PREMISES MANAGEMENT PROCEDURES GUIDANCE BOOKLET LEGIONELLA

Transcription

1 PREMISES MANAGEMENT PROCEDURES GUIDANCE BOOKLET LEGIONELLA Control of Water Hygiene (including Legionellosis risk) within Dorset County Council Occupied Premises Version 2 November 2011 Issued by: Dorset Property Dorset Property Princes House Princes Street Dorchester Dorset DT1 1TP Tel:

2 Contents 1. Introduction Purpose of this procedure Background to Legionella and prevention of Legionellosis Legionella in water systems Responsibility (who does what) Summary: Dorset County Council water hygiene management (Legionellosis risk) Risk Management Strategy Overview Premises level procedures: The Legionella log book Schematics plans of water systems Sampling protocol Training Approved panel of contractors and consultants Competent help Risk review and risk reassessment survey Directorate responsibility Management accountability Premises acquisition/disposal strategy Monitoring of site procedures Asset Management Plans (AMP) and Legionella Legionella Risk Register: Risk assessment action plan Operational procedures for building engineering systems Design standards for building engineering systems Risk assessment procedure (initial request) Legionella sampling Flowchart - Procedure when receiving Legionella positive results Premises Responsible Person (PRP) - Guide to managing water hygiene on site Introduction Understanding your risk assessment and reviewing it The written scheme Summary of typical site procedures The water hygiene log book Appendix A Water Hygiene Logbook Pro-forma Page 2 of 21

3 1. Introduction 1.1. Purpose of this guide The purpose of this guide is to communicate the importance of water hygiene to all those who have premises responsibility. This guide defines the role of the Council, the Service Directorates and Site Staff in the management of risk and should be read and understood. Non-DCC premises (e.g. joint use premises, Voluntary Aided Schools etc) fall out of the responsibility hierarchy, however, they may wish to adopt this strategy for their assurance purposes. This guide is part of a suite of documents which detail the appropriate management of building risks. Please refer to the strategy document for full details of responsibility in accordance with Dorset County Council s Health and Safety Policy. If there is any doubt about the content or implications of this guide the reader should first refer to the strategy document ( Strategy and Responsibility Statement Managing risk in the built environment ) and, if still in doubt, contact their appropriate line manager. Whilst Legionella does not have specific legislation governing requirements to manage the hazard (it falls within the Control of Substances Hazardous to Health (COSHH) Regulations), there is a specific Approved Code of Practice - The control of Legionella bacteria in water systems commonly know as the L8 (ACoP L8). This was produced by the Health and Safety Commission which sets out the expectations for managing risk in accordance with Health and Safety at Work Regulations. The Code of Practice identifies the following key actions: A suitable and sufficient assessment should be carried out to identify and assess the risk of Legionellosis from work activities and water sources and establish any necessary precautions Produce an action plan for the management of risk in the form of a written risk minimisation scheme A person should be appointed to be managerially responsible and to provide supervision for the implementation of precautions Implement and manage the precautions to control risk. NB. There are specific regulations relating to using water supplies which are enforced by the water supply companies. Whilst this guide does not deal directly with these, any management of water systems must comply with these regulations. Seek competent advice at all times if altering water systems. Page 1 of 24

4 1.2. Background to Legionella and prevention of Legionellosis Legionellosis is a form of pneumonia caused by inhaling airborne water droplets (aerosols), which are contaminated with bacterium of the Legionella species. Legionnaires Disease is one form of Legionellosis. Legionella can also cause less serious illnesses which are not fatal or permanently debilitating but which can affect all people. There is no evidence to show that the disease can be contracted from someone who is already infected or from drinking water containing the bacterium. Between cases of Legionnaires Disease are reported in England and Wales each year, compared with 180,000 cases of pneumonia from all causes. It principally affects those who are susceptible due to age, illness, immunosuppressant, smoking etc and can be fatal. Most cases have been in people aged between Legionella in water systems The bacterium causing Legionellosis can be found in most water systems, and the precise details of the means of contracting the disease are still a little speculative. However, the conditions necessary for the development and proliferation of the bacterium in the water system are known. These include: Dirty water systems The presence of sludge, scale, rust, algae and organic matter Water temperatures between C. - Legionella will multiply fastest at C. It will be killed at water temperatures above 50 0 C. Below 20 0 C it will stay dormant but will grow if the water temperature is raised and other conditions are favourable. The aim should be to reduce the risk to an acceptable level by controlling the conditions necessary for proliferation of the Legionella bacterium and all other common water borne bacteria. In practice this means: Keeping the hot water storage temperature at greater than 60 0 C, or fitting a water treatment system. Ensuring hot water distribution temperatures are above 50 0 C, or fitting a water treatment system. Maintaining cold water temperatures at less than 20 0 C. Keeping water systems clean and in good condition. Avoiding contamination of the water systems. Preventing stagnation due to the unnecessary storage of water or underutilised fittings. Maintaining and keeping in good working order any water treatment systems installed. In order to achieve this aim a programme of detailed Legionellosis risk assessments and reassessments of all Council properties is to be undertaken by competent persons. External providers should be accredited under a recommended code of conduct produced by the Legionella Control Association. Page 2 of 21

5 A systematic approach to assessing risk should be applied to the water systems, with particular reference to the factors which influence proliferation of the bacterium (i.e. cleanliness, condition, temperature, etc.), in accordance with BS The risk assessment survey results produce recommendations for the control of the bacterium. A variety of measures may be required in order to reduce risk. Risk of scalding At temperatures above 43 0 C there is a danger of scalding which increases with temperature. The risk depends on temperature and time of contact and will be greater for the following group of people: Young children of nursery and foundation stage age The elderly Persons with sensory impairment. Under normal circumstances the exposure to most other people from the temperatures of hot water and surfaces found in Council buildings should not present a significant risk. The NHS Guidance Note (HGN) - "Safe hot water and surface temperatures 1998" applies to all healthcare premises and those premises registered under the Registered Homes Act As some of the Council properties are not within either of these two categories then strictly they do not fall within the remit of this guidance. However the guidance note does state that it may also be appropriate to apply it to non-registered premises or where the occupants are equally at risk. The guidance recommends that a risk assessment should be made of all outlets and surfaces to enable the production of an action plan or risk minimisation scheme. Refer to DCC Strategy BEDS002, appended to the Design Guide - held and maintained by Dorset Property 1.4 Responsibility (who does what) The Guidance (Approved Code of Practice) Control of Legionella Bacteria in Water Systems (commonly known as L8) requires The Duty Holder (the employer or self-employed person or person in control of the water systems within a premises*) to; Have a suitable and sufficient risk assessment carried out on water systems in order to assess the specific risks and to aid the implementation of a management plan (written scheme) Appoint a Responsible Person for controlling the day to day risks. *Where no individual (organisation or person) can be identified, such as joint use properties, then a written agreement should be compiled detailing roles and responsibilities relating to water management of the property in question. Page 3 of 21

6 Implementation of L8 at Dorset County Council is as follows: Chief Executive (or governing body for some Schools) Corporate Duty Holder/ Duty Holder Head of Directorate Delegated responsibilities from Chief Executive Directorate Duty Holder - Premises Delegated responsibilities from Directorate Head Premises Responsible Person identified individual (usually head of site) who has delegated daily responsibilities - could be multiple Supported by: The Competent Person(s) within Dorset Property, external competent risk assessors and competent water system contractors. Outline of individuals responsibility ACTIVITY Setting strategy with regards to Legionellosis risk Provision of general guidance on Legionellosis and water hygiene in general Risk assessment Management of risk assessment programme PERSON RESPONSIBLE Corporate Duty Holder Mike Harries. Head of Dorset Property (On behalf of the Chief Executive) The designated Competent Person Mike Taylor. Dorset Property (Corporate Assurance) Designated Competent Person (or appointed specialist consultant) Directorate Duty Holder Decision regarding approved operating temperatures Risk management actions from risk assessment Operation under approved temperatures and conditions Maintain record of temperature checks in order to evaluate performance Directorate Duty Holder (Competent Person if special requirements apply) Directorate Duty Holder Premises Responsible Person Premises Responsible Person Avoidance of stagnation within water systems Identification of little used outlets and maintaining record of flushing regimes Maintenance/inspection of water services plant and equipment Premises Responsible Person Premises Responsible Person Directorate Duty Holder Page 4 of 21

7 1.4. Summary: Dorset County Council water hygiene management (Legionellosis risk). All occupied properties which have water systems within them should have a current formal risk review and action plan (refer to flowchart 2.8: risk management scheme procedures). Any Legionella risk is then managed as follows (each of the subjects below are explained fully later in this guide): Mitigate risk by elimination Manage remaining risks by creating a Written Scheme which may include: o Inspection and Maintenance of Risk Systems o Temperature management o Cleaning of risk outlets o Flushing regimes o Reducing the size of water systems o Disinfection Regularly review and reassess (as appropriate). Page 5 of 21

8 2. Risk Management Strategy 2.1. Overview. The strategy for the implementation of the Legionellosis risk management is as follows: Identify Legionellosis risk at each premises Remove, or reduce to an acceptable level Have clear procedures for the management of Legionellosis risk in premises i.e. the written scheme Define the responsibilities of Dorset County Council staff who are involved with the management of Legionellosis risk in buildings Appoint a named officer as the Competent Person (Legionella sp.) Maintain water systems in a safe condition Maintain a central database Raise awareness Only use competent Consultants who are members of the Legionella Control Association Use only materials which are listed in the latest addition of the WRc/WRAS Approved Materials document Only use competent Contractors, listed and approved by Dorset County Council for remedial works to minimise Legionellosis risk Ensure that all contractors are of approved plumber 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 Premises level procedures: The Legionella log book. The Premises Responsible Persons shall implement procedures set out in the premises log book accompanying this guide and shall ensure liaison with staff from Dorset Property and the management of contractors operating in their buildings. The required procedures include; Ensure water systems are operated at the correct temperatures as identified on the record sheets Ensure that hot and cold water temperatures are monitored and the temperatures recorded Report any significant deviations from the recommended temperatures to the Directorate Duty Holders/Competent Person Identify infrequently used outlets, run weekly for at least 2 minutes, consider removal Ensure regularly used shower heads are cleaned at the frequency identified in the written scheme for the premises Avoid stagnation of water in pipework. Ensure that all outlets are run on a regular basis (at least weekly for a minimum of 2 minutes) consider removal if a basin or other outlet is no longer used/required Seek advice from the Directorate Duty Holders should all or part of the property be reoccupied after mothballing for a period in excess of two weeks Avoid contamination of the water systems Avoid the creation of unnecessary aerosols of water (small droplets of airborne water) Page 6 of 21

9 Inform the Competent Person of any activity or occurrence which you believe may jeopardise water hygiene Ensure all water storage, hot water generation plant, distribution systems and any water treatment systems are inspected and maintained by a competent contractor Ensure that a risk assessment of hot water services is carried out when altering the operational use of an area or integrating more vulnerable persons with special needs into the working environment Consider any actions that may be necessary to protect all persons who may be at risk from scalding. A hard copy of the water hygiene risk assessment (the Legionellosis risk register) shall be forwarded to the Premises Manager for retention within the Premises Log Book. He/she will be responsible for advising amendments to the Register to the Directorate Duty Holders and the County Council s designated Competent Person. The Directorate Duty Holder shall ensure that the water hygiene risk assessment (the Legionellosis risk register) relating to each premises is reviewed annually and should ensure that a new assessment survey is undertaken by a competent person whenever there is doubt regarding the continued relevance of the existing documented survey. Note: If any modification to water systems is undertaken the Directorate Duty Holder and/or the Competent Person must be notified to allow updating of the Legionellosis survey information where appropriate. Risk minimisation measures such as system inspections and monitoring of water temperatures, as detailed in the specific risk assessment for the site, must be regularly undertaken by the Premises Responsible Person appointed by the Directorate Duty Holder. Any variation must be actioned immediately either by reporting to Dorset Property s helpdesk or instructing an approved Legionellosis contractor to carry out remedial works. A hard copy of the monitoring records shall be filed in the premises log book. These records shall be held for 5 years (please keep the record keeping sheets supplied with this manual as masters and copy the sheets for record keeping purposes) Schematics plans of water systems Schematics will be prepared for all premises where necessary, unless agreed with the County Council s Competent Person. Schematics will be prepared for all EPH s, special schools, residential homes, day care centres and any other site where the exposed population includes particularly susceptible individuals. Schematics will only be prepared for all other sites, if: the domestic hot water system has a capacity of greater than 300 litres the domestic cold water system has a capacity of greater than 1000 litres. Basic distribution line schematics will be prepared. These will not be to scale, but will simply be an extension of the risk assessment, designed to identify approximate layout, deadlegs and temperature test points. Schematics will not be produced for mains fed point-of-use domestic hot water systems Sampling protocol Sampling for the presence of Legionella bacteria, for general TVCs (total viable aerobic bacterial count), or for specific coliforms will only be undertaken where assessed as necessary by the Competent Person. Page 7 of 21

10 Sampling will be undertaken where temperatures fall within the following criteria and additional factors persist that could indicate an elevated risk (see premises specific Written Scheme ). System Type Capacity* Storage Temperature: Sample required: DHWS DCWS L <45 o C Yes (TVC) >45 o C No >300L <50 o C Yes (Legionella sp) >50 o C No <1000L <30 o C No >30 o C Yes (TVC) >1000L <25 o C No >25 o C Yes (TVC) *No samples to be taken from DHWS systems of less than 150 litres. In addition TVC samples may be taken if bio-fouling (surface scum or similar), heavy sediment, corrosion, discoloured water or bio-odours are reported. Samples for Legionella sp. will only be taken where specifically required, i.e. where the Competent Person deems necessary in response to a specific need (refer to 3.10 for action plan following a positive return) Training The County will implement a programme of risk awareness to include specific training for all duty holders and responsible persons. All training will be delivered by a competent person. A central record will be maintained of all training. All persons who are involved in property management including Heads of Service, Premises Managers, Supervising Officers, Site Managers, Caretakers, Consultants and Contractors require appropriate levels of training as set out in the Legionellosis Code of Practice L Approved panel of contractors and consultants Consultants and contractors must be selected from the approved panels of contractors and consultants. Consultants are to be members of the Legionella Control Association (LCA) as specified by L8, and must on request supply their certificate of membership. Contractors who are appointed to undertake risk management or mitigation works must be members of the LCA. If a Premises Manager wishes to appoint consultants or contractors directly for works involving Legionellosis risk, it is strongly advised that only companies that appear on the Dorset County Council approved lists/ frameworks should be selected. If a Premises Manager appoints a Page 8 of 21

11 contractor or consultant who does not appear on the Dorset County Council panel they shall be responsible for evaluating their competence Competent help A Competent Person will be nominated by the Corporate Duty Holder. This person will have a thorough knowledge of the control of Legionellae, be fully conversant with the design principles and requirements of water systems, including their effective operation and maintenance, and will be a Chartered Engineer. The nominated competent person will have access to specialist support in specific areas such as water treatment and microbiology. The role of the Competent Person shall be: Advising on the potential areas of risk and identifying where systems do not comply with published guidance Advising on the necessary continuing procedures for the prevention of Legionellosis Auditing the implementation and efficacy of those procedures Approving and identifying any changes to those procedures Risk review and risk reassessment survey The ACoP requires that the risk assessment should be reviewed regularly (at least every two years) and, whenever there is reason to suspect that it is no longer valid. This review will be undertaken annually by the Premises Responsible Person and recorded on the C1 form and will consider; Changes to the water system or its use Changes to the use of the building in which the water system is installed The application of the written scheme The results of checks following control measures failure reports. In conducting this review, the Premises Responsible Person will have access to competent help if required. By noting that a reassessment is required, and the reasons why, on the annual return to the Directorate Duty Holder a formal risk reassessment survey will be commissioned. Pending a full reassessment survey the Competent Person may undertake an audit of the risk and the management procedures to establish any corrective actions. Alternatively the Premises Responsible Person can make a direct request to the Competent Person for help and support in assessing the need for a risk reassessment survey. In addition to the annual risk review a rolling programme of risk reassessment surveys will be undertaken. The frequency of these reassessment surveys will be determined from a desk top appraisal of the inherent risk. Each premises is categorised by occupation/function and likelihood of proliferation/transmission, using a risk matrix, to determine its underlying risk profile. This categorisation will be undertaken by the Competent Person and will be used solely for the purpose of determining the frequency of risk reassessment survey. The inherent risk may not equate to the actual risk profile of that premises as determined by site survey*. (*This risk profile assumes that the procedural requirements of this guide are in place and the requirements of the written scheme have been addressed). Page 9 of 21

12 3. Directorate responsibility 3.1. Management accountability The Directorate Duty Holder shall ensure that a current risk assessment survey report is available for each premises within his property portfolio (see 3.8; risk assessment procedure flowchart) and that the actions arising from this survey report have been addressed appropriately (see 3.5;risk assessment action plan flowchart overleaf). The prime purpose of these procedures is to be able to demonstrate that Directorate Duty Holders have identified all relevant factors, have established appropriate corrective or preventative action and are monitoring that management plans are being implemented Premises acquisition/disposal strategy DCC operates a system of formal procedures for the acquisition, closure and disposal of premises. Whenever a premises is acquired, closed or transferred to another Directorate (in whole or in part), the incumbent Duty Holder should advise Dorset Property Corporate Assurance Team in addition to the Property Database Team. The Directorate Duty Holder shall ensure that the appropriate risk assessments and operational procedures are in place and that a Premises Responsible Person is allocated to the property at all times Monitoring of site procedures The Corporate Duty Holder must have access to competent help in the implementation of measures to control the risk of legionnaires disease and the Competent Person will undertake site audits on behalf of the Directorate Duty Holder. The site audits will be issued to the designated Premises Responsible Person and a summary of audit findings reported to the Directorate Duty Holder Group. The Premises Responsible person (see section 2.8: risk review and risk assessment survey) is required to return an annual submission for statutory management of premises risks. The water hygiene form C1 should be used to verify that site procedures are being undertaken and Directorate Duty Holders should ensure that this form is submitted to them annually. NB. The form may include actionable items and these must be discussed with the competent person Asset Management Plans (AMP) and Legionella Legionella risk management is an integral part of condition assessment procedures and Directorate Duty Holders must ensure that Legionella mitigation works are incorporated in asset management planning. The AMP Condition Assessment is used to inform the annual repairs and maintenance programme. An element given a D1 rating denotes a potential health and safety risk and is given the highest priority in the annual repairs and maintenance programme. Legionella risks fall into this category. Page 10 of 21

13 The AMP Condition Assessment on the database is a live document which can be updated/edited at any time by the Area Property Surveyors within Dorset Property. Medium and low risk mitigation work arising from the Legionella Risk Assessment Survey should be added to the AMP for the Premises Responsible Person to discuses with the assigned Property Surveyor. The Duty Holder must ensure that the PRP is aware of this and resources are available to mitigate risks as appropriate. The vast majority of properties in Dorset are subject either to a Service Level Agreement with Dorset Property or belong to the DCC Building Maintenance Indemnity Scheme (BMIS) and will have an allocated an Area Property Surveyor who will review the condition assessment of the property. Annual condition surveys are undertaken in all properties, although schools that do not have a Service Level Agreements (such as BMIS, DMIS, EDMIS etc) may not have an allocated DCC Area Property Surveyor. In these cases a condition survey will be undertaken by DCC for corporate assurance purposes and Dorset Property will write to the school listing any concerns, together with general Maintenance and Inspection advice, in a standard letter format. This letter will ask for conformation that the findings of the survey are acknowledged. If a site does not acknowledge receipt within a reasonable timescale the AMP Surveyor will advise the Directorate concerned. The AMP Condition Assessment is formally reviewed by a structured site survey every fifth year. Legionella issues and water regulations requirements are separately identified during this quinquennial survey and all water management issues linked together as an item on the AMP Condition Assessment. These quinquennial forms are reviewed by the Competent Person and a separate form produced, C3: Legionella Risk Evaluation, where a specific Legionella risk is identified which requires highlighting. The Directorate Duty Holder should ensure that the recommended actions are included in asset management planning as a priority and that the C3 form is completed and returned to the Competent Person. Page 11 of 21

14 3.5. Legionella Risk Register: Risk assessment action plan Corporate Duty Holder: Dorset Property Commission initial risk survey of property Review risk report (update data base) Implement remedial actions (< 9mnths) (non-schools) Issue report to property update report Area surveyor to review AMP (D1 priority work) Review risk report (log actions) Action identified mitigation work Establish documented management procedures Update AMP with outstanding actions (D1 priority work) Instigate AMP works in accordance with update report Regularly review management procedure records (C1 Review property portfolio. Review PRP training Have there been changes to any site since the last risk assessment? Notify competent person Page 12 of 24

15 3.6. Operational procedures for building engineering systems Temperature regimes will be employed for Legionellae control in all DCC premises, i.e. hot water should be stored at 60ºC and distributed so that it reaches a temperature of 50 C within one minute at outlets. Alternative operating temperatures will only be permitted where they have been authorised by the Competent Person and adequate control mechanisms are in place. Operating at lower temperatures to avoid scalding risk will not be acceptable without a stringent procedure for monitoring of water quality. Determination of scalding risk is the responsibility of the Directorate Duty Holder, for guidance refer to Building Engineering Design Standard BEDS002. Where fail safe thermostatic mixing valves have been installed to eliminate scalding risk they should be tested/serviced in accordance with the requirements of the Thermostatic Mixing Valve Association at intervals not exceeding six months. If precautions are to remain effective, the condition and performance of the water systems should be monitored. The frequency and extent of routine monitoring will depend on the size and operating characteristics of the system, but should be at least annually for any centralised water distribution system. The Duty Holder should ensure that engineering systems are regularly inspected and that such inspections encompass the minimum tasks identified on standard forms PH01 to PH06 (see Appendix to this document). The results of these inspections/checks should be retained for at least five years. These regular inspections are technical tasks which, in most circumstances, will require the use of a Specialist Contractor. Dorset Property maintains a list of suitable contractors who are WIAPS Approved Plumbers and/or registered with the Legionella Control Association (LCA) and who have received awareness training with respect to DCC Strategy. Dorset Property manages a term maintenance contract which may be suitable, particularly if the property has thermostatic mixing valves or shower provisions, contact Dorset Property for further information. Page 13 of 24

16 3.7. Design standards for building engineering systems Dorset County Council expects all projects to comply with the following documents; The Water Supply (Water Fittings) Regulations 1999 HSC Approved Code of Practice and Guidance L8: The control of Legionella bacteria in water systems CIBSE TM13: 2002: minimising the risk of legionnaires disease. For the procurement of minor work, such as plant refurbishments and replacements, Duty Holders should refer to DORLRC04: Legionella: Standard Work Specification which is available on the Legionella/water hygiene area of the Intranet. The Project Delivery Protocol incorporates a system of design reviews by Dorset Property Facilities Group and designers should determine that projects have recognised the fundamental requirements for Legionella risk mitigation, Dorset County Council operates a project inspection and acceptance procedure which allocates a Clerk of Works to all major projects. The Competent Person should ensure that Clerk of Works receive awareness training, and regular refresher training, with respect to the prevention of legionnaires disease in building engineering systems. Page 14 of 21

17 3.8. Risk assessment procedure (initial request) Flowchart - Procedure for water hygiene risk assessment implementation and review Water Hygiene risk assessment present? Y Is there a property specific management plan (the written scheme )? Y Is the risk assessment current and no changes within the water systems? Y N N N Refer to the assigned competent person for action. New risk assessment commissioned by competent person (CP) and issued to site (following review by CP). Review action plan and ensure all items have been implemented and understood. New risk assessment required? Y Implement written scheme. N Append risk review audit (by competent person) to existing risk assessment. Review annually or when there is a change in the water systems or how they are used. Page 15 of 24

18 3.9. Legionella sampling Legionella sampling will only be undertaken where the Competent Person has identified a particular need (see 1.8:sampling protocol); As necessary to verify the operation of a control regime (e.g. where temperature control is not the primary risk management procedure) Failure of, or concerns about, control measures A novel situation or item of equipment that is perceived to have an elevated risk to health. Following a Legionella sampling of hot and cold water systems the action levels for positive Legionella counts will be taken from the ACoP L8, Table 4. Those systems that have counts of <1000 cfu requires the following action: Retested immediately Premises Responsible Person notified A disinfection programme will be determined by the Competent Person following a risk assessment review which may require notification to Directorate Duty Holder and Corporate Duty Holder Those systems that have counts >1000 cfu Shall be subject to an immediate disinfection programme (thermal or chemical) All associated parties notified, i.e. PRP, DDH, Corporate DH, Health & Safety Dept, and Publicity Dept. The risk review may also require notification to the Health Protection Agency (e.g. if premises closure may be deemed necessary). Consultation with the HPA will establish further actions and all parties must be kept fully informed of decision and their implications (see attached flowchart 3.10). Page 16 of 24

19 3.10. Flowchart - Procedure when receiving Legionella positive results Positive Legionella counts received. Competent person reviews the risk and produces report and action plan. N Is risk high? * Y Inform: Head of PMD Directorate Duty Holder County Health and Safety Team (HPA) Communications Unit. Inform Premises Responsible Person. Close water systems/building/parts of building as appropriate. Thermally disinfect system Re-test for Legionella. Chemically disinfect system and recommission (but do not open system). Legionella Positive? Y N Open water systems/ building/ parts of building as appropriate. Amend water management procedures and implement as appropriate. Monitor and review. Carry out 2 nd Legionella re- test. * Risk assessed on following criteria: - LP > 1000 c/u - Susceptible population - Potential for aerosol generation Legionella Positive? Inform: Head of PMD Directorate Duty Holder County Health and Safety Team (HPA). Page 17 of 21

20 4. Premises Responsible Person (PRP) - Guide to managing water hygiene on site 4.1. Introduction All water systems within sites will require some management, however, the key points are: Keep equipment clean and well maintained Avoid water temperatures between 20 o c and 50 o c Avoid stagnation Keep accurate records Regularly audit procedures. Each and every establishment shall have a standard Legionellosis risk management log book which documents the measures undertaken to minimise Legionella proliferation within the building s water systems. The log book pro-forma, at the end of this document, will enable the site manager to compile records and aid the management of site risks associated with water hygiene. Whilst the risk of contracting Legionellosis is low it is important that day-to-day management procedures are property documented and can be audited. The PRP should compile a premises log book in order to keep records and manage Legionella risk (see log book pro-forma appendix) Understanding your risk assessment and reviewing it Dorset Property, Corporate Assurance Section, will issue a copy of the water hygiene risk assessment survey report to the Premises Responsible Person for retention with the Legionella log book. This report will contain corrective actions and it is the Premises Responsible Person s responsibility to review these actions in conjunction with their Directorate Duty Holder/Premises Surveyor to ensure that they are addressed within the identified time scales. The Premises Responsible Person shall annotate the site copy of the risk assessment report with the actions taken in this respect. The ACoP requires that the risk assessment should be reviewed regularly (at least every two years) and, whenever there is reason to suspect that it is no longer valid. This review will be undertaken by the Premises Responsible Person and recorded on the C1 form (see appendix A, Section 2 annual return ) and will consider: changes to the water system or its use changes to the use of the building in which the water system is installed the application of the written scheme the results of checks indicating that control measures are no longer effective. In conducting this review, the Premises Responsible Person will have access to competent help if required. By noting that a reassessment is required, and the reasons why, on the annual return to the Directorate Duty Holder a formal risk reassessment survey will be commissioned. Pending a full reassessment survey the Competent Person may undertake an audit of the risk and the management procedures to establish any corrective actions. Alternatively the Premises Responsible Person can make a direct request to the Competent Person for help and support in assessing the need for a risk reassessment survey. Page 18 of 21

21 In addition to the annual risk review a rolling programme of risk reassessment surveys will be undertaken. The frequency of these reassessment surveys will be determined from a desk top appraisal of the inherent risk. Each premises is categorised by occupation/function and likelihood of proliferation/transmission, using a risk matrix, to determine its underlying risk profile. This is carried out by the Competent Person (within DCC) and will be used solely for the purpose of determining the frequency of risk reassessment survey. The inherent risk may not equate to the actual risk profile of that premises as determined by site survey*. (*This risk profile assumes that the procedural requirements of this guide are in place and the requirements of the written scheme have been addressed) The written scheme Each property should have a documented risk management procedure formulated from the risk assessment. This document is referred to as the written scheme (see section 1 of the Appendix)and sets out the requirements for the safe operation and maintenance of all risk systems. The scheme will establish: the parameters for the correct operation of the plant and any precautions to be taken details of any start-up and shut-down procedures, plant rotation and method statements for specific tasks outline any tests that are to be completed on the systems, along with the required frequency of the tests and the acceptable control parameters short-term control measures to be applied until completion of corrective actions and long-term control measures to be applied following completion of corrective actions Summary of typical site procedures Risk assessment The appointed Premises Responsible Person should ensure that they have a current, and suitable, risk assessment in place. Where the risk assessment identifies that site conditions may permit the proliferation of unacceptable levels of Legionella sp. bacteria the recommended remedial work(s) must be undertaken as soon as reasonably practicable, and funded accordingly. The Premises Responsible Person should liaise with their Directorate Duty Holder in this respect. Where the risk assessment identifies that site conditions may permit the proliferation of minimal levels of Legionella sp. bacteria, (although the water system complies with current best practice to prevent bacterial growth) the Premises Responsible Person should implement a risk management procedure as detailed in the written scheme Communication hierarchy Responsibility for design, operation and maintenance of water systems and procedures for the control of Legionellosis is allocated to specific individuals, as summarised in 1.4 of this guide. Page 19 of 21

22 Precautions and actions The key points to remember are: Keep water storage and distribution equipment clean and well maintained. Ensure water outlets - taps and shower heads - are regularly cleaned Avoid water temperatures between 20 c and 50 c (note: where outlet temperature is restricted to avoid scalding risk this should be close to the point of discharge) Avoid stagnation Keep accurate records Regularly inspect and monitor, take action if needed Weekly procedure: Ensure that all infrequently used outlets are identified and entered on proforma C5. Flush each outlet. Where groups of outlets are unused (e.g. school holidays) flush each outlet in sequence, commencing with the outlet furthest from the storage, until temperature steadies. Record time taken to reach a steady temperature Monthly procedure: Identify taps that do not have local temperature restriction (thermostatic mixer valve) and record the time taken to reach the maximum/minimum temperature. If time taken exceeds 1 minute or if temperature fails to achieve 50 c (hot)/20 c (cold) log a failure report and notify the Directorate Duty Holder and Dorset Property Help Desk Page 20 of 21

23 Annual procedure: Check that weekly/monthly procedures have been correctly completed and filed. Initial proforma C1 to confirm that weekly/monthly records have been reviewed and that any identified deficiency has been reported and appropriate corrective action taken. Check that the system schematic is representative of the current water storage and distribution arrangements. Any significant changes to the system(s) or to how the system(s) are utilised should be referred to the Directorate Duty Holder for review of the adequacy of the existing risk assessment. Ensure that regular engineering inspection/maintenance reports from a competent water management contractor are completed and filed. Procedure: Frequency: Form C1: Audit site procedures and maintenance/inspection, check schematic is up to date and confirm risk assessment is current Form C4: Water temperature Monitoring Form C5: Identify and flush infrequently used outlets (including temporary and permanent closure of all/part of a building) Form C6: Cleaning of shower heads (refer to maintenance contracts) Annual Monthly from Sentinel Taps Weekly from identified little used outlets 6 monthly The water hygiene log book Compiling you log book will be relatively easy. See supplied pro-forma (appendix a) Key contents are: Up to date Legionella risk assessment (supplied by Dorset Property) which will include: Site risks Items requiring mitigation (to be discussed with your property surveyor) Schematics of water systems Site specific written scheme (for assessments carried out from 2011 on). Page 21 of 21

24 Appendix A Water Hygiene Logbook Pro-forma Page 22 of 21

25 PREMISES MANAGEMENT LEGIONELLA LOG BOOK For Site:

26 Note: This site log book provides the framework for the retention of records in accordance with the Written Scheme for the management of legionellosis risk at the property. Full guidance on processes and procedures relating to water hygiene risk management can be found in guidance booklet on insite or staffnet. Alternatively contact Dorset Property for help; The responsibilities of the named Premises Responsible Person for this site are: The management of identified control measures arising from the risk assessment the Written Scheme (Section 1) A formal annual review of the risk assessment and submission of C1 form to the Directorate Duty Holder (Section 2) Weekly temperature testing of representative hot and cold outlets (Section 3) Weekly review and flushing of all identified infrequently used outlets (Section 4) 6 monthly cleaning of shower heads (or as required by the written scheme) (Section 5) Maintenance of thermostatic mixer valves and the inspection of water supply and storage systems relevant to your property* (Section 6) Implementation of remedial action identified in your risk assessment and annotation of the Action Plan in conjunction with your Property Surveyor (Section 7) *Tasks to be carried out by a competent contractor (all paperwork to be completed by the contractor): 1.1. Key Contacts: Description Name Contact Details Premises Responsible Person Directorate Duty Holder Dorset Property Helpdesk property helpdesk@dorsetcc.gov.uk Dorset Property Competent Person Michael R Taylor m.r.taylor@dorsetcc.gov.uk Water Hygiene Contractor

27 Section 1 The Written Scheme* (*from post 2011 risk assessment) The Written Scheme is a documented risk management procedure which is formulated from the risk assessment and sets out the requirements for the safe operation and maintenance of all risk systems. The scheme establishes; The parameters for the correct operation of the plant and the precautions to be taken; Details of any start-up and shut-down procedures, plant rotation and method statements for specific tasks; Any tests that are to be completed on the systems, along with the required frequency of the tests and the acceptable control parameters; Short-term control measures to be applied until completion of corrective actions and; Long-term control measures to be applied following completion of corrective actions, including the established routine tasks, to ensure the correct and safe operation of the installed systems.

28 Management Procedures for Water Hygiene Risk: The Written Scheme (example) Property: Premises Responsible Person: Overview of operational procedures: The correct operation of the hot water distribution system and the cold water down service system should be monitored monthly by checking outlet temperatures at representative locations. The regular use of all outlets should be monitored on a weekly basis and any infrequently used outlets subjected to a recorded flushing regime. The cold water storage tank and the hot water generation plant should be inspected on a six month basis by a competent contractor and appropriate records kept. All showers should be in regular use and subjected to a quarterly cleaning regime. All thermostatic mixer valves should be serviced at least annually Point-of-use electric water heaters should be maintained in functional condition (if not operational for any reason they should be treated as an infrequently used outlet and subjected to a formal flushing regime Specific short-term control measures to be applied until completion of corrective actions; Specific long-term control measures to be applied following completion of corrective actions. Routine tasks to ensure the correct and safe operation of the installed systems Service Task Location(s) Frequency By Form Hot water services Review risk assessment: Have all corrective actions been addressed and signed off? Has there been a change to the systems (or how they are used) which will change the risk? Are the routine tasks correctly recorded? Samples to be taken from hot water calorifiers, note condition of drain water. Annually PRP C1 Annually Contract PH05 Check temperatures in flow and return at Calorifiers. Annually Contract PH05 Check water temp at the sentinel taps, confirm it has reached 50 C within one minute. Monthly PRP C4 Check representative taps for temperature as above on a rotational basis Annually Contract PH03 Cold water services Shower heads Little used outlets Check tank water temperature remote from ball valve and mains temperature at ball valve. (Note maximum temperatures recorded by fixed max/min thermometers where fitted). Check water temperature at the sentinel taps, confirm it falls below 20 C within one minute Check representative taps for temperature as above on a rotational basis Visually inspect cold water storage tanks and progress remedial work where required Dismantle, clean and descale shower heads and hoses Identify and flush to drain Six monthly Contract PH02 Monthly PRP C4 Annually Contract PH03 Annually Contract PH02 Six monthly or as required PRP (Contract) C6 (PH01) Weekly PRP C5

29 Section 2 Annual Return to Directorate Duty Holder Form C1 The control of legionellosis risk is dependent on the quality of the management procedures that are in place. Records are evidence that the risk is being properly managed and should be audited at least annually using form C1 overleaf. Persons with procedural responsibility should satisfy themselves that the procedures are in place and are being implemented in accordance with the County Council strategy. The Premises Responsible Person should regularly review the site procedures as set out in this booklet and should submit Form C1 to the Directorate Duty Holder annually.

30 C1 Annual Return Form to Directorate Duty Holder PROPERTY: REF: PREMISES RESPONSIBLE PERSON PROCEDURE C1 Name: Signature: Date Review Completed: Date form submitted to DDH: RISK ASSESSMENT RECORD: (The property must have a current written risk assessment) Date of last formal assessment: By (Competent Person): NB: The assessment should be reviewed regularly (at least annually) and, whenever there is reason to suspect that it is no longer valid, for example: wherever there has been changes to the water system or its use or changes to the use of the building in which the water system is installed. This review must be undertaken by the person who is control of the premises and should be documented: Risk Assessment Review Date: By (name): Signature: Recommendations of last risk assessment completed/signed off: YES/NO New formal assessment required: YES/NO Comments: PROCEDURE REVIEW 1: PROFORMA C4. (Temperature monitoring records completed) Responsible Person to review C4 records and ensure corrective action had been taken where necessary Name of person responsible: Checked (month): Initial when checked Jan Feb March April May June July Aug Sept Oct Nov Dec Hot Water: Check time to reach 50 c at sentinel outlets, recording max temp. Temp should rise to 50 c or greater within 1 min. Cold Water: Check time to fall to 20 c at sentinel outlets, recording minimum temp. Temp should fall to 20 c or less within 1 min. PROCEDURE REVIEW 2: PROFORMA C5. (Flushing regimes records completed) Responsible Person to review C5 records and ensure all infrequently used outlets have been identified Name of person responsible: Checked (Month): Initial when checked Jan Feb March April May June July Aug Sept Oct Nov Dec Flush all little used outlets for a minimum of 2 minutes Where the water system(s) have not been used for two weeks or more, flush outlets most remote from storage until temperature steadies then repeat for all little used outlets working back towards storage. PROCEDURE REVIEW 3: MAINTENANCE TASK. (Sheets PH01 to PH06 undertaken) Name of Maintenance Contractor: NB; Where a maintenance contract is not applicable (no central water storage/distribution systems) form C6 would substitute for PH01 as the record of shower head cleaning - as required by the written scheme. COUNTERSIGNED (DIRECTORATE DUTY HOLDER): ACTIONS TAKEN: Name: Date: