Policy and Guidelines for the Management and Control of Legionella

Transcription

1 Policy and Guidelines for the Management and Control of Legionella P olicy for the Management and Control of Legionella

2 1. Introduction and Policy Statement This Policy and Guidelines is intended to provide a Scheme of Precautions and safe working practices for the Management and Control of Legionellosis in the University of Chichester. The University 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 Practice (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: 52 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. 53 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. As laid down in The Health and Safety Commission's Approved Code of Practice L8 to comply, The University of Chichester 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(s) to be managerially responsible. The scope of the Policy extends to all of the properties currently owned or occupied by The University of Chichester and those properties that may come into ownership or occupation of The University of Chichester. This Policy for the Management and Control of Legionellosis shall be subject to a yearly review from the date on the front cover of this document 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 University of Chichester`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 Practice. 2. Legislation and Regulation The University of Chichester will utilise the following guidance and Approved Code of Practice to manage the associated risks within its premises: a) The Control of Legionella bacteria in water systems Approved Code of Practice & Guidance L8 (2001). Rev 3. b) Health and Safety at Work etc. Act 1974, Sections 2, 3 and 4. c) Health Technical Memorandum and 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 and Guidance L8 (ACoP L8) 2 P olicy for the Management and Control of Legionella

3 The Approved Code of Practice gives practical advice on the requirements of the Health and 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 ACoP L8 was approved on the 23 November 1999 by the Health and Safety Commission and came into effect on the 8 January 2001 and superseded The prevention and control of Legionellosis (including Legionnaires Disease) (L8rev) and is designed to give advice on how to comply with the Law. Only the Courts can give an authoritative interpretation of the law in considering the application of these regulations and guidance working under another s direction The Management of the Health and Safety at Work Regulations provide a broad framework for controlling health and safety at work. As well as requiring Risk Assessments, they also require access to competent help in applying the provisions of the health and safety law 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 4. Health and Safety at Work Act 1974 (HSWA) 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. 5. 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. 6. The Public Health (Infectious Diseases) Regulations 1988 This regulation requires that a proper Officer shall inform the Chief Medical Officer for England 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 3 P olicy for the Management and Control of Legionella

4 (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. 7. The Water Supply (Water Fittings) Regulations 1999 These regulations came into force on the 1 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. BS EN 806Specification for installations inside buildings conveying water for human consumption 5 Parts as follows: (2000) : Part 1 General (2005) : Part 2 Design (2006) : Part 3 Pipe sizing Simplified method (2010) : Part 4 Installation (2012) : Part 5 Operation & maintenance 9. BS 8558:2015 Guide to the design, installation, testing and maintenance of services supplying water for domestic use within buildings and their curtilages. Complementary guidance to BS EN BS 8558:2015 was developed to provide complementary guidance to the BS EN 806 suite of standards. Together, these documents provide best practice for the design, installation, alteration, testing, operation and maintenance of hot and cold water services for domestic use in buildings. 11. BS 8558:2015 bridges the gap in the BS EN 806 suite of standards and the withdrawn BS 6700, which excluded systems designed to work with steam or high temperature water. It provides UK guidelines to follow which do not currently exist elsewhere. 12. 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 University of Chichester by a suitably trained and competent person and will include all of the properties currently occupied and owned by the University of Chichester and provision allowed for the Risk Assessment of Properties that become occupied or owned by the University of Chichester. 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. 4 P olicy for the Management and Control of Legionella

5 It is important that Risk Assessments be undertaken in order to allow the University of Chichester 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 or that the risks are insignificant and unlikely to increase. 13. Management responsibilities Under the Control of Substances Hazardous to Health 2002 Regulations 8 and 12, Health and Safety at Work 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. Duty Holder The person on whom the overall responsibility falls shall be of an authoritative position within The University of Chichester is The Director of Estates Management or his appointed Deputy and have sufficient responsibility to authorise necessary precautions in the event of an emergency or for planned works. 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 University of Chichester Responsible Person: [Estate Management - Hard FM Manager] A Responsible Person shall be appointed by the Duty Holder to have responsibility for the day to day operation of the scheme of precautions. 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. The Responsible Person shall be 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. The Responsible Person will be closely involved in devising and the continual reviewing or auditing of the scheme of precautions and their day to day implementation. The Responsible Person shall also 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 University of Chichester. In the absence of the Responsible Person due to Holiday or illness or any other reason, the Deputy Responsible Person [Estate Management - Soft FM Manager] 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. 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. 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 Management and Control of Legionellosis for The University of Chichester The Consultant/Contractor shall assist fully in necessary emergency procedures to allow the Responsible Person/Deputy Responsible Person to complete their tasks. Service Providers Among other services, Legionella Management and Control is included in the agreement between the Companies. 5 P olicy for the Management and Control of Legionella

6 Overall responsibility cannot be delegated to 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. Responsibilities of designated 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. The following is a flow diagram of the management team and reporting routes: Duty Holder Responsible Person (Hard FM Manager) Deputy Responsible Person (Soft FM Manager) Service Provider Responsible Person 6 P olicy for the Management and Control of Legionella

7 Management Team and Contacts The Management Team as per the Policy for the Management and Control of Legionellosis involves the following; Duty Holder, Responsible Person, Deputy Responsible Person, Service Provider, Consultant/Contractor and designated Staff. The positions below must be confirmed in writing informing those appointed of their roles and responsibilities. Position Name Contact Details Duty Holder John Kingdon Acting Director of Estate Management Responsible Person Kelly Rogers Facilities Manager [Hard FM] Deputy Responsible Person Andy Howard Deputy Facilities Manager [Soft FM] Consultant/Contractor Airmec H20 Ltd Aztec West. Almondsbury. Bristol. BS32 4RX T: Health and Safety Executive Environmental Management Address: Basingstoke Priestley House Priestley Road Basingstoke RG24 9NW Fax: Basingstoke street map Covers: Berkshire, Hampshire, Oxfordshire, Isle of Wight. Phone P olicy for the Management and Control of Legionella

8 14. Managing and controlling Legionellosis In the first instance, The University of Chichester, 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 University of Chichester. 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 University of Chichester, thermal control will be primary method of control for Legionella bacteria within the water systems operated within the majority of the premises of The University of Chichester. 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 University of Chichester, 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 BS8558 and ACoP L8. The University of Chichester will continue to consider new developments and improvements in the field of Legionellosis management and 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. 15. System design considerations The University of Chichester shall, for all its water systems located in and out of any of the properties currently occupied or owned and deemed to be the responsibility of The University of Chichester as described in the introduction of this document and the Policy for the Management and Control of Legionellosis, as far as is reasonably practicable, ensure compliance to the Water Supply (water fittings) Regulations 1999 and in accordance with ACoP L8 BS8558 and BS6920 as the materials and operation of the water systems can affect the quality of the water. In addition, The University of Chichester shall as far as reasonably practicable, eliminate or reduce the potential for dissemination of water droplets or aerosols and exposure to the general population. The systems shall be maintained in a clean and sound condition and must be easily and safely accessible. All systems will be frequently used (at least weekly), or flushed to simulate the necessary usage frequency, in order to avoid stagnant water which will increase the potential of bacterial growth and proliferation. The usage frequency shall be regularly monitored and reported upon. All plant and distribution pipe-work (where accessible) shall be clearly labelled. 16. Cold water storage tanks (CWSTs) All CWSTs shall comply with the Water Supply (water fittings) Regulations 1999; where a unit does not currently meet the requirements of the Water Supply (water fittings) Regulations 1999 it shall be upgraded at times that are reasonably practicable. This should ensure that the unit is protected against the ingress of external foreign materials, the unit will be sized and arranged to minimise retention of stored water to 12 hours maximum and have a sequential throughput of fresh water, the unit and associated pipework shall be suitably insulated and correctly labelled to identify its purpose, the use of delayed-action ball valves shall be fitted (where practicable) in order to help avoid stagnation of 8 P olicy for the Management and Control of Legionella

9 water, where automated booster pumps are installed; a break tank shall be installed to eliminate the potential for backflow into the incoming main. All CWSTs shall also be constructed from materials which cannot shatter or provide a source of contamination and must be (WRAS) approved. All newly installed CWSTs shall be designed in accordance with BS8558 (GRP tanks should comply with BS7491 Parts 1, 2 and 3) and installed in locations to allow easy and safe access to aid inspection and maintenance. All CWSTs shall be maintained at a temperature of no more than 20 C at all times or a maximum of 2 C no greater than the incoming main temperature. CWSTs shall be subjected to an annual drop test or when a tank is found to have stagnant conditions (as per ACoP L8 paragraph 182 (b)) to determine the usage profile of the services the unit supplies (this entails the isolation of the make up to determine of the water retention of the tank is <24hours) and if necessary reduce the amount of stored water within the tank depending on any changes in the use of the service. A need test will be undertaken usually biennial by or at the request of the Responsible Person to determine if the unit may be removed and the services it supplies converted to incoming mains. This is usually a visual inspection taking into consideration the age and remaining working life of the tanks and its current potential risk. All results of the above tasks will be recorded within a Legionella Control Logbook. When undertaking a need test visually or using The University of Chichester records, it is determined that the tank is at the end of its useful life, the tanks and system where reasonably practicable, should be replaced with a system that does not utilise stored water. 17. Hot water calorifiers, XPHE and water heaters Calorifiers, XPHEs and water heaters will be installed in appropriate and suitable locations to allow easy and safe access to facilitate inspection and maintenance. The unit and associated pipework shall be constructed as such to aid maintenance and maintained as such to manage and control the potential for proliferation of Legionella bacteria. The cold feed to calorifiers (>150 litres) shall be protected against the warming up from the unit by the installation of a backflow prevention device to the cold feed as close to the unit as possible. Where a calorifier utilises the cold feed as a means of expansion, a S bend or thermal trap shall be fitted to the cold feed of the unit so that water that has been warmed up may not flow back into the cold supply. Each calorifier shall be adequately insulated against the effects of heat loss and be maintained in good working order. Expansion vessels shall be located on the cold feed rather than on the hot water side of the system. The length of pipework between the expansion vessel and cold feed shall be as short as possible, e.g. less than 1 metre. Expansion vessels shall be subjected to a weekly flushing regime (if practicable). Ensure that the diaphragm (or bag) is not damaged during the process. Calorifiers shall be fitted with an anti-stratification pump, where necessary, in order to avoid temperature stratification of the body of stored water. Some semi-storage/high-efficiency Calorifiers are supplied with an integral pump that circulates water in the Calorifier. De-stratification pumps shall not be fitted to this type of unit. Any circulation pumps fitted to the system shall normally be installed to the return. If dual pumps have been fitted to the service, they shall be arranged to be automatically switched on at least a weekly basis. Records of all switching shall be maintained. The calorifier shall be fitted with a suitable drain to aid maintenance and inspection on the unit. Cistern water heaters shall be maintained such that the cold tank part of the heater is kept clean and at the correct temperature (ideally at <20 C, although this may not be achievable during periods of low usage), and the hot tank part maintained at a temperature of >60 o C allowing for distribution temperatures of >50 o C. A screened vent and an insect/rodent overflow screen shall be fitted to the tank part of the unit. Instant point of use water heaters (POUH), including combination boilers, usually store small water volumes (units up to 30 litres), and because of this they do not usually need to be operated within the temperature profile and limits prescribed for larger systems ( 60 o C for the flow and 50 o C for the return and outlet ) which are necessary for thermal disinfection. These units can, therefore, be operated at user preference temperatures although they should be switched-on at all times to ensure and encourage sufficient usage. 18. Hot and cold water distribution systems 9 P olicy for the Management and Control of Legionella

10 The design and installation of the hot and cold water distribution system shall comply with the Water Supply (Water Fittings) Regulations 1999 and BS6700. The systems should be designed as such to prevent cross-connection between wholesome and non wholesome supplies taking into account the fluid categories described in Water Supply (Water Fittings) Regulations All pipework runs shall be installed and located as such to avoid thermal cross over between hot and cold services and from the environment to the cold service and shall also be insulated against the effects of temperature gain and heat loss. All pipework shall be installed to avoid blind loops and dead-ends or dead-legs and where a service is removed from the system, all dead-legs shall be removed from the pipework. In addition, all pipework shall be adequately sized in order to reduce the potential for stagnation within the supplies. Drinking water shall be provided directly from the incoming main or via a dedicated drinking water supply system. The water supply to vending and ice making equipment shall be taken from a wholesome supply up stream of a regularly used outlet with the minimum of intervening pipe run i.e. less than 3 metres. The domestic hot water system shall not be used for heating purposes. This includes all radiators, towel rails, heated bedpan racks etc, whatever the pipework configuration. Central common blending systems will not be used (for example in commonly blended shower blocks), since the length of distribution pipework containing water in the temperature range that supports bacterial growth and proliferation would far exceed the maximum permissible lengths of pipework of 2 metres in length. Where shower blocks and some systems exist that have already been installed as such, the installation of auto-drain valves will be considered, and the regular flushing of the systems will be undertaken. All TMVs shall be accessible (as far as reasonably practicable). All TMVs fitted to baths and showers shall be inspected and subjected to a fail-safe test on a six-monthly basis (carried out as described in the manufacturer s instructions). 19. Wet air handling units (AHUs) All Wet AHUs shall be maintained in a good and clean condition and free from excessive corrosion and dirt deposition. The material used to construct the unit shall not be of a material that may contaminate the unit and its water supply. All Wet AHUs will be designed so that any water/condensate collected is discharged fully, freely and as quickly as possible (1 in 20 drop) and all associated drip-trays must be designed so that they can be easily accessible for cleaning and disinfection. The drainage system fitted to the AHU shall be fitted with a suitable type A trap or u bend constructed from suitable materials for the premises. 20. WATER SOFTENERS Water softeners may, if not installed and maintained in a sufficient manor, allow growth of bacteria within the resin bed of the vessel and associated pipework. All water softeners will be made from WRc approved materials and maintained in line with the manufactures recommendations. Each unit shall be maintained full of salt for the production of brine to complete the regeneration process, and the unit automatically regenerated in accordance with the usage requirements as the unit was set up. Water softeners require to be serviced on at least an annual basis and the usage requirements and regeneration times should be considered at this time. The unit, its associated brine tank, and the surrounding environment shall be maintained in a clean condition at all times. 21. ICE MAKING MACHINES Ice is defined as food under the Food Safety Act 1990 and must be made, stored and handled so that it is not contaminated, a requirement of the Food Safety (General Food Hygiene) Regulations Although generally not fitted to any of the properties The University of Chichester are responsible for, in the event that an ice making machine is installed, they should be well managed. 10 P olicy for the Management and Control of Legionella

11 Ice making machines are generally not considered to be a source of increased bacterial proliferation however, if not properly maintained or used they can suspend certain bacteria in a dormant state which may pose a risk during periods of usage or when ice is allowed to melt. In order to control the potential of microbiological and other contamination, the following actions shall be considered and implemented: The supply to the unit shall be directly from the domestic incoming main and the supply pipe is as short as possible and the machine shall be located away from any heat sources (such as radiators and hot water pipework). The machine will be used in conjunction with the manufactures instructions, with regard to ambient temperatures, ventilation, water, electrical and drain connections. The machine will be cleaned and disinfected in accordance with the manufactures instructions; this should include the disposal of ice within the machine which should now be considered contaminated. All tools or scoops being used in conjunction the machine shall also be cleaned and disinfected. 22. ALL OTHER SYSTEMS All water systems located on or in any property owned, occupied, or managed and deemed the responsibility of The University of Chichester shall be constructed from materials that cannot provide a nutrient source for bacteria proliferation or support bacterial growth. 23. 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 Practice 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 University of Chichester properties). ACoP L8 Appendix 1 Checklist 2: Hot and Cold Water Services Service Task Frequency Hot water services Cold water services Shower heads Little-used outlets Arrange for samples to be taken from hot water calorifiers, in order to note condition of drain water Check temperatures in flow and return at calorifiers Check water temperature up to one minute to see if it has reached 50 o C in the sentinel taps Visual check on internal surfaces of calorifiers for scale and sludge. Check representative taps for 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 fixed max/min thermometers where fitted Check that temperature is below 20 o C after running the water for up to two minutes in sentinel taps Visually inspect cold-water storage tanks and carry out remedial work where necessary. Check representative taps for temperature as above on a rotational basis Dismantle, clean and de-scale shower heads and hoses Flush through and purge to drain, or purge to drain immediately before use, without release of aerosols Annually Monthly Monthly Annually Six monthly Monthly Annually Quarterly or as necessary Weekly 11 P olicy for the Management and Control of Legionella

12 ACoP L8 Section 169 Table 3: Monitoring the Temperature Control Regime. Standard to meet Frequency Check Cold water Hot water Monthly Six monthly Sentinel taps If fitted, input to TMV's on a sentinel basis Water leaving and returning to calorifier Incoming cold water inlet (at least once in the winter and once in the summer) The water temperature should be below 20 o C after running the water for up to two minutes The water should preferably be below 20 o C at all times (but see paragraph 156 of L8) 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 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 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 12 P olicy for the Management and Control of Legionella

13 ACoP L8 Appendix 1 Checklist 3: Other Risk Systems System/Service Task Frequency Six monthly or If equipment fitted with UV lights, check to ensure according to effectiveness of lamp (check to see if within working life) manufacturer's Ultrasonic and clean filters instructions humidifiers/ As part of machinery foggers and water Ensure automatic purge of residual water is functioning shut down misting/spraying As indicated by Risk systems Clean and disinfect all wetted parts Spray humidifiers, air washers and wet scrubbers Water softeners Emergency showers and eye wash sprays Sprinkler and hose reel systems Sampling for Legionella Clean and disinfect spray humidifiers/air washers and make-up tanks including all 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 Assessment As indicated by Risk Assessment Six monthly Weekly As recommended by manufacturers Six monthly or more frequently if recommended by manufacturers As directed Lathe and machine tool coolant systems Clean and disinfect storage and distribution system Six monthly Spa baths Check filters - sand filters should be backwashed daily Daily Check water treatment - pools should be continuously treated with an oxidising biocide Three times daily Clean and disinfect entire system Weekly Clean and disinfect distribution pipework, spray heads Horticultural misting and make-up tanks including all wetted surfaces, descaling as necessary systems Annually Vehicle washes Vehicle Screen Wash Systems Indoor fountains and water features 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 As manufacturers' instructions Weekly Interval depending on condition Endless Pool Empty and clean after each use undertaken by SARC As and when 13 P olicy for the Management and Control of Legionella

14 24. 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, 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. 14 P olicy for the Management and Control of Legionella

15 (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. RE PLANNED MAINTENANCE TASK SPECIFICATIONS TASK (see Risk Assessment) PAGE (see Risk Assessment) DEAD-LEG AND INFREQUENTLY USED OUTLET FLUSHING 19 COLD WATER STORAGE TANK TEMPERATURE MONITORING 20 COLD WATER STORAGE TANK GENERAL CONDITION 21 TANK CLEANING 22 CALORIFIER MANUAL TEMPERATURE MONITORING 23 CALORIFIER GENERAL CONDITION INSPECTIONS 24 COLD WATER TEMPERATURE MONITORING - DCWS & MAINS SUPPLY OUTLETS 25 HOT WATER TEMPERATURE MONITORING - DIRECT FED OUTLETS 26 HOT WATER TEMPERATURE MONITORING - BLENDED OUTLETS 27 SHOWER HEAD CLEANING AND DISINFECTION 28 THERMOSTATIC MIXING VALVE (TMV) CLEANING AND DISINFECTION 29 AHU TRAP CLEANING AND DISINFECTION 30 COMPONENTS INSPECTION, CLEANING AND DISINFECTION OF PERMANENTLY OR INTERMITTENTLY WETTED SURFACES WITHIN THE AIR HANDLING SYSTEM P olicy for the Management and Control of Legionella

16 EXTERNAL WATER FOUNTAIN CLEANING AND DISINFECTION 32 TAKING AND INTERPRETING DIPSLIDES DEAD-LEG AND INFREQUENTLY USED OUTLET FLUSHING When a system or water outlets is not frequently used, the conditions within the disused areas can be ideal for the development of stagnant water conditions, and can increase the potential for bacterial growth, including Legionella, within the pipework and disused outlets. A flushing programme will be aimed to remove the stagnated products that may have occurred or reduce the potential for stagnation occurring within the pipework. In the first instance, the idea is to completely remove the dead leg pipework from the system or reduce it in length to <350mm. It is important to ensure that the affected outlet/s be flushed for an appropriate length of time to allow for the complete purging of the outlet and its pipework. 1) Identify areas/outlets to be flushed. 2) Ensure that the system/outlet can be flushed for a minimum of 2 minutes, safely and in a tidy manner into an appropriate drain if not plumbed for drainage. 3) Ensure that the flushing of water from outlets does not create an unnecessary amount of aerosol (this can be achieved by wrapping a towel or clean cloth around the outlet and turning on the outlet slowly at first). 4) Run the hot and cold or the mixed water in turn for a minimum of 2 minutes or for a period of time necessary to draw water from the outlet at temperatures exhibited throughout the rest of the system. 5) If an area consisting of a number of outlets require flushing, it is important to begin with the nearest outlet to the main distribution pipe work, working progressively away from the main distribution pipe work. 6) Where showers need to be flushed, it is important to ensure that, where practicable, the shower-head is removed in order to reduce the potential of aerosol production. Where the head is fixed, exposure to the aerosol produced must be minimised. One method that can be employed in this situation is the use of a transparent plastic bag, fixed around the shower- head, with one corner pierced to allow partial discharge of water. 7) Log all procedures and results. 26. COLD WATER STORAGE TANK TEMPERATURE MONITORING 1) Care should be taken not to contaminate the tank from any loose materials that may fall into the unit and by using clean equipment. 2) Care should also be taken when gaining access to the internal parts of the tank do not put yourself or any other in any unnecessary danger. 3) Using an electronic and calibrated thermometer, measure, and record the temperature of the body of the stored water. Although in some cases this is not possible, the measurement of the stored water temperature should be as far away from the ball valve as possible. 4) If not operating, depress the ball valve and measure the temperature of the water after allowing a suitable flush of the make up water. 5) Measure and record the ambient temperature near to where the tank is located. 6) Ensure that all log sheets are filled in fully. 27. COLD WATER STORAGE TANK GENERAL CONDITION In order to ensure that tanks are maintained in as clean a condition as possible it is important to ensure that the units be inspected on at least an annual basis and possibly more often depending on the data obtained and the condition of the unit. 1) Care should be taken not to contaminate the tank from any loose materials that may fall into the unit and by using clean equipment. 2) Care should also be taken when gaining access to the internal parts of the tank do not put yourself or any other in any unnecessary danger. 3) If the insulation allows for an inspection of the external condition of the tank walls, inspect for corrosion pitting and leaks. 16 P olicy for the Management and Control of Legionella

17 4) On gaining access to the internals of the tank, visually inspect internal walls of tank for signs of scale, corrosion, sediment coverage of the base and slime/bio film to the walls. 5) Inspect tank and associated valves/pipework for leaks and check valves for operation. 6) Look for signs of stagnation such as water surface dirt, oil films, insects, smell, low input, or temperature differential for multiple linked tanks. 7) Visually inspect for algae growth indicated by either green or red plant like growth on water surface 8) Inspect the insulation looking for signs of wear or damage and areas where the insulation has been removed 9) Ensure that the lid is correctly fitted and that any bolts are securely tightened. 10) Visually inspect if practicable that all insect/rodent screens fitted are clear from debris. 11) Check that the ball valve operates correctly. 12) Visually inspect all booster pumps fitted for correct operation. 13) Ensure that the appropriate log sheets are filled in noting any areas of concern to report to the Responsible Person or Deputy Responsible Person. 28. TANK CLEANING When a cold water storage tank becomes dirty, as directed by a monitoring programme, it is necessary to clean and disinfect the internal parts of the unit to reduce the potential for increased bacterial activity. The following procedure should be followed: 1) Care should be taken not to contaminate the tank from any loose materials that may fall into the unit and by using clean equipment 2) Care should also be taken when gaining access to the internal parts of the tank do not put yourself or any other in any unnecessary danger. 3) Isolate the tank from the system. 4) All of the water should be drained from the unit; if the unit is excessively dirty or contaminated it should be disinfected using the disinfection procedure detailed later in this procedure. 5) The internal surfaces of the unit shall be cleaned using scrubbing materials, jet washer, and wet vacuum (no chemical dispersants are to be used at this stage). 6) Following full clean of the internal surfaces of the unit the unit shall then be refilled. The ph of the water shall be measured and must be between 5.5 and 9.0 before chlorinating solution is introduced. If ph is found to be below 5.5 the system shall be drained, flushed, and refilled with fresh water. 7) The chlorinating agent should give a minimum free chlorine concentration of 50ppm (50mg/l), and when full, allow to stand for 1 hour. 8) An allowance for ph adjustment should be followed in order to ensure sufficient amounts of disinfecting agent are added, this may mean levels in excess of 50ppm (50mg/l) may need to be present depending on ph. 9) After 1 hour, measure free chlorine level. If free chlorine level is below 30ppm, repeat steps 5 and 6. 10) The tank shall be drained and then thoroughly flushed out with clean mains water until tests indicate that the residual chlorine concentration is no greater than 0.5ppm (0.5mg/l), or that present in the mains water supply. 11) Where the volume exceeds 5000 litres, the disinfected water must be neutralised using sodium thiosulphate before disposal. The neutralised waste should not be drained through the system. 12) The tank shall then be refilled and confirmation should be given that no disinfecting agent residue is present. NB: All PPE will be utilised for the purposes of tank cleaning and disinfection ensuring all COSHH requirements including Risk Assessment are followed. All confined space requirements and permits to work shall be followed. 29. CALORIFIER MANUAL TEMPERATURE MONITORING 1) Care should also be taken when gaining access to the unit do not put yourself or any other in any unnecessary danger. 2) Record the Set temperature setting of the thermostat. The temperature should be >60 C. 3) Measure the Flow temperature using a calibrated contact thermometer or fitted gauge. Temperature to be taken from Flow pipework as close to the Calorifier as possible. The temperature should be >60 C. 4) Measure the Return temperature using a calibrated contact thermometer or fitted gauge. Temperature to be taken from Return pipework as close to the Calorifier as possible. The temperature should be >50 C. 5) Ensuring safe and suitable drainage facilities are present, close the cold feed and open the drain of the calorifier and flush 5 litres. Take the temperature of the drain water (closing the cold feed will ensure that the temperature is taken from the base of the unit and not from the higher pressure cold feed). Note the condition of the initial drain flush and subsequent flush water. 6) Re-instate the cold feed to the system without delay. 7) The base temperature should be >50 C. 17 P olicy for the Management and Control of Legionella