Legionella Policy

1.0 Purpose

1.1 It is TDC's responsibility to ensure that the appropriate precautions for the control of Legionella bacteria are identified through a site specific “Legionella” risk assessment process, and appropriate control measures implemented to ensure, so far as it is reasonable and practicable, the health, safety and welfare of employees and others.

The minimum standards to be met include; BS8580:2010 - Water Quality Risk assessments for Legionella Control – Code of practice
Preparation of a written scheme for preventing or controlling the risk,
Implementation, management, monitoring and recording of precautions to include regular inspection, microbiological monitoring, temperature checks and flushing, where appropriate;
Seeking suitable advice and assistance from competent persons, Corporate Health and Safety, or specialist consultant. Must be Legionella control Association (LCA) accredited.
Appointment of a person or persons to be managerially responsible for water systems at each premises, i.e. The Responsible Person (need to report any issue to corporate director) Nominated Officer (dealing with day to day issues). See Appendix 1
To meet the requirements of the HSE Approved Code of practice (HSE ACOP L8 2013 – Legionnaires' disease - The Control of Legionella Bacteria in Water Systems and accompanying documents HSG 274 Parts 1 to 3

2.0 Scope

2.1 This policy applies to all Tendring District Council buildings with water systems: hot and cold-water supply systems, spa baths, pools and showers, seafront taps or any other water system that is deemed to create an aerosol. All buildings will need an initial risk assessment, from which a written scheme and appropriate control measure can be complied, where TDC is either the “employer” or is in control for the premises.

3.0 Policy Statement

3.1 Tendring District Council has a legal duty to safeguard the health, safety, and welfare, of its employees, visitors, contractors and others under the following legislation in relation to Legionella bacteria in hot and cold-water systems:

The Health and Safety at Work Act 1974 sections 2 and 3 require the safeguarding of employees and others who may be affected by the Council’s work or systems.
The Management of Health and Safety at Work Regulations 1999 require risk assessments for all work practices and systems where there is a significant risk to the health, safety, and welfare of employees and others.
The Control of Substances Hazardous to Health Regulations 2002 (COSHH) are more specific in relation to Legionella bacteria as they are designed to control the risk from a range of hazardous substances including biological agents.
The Reporting of Injuries, Diseases, and Dangerous Occurrences Regulations 2013 (RIDDOR) require cases of Legionellosis to be reported to the employer’s enforcing authority.

The strategy for the implementation of the Legionella Management Policy is as follows:

To have clear procedures for the management of Legionella in premises, including identification, monitoring of physical conditions, provision of information to personnel, remedial action where necessary, and emergency procedures.
To define the responsibilities of Tendring District Council staff who are involved with the management of legionella in Council buildings.
To appoint and train Responsible Persons, and Nominated Officers who will have day to day responsibility for the implementation of the policy.
To maintain water systems in a safe condition so that they present a minimum risk to building users as far as reasonably practicable.
Legionella risk assessments will be undertaken on a two-year rolling programme, or sooner if a significant change occurs, by an independent water management company, who is a member of the Legionella Control Association
To train relevant Tendring District Council staff, as appropriate, in matters relating to the safe management of Legionella in Council occupied premises. Provide refresher training every 2- 3 years.
To only use specialist contractors to complete remedial works to minimise legionella risk with required training and qualification and experience. To only use materials which are listed in the latest addition of the Water Regulations Approval Scheme (WRAS) “Approved Fittings / Materials Directory” and this to be checked to ensure the whole appliance is approved.
Ensure that all contractors are of “approved contractor” status under the “Water Supply (Water Fittings) Regulations, 1999”, and to ensure that all work is in compliance with these and any other relevant regulations.

4.0 Background on legionella and safe water systems

Legionnaire’s disease is a potentially fatal form of pneumonia that is normally contracted by inhaling tiny droplets of water in the form of sprays or aerosols that contain Legionella pneumophila bacteria. Similar strains of the bacteria can also cause less serious non-fatal illnesses such as Pontiac fever and Lochgoilhead fever. The collective name for this group of diseases is Legionellosis.

The initial symptoms of Legionnaires disease include high fever, chills, headache, and muscle pain. Patients may develop a dry cough and most suffer difficulty breathing. Approximately one third of those affected will also develop diarrhoea or vomiting and approximately a half will become confused or delirious. Infection is fatal in approximately 12% of reported cases but once diagnosed Legionnaires disease can usually be effectively treated with appropriate antibiotics.

Certain groups of people are more susceptible to contracting Legionnaires disease, they include:

Those over 45 years of age
Smokers
Alcoholics
Diabetics
Those with cancer or chronic respiratory or kidney disease
Others with an immunosuppressed condition

Legionella bacteria are commonly found in the natural environment in rivers, lakes, streams, and reservoirs, but they will readily colonise man-made water systems such as cooling towers, hot and cold water systems, or any other system that uses or stores water if conditions allow.

For the bacteria to survive and proliferate in man-made water systems they require a good supply of nutrients in the form of algae, sludge, scale, biofilm, or other bacteria, and a temperature range of between 20°c and 50°c. At temperatures below 20°c the bacteria will survive but in a dormant state waiting for the temperature to rise, but they will not survive temperatures above 60°c.

In order to reduce the likelihood of exposure to Legionella bacteria it is important to maintain all hot and cold-water systems in such a way that:

Does not allow proliferation of the bacteria
Reduces exposure to water droplets, sprays, and aerosols

This will be achieved by:

Keeping the hot water storage temperature at greater than 60°C
Ensuring hot water distribution temperatures are above 50°C
Maintaining cold water temperatures at less than 20°C
Keeping water systems clean and in good condition.
Controlling contamination of the water systems;
Preventing stagnation due to the unnecessary storage of water;
Where fitted, maintaining and keeping in good working order any water treatment systems installed.
The Responsible Person, or their Deputy, will appoint an independent water management company, who is a member of the Legionella Control Association, to provide on-going, competent help for the organisation.

5.0 Management Responsibilities (under HSAWA 1974 section 37)

5.1 The Chief Executive as the statutory duty holder is responsible for:

Ensuring that effective arrangements are in place for managing legionella risks.
Ensure the management arrangements for legionella control are produced and implemented.
Ensuring sufficient resources are provided to enable the management arrangements to be effectively implemented.

5.2 Directors/Assistant Director are responsible for ensuring the following in respect of their directorates:

that they are aware as an appointed person of their responsibilities for the management of legionella,
that all appropriate officers within their directorate are identified as Responsible or Nominated Officers
that all identified Responsible Officers and Nominated Officers are formally notified of their responsibilities and trained in the management of legionella
that they report to the Chief Executive on a regular basis on the effectiveness of arrangements and controls in their directorates.

In addition, the Directors and Assistant Directors are responsible for:

Ensuring that an effective legionella management framework is produced and maintained which comprises of the legionella policy, risk assessment, relevant training, budget provision and a corporate monitoring, checking and reporting regime.
Monitoring the implementation and effectiveness of the management plan and reporting regularly to the Chief Executive on the overall arrangements for managing the risk of Legionella.

5.3 Relevant senior managers:

Senior Managers will carry out the following functions on behalf of the Corporate Directors/Assistant Directors:
Ensure a risk assessment, carried out by a specialist company, is commissioned covering in all parts of the Council to identify and assess the risk of exposure to legionella from work activities and water systems and to put in place any necessary control measures. Risk assessments to be carried out every 2 years or sooner if considered necessary.
To ensure there are appropriate managerial systems in place to guarantee specified checks and maintenance are completed for officers in the health and safety role.
Take all reasonable steps to ensure the competence of the person or water Management Company appointed to complete the risk assessment and the competence of contractors and others employed to carry out work on water systems.
To liaise with the Responsible Person in their area of responsibility on matters associated with the control of legionella as necessary.
In conjunction with the Assistant Director for Partnerships and the Health and Safety Team
ensure that all staff are trained as appropriate, and necessary, for their role
maintain an ongoing programme of training for all staff who have, or may have, responsibility for implementing this Policy, Council procedures, testing, cleaning or recording of any function under this Policy
maintain the training record of all such Council staff. A central record of training needs to be held by HR and monitored corporate health and safety.

5.4 The Assistant Director for Partnerships and the Health and Safety Team will:

Consult with Senior Managers on the officers identified as a Responsible Person or a Nominated Officer and confirm in writing to those officers what is expected of them, relating the control of legionella.

In conjunction with the Senior Managers:

Ensure new staff are trained in legionella procedures and controls applicable to their post within 3 months of their start date.
The Council's Human Resource team assisted by the Corporate Health and Safety team to maintain a central training record, to ensure refresher training is monitored and carried out within 3 years for all identified staff.

* 5.5 A Responsible Person is expected to;

Assisting in the development of the policy and ensuring the allocation of resources, for the management of legionella risk within their allocated area.
Dissemination of this policy and procedures to other council staff as appropriate.
Implement the procedures set out in this document and control measures in the risk assessment at their premises, and others in the management of legionella at their sites.
Ensure that Nominated officers are checking infrequently used outlets and that these are included in a weekly flushing programme.
Ensure that Nominated officers are checking all shower heads & hoses and ensure they are cleaned and disinfected at least quarterly or more frequently if identified by the external risk assessment.
Prevent and minimise any possible contamination of the water systems within their buildings such as heat gain to the cold water system or the ingress of dirt or wildlife and insects into the system.
Ensure that water treatment systems that may be used and fitted are operated and maintained as instructed;
Ensure the risk assessment report is updated every two years by the appointed water management company or sooner if there is a chance identified.
Liaise with Nominated Officer to ensure any remedial works identified as part of the risk assessment are completed within the set time frames detailed in the report
Where there is a change to the use of a building contact to be made with the appointed water management company and a request to be made for an updated risk assessment be completed. Any recommendations identified to be implemented at the earliest opportunity.
Maintain records in writing, and electronically if appropriate, of all inspections and/or testing, cleaning and disinfection of systems or equipment requiring the same, and to include all communications with and outcomes of discussions with the water management company.
Monitor any actions delegated to others to ensure the actions have been carried out
Check that any necessary planned preventative maintenance, inspection and testing is being carried out

See appendix 1

* 5.6 Nominated Officers are expected to;

Carry out the day-to-day liaison with the independent water management company for advice, water sampling, and the interpretation of sampling results.
When a non-compliant situation occurs i.e. temperatures do not comply with set parameters they shall report this occurrence to the relevant Responsible Officer and appointed water management company and ensure action is taken to address and resolve the issue. (see appendix 1)
Ensure infrequently used outlets are included in a weekly flushing programme. Report any problems back to Responsible Officer.
All shower heads & hoses should be cleaned and disinfected at least quarterly or more frequently if identified by the external risk assessment. Report any problems back to the Responsible Officer.

See appendix 1

5.7 Appointed Independent Water Management Company:

To be independent from any remedial work provision.
To be members of the Legionella Control Association.
Operate an ISO 9001:2008 quality system or whatever system shall replace ISO 9001:2008.
To provide prompt and competent technical support to Tendring District Council either in person, on the telephone or via email.
Inform Tendring District Council of changes to law, regulation, guidance, and technical best practice including latest developments within the industry and advise as to their implementation.
Undertake legionella risk assessments of Council properties at least every two years including the provision of schematic drawings.
Provide risk minimisation schemes to accompany the risk assessment reports.
To regularly review the contract and discuss any issues identified and review responsibility’s to ensure there is clarity between the Council and the contractor. This should be document.

6.0 Risk Assessment

6.1 Legionella risk assessments will be completed by the appointed water management company every two years at all Tendring District Council premises where water is present on site.

6.2 Risk assessments will also be completed following any significant material change to the fabric or use of a building.

6.3 Schematic drawings will be produced or reviewed at all sites as part of the risk assessment process with any changes to the system being updated on the drawing.

6.4 Schematic drawings will identify the following:

Origin of water supply;
General layout of the system;
All associated storage and header tanks;
All standby equipment;
Any problem areas such as dead legs or blind ends
All system plant, for example water softeners, filters, strainers, pumps, non-return valves and all outlets, for example showers, wash hand basins etcetera
All associated pipework and piping routes.

6.5 The Responsible Person will notify the Senior Managers of all remedial works identified by the risk assessment and ensure the same are completed as soon as reasonably practicable.

7.0 Contractors

It is important that when a contractor is engaged at any stage that checks are made to ascertain that the contractor has the necessary training and requirements to fulfil the task you have asked them to carry out.

This is particularly relevant if you have instructed one contractor and this is then subcontracted out to another company to carry out the work.

There should not be any assumption made that the contractor will have the required training or experience to carry out the task. The Health and Safety Executive (HSE) will expect TDC to have checked these facts before they are allowed to carry out any work on site. These checks should not be made retrospectively.

This is in line with Construction Design and Management Regulations 2015 (CDM)

8.0 Water sampling

8.1 Water sampling will be carried out as recommended by the appointed water management company, where there has been a higher risk identified or an ongoing issue is being addressed.

8.2 Testing of water samples will only be carried out by a UKAS accredited laboratory.

8.3 The Responsible Person will notify the Senior Managers of all positive Results from water sampling and any remedial actions required and ensure the same are completed as soon as reasonably practicable. If a poor result is received a record should be made on the log sheet and the relevant action taken.

Legionella >100 cfu/l and up to 1000

Recommended Actions

Either:

if the minority of samples are positive, the system should be resampled. If similar results are found again, a review of the control measures and risk assessment should be carried out to identify any remedial actions necessary or
if the majority of samples are positive, the system may be colonised, albeit at a low level. An immediate review of the control measures and risk assessment should be carried out to identify any other remedial action required. Disinfection of the system should be considered

>1000 cfu/l

Recommended Actions

The system should be resampled and an immediate review of the control measures and risk assessment carried out to identify any remedial actions, including possible disinfection of the system. Retesting should take place a few days after disinfection and at frequent intervals.

9.0 Corporate Health and Safety Officer Role

9.1 Undertake suitable Legionella training and ensure this is kept up to date.(within a three year period)

9.2 Monitor and Audit services to ensure effective checks and controls are in place.

9.3 Review and update legionella policy, every 2 years or when a significant change has occurred or guidance or legislation has been updated.

9.4 Advise Chief Executive and report findings following regular inspections to Senior Managers and responsible officer.

10.0 Inspection and monitoring checklist

10.1 The Responsible Person, will ensure that all inspection and monitoring procedures applicable to their site and listed in 9.2 the Inspection and Monitoring Checklist, are carried out at the frequency stated in the checklist, or as identified by the risk assessment, and results entered in the Legionella Log Book.

10.2 Inspection and Monitoring Checklist:

Calorifiers

Inspect calorifier internally by removing the inspection hatch or using a boroscope and clean by draining the vessel. The frequency of inspection and cleaning should be subject to the findings and increased or decreased based on conditions recorded

Annually, or as indicated by the rate of fouling

Where there is no inspection hatch, purge any debris in the base of the calorifier to a suitable drain Collect the initial flush from the base of hot water heaters to inspect clarity, quantity of debris, and temperature

Annually, but may be increased as indicated by the risk assessment or result of inspection findings

Check calorifier flow temperatures (thermostat settings should modulate as close to 60 °C as practicable without going below 60 °C) Check calorifier return temperatures (not below 50 °C, in healthcare premises not below 55 °C)

Monthly

Hot water services

For non-circulating systems: take temperatures at sentinel points (nearest outlet, furthest outlet and long branches to outlets) to confirm they are at a minimum of 50 °C within one minute (55 °C in healthcare premises)

Monthly

For circulating systems: take temperatures at return legs of principal loops (sentinel points) to confirm they are at a minimum of 50 °C (55 °C in healthcare premises). Temperature measurements may be taken on the surface of metallic pipework

Monthly

For circulating systems: take temperatures at return legs of subordinate loops, temperature measurements can be taken on the surface of pipes, but where this is not practicable, the temperature of water from the last outlet on each loop may be measured and this should be greater than 50 °C within one minute of running (55 °C in healthcare premises). If the temperature rise is slow, it should be confirmed that the outlet is on a long leg and not that the flow and return has failed in that local area

Quarterly (ideally on a rolling monthly rota)

All hot water systems: take temperatures at a representative selection of other points (intermediate outlets of single pipe systems and tertiary loops in circulating systems) to confirm they are at a minimum of 50 °C (55 °C in healthcare premises) to create a temperature profile of the whole system over a defined time period

Representative selection of other sentinel outlets considered on a rotational basis to ensure the whole system is reaching satisfactory temperatures for legionella control

Point Of Use - water heaters (no greater than 15 litres)

Check water temperatures to confirm the heater operates at 50–60 °C (55 °C in healthcare premises) or check the installation has a high turnover

Monthly–six monthly, or as indicated by the risk assessment

Water heaters

Inspect the integral cold water header tanks as part of the cold water storage tank inspection regime, clean and disinfect as necessary. If evidence shows that the unit regularly overflows hot water into the integral cold water header tank, instigate a temperature monitoring regime to determine the frequency and take precautionary measures as determined by the findings of this monitoring regime.

Annually

Check water temperatures at an outlet to confirm the heater operates at 55–60 °C

Monthly

Cold water tanks

Inspect cold water storage tanks and carry out remedial work where necessary

Annually

Check the tank water temperature remote from the ball valve and the incoming mains temperature. Record the maximum temperatures of the stored and supply water recorded by fixed maximum/minimum thermometers where fitted

Annually (Summer) or as indicated by the temperature profiling

Cold water services

Check temperatures at sentinel taps (typically those nearest to and furthest from the cold tank, but may also include other key locations on long branches to zones or floor levels). These outlets should be below 20 °C within two minutes of running the cold tap. To identify any local heat gain, which might not be apparent after one minute, observe the thermometer reading during flushing

Monthly

Take temperatures at a representative selection of other points to confirm they are below 20 °C to create a temperature profile of the whole system over a defined time period. Peak temperatures or any temperatures that are slow to fall should be an indicator of a localised problem.

Representative selection of other sentinel outlets considered on a rotational basis to ensure the whole system is reaching satisfactory temperatures for legionella control

Check thermal insulation to ensure it is intact and consider weatherproofing where components are exposed to the outdoor environment

Annually

Showers and spray taps

Dismantle, clean and descale removable parts, heads, inserts and hoses where fitted

Quarterly or as indicated by the rate of fouling or other risk factors, e.g. areas with high risk individuals

Point of Use filters

Record the service start date and lifespan or end date and replace filters as recommended by the manufacturer (0.2 μm membrane POU filters should be used primarily as a temporary control measure while a permanent safe engineering solution is developed, although long-term use of such filters may be needed in some healthcare situations)

According to manufacturer’s guidelines

Base exchange softeners

Visually check the salt levels and top up salt, if required. Undertake a hardness check to confirm operation of the softener

Weekly, but depends on the size of the vessel and the rate of salt consumption

Service and disinfect

Annually, or according to manufacturer’s guidelines

Multiple use filters

Backwash and regenerate as specified by the manufacturer

According to manufacturer’s guidelines

Infrequently used outlets

Consideration should be given to removing infrequently used showers, taps and any associated equipment that uses water. If removed, any redundant supply pipework should be cut back as far as possible to a common supply (e.g. to the recirculating pipework or the pipework supplying a more frequently used upstream fitting) but preferably by removing the feeding ‘T’ Infrequently used equipment within a water system (i.e. not used for a period equal to or greater than seven days) should be included on the flushing regime Flush the outlets until the temperature at the outlet stabilises and is comparable to supply water and purge to drain Regularly use the outlets to minimise the risk from microbial growth in the peripheral parts of the water system, sustain and log this procedure once started. For high risk populations, e.g. healthcare more frequent flushing may be required as indicated by the risk assessment

Weekly, or as indicated by the risk assessment

Thermostatic Mixing Valves (TMV)

Risk assess whether the TMV fitting is required, and if not, remove.

Where needed, inspect, clean, descale and disinfect any strainers or filters associated with TMVs.

To maintain protection against scald risk, TMVs require regular routine maintenance carried out by competent persons in accordance with the manufacturer’s instructions.

Annually or on a frequency defined by the risk assessment, taking account of any manufacturer’s recommendations

Expansion vessels

Where practical, flush through and purge to drain

Monthly–six monthly, as indicated by the risk assessment

11.0 Record keeping

11.1 All information and data relating to the management and control of legionella will be kept in a Legionella File at all applicable Tendring District Council premises and will include:

A written scheme for each site, detailing what actions are being done, when this is to be carried out and who is going to be doing it;
Risk assessment records
Results of all inspection and monitoring applicable to their site as defined in the Inspection and Monitoring Checklist;
Maintenance of thermostatic mixing valves;
Water tank inspection reports;
Results of any ad-hoc assessments and water sampling;
Schematic plans showing location and layout of water systems;
Works undertaken to minimise legionella risk;
Water sampling results;
Training records;
Equipment calibration records and certificates;

12.0 Training

12.1 Any role identified in this policy that has a responsibility for legionella awareness will receive training within a three year period. (monitored by HR and booked by corporate health and safety) These job roles are identified in Appendix 1.

13.0 Audit and Review

13.1 All sites are required to be audited at least once per year, more frequently if considered appropriate

13.2 The Corporate Health and Safety Officer will review the Council’s policy and procedures for the management and control of legionella risks which will have included unannounced inspections of sites and an annual report will be provided to the Management Team. The report will confirm the level of compliance with the required checks and monitoring systems within the Council premises and will consider if the Policy and arrangements are appropriate and effective. Where any assessment is undertaken, records of the assessments and unannounced spot checks should be put on the file at the site and a copy held centrally by Corporate Health and Safety. Any issues identified should be addressed at the earliest opportunity and followed up if required.

13.3 Where necessary the report will recommend actions to improve compliance.

13.4 Report back to Health and Safety Meeting Audit Committee and Chief Executive.

Appendix 1

[See attached document.]

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