Legionella Risk Management Policy

Legionella Risk Management Policy Purpose The purpose of this policy is to ensure that as far as possible all users of Denefield School are protected from the incidence of Legionnaire s disease. Policy detail The Governors of Denefield School have agreed to adopt the West Berkshire Legionella Risk Management procedure. All relevant details regarding roles and responsibilities and testing regimes are container within this procedure. The governors role will be to ensure that the relevant testing is completed and that an up to date risk assessment is carried out by a professional company. Reporting The Finance & Business Director will report on an annual basis to the Curriculum & Premises committee and confirm that all testing has been carried out and report any results that may be of concern. Review and evaluation On receipt of the professional risk assessment the Governors will review the necessary actions and ensure that these are carried out in a timely manner. Links: WB Legionella Risk Management Procedure, Updated March 2011 Governors Health & Safety policy Approved by Governors: June 2014 Date for Review: June 2017 1

Contents 1. Purpose... 4 2. Scope and Application... 5 3. Background... 5 4. Definition of Terms... 5 5. Roles and Responsibilities... 6 6. Overview of Legionella Risk Management... 7 7. Risk Assessment.8 8. Training.8 9. Advice and further information. 9 Appendix Logbook and checklists 3

1. Purpose 1.1. It is the policy of West Berkshire Council (WBC) to ensure that appropriate precautions for the control of Legionella bacteria are identified through a Legionella risk assessment process, and appropriate control measures implemented to ensure, so far as is reasonably practicable, the health, safety and welfare of employees and others. The minimum standards to be met include; Carrying out Suitable and Sufficient Legionella Risk Assessments; Preparation of an Action Plan or written scheme for preventing or controlling the risk, where appropriate; 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 Team, or Specialist Consultant; Appointment of a person or persons to be managerially responsible for water system at each premise, i.e. the Responsible Person & Competent Person; To otherwise meet the requirements of the HSE Approved Code of Practice; Legionnaire s disease: The Control of Legionella bacteria in water Systems. 2000 (L8) 1.2 The Health and Safety Executive promotes sensible risk management, and states that this is not about: creating a totally risk free society; generating useless health and safety paperwork; exaggerating or publicising trivial risks; stopping recreational activities where the risk are managed. 2. Scope and Application 2.1. This policy applies to all WBC buildings with water systems including: hot and cold water supply systems, cooling towers, spa baths, pools and showers where WBC is either the employer or is in control of the premises. 2.2. In accordance with the WBC s Statement of Policy on Health, Safety and Welfare, Directors are responsible for applying the Council s Health, Safety and Welfare Policy within their respective Service Areas. 2.3. Within Community and Voluntary Controlled schools, WBC is the employer and as such requires schools to meet the minimum standards defined within the above policy statement. Although these schools may put in place their own arrangements to meet these standards it is advised that adoption of the arrangements in this procedure may be the simplest option for the school. This policy does not apply to Foundation or Voluntary Aided Schools (as the Governing body is the employer ) although they may wish to adopt this as a ready-made means of securing legal compliance. 3. Background 3.1. Legionella bacteria are naturally present in the environment and if water conditions are favourable to the bacteria i.e. warm, nutritious and stagnant, they will proliferate. 4

Disturbance of this contaminated water can cause tiny droplets to become airborne which, if inhaled, can cause a potentially fatal type of pneumonia called legionnaires disease. Those people especially at risk are the old or those who are ill as their immune system is less able to fight the disease. 3.2. Making sure adequate & appropriate management arrangements exist for controlling Legionella is a requirement defined within the Legionnaires disease; The Control of Legionella bacteria in water systems, Approved Code of Practice and Guidance L8. The Health and Safety at Work, etc. Act 1974 and the Control of Substances Hazardous to Health 2002 (as amended), are both relevant to legionella issues. 3.3. The Approved Code of Practice has been produced to focus attention on those water systems where it is reasonably foreseeable for persons to be exposed to legionella bacteria, where no controls are in place, such as cooling towers, evaporative condensers, plant where stored water temperature exceeds 20 0C and which releases a aerosol. The Approved Code of Practice Guidance states that, Not all systems listed will require elaborate assessment and control mea sures. A simple risk assessment may show that the risks are low and in such case no further action will be necessary. Examples include small domestic-type water systems where temperatures and turnover are high, or where instantaneous water heaters are used. 3.4. This Procedure defines the system by which WBC manages the risk from Legionella and is focused upon preventing water conditions favourable to the bacteria existing in any of the councils managed water systems including hot and cold water services, spa baths, pools and showers. This requires the commitment of both the Council as the landlord and the occupants of the building. 4. Definition of Terms Legionella Legionella Risk Assessment H.S.E Responsible Person (RP) Log Book Maintenance A potentially dangerous type of bacteria when inhaled with water vapour. Bacterium grows best in warm, nutrient rich water A specific risk assessment carried out to determine the risk level of Legionella proliferation, and exposure from a specific water system. Health and Safety Executive, the National Independent watchdog for work related health, safety and welfare. The RP is defined in the Regulatory Reform (Fire Safety) order 2005, and other legislation, and this person has control of the building and its facilities. The RP may appoint a Competent Person for the building, who is given the day to day responsibility for in-house checks. A record book provided to record all local checks and tests carried out, as specified by legionella risk assessment, e.g. sentinel taps hot water temperature checks. Cleaning, repair, tests etc required to minimise bacterial growth. Split between the WBC Property Services maintenance contractor and the Local appointed person; 5

Sentinel Taps These are the taps at the start and end of a re-circulating hot or cold water distribution system, which will be nearest and furthest from the storage tank. 5. Roles and Responsibilities 5.1. Corporate Directors: To provide suitable and sufficient resources for Heads of Service and management in order for them to carry out their duties and responsibilities in accordance with this Procedure. Monitor the application of this procedure. 5.2. Heads of Service: Formally identify the manager who will be responsible for each premise. Ensure that managers and staff assist the RP and CP for legionella issues. 5.3. Responsible Person: Ensure the Legionella risk assessment addresses all water systems in the premises. For low risk and simple water systems the risk assessment may only need to be reviewed by the RP or CP on a 2 yearly basis. Where the premises has a complicated hot and cold water distribution system, and/ or complex equipment, e.g. evaporative condenser, and there is not expertise on site, then specialist legionella services should be bought in. Property Services provide a specialist legionella surveying and risk assessment service, and a corporate maintenance contract. The RP should ensure an equal standard is met where the Property Services contractor is not used. 5.3.1. Where necessary, as specified by the risk assessment, the RP needs to identify, appoint, instruct and train a member of staff to carry out regular visual inspections and temperature checks in accordance with the log book, where appropriate. An appropriate thermometer should also be provided and maintained for this purpose e.g. digital probe thermometer. 5.3.2. Notify relevant persons in WBC of any alterations to the water systems e.g. use premises alteration form, and ensure legionella risk assessment is reviewed. 5.3.3. Monitor the controls to ensure they remain effective, e.g. inspect log book to ensure maintenance and inspections are actually done and recorded. Keep records to provide evidence you are complying with the above standards where needed (as identified by risk assessment). 5.3.4. Notify the Head of Property Services and the Corporate Health and Safety Team of any planned or unplanned visits by any enforcement authority (i.e. Thames Water, HSE). Also, to notify any problems with the water system / Legionella precautions immediately to Property Services and Health and Safety Team if appropriate. In partnership with Property Services monitor the works of any contractors carrying out work on any water systems in the premises for which you are responsible. 5.4. Nominate a Competent Person(s) to complete the log book where necessary (see appendix) ensuring instructions are followed. Contact Property Services for any additional advice and support on maintenance issues. 5.5. Property services: Supply a service to appoint and monitor compliance with an appropriate and competent Legionella maintenance contract covering WBC buildings. Arrange a specialist contractor to carry out Legionella risk assessments for building water system facilities if requested, where this service is needed. 5.5.1. Arrange a specialist contractor to carry out remedial works/recommendations arising from risk assessments where requested by service users. Monitor compliance with 6

the requirements of this Procedure and provide timely reports to the Head of Property Services. 5.5.2. Ensure the risk of Legionella is considered at the design stage of any building/ structural alteration project. 5.6. Corporate Health and Safety Team: Provide Training for managers responsible for premises (e.g. part of the Buildings Competent Persons safety course). Provision of advice and assistance in support of this procedure, and the HSE ACOP. Monitor and periodically audit building arrangements, to ensure appropriate Legionella controls are in place. 6. Overview of Legionella Risk Management 6.1.1 The following figure provides an overview of Legionella management precautions in WBC. Flow Diagram: Health and Safety Management of Legionella risk POLICY West Berkshire Council Legionella Risk Management Procedure demonstrates our commitment to ensuring premises water systems meet minimum standards. Local commitment to the policy by Responsible Person (s)/ building managers ORGANISING Managers responsible for premises know & accept their Legionella responsibilities Maintenance & testing contract /arrangements in place Local appointed person identified, instructed and trained Competent Persons and Risk Assessors. Property Technical advice available to premises managers AUDIT Periodically audit legionella compliance with this Procedure by Corporate H&S during health and safety audits PLANNING & IMPLEMENTATION Legionella Risk assessment completed for each building Necessary improvements to water systems prioritised and scheduled in Action Plan. Assessment reviewed on a 2 yearly cycle as minimum. MO NITORING Corporate Health & Safety Team and Property Services to monitor system and contractor. Logbook system to be monitored where used. Regular local checks, where necessary, e.g. water temperature done by Local appointed person e.g. Caretaker or CP. REVIEWING WBC periodically reviews Legionella Risk assessments Local review of arrangements following any reported concerns to water system. Corporate review of Legionella Procedure every 2 years. 7

7. Risk Assessment 7.1 Each premise must undertake a legionella risk assessment (LRA). Most premises will have had an Envex Legionella Survey and LRA completed, which will give details of the buildings water system. These documents should enable the LRA to be reviewed by either the RP, CP or Risk Assessor on a two yearly basis. Those premises which have a low risk water system, where the risk assessment has identified as insignificant risk, are unlikely to need to take any further measures after completion of the Legionella Risk Assessment. The HSE Approved Code of Practice states, not all of the systems listed will require elaborate assessment and control measures. A simple risk assessment may show that the risks are low and in such case no further action will be necessary. Examples include small, domestic-type water systems where necessary temperatures and turnover are high, or where instantaneous water heaters are used. Further guidance is available from the Corporate Health and Safety Team. 7.2 WBC properties can be split into two risk groups, those (A) high risk premises, which include occupants that are susceptible, i.e. healthcare premises, residential homes, and (B) low risk premises, as detailed in the table below. Premise Risk Type (A) High Risk premises (B) Low Risk Premise Sheltered Housing Leisure Centre s Special Schools Buildings with Cooling Towers or Evaporative Condensers Properties with Gravity Fed Water Systems with Recirculation Offices Commercial premises Small Public/ Leisure buildings (toilets, pavilions, etc) Small schools Library s The local Legionella Risk Assessment will determine the risk. This table should only be used as a guide. 7.3 If in producing the legionella risk assessment it is identified that the water system does not store water between the temperatures of 20 0C and 50 0C, then only monitoring will be needed to ensure that this control continues to be in place. 7.4 Record Keeping: If the risk assessment identifies the need for ongoing monitoring, all or part of the log book in the appendix will need to be completed. Alternatively the Envex log book may be used. 8. Training 8.1. A training needs analysis should first be undertaken, those premises where the risk assessment has shown there to be an insignificant legionella risk, then no specific training is likely to be needed, other than that provided for the FLASH form system. Where significant risk has been identified, and control measures need to be in place, the RP and CP for the premise may seek training to support them with their responsibilities for premises, or others, e.g. caretaker. Contact Property Services or the Corporate Health and Safety Team for information on legionella training. 8.2. Managers responsible for premises must ensure the Competent Person nominated to manage/perform temperature checks, etc, fully understands the instructions provided. 8

If required, further support, advice and training is available from Property Services and the Corporate Health and Safety Team. 8.3. Managers must ensure records of all training and instruction (where appropriate) are held. 9. Advice and further information 9.1. Further advice, information and guidance to support this procedure can be obtained from the resources below. 9.2. Suspected Outbreak: If it is suspected that the properties water system is implicated in a legionella disease case the Corporate Health and Safety Team must be notified immediately in order to organise the WBC response to the situation. 9.3. Other contact details for information sources including; Property Services Manager: 01635 519831; Property Helpdesk: 01635 519869; The Corporate Health & Safety Team: 01635 519310, or healthandsafety@westberks.gov.uk West Berkshire Intranet site, see Health and Safety link on front page; The Directorate specific Intranet site; The Internet e.g. the official Health and Safety Executive website www.hse.gov.uk, which holds information on legionella, and COSHH Regulations 2002; Guidance Documents/ Leaflets: Legionnaires Disease: The Control of Legionella bacteria in water systems. Approved Code of Practice 2000 (L8); IND (G) 253(L) Controlling Legionella in nursing and residential care homes; HS(G) 104 Health & Safety in Residential Nursing Homes. 9

Appendix 1. WBC Log book Legionella Control Log Book Property Name Building Owner Responsible Person for Building Competent Person for Building (if applicable) Person in charge of reviewing Legionella Risk Assessment Date Log Book started 2009 Schematic available Risk Assessment (RA) available Denefield School Denefield School Glyn Whiteford Dave Flower Roz Doctor Yes Yes Review date of Risk Assessment June 2014 Does RA contain an Action Plan Yes / No for remedial Works? New RA not yet received Does RA require routine Yes maintenance? Give date when all remedial works To be confirmed when assessment completed completed. Person responsible for undertaking Dave Flower routine monitoring work (weekly/monthly/quarterly). Does Risk Assessment require Yes Bacteriological Water Testing? Detail of operations relevant to controlling risk/ local management plan: Regular routine testing 6 monthly tank cleaning by Aquavent 3 yearly risk assessment Most WBC sites have been issued with an ENVEX Legionella Log Book for recording the monitoring data. The checklist and recording sheets attached with this Procedure are to ensure that all appropriate information and suitable recording formats are available, where the ENVEX log book is not appropriate to the premises and the Legionella Risk Assessment carried out. Contact Property Services for further information as to where an ENVEX Legionella Log Book can be obtained. 10

Completion Instructions Introduction This log book has been prepared to comply with the Approved Code of Practice The Control of Legionella bacteria in water systems 2000 (L8). The required actions to control the risk from Legionella are split between the management on each site (RP or CP) and the councils appointed maintenance contractor (conducting more technical aspects). These can be carried out by a Competent Person /caretaker to help reduce costs. The LRA and water services you have within your premises will determine the frequency of visits and tasks required to be carried out under these regulations (if any), and adaptations may need to be made to the log book tables. Thermometers In order to check water temperatures you are required to purchase and maintain a basic thermometer suitable for checking water temperatures range 0 C - 100 C e.g. digital probe thermometer. These are widely available and are not expensive. To ensure the thermometer remains accurate you should calibrate this monthly. The simplest way to do this is to use boiling water and crushed ice water to check 100 C and 0 C respectively. Adjust accordingly and keep records. If more than 1 C out then please purchase a new thermometer. Completing and recording water temperatures Water temperature record sheets need to be filled in and kept within the logbook. It is usual to spread this over the 12 months, i.e. if you have 24 taps you need to sample 2 per month. Outlets failing to meet the required temperature should be reported for suitable action and retested in subsequent months until satisfactory. Hot Water should be at least 50 o C after 1 minute and cold water below 20 o C after 2 minutes flow. Flushing infrequently used taps and showers Hot or warm water left in pipes for long periods can allow Legionella bacteria to multiply presenting a risk when finally discharged e.g. school showers after summer holidays. Identify infrequently used taps and showers on the Weekly flushing record sheet and record when flushing takes place. Flush each tap/ shower for several minutes to ensure stagnant water is fully discharged. Flush all sentinel taps monthly. Hot and Cold Water Temperature Monitoring A schedule for precautionary checks on hot, cold water taps and showers (where there is water storage), the responsible person should organise checks to be carried out at the frequencies indicated below. Where the temperatures fall outside the standards actions should be taken to resolve the problem. Weekly Checks Showers: that are not in uses for over a one week period must be flush from 2 minutes at both maximum and minimum temperature. A plastic bag should be secured over shower head with corner cut off to allow water to escape. Monthly Checks Taps: Temperature of cold water sentinel taps (nearest and furthest to the storage tank), to check that water is below 20 C. 11

Run cold tap for 2 minutes then measure temperature by inserting calibrated digital thermometer in the water flow and record reading. Temperature of hot water sentinel taps (nearest and furthest to the calorifier/ water heater), to check that water is above 50 C. Run hot tap for 1 minute then measure temperature by inserting calibrated digital thermometer in hot water flow and record reading. Actions in the event of negative temperature monitoring checks In the event of a negative temperature test result being noted, (i.e. either Hot water below 50c or cold above 20c) by the RP or CP the following actions should be carried out. If hot water: then the boiler settings need to be reviewed to ensure that the temperature can be raised. Further additional temperature checks should be made after 48 hours to ensure that the problem does not persist. If the temperature can not be raised to the required level then further action needs to be taken to ensure the boiler is serviced / checked. If cold water then the situation should be monitored more closely for a period. In the event that the temperature remains above the required 20c then further advice needs to be sought from Property Services. In either case if monitoring indicates an ongoing issue then the water supply must be examined/ tested by a suitably qualified contractor to ensure that the Legionella risk is managed. In the event that a test of the water supply indicates that Legionella is present in high concentrations then the following actions need to be carried out: Inform the Corporate H&S Team and Property Services, who will take relevant steps to ensure that the issue can be monitored. To shut down any processes which are capable of generating and disseminating airborne water droplets and keep them shut down until remedial cleaning or other work has been done. To immediately arrange emergency disinfection to be undertaken if required. Depending on the client group or staff group that may have been exposed monitor client / staff health to discern whether there are any undiagnosed cases of illness. Health and Safety: Completion of the above checks presents little risk to the health and safety of staff. Further Information First point of contact if you have any property maintenance queries contact: Property Services Manager: 01635 519831; or Property Helpdesk: 01635 519869; or Corporate H&S Team healthandsafety@westberks.gov.uk 12

HOT AND COLD WATER SYSTEMS CHECKLIST Use the checklists to keep up to date with water systems maintenance requirements for your site. Please be aware that not all tables may be relevant to your site, i.e. you may not have showers. Fill in dates of when work is carried out and initial/ signature in the signed columns. MONTHLY HOT AND COLD WATER TEMPERATURE RECORD SHEET HOT WATER TAP OUTLET RECORD SHEET Hot Water to be at least 50 o C after 1 minute Date Location Temp ( o C) Signed HOT WATER STORAGE CALORIFIER/WATER HEATER SHEET Date Location Flow Temp 60 o C Return Temp 50 o C Page 13 of 13 Version 2.0 Legionella Risk Management Procedure Nov 2010

COLD WATER RECORD SHEET Cold water to be below 20 o C after 2 minutes Date Location Temp ( o C) Signed If temperatures are not achieved, contact Property Services Helpdesk/ Property Services Manager. Page 14 of 14 Version 2.0 Legionella Risk Management Procedure Nov 2010

WEEKLY FLUSHING RECORD SHEET for infrequently used taps and showers Date Location OK (Yes/ Fault Notified Person/ Signature No) (if applicable) Flush shower/ tap for several minutes taking care not to generate aerosols / droplets. Page 15 of 15 Version 2.0 Legionella Risk Management Procedure Nov 2010

Bacteriological Water Testing Results Table Date Sampling Company Sample Location Pass/ Fail Bacteria sampling only usually carried out routinely for Cooling Towers/ High Risk Systems. QUARTERLY CLEANING/ DISINFECTION RECORD SHEET for infrequently used taps and showers Date Location Action undertaken, e.g. Person/ Signature shower dismantled, cleaned, de-scaled & disinfected.