WILTSHIRE POLICE FORCE PROCEDURE. Control of Bacteria in Water Systems

Transcription

1 WILTSHIRE POLICE FORCE PROCEDURE Control of Bacteria in Water Systems Date of Publication: June 2017 Version: 10.0 Next Review Date: June 2018

2 TABLE OF CONTENTS PROCEDURE... 3 PROCEDURE OVERVIEW... 3 GLOSSARY OF TERMS... 3 RELATED POLICIES, PROCEDURES and OTHER DOCUMENTS... 3 DATA PROTECTION... 3 FREEDOM OF INFORMATION ACT MONITORING and REVIEW... 3 WHO TO CONTACT ABOUT THIS PROCEDURE Legal Requirements General Introduction Responsibilities Operational Policing Risks Risk Assessment Action Plan Information, Instruction, Training, Supervision and Consultation Version: Next Review Date: June 2018 Page 2 of 13

3 PROCEDURE OVERVIEW PROCEDURE The object of this procedural guide is to clearly define Wiltshire Police s arrangements and procedures for the control and management of bacteria in water systems. The aim of this procedural guide is to reduce/remove the conditions that could encourage bacterial growth, bacterial infection and the proliferation and distribution of potential pathogens including Legionella. GLOSSARY OF TERMS OPCC ACOP HSE PPE Term Meaning Office of the Police and Crime Commissioner Approved Code of Practice Health and Safety Executive Personal Protective Equipment RELATED POLICIES, PROCEDURES and OTHER DOCUMENTS GRA 038 Controls of Bacteria in Force Water Systems. DATA PROTECTION Any information relating to an identified or identifiable living individual recorded as a consequence of this procedure will be processed in accordance with the Data Protection Act 2018, General Data Protection Regulations and the Force Data Protection Policy. FREEDOM OF INFORMATION ACT 2000 This document has been assessed as suitable for public release. MONITORING and REVIEW Compliance with this procedure document will be regularly monitored and reviewed by various mechanisms. These include the Facilities Management Department, Facilities Management Services Consultant, Health and Safety Department, and line managers. The procedure document will be formally reviewed by the Force Occupational Health and Safety Committee annually and/or if there is a significant change in legislation or work activity, procedures or equipment. As the client, Wiltshire Police must effectively manage and supervise the work of contractors. s and sub contractors are expected to also monitor their health and safety performance, this may include checking their risk assessments are up to date and the control measures are working. The effectiveness of control measures for bacteria will be continuously monitored by the relevant contractors and the Head of Facilities and Supplies. The Force risk assessments will be reviewed annually, the contractor risk assessments will be reviewed every two years and when the situation changes or if for any other reason it is believed that the original assessment is no longer valid. This may include changes to the water system or its use, results indicating that the control measures are no longer valid or a case of legionnaire s disease / Legionellosis is associated with the system. The review will be undertaken by the Head of Facilities and Supplies, the Head of Health and Safety and the Force s Facilities Management Services Consultant. WHO TO CONTACT ABOUT THIS PROCEDURE Sarah Somers, Head of Health and Safety Kim Glenister, Head of Facilities and Supplies Version: Next Review Date: June 2018 Page 3 of 13

4 1. Legal Requirements Health and Safety at Work Act 1974 requires every employer, so far as is reasonably practicable, to ensure the health, safety and welfare at work of their employees and anyone else affected by their undertakings. These duties extend to the risks from bacteria which may arise from work activities. The Management of Health and Safety at Work Regulations 1999 require Wiltshire Police to: Undertake a systematic general examination of all work activities. Identify the significant risks arising out of work. Assess the risks to the health and safety of those in their employment. Assess the risks to health and safety of persons not in their employment who are working on Wiltshire Police premises or affected by their business. Implement control measures to reduce these risks as far as is reasonably practicable. Record and review their assessments if there is reason to suspect that they are no longer valid or there has been a significant change in working practice. The Reporting of Injuries, Diseases and Dangerous Occurrence Regulations 1995 require the employer to report to the HSE, accidents and diseases which arise out of or in connection with work. Cases of Legionellosis are reportable under RIDDOR if a doctor notifies the employer and if the employees current job involves work near cooling systems that use hot water service systems in the workplace. The Control of Substances Hazardous to Health Regulations 2002 provides a framework of actions designed to control the risk from hazardous substances including biological agents. The essential requirements of COSHH are: Risk assessment. Prevention of exposure or substitution to a safer substance. Control of exposure where substitution is not reasonably practicable. Maintenance, testing and examination of control measures. Provision of information, instruction, training and supervision of employees. Where appropriate, provide health surveillance where exposure may lead to an identifiable disease or adverse health effect. The approved code of practice (L8) has been used as a guide and for reference in developing and writing this procedural guide. The principal requirements with L8 are: Identify and assess sources of risk. Prepare a scheme or course of action for preventing and controlling the risk. Implement and manage the scheme, appointing a person to be managerially responsible. Keep records and ensure what is being actioned is effective. 2. General Introduction Legionnaire s disease is a potentially fatal pneumonia caused by bacteria. It is the most well known and serious form of a group of diseases known as Legionellosis. Legionellosis (including Legionnaire s disease) is generally caused by the inhalation of aerosols containing bacteria. Version: Next Review Date: June 2018 Page 4 of 13

5 Aerosols can be generated from any water outlet and can remain suspended in the air for an extended length of time. As a consequence all water outlets may present a foreseeable risk without adequate management and control. The risks from bacteria increase if the water in the system is stagnant (i.e. in dead legs or when the system is not in use for a period of time.) Everyone is susceptible to infection but some people are at a higher risk, including immunosuppressed people. The disease cannot be passed on from one person to another. Certain immuno-suppressed people may also contact legionnaire s disease through other means such as small cuts, bruising and ingestion. This has been taken into account in all the risk assessments especially those premises which contain custody suites. It should be noted, that good operating procedures, management and risk assessments should minimise these risks. Bacteria are present in water systems and do not pose a concern if the appropriate control measures are in place and maintained. Where is Legionella found? Legionella bacteria are common in natural water courses such as rivers and ponds. They may also contaminate water systems such as cooling towers and hot and cold water services. They survive in low temperatures and thrive at temperatures between 20 and 45 degrees centigrade if the conditions are right. Legionella bacteria do not survive for any lengthy period above 60 degrees. 3. Responsibilities Management Responsibilities The Chief Constable, in conjunction with the Office of the Police and Crime Commissioner, has overall responsibility for all aspects of water quality within Wiltshire Police. Compliance with certain elements and tasks have been delegated to either Wiltshire Police employees or contractors. These are highlighted by the below flowchart. The Chief Constable recognises that accountability however, cannot be delegated. Management Structure Chief Constable OPCC Chief Finance Officer Head of Facilities & Supplies Responsible Facilities Management Services Main General Specialist Version: Next Review Date: June 2018 Page 5 of 13

6 Head of Facilities and Supplies Responsibilities The Health and Safety Executive Approved Code of Practice (L8) requires that one person should be appointed as being responsible for overseeing the assessment of risk associated with Legionella. The Responsible Person for Wiltshire Police will be the Head of Facilities and Supplies. Responsibilities of the Head of Facilities and Supplies include: Completing a risk assessment for all Force owned premises/sites in conjunction with the Force s Facilities Management Services Consultant and the Head of Health and Safety. Develop suitable schemes / action plans to keep risks to a minimum and should consider cost, risk and difficulty. Identify opportunities to reduce under utilised water services in accordance with health and safety guidance and best practice. Ensure remedial actions identified from the risk assessment are prioritised and implemented. Ensuring the local authority / Health and Safety Executive are informed (if required). This will be achieved in consultation with the Head of Health and Safety. Ensuring senior management are kept informed of any risks. Assisting in the preparation of a press statement and ensuring that any media relations personnel are informed at the appropriate stage. To lead in the instigation of an Incident Control Team in the event of detected bacterial samples or an outbreak. To maintain a log of the teams meetings and actions. Local Management Responsibilities In support of the Force Head of Facilities and Supplies, local management are responsible for; Supporting and engaging with the Head of Facilities and Supplies to help deliver the necessary local procedures for the prevention and control of bacteria growth. Ensuring appropriate communication with their staff. Feeding any additional information to the Force s Responsible Person Head of Facilities and Supplies as required. Health and Safety Manager Responsibilities The Head of Health and Safety responsibilities include; Undertaking period audit of compliance with this Policy and submitting reports and recommendations to the appointed Senior Duty Holder and advising on legal duties placed on the organisation. Providing advice on controlling and reducing risks associated with bacteria to all staff who have prescribed duties under this policy. Responsibilities Wiltshire Police and the Facilities Management Services Main s will research and ensure the competence of contractors in the area of work before entering into contracts for the treatment, monitoring and cleaning of the water systems and other aspects of water treatment and control. Refer to the Control of s Procedural Guide for full details of contractor management within the Force. Version: Next Review Date: June 2018 Page 6 of 13

7 All s employed by Wiltshire Police are responsible for: Ensuring the health, safety and welfare of themselves and other affected by their actions. Carrying out work in accordance with the service contract. Carrying out any work in accordance with safe systems of work and any training. Comply with Wiltshire Police Site Rules, provided at the tender stage. Employee Responsibilities The Health and Safety at Work Act 1974 requires employees to report hazards in the work place. These include biological hazards and therefore risks of Legionella. All employees must therefore contact the Facilities Department if they notice the following: Loss of temperature in the hot water system. Loss of pressure in either the hot or cold water systems. A basin or shower which is infrequently used. Design and Build New Builds / Major Works / PFI Projects It is essential that the actions defined within this document are reviewed and taken into consideration for every new build, PFI project and major works. The senior manager / project manager must ensure the new build is planned, designed and maintained in accordance with the recommendations of Health and Safety Executive Guidance (L8) and incorporating innovation for reduction of risk purposes. Responsibility of Shared Occupation / Partner Premise The host / Estate owner of the property shall be responsible for the management of this Legislation e.g. Wiltshire Council shall be responsible for compliance at Swindon Borough and Wiltshire Council Premises and Offices and Health and Wellbeing Centres. The Fire Service shall be responsible for compliance at the shared Bradford on Avon and Mere Collocation Sites. 4. Operational Policing Risks Risks It is possible that police officers and operational police staff may be exposed to Legionella in an operational police environment. This may occur for example in cannabis cultivation (hydroponics) environments where plants are grown in warm conditions in water / nutrient solutions. It has been known for Legionella to be present in air water droplets as high humidity levels occur or are required during cultivation. All officers who may be exposed to this environment should be aware of these issues and appropriate advice should be sought when working in such areas. Reference should be made to Force Generic Risk Assessments (available within the Health and Safety Department s portal site access through the Force Structure drop down on Firstpoint) regarding this work activity. Any pre-planned operation must have an operational risk assessment undertaken where the hazard of Legionella should be identified and appropriate control measures identified. These may include the wearing of appropriate respiratory protective equipment required as a preventative proactive control. Advice and Guidance Further advice and guidance in relation to the operational risks and control measures in relation to Legionella can be sought from the Force Health and Safety Department. Out of hours assistance Version: Next Review Date: June 2018 Page 7 of 13

8 and support is also available via the Force Operations Room Inspector / Supervisor in case of emergency. 5. Risk Assessment Risk Assessment A suitable and sufficient risk assessment will be carried out for all Wiltshire Police sites detailing the arrangement for the control of spread of Legionnaire s disease. The assessment will identify the risk of exposure to bacteria from work activities and the water system on the premises and detail any required control measures. The risk assessment will be completed by the Head of Health and Safety, Head of Estates and Facilities and Estates Management Services Consultant. All risk assessments will be reviewed annually, if the situation changes or if any other reason if it is believed the assessment is no longer valid. Risk Assessment Template Name of Station / Premises Address of Station / Premises Name of persons completing the Assessment Date of Assessment Details of the water system present within the building Details of any control measures in place including monitoring and testing Details of people exposed and levels of vulnerability Overall Level of Risk (using below matrix) Assessment Review Date Qualitative Risk Assessment Matrix Probability Consequences Impossible Rare Unlikely Moderate Likely Certain Negligible Minor Serious Major Fatality Multiple Fatalities Level of Risk No Risk Low Risk Moderate Risk Significant Risk High Risk Risk Assessment In addition to the above Force risk assessments, the Force approved contractor will also complete a risk assessment for all Wiltshire Police premises under our control every two years or if there are any significant changes or alterations to the services/systems. Version: Next Review Date: June 2018 Page 8 of 13

9 The Force approved contractor will also complete a risk assessment of the entire domestic water system at each site. The risk assessments will include a full schematic diagram of the water system on each site. This is to ensure compliance with L8 and including a full condition report of each item of plant including: Ion exchange water softeners Cold water storage tanks Calorifiers / hot water generators Showers and spray producing outlets Hot and cold water outlets Humidifiers Thermostatic Mixing Valves These risk assessments will be reviewed by the contractor as per their contract agreement on a two yearly basis or if there are any significant changes or alterations to the services/systems. Written Schemes Where the risk assessment shows that there is a reasonable foreseeable risk, Wiltshire Police will ensure that steps are taken to avoid the risk wherever possible. When risks cannot be avoided a written scheme for controlling the risk will be developed. The written scheme will be developed by the Force Head of Facilities and Supplies in conjunction with the Facilities Management Services Consultant, Specialist and Head of Health and Safety as required. The written scheme will include: An up to date plan showing the layout of the plant or system. A description of the correct and safe operation of the system. Precautions to be taken including any physical treatments such as flushing the system or chemical treatments. Details of the frequency, sampling locations and procedure to ensure consistency. Checks to be carried out to ensure the efficiency of the scheme and the frequency of such checks. Remedial action to be taken in the event that the scheme is shown not to be effective. Planned Preventative Maintenance and Monitoring (PPM) Schedule The following table details the frequency of tasks scheduled by the Facilities Department in conjunction with the Force s Facilities Management Main. Activity Frequency Responsibility Drain, clean and chlorinate all cold water storage Annual tanks feeding communal systems. Water system testing and monitoring of the cold water storage tanks. Sample for total viable counts Annual and E-Coli from each communal tank. Water system testing and monitoring of communal chlorifiers. Sample for pneumophilia from each chlorifier Descaling and disinfection of Calorifiers Temperature Check of all Sentinels Annual Annual Annual Version: Next Review Date: June 2018 Page 9 of 13

10 Water system testing and monitoring of showers and spray producing services. Sample each bank of showers for pneumophila. Descaling, cleaning and disinfection of showerheads. Monitoring of water temperatures at select sentinels Flushing of all outlets continuously for 5 minutes Installation of GNET wireless flushing temperature monitoring system in a number of key sites EM, HQ, CCC HQ, EH, ET, ED, EN, DH Annual audit of GNET installations 3 monthly 3 monthly Monthly Weekly Ongoing Annual Cleaning or GNET Refer to Service Contract held by the Force Head of Facilities and Supplies for full details. All records will be kept by the Force s Facilities Management Main for a period of five years. Any abnormal results will be highlighted to the Force Head of Facilities and Supplies. Control Measures There are many ways in which exposure to bacteria can be controlled and the complexity of the controls will depend on the risks posed by the individual system. Wiltshire Police will adopt the following control measures to reduce the proliferation of Legionella. Maintain water temperature (at 60 C out, return of 55 C). Cold water supplies to be less than 20 C. Keeping the system clean to avoid the buildup of sediments which may harbour bacteria. Avoidance of water stagnation. Removal of dead legs and modifications to area where growth may occur. Water tanks shall be cleaned on a regular basis to remove sediment, sludge, scale and organic material. All outlets to be opened/flushed for at least 5 minutes each week. After an alterations, modifications or repairs to pipe work are completed disinfection has to be completed. Installation of proactive wireless flushing and temperature monitoring systems at key identified sites. Appropriate disinfection, service and flushing regimes, dependent on their nature and frequency of use, in place for all jet wash and car wash facilities. Suitable flushing arrangements in place for all outside taps and water outlets, dependent on their nature and frequency of use Where temperature is not the primary method for controlling bacteria the associated control programmes must be at least as effective and monitoring be compliant with L8. Other treatments include: Biocide Treatment Chlorine Dioxide Version: Next Review Date: June 2018 Page 10 of 13

11 Ionisation Ozone Ultraviolet Intermittently / Infrequently used Outlets and Showers If outlets are identified as not necessary, the supplies shall be terminated at source by the removal of the tee and new pipe inlet, eliminating the risk. Suitable arrangements are in place to ensure that all taps, showers and appliances within departments / stations are flushed for 5 minutes continuously once a week. All taps and appliances must also be flushed for a period of 5 minutes where there has been a temporary closure of the station / department i.e. for building works. Data Management All water sampling will be arranged by the Force s Facilities Management Services Main as per contract agreements. Water temperatures at representative hot and cold outlets will also be measured monthly. All failures and variations will be investigated and reported to the Force Head of Facilities and Supplies and all records will be kept by the Force s Facilities Management Services Main for a period of five years. Following survey and risk assessment of organisations premises by professional contractors, an accurate record of all data relating to water such as temperatures, flushing undertaken, cleaning, dosing and pasteurisation will be kept securely by the contracted services provider. This will be available for inspection at any time by authorised organisations employees or others who may require this information such as s or HSE Inspectors. 6. Action Plan Action Plan in the event of low bacterial counts being detected as part of planned maintenance The Head of Facilities and Supplies in conjunction with Force s Facilities Management Services Main, in consultation with local management will lead the initial investigation and action plan. Expert guidance will be obtained from Specialist s who will advise the Force on the most appropriate course of action to regain control. Extra Ordinary Action Plan in the event of significant bacterial counts as part of the planned maintenance or an outbreak The Force Head of Facilities and Supplies and Facilities Management Services Main will lead the investigation and will ensure the Local Authority and Health and Safety Executive are informed as required. The Head of Facilities and Supplies will set up the Incident Control Team, who would normally comprise of: Force Head of Facilities and Supplies Head of Health and Safety Local Manager Facilities Management Services Consultant Specialist s Other relevant persons as required. The Incident Control Team are responsible for the investigation of the problem and progress and necessary action plan. Minutes are to be kept and a log of actions taken and test results are to be recorded and kept by the Facilities Management Services Consultant. The Head of Facilities and Supplies will ensure Senior Management of the Force are kept informed of the progress and Version: Next Review Date: June 2018 Page 11 of 13

12 developments of the incident. A L8 management plan pro forma will be instigated to monitor, manage and document the management plan for each detection. Standard Action Plan in the event of significant bacterial counts as part of planned maintenance or an outbreak The Force Head of Facilities and Supplies and Facilities Management Services will mobilise a management plan which will include: Notification to all appropriate business and local managers, including the Head of Health and Safety of receipt of positive L8 sample. Closure of services as appropriate Cease standard water flushing by cleaning contractor Mobile daily water flushing regime by water management contractor. Undertake site disinfection Regular resampling of water until receipt of undetected L8 sample. Regular review of management plan. Non Standard Action Plan in the event of low level non type bacterial count as part of planned maintenance The Force Head of Facilities and Supplies, following consultation with the Facilities Management Services and appropriate business and local manager, including the Head of Health and Safety, recommend the mobilisation of a low key management plan which will include: Notification to all appropriate business and local managers, including the Head of Health and Safety of receipt of positive, but non-legionella type bacterial count (not SG1) Keep the water outlet open. Seek the daily flushing of the water outlet by the cleaning contractor. Promote the increased use of the water outlet by WPA staff. Undertake site disinfection Regular re-sampling of water until receipt of undetected non-sg1 sample. Regular review of management plan Immediate Actions Depending on the nature and scale of the incident, some immediate actions may include: Stopping access to all or certain parts of the building. Cease using the identified outlets. Relocation of custody suites to the fall back sites (as required). Sampling and testing of water from hot and cold taps and showers as required. Isolation and closure of showers. Emergency cleans Disinfection of water services in accordance with BS6700. Inspection of maintenance records for preventative works. Elevation of DHW temperatures to 55 C - 60 C at outlets and placing of warning notices of raised temperatures as required. Regular flushing of the outlets. Version: Next Review Date: June 2018 Page 12 of 13

13 Identification and removal of any dead legs in the pipe work. Health and Safety Executive The Health and Safety Executive will be contacted in the event of an outbreak by the Head of Health and Safety as per the requirements of the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations The HSE may choose to be involved in the investigation of an outbreak. 7. Information, Instruction, Training, Supervision and Consultation Information and Instruction All staff who are involved in the maintenance of water systems will be provided with appropriate information to ensure they are aware of the risks associated with any plant and equipment. These staff will have regular access to relevant risk assessments and action plans. Wiltshire Police will ensure appropriate communication systems are in place between themselves and any contractors / consultants. Training Wiltshire Police will ensure that key staff will be identified and provided with appropriate training. This training will be recorded. Wiltshire Police will ensure via method statements and risk assessments that all contractors are competent and adequately trained. Wiltshire Police will ensure that all contractors are suitability trained as part of the tender and service agreement contracts. Supervision Wiltshire Police will ensure that adequate supervision from line managers, team leaders and nominated persons is in place. Wiltshire Police will also ensure that suitable arrangements for the supervision of contractors (where required) is in place. Consultation Wiltshire Police are committed to consulting with their employees or their representatives on the identified risks of exposure to bacteria and on the measures taken to control the risks. This is achieved through formal consultation with both the Police Federation and Unison Staff Associations. The Associations are given the opportunity to comment and view the Force procedural document and subsequent risk assessments via the Force Occupational Health and Safety Committee. The Force procedural document is available for all employees to view via the Policy and Procedures Link on the Force Intranet site. Version: Next Review Date: June 2018 Page 13 of 13