LEGIONELLA MANAGEMENT AND CONTROL POLICY. Documentation control

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1 LEGIONELLA MANAGEMENT AND CONTROL POLICY Documentation control Reference: HS/EI/004 Approving Body: Trust Board (CEO) Date Approved: 8 Implementation Date: 22 Version: 4 Summary of Changes from Changes to Legislation Previous Version Supersedes: Version 3 (March 2012) Consultation Undertaken: Directorate of Estates and Facilities Management, Legionella & Water Safety Steering Group, Estates Legionella Control Teams, ORC, Trust Health and Safety Committee, Directors Group Date of Completion of 6 February 2013 Equality Impact Assessment Date of Completion of We Are Here For You Assessment 6 February 2013 Date of Environmental Imp[act Assessment 6 February 2013 Legal and/or Accreditation Implications Target Audience: Approved Code of Practice (L8) Legionnaires Disease The Control of Legionella Bacteria in Water Systems All Trust staff, occupiers of Trust premises and Contractors Review Date: May

2 Lead Executive: Author/Lead Manager: Chief Executive Mark Jackson Head of Estate Operations Extension Further Guidance/Information: Andrew Camina Assistant Head of Estate Operations Extension

3 Contents 1 INTRODUCTION 4 2 EXECUTIVE SUMMARY 4 3 POLICY STATEMENT 5 4 DEFINITIONS THE ESTATE THE TRUST S SERVICE PROVIDERS 5 5 ROLES AND RESPONSIBILITIES COMMITTEES INDIVIDUAL OFFICERS (DELEGATED RESPONSIBILITIES) 9 6 PROCEDURAL REQUIREMENTS 16 7 TRAINING & IMPLEMENTATION TRAINING IMPLEMENTATION RESOURCES 17 8 TRUST IMPACT ASSESSMENTS EQUALITY IMPACT ASSESSMENT ENVIRONMENTAL IMPACT ASSESSMENT HERE FOR YOU ASSESSMENT 17 9 POLICY PROCEDURE MATRIX DOCUMENT RELEVANT LEGISLATION; NATIONAL GUIDANCE AND ASSOCIATED NUH DOCUMENTS APPENDIX A EQUALITY IMPACT ASSESSMENT APPENDIX B ENVIRONMENTAL IMPACT ASSESSMENT APPENDIX C HERE FOR YOU ASSESSMENT 28 APPENDIX D CERTIFICATE OF EMPLOYEE AWARENESS 30 3

4 1 Introduction Nottingham University Hospitals NHS Trust, hereinafter known as the Trust, accepts its responsibility under the Health and Safety at Work etc. Act 1974 and the Control of Substances Hazardous to Health Regulation 2002 (as amended), to take all reasonable precautions to prevent or control the harmful effects of contaminated water to residents, patients, visitors, staff and other persons working at or using its premises. 2 Executive Summary Legionnaires disease is a potentially fatal pneumonia caused by legionella bacteria. It is the most well-known and serious form of a group of diseases known as legionellosis. Other similar (but usually less serious) conditions include Pontiac fever and Lochgoilhead fever. Infection is caused by breathing in small droplets of water contaminated by the bacteria but the disease cannot be passed from one person to another. They survive low temperatures and thrive at temperatures between C if the conditions are right, eg if a supply of nutrients is present such as rust, sludge, scale, algae and other bacteria. They are killed by high temperatures. As required by the Health and Safety Commissions Approved Code of Practice (L8), (3 rd Edition Nov 2000) the Trust has to: Identify and assess sources of risk; Prepare a control system for preventing, reducing or controlling the risk; Implement and manage and monitor precautions; Maintain suitable and sufficient records of the precautions implemented and will carry this out for each of the health care premises within the Trust's control. Appoint a person to be managerially responsible for the maintenance and leadership of the control system and measures adopted. notify the local authority that we have cooling tower(s) on site and associated duties 4

5 3 Policy Statement The Trust will provide a framework for the prevention of infection from water borne bacteria through inhalation or aspiration. This policy and associated procedure document applies to all Trust premises and its aim is to maintain a structured Procedure and Reporting Schedule, for the Management and Control of Legionellosis, including Legionnaires Disease, in compliance with current Guidelines/ The primary defence strategy for reducing the risks posed by Legionella will be through a temperature control regime. This regime may be supplemented by the additional use of chemical and other water treatment methods but will not be replaced by any other method. 4 Definitions 4.1 The Estate For the purposes of this Policy, the Estate comprises all the buildings currently owned or occupied (under a full maintenance lease or otherwise) by the Trust. The Trust maintains a full list of properties for which it has responsibility. This list is controlled and maintained by the Estates Land and Property Manager. 4.2 The Trust s Service Providers For the purposes of this Policy, the Service Providers are organisations that supply the Trust with services pertaining to "Legionellosis Management & Control", whether accommodation, and or Facilities Management, Water Treatment, Consultancy, etc. 5

6 5 Roles and Responsibilities Management arrangements for the control of Legionella will be in accordance with a Policy that has been: Formulated to incorporate the requirements of current legislation and guidance; Ratified and accepted by the Trust Board; Adopted by the Directors Group (DG); and Given wide circulation throughout the Trust, to inform all staff of their own, and others obligations Overview and interaction schematic of the Trust s Legionellosis Management & Control Management Teams Chief Executive Clinical Risk Committee Infection Prevention Control Committee Infection Control Officer/Consultant Microbiologist Infection Control Officer External Legionella Control Consultant Legionella & Water Safety Steering Group Specialist Advisors Responsible Person Contractors Deputy Responsible Person Designers Estates Legionella & Water Safety Control Team City Hospital Campus Estates Legionella & Water Safety Control Team Queens Medical Campus Ward and Departments responsibilities 6

7 5.1 Committees Legionella and Water Safety Steering Group The Trust s Infection Prevention and Control Committee has a specialist sub group which provides third party assurance and creates a robust governance framework to ensure that the Trust operates effective management systems for the control of Legionnaires Disease and hot and cold water systems. The Legionella & Water Safety Steering Group shall meet monthly to: i. Monitor and review the development and implementation of Policies and Procedures for the prevention of Legionnaires Disease and Water Safety. ii. Prioritise the identified tasks into action plans identifying, initially, cost and service implications and then on to structured and timetabled progress targets. iii. Review and approve changes to the Policies and Procedures prior to ratification by the Infection Prevention and Control Committee. iv. Implement the Trust s Control of Infection Outbreak Plan and co-ordinate the Estates Legionella and Water Safety Control Team and all other relevant personnel, in the event of an outbreak. v. Ensure that Legionella Management & Control issues are communicated to all relevant staff throughout the organisation and to relevant stakeholders, i.e. University, Local Government and HSE. vi. Provide guidance on issues faced by the Trust in relation to Legionella Management & Control. vii. Be a forum for the communication of issues faced and the developments made in Legionella Management & Control to ensure a standard approach is adopted across the Trust. viii. The Chair of the Group will report to the IPCC on a monthly basis. This Policy is reviewed annually by the Legionella & Water Safety Steering Group and any proposed amendments ratified by the Infection Prevention and Control Committee prior to approval by Directors Group; Management arrangements are kept under review and revised as and when necessary. Any proposed revisions shall be submitted to the Infection Prevention and Control Committee via the Legionella & Water Safety Steering Group for approval before incorporation into the Policy; 7

8 The Trust Board are kept fully informed of the Legionella and water quality risks and the financial implications of, managing, reducing or removing them; The Group s membership shall consist of: Representative for Trust s Control of Infection Team. (Chair); Responsible Person (Water). (representing the Estates Legionella and Water Safety Control Team of each campus); Deputy Responsible Person (Water). (representing the Estates Legionella Control Team of each campus); External Legionellosis Management & Control Consultant providing third party independent assurance; Head of Organisational Quality, Risk and Safety; Estates and Facilities Health and Safety Advisor; Engineering Managers (Water) for both campus s; Representative from Clinical Directorates; Representative from Capital Projects Representative from Trust Health & Safety Committee; Representative from the Primary Care Trust; Representative from Nottingham University. The Chair of the Legionella & Water Safety Steering Group will liaise with the Medical Director on clinical issues raised by the group Estates Legionella and Water Safety Control Team (ELWCT) The Estates Legionella & Water Safety Control Team shall meet monthly to: i. Carry out remedial work highlighted during Risk Assessment. ii. Produce minutes of the meetings held and retain with Legionella management records for a minimum of 5 years. iii. Ensure records of the Risk Assessments and associated precautions are implemented and maintained. iv. Implement maintenance and inspection routines, as described in the Risk Assessment (or Risk Assessment Review) for the control of Legionella as required in HTM and other associated guidance documents. v. Keep maintenance and monitoring records and make available for inspection. Written and computer records will be kept for a minimum 5 years. 8

9 vi. Ensure that where equipment is used for temperature monitoring and water sampling that it is kept in good working order and calibrated. vii. Ensure record drawings of systems are available and kept updated and previous versions are retained for 5 years. viii. Ensure the competence of staff or external contractors used for any aspect of monitoring and/or maintaining the precautions for Legionella control. ix. Audit Precautions on the Control of Legionella. x. Issue a compliance report to the Responsible Person, as requested, but at least on a Monthly basis to the Legionella and Water Safety Steering Group. xi. The minutes of the ELWCT monthly meetings shall be submitted to the Legionella and Water Safety Steering Group for information and review to provide an item of objective evidence that responses to identified risks and the progress of remedial action plans has been timely, complete and effective and that the residual risk level has been determined and recorded. Minutes of the Legionella & Water Safety Steering Group monthly meeting shall be submitted to the Infection Prevention and Control Committee for information; A status and progress report will be issued annually to the Infection Prevention and Control Committee. The Team s membership shall consist of: Responsible Person; Nominated Deputy Responsible Person; Engineering Design Manager; Estates Managers; Engineering Managers; Maintenance Supervisors; Maintenance Chargehands; Capital Project Managers; Estates Administration 5.2 Individual Officers (Delegated Responsibilities) Current statutory legislation requires both management and staff to be aware of their individual and collective responsibility 9

10 for the provision of wholesome, safe hot and cold water supplies, and storage and distribution systems in healthcare premises. The Trust Board delegates to the Chief Executive, responsibility for the implementation of this Policy Management Management is defined as the owner, occupier, employer, general manager, Chief Executive or other person who is ultimately accountable, and on whom the duty falls, for the safe operation of healthcare premises. A person intending to fulfil any of the staff functions specified below should be able to prove that they possess sufficient skills, knowledge and experience to be able to perform safely the designated tasks Infection Control Officer/Consultant Microbiologist The infection control officer or consultant microbiologist if not the same person, is the person nominated by management to advise on infection control policy and to have responsibility for the implementation of all necessary measures to ensure the maintenance of water quality. The Consultant Microbiologist shall chair the Legionella and Water Safety Steering Group This shall be acceptable to the Legionella and Water Safety Steering group and the Infection Prevention and Control Committee and they will confirm any amendments to the policy Responsible Person (Water) & Deputy Responsible Person (Water) This designated staff function was known previously as the Nominated and Deputy Responsible Person (Legionella) & (Water). The implementation of an effective maintenance policy must incorporate the preparation of fully detailed operating and maintenance documentation and the introduction of a logbook system. 10

11 The Chief Executive has appointed in writing the Responsible Person (Water), herein after called the Responsible Person, to manage the policy and procedures. In his absence the appointed, Deputy Responsible Person (Water) will carry this out, herein after called the Deputy Responsible Person. The Responsible Person shall ensure that the following management arrangements are implemented as a minimum: i. Possess adequate professional knowledge and following appropriate training, shall be appointed in writing by management to devise and manage the necessary procedures to ensure that the quality and safety of water and their systems in the healthcare premises are maintained; ii. Be a manager with sufficient authority to ensure that all operational procedures are carried out in an effective and timely manner; iii. Be required to liaise closely with other professionals in various disciplines; iv. Be supported by specialists in specific subjects such as water treatment and microbiology, but he/she must undertake responsibility for calling upon and coordinating the activities of such specialists; v. Be aware that manufacturers, suppliers, installers and service providers have specific responsibilities that are set out in the Health and Safety Commission s (2000) Approved Code of Practice L8; vi. Appoint a deputy to whom delegated responsibilities may be given. The deputy shall act for the Responsible Person (Water) on all occasions when he/she is unavailable. A full Legionella risk assessment has been undertaken and documented for each of the Trust s premises; A fully documented annual risk audit is undertaken for each of the Trust s premises; An Action Plan and Risk Reduction Schedule have been prepared to address any risks identified; Appropriate planned maintenance regimes are devised and implemented and their outcomes fully documented; Appropriate preventative regimes are agreed with and implemented by users and that all actions are logged by them; Corrective measures required as the result of planned maintenance or user regimes are either taken without delay, or 11

12 where there are significant financial implications, seek the necessary funding; In conjunction with the Deputy Responsible Person, procedures are implemented on all capital works to incorporate fully, both the requirements of the Policy and those laid out in the current legislation and guidance; Wherever necessary within the scope of the policy, a Risk Assessment is carried out on completion of work and the result documented. This will apply to all works, whether capital or not; Estates staff are given initial Legionella Awareness Training, with two-yearly updates thereafter; All staff, through the Legionella & Water Safety Steering Group, are kept up to date with Legionella issues; All documentation is kept for a minimum period of ten years; vii. They should possess a thorough knowledge of the control of Legionella and would ideally be a Chartered Engineer, microbiologist or other professionally qualified person. This role, in association with the infection control officer and maintenance staff involves: i. Carrying out Risk Assessments and two-yearly Risk Assessment Reviews on all water systems and air conditioning plant, ii. Advising on potential areas of risk and identifying where systems do not adhere to this policy and procedures document, iii. Liaising with the water undertakers and environmental health departments and advising on the continuing procedures necessary to ensure acceptable water quality, iv. Monitoring the implementation and efficacy of those procedures, v. Approving and identifying any changes to those procedures, vi. Ensuring equipment that is to be permanently connected to the water supply is properly installed, vii. Ensuring adequate operating and maintenance instructions exist and adequate records are kept. viii. Auditing of the management and control systems for the control of Legionella in the Trusts water and ventilation systems. ix. Put in place arrangements for reporting an outbreak or suspected outbreak of Legionella. x. Issue a compliance report to the Legionella and Water Safety Steering Group, on a monthly basis. 12

13 xi. Assess the training needs for training of staff in Control of Legionella. xii. Liaise with suitable training specialists to provide approved courses on the management and control of Legionella. xiii. Ensure personal training records are kept up to date. xiv. Ensure the competence of staff or external contractors used for any aspect of monitoring and/or maintaining the precautions for Legionella control. xv. The Responsible Person should be fully conversant with design principles and requirements of water systems and should be fully briefed in respect of the cause and effect of water-borne organisms, for example Legionella pneumophila Engineering Officer (Site Responsible Water) An Engineering Officer will: i. Possess adequate knowledge and following appropriate training, shall be appointed in writing by management to implement and manage the necessary processes and procedures to ensure that the quality of water in the healthcare premises is maintained, ii. Carry out remedial work highlighted during Risk Assessment, iii. Ensure records of Risk Assessment and associated precautions are implemented are maintained, iv. Implement maintenance and inspection routines, as described in the Risk Assessment (or Risk Assessment Review) for the control of Legionella as required in HTM04-01 and other relevant and associated guidance documents, v. Keep maintenance and monitoring records and make these available for inspection. Written and computer records are to be kept for a minimum of 5 years, vi. Ensure record drawings of systems are available and kept updated, vii. Be required to liaise closely with other professionals in various disciplines, viii. Be supported by specialists in specific subjects such as water treatment and microbiology, but he/she must undertake responsibility for calling upon and coordinating the activities of such specialists, ix. Be aware that manufacturers, suppliers, installers and service providers have specific responsibilities that are set out in the Health and Safety Commission s (2000) Approved Code of Practice L8. 13

14 5.2.5 Tradesperson or Assistant (Competent Person) A tradesperson or Assistant is someone, who is appointed in writing, by the Responsible Person (Water) to carry out, under the control of the maintenance technician, work on water, storage and distribution systems Installer An installer is the person or organisation responsible for the provision of the water, storage and distribution system Contractor A contractor is the person or organisation designated by management to be responsible for the supply, installation, validation and verification of hot and cold water services, and for the conduct of the installation checks and tests. It is essential to ensure that contractors have suitable qualifications in relation to the control of Legionella. (For example companies/individuals who are members of the Legionella Control Association) Contract Supervising Officer The person nominated by management to witness tests and checks under the terms of contract. He/she should have specialist knowledge, training and experience of hot and cold water supply, storage and mains services Capital Project Officers/Managers Designers and installers of hot and cold water distribution systems are required by the Water Supply (Water Fittings) Regulations 1999 to notify the water undertaker of any proposed installation of water fittings and to have the water undertakers consent before installation commences. It is a criminal offence to install or use water fittings without their prior consent. Capital Project Officer/Managers will consult the appointed external specialist with respect to Legionella compliance as follows: All new and altered water systems shall comply with the requirements of L8, HTM At the design stage the consulting engineer shall liaise with the appointed external specialist, retained by the Trust to provide advice in respect of compliance water systems and Legionella. 14

15 The appointed external specialist will provide input advice to the design process in respect to the construction phase and for the subsequent operational service thereafter. In any event the Trust will require a risk assessment and certificate of compliance for the water systems upon completion, to be provided via the consulting engineer. The specification, and the consulting engineer s competence and interpretation of the requirements. The contractor s competence and their interpretation of the requirements. The plumber s competence and interpretation with respect to site conditions, the existing and new installation and commissioning requirements. The Clerk of Works competence and interpretation of the requirements. Prior to hand over of a new or modified system Operating and maintenance manuals shall be provided in accordance with the requirements of BSRIA s Application Guide 1/87: Operational and Maintenance Manuals for building services installations Appointed External Specialists (Capital) The appointed external specialist shall: In conjunction with the appointed design engineer contribute to the design process, to ensure all water and air systems, implicated within the design remit, comply with the requirements of L8, HTM Provide design compliance certificate. Carry out a risk assessment, to establish the risk during the construction phase and advise on the control measures which need to be put in place to mitigate identified risks. Carry out audits and monitoring during construction, to ensure upon completion the scheme complies with the requirements. Upon completion, verify the installation is compliant with the above requirements, with respect to installation and commissioning. Provide compliance/verification certification. Carry out a risk assessment to determine and then advise of the in-use risk, and identify any control measures that need to be established. The risk assessment and control measures shall be available to the Trust at Handover of the system(s). Provide electronic copies of the certificates and risk assessment to the following: - Capital Project Officer/Manager; Responsible Person Water; The Client User and 15

16 The site specific Engineering Manager with day-to-day responsibility for Legionellosis management Appointed External Specialists (Maintenance) The appointed external specialist shall: Undertake a quarterly audit of the Trusts internal management procedures associated with legionella on a site specific base Undertake a quarterly audit of the Trusts internal management procedures associated with legionella and cooling towers on a site specific base Ward/Departments Regular flushing of all outlets is one of the two key elements in keeping water systems clean and maintaining the Legionella bacteria population at below harmful levels. All outlets shall be flushed everyday at full flow for 2 minutes. If outlets are not used regularly the water in the pipe leading to them will remain stagnant creating a risk of bacterial growth. The flushing of these outlets shall be recorded on the outlet flushing data sheet (See Legionella Management Control & Procedures Appendix C 22.4). 6 Procedural Requirements This policy is to be read in conjunction with the Legionella Management Control & Procedures Document 7 Training & Implementation 7.1 Training The Responsible Person shall ensure that the Estates Legionella & Water Safety Control Team and all other staff involved in or associated with the Management & Control of Legionnaires disease will undertake regular in-depth training courses to ensure they kept updated on new developments in the management and control of water services. 16

17 Training will be carried out at least bi-annually to ensure the competent staff can fulfil the performance of their specific duties. Attendance will be recorded and maintained ready for inspection if required. 7.2 Implementation This Policy and attached Procedure are monitored and audited for the Trust at the Legionella and Water Steering Group 7.3 Resources No additional resources are required (unless there is a change in current legislation) 8 Trust Impact Assessments 8.1 Equality Impact Assessment An equality impact assessment has been undertaken on the Policy and Procedural documents and has not indicated that any additional considerations are necessary. 8.2 Environmental Impact Assessment An environmental impact assessment has been undertaken on the Policy and Procedure and has indicated that additional considerations are necessary. 8.3 Here For You Assessment A Here for You assessment has been undertaken on the Policy and Procedural documents and has not indicated that any additional considerations are necessary. 17

18 9 Policy Procedure Matrix Document Minimum requirement to be monitored Management Procedures (Estates) Management Procedures (Cooling Towers) Bi-Yearly Risk Assessments Legionella Risk Assessments (Capital Projects Responsible individual/ group/ committee Process for monitoring e.g. audit Frequency of monitoring Responsible Person Water Audit Quarterly Responsible Person Water Audit Quarterly Responsible Person Water Responsible Person Water Bi-Annual Risk Assessments Updating of Risk Assessment Bi-Annual After Every Capital Scheme Responsible individual/ group/ committee for review of results Legionella and Water Safety Steering Group Legionella and Water Safety Steering Group Site Responsible Person Water Capital Project Officer/Manager Responsible individual/ group/ committee for development of action plan Estates Legionella and Water Safety Control Team Estates Legionella and Water Safety Control Team Estates Legionella and Water Safety Control Team Capital Projects Responsible individual/ group/ committee for monitoring of action plan Infection Prevention and Control Committee Infection Prevention and Control Committee Estates Legionella and Water Safety Control Team Estates Legionella and Water Safety Control Team 18

19 10 Relevant Legislation; National Guidance and Associated NUH Documents Acts: Environment Protection Act 1990 Environment Act 2005 Food Safety Act 1990 Health and Safety at Work Act 1974 Health Act 2006 Occupiers Liability Act 1957 Regulations that Underpin the Acts: Construction (Design and Management) Regulations 2007 Control of Substances Hazardous to Health Regulations 2002, Regulation 6 (COSHH) Health & Safety Commission Approved Code of Practice & Guidance 2000 The Control of Legionella bacteria in water systems (L8) The Management of Health and Safety at Work Regulations 1992 and The Health and Safety (Miscellaneous Amendments) Regulations 2002 The Public Health (Infectious Diseases) Regulations 1988 The Water Supply (Water fittings) Regulations 1999 The Water Supply (Water Quality) Regulations 2000 British Standards: BS EN806-2:2005 Specification for installations inside buildings conveying water for human consumption. BS EN1267:2009 Chemicals used for treatment of water intended for human consumption. Chlorine dioxide generated in situ BS1710:1984 Specification for identification of pipeline services BS4485-3:1988 Water Cooling Towers. Code of Practice for Thermal and Functional Design BS4485-4:1996 Water Cooling Towers. Code of Practice for Structural Design and Construction BS5589:1989 Code of Practice for Preservation of Timber BS ISO6144:2006 Gas analysis. 19

20 BS6700:2006 Design, installation, testing and maintenance of services supplying water for domestic use within buildings and their curtilages BS6920-4:2001 Suitability of non metallic products for use in contact with water intended for human consumption with regard to their effect on the quality of the water BS7592:2008 Sampling for Legionella Bacteria in Water Systems. Code of Practice BS7671:2008 Requirements for Electrical Installations. IEE Wiring Regulations, 17th Edition BS8580:2010 Water Quality - Risk Assessments for Legionella. Code of Practice. ISO/IEC17025:2005 General requirements for the competence of testing and calibration laboratories Department of Health Guidance: Health Facilities Notes Heath Building Notes Health Guidance Notes Health Technical Memorandums The Control of Legionella, hygiene, safe hot water, cold water and drinking water systems HTM Part A and Part B Health Technical Memorandum 64: Sanitary assemblies Heating and ventilation systems Health Technical Memorandum 03-01: Specialised ventilation for healthcare premises. Health Guidance Note Safe hot water and surface Temperatures 1998 National Health Service Model engineering specifications D 08 Thermostatic mixing valves (Healthcare Premises) Model Engineering Specification C Rev 3 PHLS Hygiene for Hydrotherapy Pools nd Edition Health Building Note 13 Sterile Service Departments 2004 Other Guidance Water Fittings and Materials Directory (Water Regulations Advisory Scheme) CIBSE Commissioning Code W: Water Distribution Systems (2010) 20

21 BSRIA s Application Guide 1/87: Operation and maintenance manuals for building services installations (1990). NUH Legionella Management & Control Procedures 21

22 January Appendix A Equality Impact Assessment Q1. Date of Assessment: 6 February 2013 Q2. For the policy and its implementation answer the questions a c below against each characteristic (if relevant consider breaking the policy or implementation down into areas) Protected Characteristic a) Using data and supporting information, what issues, needs or barriers could the protected characteristic groups experience? i.e. are there any known health inequality or access issues to consider? b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics, screening c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality The area of policy or its implementation being assessed: Race and Ethnicity Not Applicable N/A Not Applicable Gender Not Applicable Not Applicable Not Applicable Age Not Applicable Not Applicable Not Applicable Religion Not Applicable Not Applicable Not Applicable Disability Not Applicable Not Applicable Not Applicable Sexuality Not Applicable Not Applicable Not Applicable

23 January 2013 Pregnancy Maternity Gender Reassignment and Marriage and Civil Partnership Socio-Economic Factors (i.e. living in a poorer neighbour hood / social deprivation) Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable Area of service/strategy/function Q3. What consultation with protected characteristic groups inc. patient groups have you carried out? Not Applicable Q4. What data or information did you use in support of this EQIA? Not Applicable Q.5 As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments? None Q.6 What future actions needed to be undertaken to meet the needs and overcome barriers of the groups identified or to create confidence that the policy and its implementation is not discriminating against any groups What By Whom By When Resources required None identified - - -

24 Q7. Review date On review of this policy January 2013

25 January Appendix B Environmental Impact Assessment The purpose of an environmental impact assessment is to identify the environmental impact of policies, assess the significance of the consequences and, if required, reduce and mitigate the effect by either, a) amend the policy b) implement mitigating actions. Area impact of Environmental Risk/Impacts to consider Action Taken (where necessary) Waste and Is the policy encouraging using more materials/supplies? materials Is the policy likely to increase the waste produced? Does the policy fail to utilise opportunities for introduction/replacement of materials that can be recycled? Soil/Land Is the policy likely to promote the use of substances dangerous to the land if released (e.g. lubricants, liquid chemicals) Does the policy fail to consider the need to provide adequate containment for these substances? (e.g. bunded containers, etc.) Water Is the policy likely to result in an increase of water usage? (estimate quantities) Is the policy likely to result in water being polluted? (e.g. dangerous chemicals being introduced in the water) Does the policy fail to include a mitigating procedure? (e.g. modify procedure to prevent water from being polluted; polluted water containment for adequate disposal) No No No Yes See guidance below No Yes See guidance below Yes See guidance below No

26 January 2013 Air Is the policy likely to result in the introduction of procedures and equipment with resulting emissions to air? (e.g. use of a furnaces; combustion of fuels, emission or particles to the atmosphere, etc.) Does the policy fail to include a procedure to mitigate the effects? Does the policy fail to require compliance with the limits of emission imposed by the relevant regulations? Energy Does the policy result in an increase in energy consumption levels in the Trust? (estimate quantities) Nuisances Would the policy result in the creation of nuisances such as noise or odour (for staff, patients, visitors, neighbours and other relevant stakeholders)? No No No No No Soil/Land and Water Guidance: The acceptable levels of impact on the environment are stated below as set out following discussion with Severn Trent Water for using Chlorine Dioxide and Sodium Hypochlorite which are mentioned in this policy and procedure. Chlorine Dioxide when used on Ward E17 at the QMC is kept low in order to keep the total oxidants within the Secretary of State's legal requirement (for drinking water) BS EN12671:2009 of 0.5ppm at the water outlets. This therefore does not have an impact on the environment. Chlorine Dioxide solutions do not require neutralisation prior to disposal to foul sewer BUT disinfectant solutions of more than 2000 litres must be neutralised before disposal with sodium bisulphite (SB) or sodium

27 January 2013 thiosulphate (ST) at the rate of 350 gm SB/m 3 or 525 gm ST/m 3 of disinfectant solution with a residual level of acceptance of below 20ppm. Chlorine dioxide does not chlorinate organic material, resulting in significant decreases in trihalomethanes (THMs), haloacetic acids (HAAs) and other chlorinated organic compounds. Other properties of chlorine dioxide make it more effective than chlorine, enabling a lower dose and resulting in a lower environmental impact. Sodium Hypochlorite solutions do not require neutralisation prior to disposal to foul sewer BUT disinfectant solutions of more than 5000 litres must be neutralised before disposal with sodium bisulphite (SB) or sodium thiosulphate (ST) at the rate of 350 gm SB/m 3 or 525 gm ST/m 3 of disinfectant solution with a residual level of acceptance of below 50ppm.

28 January Appendix C Here For You Assessment The We Are Here For You service standards have been developed together with more than 1,000 staff and patients. They can help us to be more consistent in what we do and say to help people to feel cared for, safe and confident in their treatment. The standards apply to how we behave not only with patients and visitors, but with all of our colleagues too. They apply to all of us, every day, in everything that we do. Therefore, their inclusion in Policies and Trust-wide Procedures is essential to embed them in our organization. Please rate each value from 1 3 (1 being not at all, 2 being affected and 3 being very affected) Value 1. Polite and Respectful Whatever our role we are polite, welcoming and positive in the face of adversity, and are always respectful of people s individuality, privacy and dignity. 2. Communicate and Listen We take the time to listen, asking open questions, to hear what people say; and keep people informed of what s happening; providing smooth handovers. 3. Helpful and Kind All of us keep our eyes open for (and don t avoid ) people who need help; we take ownership of delivering the help and can be relied on. 4. Vigilant (patients are safe) Every one of us is vigilant across all aspects of safety, practices hand hygiene & demonstrates Score (1-3)

29 January 2013 attention to detail for a clean and tidy environment everywhere. 5. On Stage (patients feel safe) 1 We imagine anywhere that patients could see or hear us as a stage. Whenever we are on stage we look and behave professionally, acting as an ambassador for the Trust, so patients, families and carers feel safe, and are never unduly worried. 6. Speak Up (patients stay safe) 1 We are confident to speak up if colleagues don t meet these standards, we are appreciative when they do, and are open to positive challenge by colleagues 7. Informative 1 We involve people as partners in their own care, helping them to be clear about their condition, choices, care plan and how they might feel. We answer their questions without jargon. We do the same when delivering services to colleagues. 8. Timely 1 We appreciate that other people s time is valuable, and offer a responsive service, to keep waiting to a minimum, with convenient appointments, helping patients get better quicker and spend only appropriate time in hospital. 9. Compassionate 1 We understand the important role that patients and family s feelings play in helping them feel better. We are considerate of patients pain, and compassionate, gentle and reassuring with patients and colleagues. 10. Accountable 1 Take responsibility for our own actions and results 11. Best Use of Time and Resources 1 Simplify processes and eliminate waste, while improving quality 12. Improve 1 Our best gets better. Working in teams to innovate and to solve patient frustrations TOTAL 12

30 14 Appendix D Certificate of Employee Awareness Document Title Legionella Management and Control Policy Version (number) 4 Version (date) 8 I hereby certify that I have: Identified (by reference to the document control sheet of the above policy/ procedure) the staff groups within my area of responsibility to whom this policy / procedure applies. Made arrangements to ensure that such members of staff have the opportunity to be aware of the existence of this document and have the means to access, read and understand it. Signature Print name Date Directorate/ Department The manager completing this certification should retain it for audit and/or other purposes for a period of six years (even if subsequent versions of the document are implemented). The suggested level of certification is; Clinical directorates - General Manager Non clinical directorates - Deputy Director or equivalent. The manager may, at their discretion, also require that subordinate levels of their directorate / department utilize this form in a similar way, but this would always be an additional (not replacement) action.

31 15 Appendix E Contact Information Cross Campus Assistant Head of Operations Responsible Person (Water) NUH Andrew Camina Extension Estates & Facilities Health and Safety Manager Lesley Khan Extension City Campus Estates Operations Manager Engineering Chris Smith Estates Operations Officer Engineering Site Responsible Person (Water) Nick Taylor Estates Operations Officer Responsible Person (Water) Paul Grice Engineering Deputy Site QMC Campus & Ropewalk House (Including Cooling Towers) Estates Operations Manager Engineering Gareth Jones Estates Operations Officer Engineering Site Responsible Person (Water) Geoff Leafe Estates Operations Officer Responsible Person (Water) Clive Grimshaw Engineering Deputy Site

NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST. PATIENT DATA QUALITY POLICY Documentation Control

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