OHSS Control of Legionella Guidance 103.1 Control of Legionella This guidance supports the Control of Legionella Health and Safety Management Standard. Contents 1 Introduction 2 2 Responsible and Appointed Persons Designation 2 3 Transfer of Responsibility 2 4 Shared Water Systems or Equipment 3 5 Equipment Owned by the Unit 3 6 Risk Assessment 4 7 Control Measures and Monitoring 4 8 Training 5 9 Record Keeping 5 10 Audit 6 11 Referenced Material 6 12 Appendix 1 7 Page 1 of 7
Introduction Legionnaires disease is a potentially fatal form of pneumonia which can affect anyone, but principally affects those who are susceptible because of age, illness, immunosuppression, smoking etc. Legionnaires disease is normally contracted by inhaling Legionella bacteria, in tiny droplets of water (aerosols), deep into the lungs; there is no documented evidence of the disease passing from person to person. Legionella bacteria are widespread in the environment; they may also contaminate and grow in purpose-built (man-made) water systems such as cooling towers, evaporative condensers and hot and cold water systems. The favourable conditions created in man-made water systems causes Legionella bacteria to multiply, increasing the risk that human exposure to the bacteria will occur. To ensure that the University controls the risk of legionella all Units must follow the University Management Standard for the Control of Legionella. This guidance document is a supplement to the Management Standard and has been produced to provide Units with further detail on how the University manage the risk of legionella bacteria. Responsible and Appointed Persons Designation Please refer to the Health and Safety Management Standard for Controlling the Risk of legionella for further roles and responsibilities. The following information has been extracted: Duty Holder The Vice Chancellor is the Duty Holder and has overall responsibility for health and safety. The Duty Holder should specifically appoint a competent person or persons to take day-to-day responsibility for controlling any identified risk from legionella bacteria, known as the responsible person. Responsible Person - Someone with day-to-day responsibility for controlling any identified risk from Legionella bacteria. The Vice Chancellor, through the Faculty Pro Vice Chancellors and Registrar, has nominated each Head of Unit as the Responsible Person for their specific area(s). Appointed Person - The person who has been given responsibility for carrying out activities specified within risk assessments for the control of legionella bacteria. Each Unit will provide a list of their Appointed Persons to their Faculty Estates Coordinator. The Faculty Estates Coordinator will provide the following lists to ESS: Unit Responsible Persons Unit Appointed Persons ESS will use the lists to ensure the identified persons have access to the records for building database and set up appropriate flags on the system to ensure the relevant control measures are completed in appropriate timescales. Page 2 of 7
Transfer of Responsibility To ensure all water systems are risk assessed and appropriate controls are in place for controlling the risk of legionella it is crucial that all University Units know what they are responsible for. ESS will define the location in every water system where the responsibility for the water management system is transferred from ESS to the relevant Unit. This location is generally referred to as the point of use and this could be located in various locations within buildings. ESS will clarify, via description and schematic, where this location is in the water system and allow Units to ensure no equipment or systems are missed. Units who share equipment or water systems must implement the standards within the Shared Water Systems or Equipment section of this guidance document. Shared Water Systems or Equipment Shared water systems could be used in many locations in the University including shared working areas such as laboratories and workshops. In shared locations, e.g. multi user locations, there must be clarity on who, e.g. Unit and Responsible Person, is taking ownership of the water system or equipment connected to the water system. Accountabilities and responsibilities for the control of legionella must be agreed. Examples of equipment or systems include de-ionised water, showers and water hoses. Units are to co-ordinate and agree who takes the lead for all shared water systems; this will include all equipment used after the point of use designated by ESS. Units must inform the Faculty Estates Co-ordinator, ESS and the Water Hygiene Provider. Where the ESS or Unit works with external organisations within the University Campus formal agreement must be made in respect to the management of water systems, equipment and risk from legionella bacteria. The agreement must clearly define who and at which point the responsibility for managing the risks of legionella changes from one organisation or unit to another. The agreement for shared water systems or equipment must be formalised and signed by a senior manager in both organisations. The following documents could be used for this process: Tenancy Agreement Faculty working together document - where available Letter Equipment Owned by Units Units will asset register number all scientific as well as any other equipment temporarily or permanently connected to the water system and identify their location on a schematic drawing. Equipment which is not connected to the water system but uses water must also be identified. Units are then to provide an asset register for areas within their control to the Estates Coordinator, ESS and Water Hygiene Provider. Page 3 of 7
The following list, not exhaustive, include examples of equipment that use water and would need to be included in the Unit asset register: Horticultural misting systems Evaporative cooling systems Water tanks Showers De-ionised water systems Taps and hoses Eye wash stations Please refer appendix 1, which provides a list of equipment which falls outside the scope of the Control of Legionella Management Standard. Risk Assessment Units will arrange for the contractor chosen by ESS to visit, assess, maintain and monitor Unit owned water systems. Units will ensure that all water systems and equipment using water identified in their asset register is risk assessed. The Unit is responsible for receiving risk assessment reports from the Water Hygiene Provider. Where new equipment or changes to working practices add additional risks of legionella bacteria growth they should adjust their asset registers and inform ESS and the Faculty Estates Coordinator. They must also contact the Water Hygiene Provider and request a risk assessment and schemes of examination. Risk assessments will be uploaded to the Records for Building Database by the Unit s Appointed Person. Equipment such as taps and showers will have generic controls specified with the risk assessment and Units must implement the control measure according to the ESS Policy. Risk assessments should be reviewed every 2 years or immediately if there reason to believe it is no longer valid, if there is a significant change in the work activity to which it relates or if the results of health surveillance or monitoring indicate it to be necessary. Control Measures and Monitoring Units will ensure that Appointed Persons are trained, aware of and implement the control measures specified in legionella risk assessments. Appointed Persons will implement and maintain suitable control measures identified in risk assessments or University H&S Management Standard and Guidance for their equipment. The records must include actions undertaken by the Water Hygiene Provider and should clearly identify Units control of legionella bacteria. Page 4 of 7
There may be several actions required, e.g. inspection, cleaning and disinfection, the Appointed Persons will ensure that equipment is serviced and maintained to the standard required to control Legionella bacteria within the University. The Appointed Person will ensure that records are maintained, either locally or on the records for building database, as required. Automated alerts will be set up by ESS which will alert Faculty and Units, if controls or actions have not been undertaken in the correct timescales. Faculty Estates Coordinators will monitor and pursue Units when actions have not been undertaken and to seek assurance via the records for buildings database for completed actions. Where actions are not complete the Faculty will inform Heads of Units and ensure suitable controls have been implemented. Training To ensure staff are competent to perform their tasks; training and instruction commensurate with their level of responsibility will be organised and delivered. Managers responsible for high risk locations or staff who are providing advice and assistance to users will attend an accredited course, e.g. ESS, OHSS, Mechanical and System Engineering. Responsible and Appointed Persons will attend an internal course provided by ESS/OHSS Refresher training will be provided on a 3 yearly basis. Training on the recording system will also be provided by ESS see below. Record keeping It is very important that there is a record of legionella control so that the University can monitor its management system and, where required, provide assurance to the VC and enforcement authorities, e.g. Health and Safety Executive. To achieve this; the University will store all legionella risk assessment on the Records for Buildings Database. The database will be accessible to all relevant ESS staff, Unit Responsible and Appointed Persons, Estates Facilities Coordinators and OHSS. The Unit, Appointed Persons, will upload the risk assessments and schemes of examination for their owned identified equipment and systems to the database as well as the control measures required to control the risks of legionella bacteria. However, some of these records maybe kept locally: The Unit will ensure records of servicing and maintenance are retained along with a log detailing flushing regimes (See Appendix 3 of the ESS The Control of Legionella Bacteria in Water Systems Policy). The Records for Buildings database will store the following records in respect to the management of legionella: The Risk Assessment Page 5 of 7
Asset registers for all University equipment detailing Schematic diagrams of the systems A written scheme for controlling the risk of exposure to Legionella Records of control checks Chlorination certificates and records Records of any remedial works carried out COSHH data regarding any chemicals used for dosing water systems or cooling towers Details of management responsibilities Responsible and Appointed Persons Audit Each Unit will provide an annual report on the control of legionella via the University health and safety annual reporting system. Audits of the legionella management system and associated records will be carried out annually by a suitably qualified and independent Water Hygiene Service Provider. Reports will be entered on the records for building database and any recommendations made will be considered and or implemented by the Unit Responsible or Appointed Person. OHSS will undertake audits as per the HASMAP audit programme and each unit will be audited on a 3-4 year basis. These audits don t primarily focus on legionella; however, are likely to include the management of legionella within Units when considered a significant risk. Reference Material Health and Safety Management Standard for Controlling the Risk of Legionella ESS The Control of Legionella Bacteria in Water Systems Policy Page 6 of 7
Appendix 1 (DETAILS TO BE PROVIDED FOLLOWING CONSULTATION WITH FACULTY REPRESENTATIVES.) Water baths Thermal disinfecting by regularly heating the water up to 60 C (once a month would be satisfactory) to kill off any contamination To change the water at least monthly and clean the water bath to remove sediment, sludge, scale or organic material, which can act as a source of nutrient for legionella To treat the water with biocide tablets or chlorine. (Further advice would be required to establish the correct type of biocide for the application, its dosage and regularity). This approach would also have a cost implication. Page 7 of 7