises, to ensure that there is a management regime for the preparation, design, installation and maintenance of plant, equipment and systems. 7

8 3.3 Control of Substances Hazardous to Health Regulations 2002, Regulation 6 (COSHH) The 2002 COSHH regulation includes exposure to biological agents if they are directly connected to the workplace. Only biological agents that are beyond the control of an employer (such as catching an infection from a workmate) are not covered under COSHH. The requirements of COSHH are to: 1) Assess the risk of exposure 2) Decide what precautions are needed 3) Prevent or adequately control the exposure 4) Ensure that control measures are used and maintained 5) Prepare plans and procedures to deal with accidents incidents and emergencies These regulations also apply to the chemicals which may be used to control the growth of organisms in water supply. 3.4 The Public Health (Infectious Diseases) Regulations 1988 This regulation requires that a proper Officer shall inform the Chief Medical Officer of any serious outbreak of any disease which has, to his knowledge occurred in his district. This includes Legionnaires Disease. a proper Officer shall, if his district or port health district is in England immediately inform the Chief Medical Officer for England, or, if his district or port health district is in Wales immediately inform the Chief Medical Officer for Wales of (a) Any case or suspected case of a disease subject to the International Health Regulations and (b) any serious outbreak of any disease (including food poisoning)which to his knowledge has occurred in his district or port health district, and he shall similarly inform the appropriate Medical Officer of the appropriate District Health Authority. 3.5 The Water Supply (Water Fittings) Regulations 1999 These regulations came into force on the 1 st July 1999 and apply in detail the supply and design of water fittings and the application of the water fittings within a property owned or occupied by an employer. These regulations should be utilised as a guide for employers undertaking upgrading or replacing of water services within their properties and for new build projects. 8

9 3.6 BS 6700:1997 Specification for Design, installation, testing and maintenance of services supplying water for domestic use within buildings and their cartilages This standard specifies the requirements for and gives recommendations on the design, installation, alteration, testing and maintenance of services supplying water for domestic use within buildings and their curtilages. It covers the system of pipes, fittings and connected appliances installed to supply any building, whether domestic or not, with water for drinking, culinary, domestic laundry, ablutionary, cleaning and sanitary purposes. 4 Scope The policy applies to all properties owned and maintained by the Trust including properties leased, rented or occupied under lease or other occupancy agreement. 5 Aims and Objectives The Trust is committed to ensuring that all water systems is installed, inspected, serviced and maintained in accordance with all of the relevant legislation and guidance to ensure that such equipment does not pose a health or operational risk to either, staff, patients or members of the public. Application of the arrangements set out in this Policy will ensure that the Trust meets its statutory obligations and operates within approved safety standards and codes of practice. 6 Purpose Implementation of this policy will: Ensure that water systems are suitable for its intended use and is maintained to satisfactory performance levels. Contribute to the overall control of infection agenda within the Trust. Comply with health and safety legislation requirements. Ensure the standards set out initially Standards for Better Health and modified over time by the Care Quality Commission are met. Maintain the health, comfort and environment for all Patients, staff and visitors to the Trust by ensuring adequate water management exists and it is fully functional. 7 Related Policies FIN 05 Control of Contractors Policy GOV 02 Health and Safety Policy PH 03 Infection Control Policy PROV 19 Infection Control Outbreak Policy 9

10 8 Roles and Responsibilities The Trust has a management responsibility to ensure that inspection, service and maintenance activities are carried out safely without hazard to staff, patients or members of the public. Under the Control of Substances Hazardous to Health 2002 Regulations 8 and 12, Health and Safety at Work etc. Act 1974 Sections 2, 3 and 4 and the Management of Health and Safety at Work Regulations 1999 Regulation 5 and the ACoP L8 the Duty Holder (the person whom holds overall responsibility) should appoint a person to take managerial responsibility and provide supervision of the implementation of the scheme of precautions. 8.1 Chief Executive The Chief Executive of NHS Northamptonshire has an overall responsibility for ensuring that sufficient and suitable procedures and resource are in place to manage and maintain the Trust's water systems and in effect is the Duty Holder under the regulations. The Duty Holder shall appoint a suitably trained and competent person to the position of Responsible Person whom will have responsibility for the day to day operation of the scheme of precautions and management and control of Legionellosis. The Duty Holder shall oversee and be ultimately responsible for the Management and Control of Legionellosis within the premises owned and occupied by The Trust. 8.2 Director of Operations and Policy The Executive Director responsible for creating a suitable range of arrangements to deliver the policy aims and aspirations. He/ she should: Set out the standards and quality of service to be provided. Ensure that sufficient and competent staff and resources are applied to investment, design, maintenance and performance monitoring of systems covered by this policy. 8.3 Provider Services Provider Services, as the provider of the commissioned health care services and activity, have roles and responsibilities ensuring that the environment is managed appropriately to reflect national standards in relation to the health and safety and well being of all staff, visitors, patients and others who have access. Managing Director Ensures policy is implemented operationally and monitored as part of clinical assurance. 10

11 Management responsibility for ensuring that there is a managed environment which minimises the risk of infections to patients, visitors, staff, contractors and all who use the premises for any purpose. Ensuring the quality schedules of contracts for commissioned services reflect national standards in relation to infection prevention and control. Ensuring that appropriate information, instruction and training is provided to employees within the organisation. Board Responsible for the implementation of policies and the monitoring of progress through reviews and reports. Monitoring assurance provided against the implementation of this policy in line with national standards in relation to infection prevention and control. Infection Prevention Team Responsibility of the Infection Prevention Team (IPT) to provide input into Estates & Facilities (E&F) projects and schemes that this policy applies and to identify appropriate solutions. The IPT to liaise with the E&F team to ensure appropriate action is taken internally and externally by Consultants and Contractors commissioned and controlled by the organisation to thereby reduce ant risk of cross infection. Both teams should ensure all work is carried out in accordance with Infection Control Policies and Protocols referred to within this policy and other related policies. 8.4 Associate Director Estates (Responsible Person) Acts as Deputy to the Associate Director of Finance and line manages the strategic and operational aspects of the estate. He/she is therefore designated as the Responsible person. The Responsible Person shall: be suitably informed and competent to ensure that the control measures will be undertaken in a safe and technically competent manner in a managerial position or equivalent and also have sufficient authority to authorise necessary precautions in the event of an emergency or for planned works. will be closely involved in devising and the continual reviewing or auditing of the scheme of precautions and their day to day implementation. hold responsibility for the undertaking of Legionella Risk Assessments on a 2 yearly basis and for the Reviews of the Risk Assessments as and when necessary for all properties that are owned or occupied by The Trust. 11

12 It will be the responsibility of the Responsible Person to carry out and oversee the necessary remedial actions highlighted by the Risk Assessments and to maintain all records associated to the Management and Control of Legionellosis for a period of 5 years and archive records for a period of 15 years. The Responsible Person shall also ensure that all involved staff shall be suitably trained to a competent level and that all contractors involved in the scheme of precautions are suitably qualified and competent to undertake the tasks contracted to them. In the event of an outbreak or of the reporting of elevated results, the Responsible person shall undertake to put in place the arrangements as per the outbreak and elevated results procedure. 8.5 Head of Estates (Deputy Responsible Person) A Deputy Responsible Person shall be appointed by the Duty Holder to have responsibility for the day to day operation of the scheme of precautions and be answerable to the Responsible Person. The Deputy Responsible Person shall be suitably informed and competent to ensure that the control measures will be undertaken in a safe and technically competent manner. In the absence of the Responsible Person due to Holiday or illness or any other reason, the Deputy Responsible Person shall undertake the duties of the Responsible Person with guidance from the Duty Holder and approved Consultant/Contractor until such time that the Responsible Person may be present to undertake such duties, however in this instance, the overall responsibility fall on the Duty Holder who should satisfy himself that adequate precautionary measures are undertaken. 8.6 Consultant/Contractor It is the responsibility of the Consultant/Contractor to ensure that all goods and services be provided fit for purpose in a timely manner and to apply site knowledge when discussing/consulting on the M0anagement and Control of Legionellosis for The Trust. The Consultant/Contractor shall assist fully in necessary emergency procedures to allow the Responsible Person/Deputy Responsible Person to complete their tasks. 8.7 Service Providers It is the responsibility of the Service Provider to undertake all tasks assigned to them and ensure that records of all maintenance in connection to the Management and Control of Legionellosis. The Service Provider shall liaise closely with the Responsible Person to ensure continued compliance to the regulations. Among other services, Legionella Management and Control is included in 12

13 the agreement between the Companies. Overall responsibility cannot be delegated to service providers. 8.8 Estate Staff It is the responsibility of all staff involved in the Management and Control of Legionellosis to ensure that all tasks in place under the scheme of precautions or pre planned maintenance programme be undertaken in a complete and methodical manner and all records are fully maintained. 8.9 Project Managers Manage Trust Estates and Capital Projects and in doing so ensures that: All new installations meet the latest legal and technical standards. Ensure that any appointed design consultants have appropriate input and influence on the design of all new installations and is invited to witness commissioning and performance checks. Ensure that all new installations are accessible and maintainable without resort to specialist access equipment or the need for removal of finishes/infrastructure. Ensure that maintenance teams have comprehensive operations and maintenance manuals handed over on completion of schemes. Ensure that appropriate training and familiarisation is provided to in house and contract maintenance teams General Users This is the local manager responsible for unit, e.g. the head of department, building manager, etc. They have the responsibilities for: To report defects to the Estates helpdesk Flush any low usage outlets on a regular basis as specified by the Responsible person. Ensure reasonable access for maintenance to be carried out as laid down in this policy. Reporting all incidents (including near misses) on the Trust Incident reporting system 8.11 Health & Safety Manager The Trusts Health & Safety Manager is responsible for providing advice and guidance on the requirements of this Policy; including proposing changes to this Policy as and when new legislation or regulations are introduced. 9 Processes and procedures 9.1 Standards In many existing systems, original design and commissioning information will not be available. It will therefore be necessary to determine a suitable 13

14 level of system performance based on the function, purpose and age of the installation 9.2 Managing and Controlling Legionella In the first instance, The Trust, as a starting point of reference and to effectively determine a progressive method of control, shall undertake to complete Risk Assessments on all of the water systems in all of the buildings owned or occupied by The Trust. The Risk Assessment shall consider and recommend a method of control for continued control of Legionella bacteria that may be present in a particular water system. It has been well documented that thermal control is an effective method of control for Legionella bacteria growth. In the case of The Trust, thermal control will be primary method of control for Legionella bacteria within the water systems operated within the majority of the premises of The Trust. Thermal disinfection will be achieved in each property by maintaining cold water temperatures at <20 C at all times and by maintaining the domestic hot water at >60 C at the hot water source or plant and >50 C at all outlets and if fitted to the return supply to the hot water source. In addition, to thermal disinfection and to aid thermal disinfection a number of other treatment methods are in use for a number of the sites operated by the Trust, these include: ionisation and chlorine dioxide. All water systems shall be maintained in a clean condition including all cold water storage tanks, calorifiers, cistern type water heaters and all associated pipework. Furthermore, all systems that utilise water in any way whatsoever shall be used on a frequent basis (at least weekly) or systems that do not get utilised on a frequent basis shall be flushed on a twice weekly basis. Where a Risk Assessment for staff or residents or persons has been undertaken for the risk of scalding from hot water and has been deemed to be high, the use of thermostatic mixing valves at each assessed outlet shall be considered. In order that the scheme of precautions set out above can be successful, the programme must be monitored at regularities set out in the ACoPL8, and under the influence of the Responsible Person, depending on the plant operated and the potential for persons to be exposed to droplets. Records of all planned monitoring of the water systems shall be maintained and be made available for the purposes of inspection. During specific circumstances, when Thermal Disinfection is shown, by the various Monitoring Tasks, to be failing, the water quality shall be maintained by ensuring the shot-dosing of a suitable disinfecting agent, the levels of which must be maintained within the recommended limits for achieving disinfection as specified within the current edition of BS6700:2006 Clause 14

15 3:1:10:1997 and ACoP L8. The Trust will continue to consider new developments and improvements in the field of Legionellosis Management & Control, in order to ensure that the control of the prevailing risk of Legionellosis posed by the various systems is constantly reviewed and improved and always maintained at the maximum level. 9.3 Risk Assessment As recommended in the ACoP L8 section 23; A suitable and sufficient assessment is required to identify and assess the risk of exposure to Legionella bacteria from work activities and on the premises and any necessary precautionary measures. Risk Assessments are also a requirement of the Control of Substances Hazardous to Health 2002 Section 6 and The Management of Health and Safety at Work Regulations 1999 Regulation 3 and The Health and Safety at Work etc. Act 1974 Sections 2, 3 and 4. A Risk Assessment will be undertaken by or on behalf of The Trust by a suitably trained and competent person and will include all of the properties currently occupied and owned by The Trust and provision allowed for the Risk Assessment of Properties that become occupied or owned by The Trust. The assessment will identify and consider all water sources including domestic and non-domestic water systems where applicable for the risk of Legionellosis from work activities and water sources on the premises and propose any necessary precautionary measures or changes to the existing scheme of precautions. The assessment will identify and evaluate all potential sources of risk and: 1) The particular means by which Legionella bacteria is to be prevented, or 2) If prevention is not reasonably practicable, the particular means by which the risk of exposure to Legionella bacteria is to be controlled. In addition, the Risk Assessment must consider the overall management scheme of precautions and include the findings within the Risk Assessment report. In the instance of problem areas and at the discretion of the responsible person, the use of reassurance sampling during a Risk Assessment will also be considered and although the recommendation will invariably be similar, reassurance sampling will serve as an indicator and not a control measure. It is important that Risk Assessments be undertaken in order to allow The Trust to effectively manage and control the presence of Legionella bacteria and not just to comply, as undertaking a Risk Assessment and not continuing with the recommendations is still a non compliance, unless the Risk Assessment demonstrates there to be no reasonably foreseeable risk 15

16 or that the risks are insignificant and unlikely to increase. The following is a flow diagram of the management team and reporting routes: Duty Holder Responsible Person Deputy Responsible Person Service Provider Deputy Responsible Person 9.4 Record Keeping It is the responsibility of the Responsible Person to ensure that the records are kept, including details of: 1) The person or persons responsible for conducting the Risk Assessment, managing, and implementing the written scheme of precautions. 2) The significant findings of the Risk Assessments. 3) The written scheme for Legionella control and details of its implementation. 4) The results and/or monitoring, inspection, test or check carried out, and the dates and signature of the staff undertaking the task. This should include details of the state of operation of the system, i.e. in use/not in use. 5) Details of remedial actions/works with dates and sign off on completion. All current records shall be retained throughout the period in which they are current and for at least 2 years after that period. Record results of any monitoring, inspection or remedial actions should be kept for a period of at least 5 years thereafter. 9.5 Training 16

17 The users and those who maintain any water systems will need to be properly trained in order to discharge their responsibility Comprehensive training records should be kept. 10 Monitoring effectiveness and compliance This Policy for the Management and Control of Legionellosis shall be subject to a yearly review in order to allow for any changes in the legislation or regulations for the Management and Control of Legionellosis. The review shall take into account any changes in control methods that may affect The Trust s current methods of Legionella control. Any changes to the Policy and its affects on the scheme of precautions shall be discussed by the Responsible Person and Duty Holder in order to allow for changes to the scheme or precautions to comply with current legislation/regulation/guidance. The review of this document may be undertaken by the Responsible Person, Duty Holder, or Consultant to The Trust. 17

18 APPENDIX 1 Policy Guidance GUIDANCE 1: PRE PLANNED MAINTENANCE AND REVIEWS As dictated by the Risk Assessments all systems shall be monitored in order to ensure that the systems are operating within the control limits set out as per the ACoP L8. All tasks undertaken for the control of Legionellosis shall have the results recorded and maintained in a logbook system that shall be maintained for 5 years. The tasks as per ACoP L8 and to be undertaken by The Trust are as follows: (The following tables are extracts from the ACoP L8. Some of the services listed here may not be present within all of The Trust s properties) ACoP L8 Appendix 1 Checklist 2: Hot and Cold Water Services Service Task Frequency Arrange for samples to be taken from hot water calorifiers, in order to Annually note condition of drain water Check temperatures in flow and return at calorifiers Monthly Hot water services Check water temperature up to one minute to see if it has reached 50 o C Monthly in the sentinel taps Visual check on internal surfaces of calorifiers for scale and sludge. Check representative taps for Annually temperature as above on a rotational basis Check tank water temperature remote from ball valve and mains temperature at ball valve. Note maximum temperatures recorded by Six monthly fixed max/min thermometers where fitted Cold water services Check that temperature is below 20 o C after running the water for up Monthly to two minutes in sentinel taps Visually inspect cold-water storage tanks and carry out remedial work where necessary. Check Annually representative taps for temperature as above on a rotational basis Shower heads Dismantle, clean and de-scale Quarterly or as shower heads and hoses necessary Flush through and purge to drain, or Little-used outlets purge to drain immediately before Weekly use, without release of aerosols ACoP L8 Section 169 Table 3: Monitoring the Temperature Control Regime. 18

19 Frequency Monthly Check Sentinel taps Drinking water outlets If fitted, input to TMV's on a sentinel basis Water leaving and returning to calorifier Standard to meet Cold water Hot water The water temperature should be below 20 o C after running the water for up to two minutes The sentinel closest the incoming main will be checked to ensure the incoming main temperature is <20 C within 2 minutes of flushing at full flow. The water temperature should be at least 50 o C within a minute of running the water The water supply to the TMV temperature should be at least 50 o C within one minute of running the water Outgoing water should be at least 60 o C, return at least 50 o C Notes This check makes sure that the supply and return temperatures on each loop are unchanged, i.e. the loop is functioning as required One way of measuring this is to use a surface temperature probe If fitted, the thermometer pockets at the top of the calorifier and on the return leg are useful points for accurate temperature measurement. If installed, these measurements could be carried out and logged by a building management system 19

20 Six monthly Incoming cold water inlet (at least once in the winter and once in the summer) The water should preferably be below 20 o C at all times (but see paragraph 156 of L8) The most convenient place to measure is usually at the ball valve outlet to the cold water storage tank Annually Representative number of tabs on a rotational basis. (including drinking water outlets) The water temperature should be below 20 o C after running the water for two minutes The water temperature should be at least 50 o C within one minute of running the water This check makes sure that the whole system is reaching satisfactory temperatures for legionella control Management of drinking water. All drinking water will be provided to Trust premises directly from the incoming main or via point of use portable drinking water fountains. As far as is reasonably practicable, drinking water will not be provided form cold water storage tanks or from a treated water source (other than the incoming main). Where drinking water must be provided form a cold water stored supply, the containing vessel will meet the requirements of the Water Supply Regulations The incoming main temperatures will be included in the monitoring regimes as described above. All drinking water outlets will be maintained in a clean condition and included in the flushing regime (when infrequently used) described above. Where drinking water is provided using portable drinking water fountains the storage of the replacement bottles will be in accordance with the manufacturers recommendations and in conditions that will not encourage bacteria growth i.e in a cool and clean environment, not in direct sunlight and stored for periods of no longer than 1 month. Should the Responsible Person have any reason to suspect that the quality of the drinking water is reduced in any way then bacteria sampling (TVC, E-Coli, and Coliforms) will be arranged and the affected outlets sampled to confirm the bacterial quality of the water. 20

21 ACoP L8 Appendix 1 Checklist 3: Other Risk Systems System/Service Task Frequency Six monthly or If equipment fitted with UV lights, check to according to ensure effectiveness of lamp (check to see if manufacturer's Ultrasonic within working life) and clean filters instructions humidifiers/ As part of foggers and Ensure automatic purge of residual water is machinery shut water functioning down misting/spraying As indicated by systems Clean and disinfect all wetted parts Risk Assessment As indicated by Sampling for Legionella Risk Assessment Clean and disinfect spray humidifiers/air Spray washers and make-up tanks including all Six monthly humidifiers, air washers and wet scrubbers Water softeners Emergency showers and eye wash sprays Sprinkler and hose reel systems Lathe and machine tool coolant systems Spa baths Horticultural misting systems Vehicle washes Vehicle Screen Wash Systems Indoor fountains and water features wetted surfaces, de-scaling as necessary Confirm the operation of non-chemical water treatment (if present) Clean and disinfect resin and brine tank - check with manufacturer what chemicals can be used to disinfect resin bed Flush through and purge to drain When witnessing tests of sprinkler blow - down and hose reels ensure that there is minimum risk of exposure to aerosols Clean and disinfect storage and distribution system Check filters - sand filters should be backwashed daily Check water treatment - pools should be continuously treated with an oxidising biocide Clean and disinfect entire system Clean and disinfect distribution pipework, spray heads and make-up tanks including all wetted surfaces, de-scaling as necessary Check filtration and treatment system, clean and disinfect system Top up the screen wash to all vehicles using a suitable additive solution mixture. Clean and disinfect ponds, spray heads and make-up tanks including all wetted surfaces, de-scaling as necessary Weekly As recommended by manufacturers Six monthly or more frequently if recommended by manufacturers As directed Six monthly Daily Three times daily Weekly Annually As manufacturers' instructions Weekly Interval depending on condition 21

22 GUIDANCE 2: MONITORING OF ALTERNATIVE TREATMENT REGIMES: Where an alternative treatment regime has been installed into a site the treatment regime will be monitored and additional sampling for Legionella completed as recommended in accordance with ACoP L8 Part 2 Paragraph 174 and 178 (paras also included). Monitoring the Chlorine Dioxide regime 174 For most systems, routine inspection and maintenance will usually be sufficient to ensure control see paragraphs ) if the following areas are checked at regular intervals and remedial action taken when necessary, with details of all actions being recorded (see also paragraph 172): (a) the quantity of chemicals in the reservoir; (b) the rate of addition of chlorine dioxide to the water supply; (c) on a monthly basis, the concentration of chlorine dioxide should be measured at the sentinel taps - the concentration should be at least 0.1mg/l; and (d) on an annual basis, the chlorine dioxide concentration at a representative number of outlets - the concentration should be at least 0.1mg/l. Monitoring the ionisation regime 178 For most systems, routine inspection and maintenance will usually be sufficient to ensure control (see paragraphs ) if the following parameters are also monitored at regular intervals and remedial action taken when necessary, with details of all actions being recorded (see also paragraph 172): (a) the rate of release of copper and silver ions into the water supply; (b) the silver ion concentrations at sentinel outlets should be checked monthly - this should be at least 20µg/l at outlets; (c) the measurement of silver ion concentrations at representative taps selected on a rotational basis once each year - this should be at least 20µg/l at outlets; (d) the condition and cleanliness of the electrodes; and (e) the ph of the water supply. General Monitoring The ACOP says that the risk from exposure to Legionella should be prevented or controlled and that the precautions taken should be monitored to ensure that they remain effective. The following section on monitoring offers guidance on how to achieve this in hot and cold waters systems. 180 All water services should be routinely checked for temperature, water demand and inspected for cleanliness and use. Ideally, the key control parameters should be monitored by a building management system if one is present. This will allow early detection of problems in maintaining the control regime. 181 The frequency of inspection and maintenance will depend on the system and the risks it presents. All the inspections and measurements should be recorded and should include: (a) The name of the person undertaking the survey, signature or other identifying code, and the date on which it was made (computer records are acceptable); and (b) A simple description and plan of the system and its location within and around the building. This should identify piping routes, storage and header tanks, 22

23 calorifiers and relevant items of plant, especially water softeners, filters, strainers, pumps and all water outlets. Annual check 182 This should comprise the following. (a) Visual inspection of the cold water storage tank to check the condition of the inside of the tank and the water within it. The lid should be in good condition and fit closely. The insect screen on the water overflow pipe should be intact and in good condition. The thermal insulation on the cold water storage tank should be in good condition so that it protects it from extremes of temperature. The water surface should be clean and shiny and the water should not contain any debris or contamination. The cold water storage tank should be cleaned, disinfected and faults rectified, if considered necessary. If debris or traces of vermin are found then the inspection should be carried out more frequently. (b) Making a record of the total cold water consumption over a typical day to establish that there is reasonable flow through the tank and that water is not stagnating. This can be done by fitting a temporary water flow meter over the outlet pipe and recording the consumption. It can also be measured by holding the ball valve supplying the water in the closed position and measuring the rate of water level drop within the vessel. Whenever the building use pattern changes, this measurement should be repeated. (c) Draining the calorifier and checking for debris in the base of the vessel. The calorifier should then be cleaned if considered necessary. (d) Checking the plans for both the hot and cold water circuits to make sure they are correct and up to date - this should be done by physical examination of the circuits, if possible. Plans should be updated if necessary. (e) Ensuring that the operation and maintenance schedules of the hot and cold water systems are readily available and up to date with named and dated actions throughout the previous year. (f) Checking the existence of all water connections to outside services; kitchens, fire hydrants and chemical wash units. Any insulation should be checked to ensure that it remains intact. Any water outlets that are no longer used should be removed. 23

24 GUIDANCE 3: ELEVATED SAMPLE PROCEDURE AND OUTBREAK PROCEDURE Legionnaire s Disease is not notifiable under public health legislation in England and Wales but, in Scotland, Legionellosis (i.e. all diseases caused by Legionella) is notifiable under the Public Health (Notification of Infectious Disease) (Scotland) Regulations The Public Health Laboratory Service defines an outbreak as two or more confirmed cases of Legionellosis occurring in the same locality within a sixmonth period. Location is defined in terms of the geographical proximity of the cases and requires a degree of judgement. It is the responsibility of the proper Officer, who is appointed by the Local Authority under public health legislation and is usually a Consultant in Communicable Disease Control for the declaration of an outbreak. In the event of a suspected outbreak, the Responsible Person shall undertake to inform the proper Officer as detailed above. All persons involved from The Trust shall follow the Outbreak Procedure detailed next. This procedure is also located in the Procedure Manual for the Management and Control of Legionellosis Section 7 page

25 GUIDANCE 4: OUTBREAK PROCEDURE Please note: this Outbreak Procedure is not to be confused with the Elevated Sample Procedure described in the previous section. As stated, an outbreak is defined as two or more confirmed cases of Legionellosis occurring in the same locality within a six-month period and can only be declared by the Local Authority Proper Officer. In the event of an outbreak being declared and suspected to be sourced in the locality of The Trust s properties, it is important to ensure that the Management Team, as described earlier, implement the following procedure to effectively manage and control the suspected risk. 1 All individuals involved in the scheme of precautions will be involved in the event of an outbreak. They shall be known as the Major Outbreak Team. It is important for the major outbreak team (usually the Responsible Person) to establish points of contact with the Local Health Authority or Hospital Trust and the Local Authority Health Officer. 2 The Risk Assessment for the building affected should be addressed to assist in identifying areas of most concern and likely areas for routes of infection. 3 All potential sources of generating an aerosol shall be taken out of use (Showers, Air Handling Units, and Cooling Units). 4 It is important to ensure that the systems suspected of being a potential source of infection are NOT cleaned and disinfected to allow for sampling of the system. 5 Samples of the source shall be taken and submitted to UKAS accredited laboratory for analysis. 6 An investigation in the breakdown of the scheme of precautions shall be undertaken. All aspects of the scheme of precautions shall be audited including monitoring and record keeping. 7 By this time the Local Authority Public Health Officer (responsible for declaring an outbreak) /Health and Safety Executive Officer may be closely involved with the Major Outbreak Team. The Major Outbreak Team shall comply fully with the requests of the Officer. 8 Under the instruction of the Public Health Officer all water systems shall be cleaned and disinfected in accordance with BS6700:1997/ACoP L8. 9 All areas of concern such as showers, AHU and Cooling Towers shall be addressed by the individual cleaning and disinfection of the items. 10 All systems shall be refilled and thoroughly flushed on a daily basis until the system can be declared bacteria free. (It is important to maintain records of all remedial actions before, during, and after the outbreak). 11 The system shall be re-sampled after 4 days of the system being cleaned and disinfected to allow the system to stabilise although flushing of the system shall continue. 12 Once the sampling regime shows there to be no Legionella bacteria present in the system. The system shall be re-instated. Should the sampling suggest that there are still Legionella bacteria present above satisfactory levels, steps 7 to 10 shall be repeated paying particular attention to other sources that may have been omitted from the previous procedure. 13 An immediate review of the Monitoring Programme shall be undertaken in order to identify areas where the control scheme of precautions has failed to 25

26 effectively control the proliferation of Legionella bacteria and suggestions as to necessary changes to the scheme of precautions for greater control. 14 The Major Outbreak Team shall continue to assist the investigating Officers of the Outbreak Team. 26

27 GUIDANCE 5: MEASURED PARAMETER RECOMMENDED LIMITS The following information is to allow the maintenance staff to undertake tasks and follow measured parameter limits for remedial action. PARAMETER SET POINT Cold Water Temperatures All Cold Water Outlets Maximum 20 C Hot Water Temperatures Storage Calorifier Thermostat Set Point Minimum 60 C Storage Calorifier Flow Minimum 60 C Storage Calorifier Return Minimum 50 C Storage Calorifier Drain/Base Minimum 50 C Storage Calorifier Cold Feed Maximum 20 C HWS Sentinel Outlets Minimum 50 C Cistern Type Water Heater Thermostat Set Point Minimum 60 C Cistern Type Water Heater Flow Minimum 60 C Cistern Type Water Heater Clod Feed/Tank Section Maximum 20 C Cistern Type Water Heater HWS Outlets Minimum 50 C Instant Water Heaters <30 Litres Thermostat Set Point Instant Water Heaters <30 Litres Flow Instant Water Heaters <30 Litres Cold Feed Instant Water Heaters <30 Litres HWS Outlets Blended Outlets Showers Basins/Sinks Baths Bidets Measured Parameters Continued: Biological Contamination Legionella Bacteria <100 cfu/litre Legionella Bacteria >100 but <1000 cfu/litre User Comfort Temperature User Comfort Temperature Maximum 20 C User Comfort Temperature Maximum 41 o C Maximum 41 o C Maximum 44 o C Maximum 37 o C Growth Is Insignificant Growth is Significant 27

28 Legionella Bacteria >1000 cfu/litre Growth is Highly Significant For Drinking Water T.V.C. Total Viable Count <50 cfu/ml T.V.C. Total Viable Count >50 cfu/ml and <500cfu/ml T.V.C. Total Viable Count >500cfu/ml Growth is Insignificant Growth is Significant Growth is Highly Significant E. COLI and Coliforms <1cfu/ml >1cfu/ml Growth is Insignificant Growth is Highly Significant Dipslides Bacteria/Yeasts <10 4 Bacteria/Yeasts >10 4 to >10 6 Mould <10 2 Mould 10 3 to 10 4 Insignificant Growth Significant Growth Insignificant Growth Significant Growth 28

29 GUIDANCE 6: ELEVATED SAMPLE PROCEDURE Elevated samples from the routine inspection/monitoring are not considered to be an outbreak or indicative of or to an outbreak. When the sampling programme yields elevated results from either dipslide monitoring or Legionella or TVC sampling as detailed on the Measured Parameter Recommended Limits table, the elevated sample procedure should be followed, this is located in The Trust s Procedure Manual for the Management and Control of Legionellosis Section 5 page 14 and is also detailed below. The following should be read in reference to the above table noting only some of the recommendations are applicable to the item mentioned above. Insignificant 1) No further action required, maintain current monitoring regime. Significant 2) Clean, de-scale and disinfect all removed shower heads and outlets and replace onto system immediately following disinfection. 3) Carry out a system clean and disinfection (within 2 days of results) and resample after 4 days from disinfection. 4) If result still persists, repeat de-scale, clean and disinfection and re-sample after 4 days from disinfection. 5) If result still persists follow procedures described in the Highly Significant section below. 6) Consider the source of contamination. Highly Significant 7) Isolate system and carry out a system clean disinfection immediately or at least before the system is used again. Re-sample after 4 days from disinfection. 8) Remove all shower heads in contaminated area until post-disinfection biological analysis indicates the removal of contamination. 9) Clean, de-scale and disinfect all removed shower heads and replace onto system when post-disinfection biological analysis indicate the removal of contamination. Ensure that shower heads are in a dry state while disconnected to prevent stagnation. 10) Where showers are required to remain in use following indication, they shall be fitted with a suitable HEPA filter to enable continued use of the facility. Where such filters are fitted, they should be changed according to manufacturer s instructions. 11) If result still persists, repeat system clean and disinfection and re-sample after 2 days from disinfection and reconsider sources of contamination. 29