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Contents

1. Introduction
2. Responsibilities
   
   Appendix A: Guidance for the Control of Legionella
   
   Appendix B: Model Premises - Specific Risk Assessment of Contracting Legionellosis Hazard

1. Introduction

This Policy has been developed to help ensure DMR Services complies with the requirements detailed in the HSE Approved Code of Practice and Guidance (ref. L8), “Legionnaires’ disease: The control of Legionella bacteria in water systems”.

Compliance with this document should then ensure compliance with the legislative requirements of the Control of Substances Hazardous to Health Regulations 2002.

The Appendix to the Policy gives background information on Legionella and guidance on undertaking a risk of assessment of harm from Legionella, if required.  

The risk of contracting Legionellosis from DMR Services premises is generally low due to water systems being used frequently, but a managed approach to the condition and use of water systems it vital to manager risk, raise awareness of standards and ensure compliance with specific statutory requirements.

Key Points

• This Policy outlines the requirements for managing Legionella in DMR Services occupied premises;
• The specific role of DMR Services in commissioning and managing physical assessments of water systems is described;
• Responsibilities in relation to this Policy fall on Regional Managers, homes Managers, Personnel and Training Services Health and Safety Adviser, Maintenance Department and employees;
• Detailed information and guidance on Legionella is given in the attached Appendices;
• Copies of all the Health and Safety Policies can be found on shared folders and or Health and Safety File.

2. Responsibilities

Area Managers of the Company

Where DMR Service is responsible for the maintenance of the buildings’ water system; The health and safety officer or maintenance manager will instruct physical surveys of water systems in DMR Services buildings by way of a hazard assessment to determine the likelihood of colonization by Legionella in water services, the potential for the proliferation of Legionella bacteria in aerosols and to establish a premises-specific asset register.

Will ensure that, where the owner, landlord, sub-lessor or agent of any premises occupied by DMR Services is in control of the maintenance and repair of the water system that they are made aware of their responsibilities in respect of the control of Legionella bacteria and the requirement to meet the standards set out in this Policy.

Ensure that any review of the design and construction of water systems, determine any necessary physical remedial action, e.g. removal of redundant plant, pipe work, dead legs, and specify their safe operation and maintenance, in accordance with ACOP, and

Determine from the survey where necessary any appropriate control methods for the treatment and monitoring of water systems (in accordance with the requirements of ACOP), including a written scheme to implement the necessary control measures. This will be carried out with advice from the Health and Safety Officer and Maintenance Manager.

Homes Managers must make arrangements within their homes to ensure that:

In respect of premises under their direct control, a premises-specific assessment of the risk of contracting Legionellosis is carried out, to consider if it is possible that water in a fine mist (aerosol) will be produced, e.g. through the use of showers, spray taps and hoses.

As the homes are occupied by young persons this is classed as a risk group this must be taken into account when carrying out the risk assessment. Note: An example of a model risk assessment is given in the appendix below.
(It should be noted that provided appropriate water treatment regimes are in place and there is no equipment which could give rise to (the inhalation of) water vapour droplets, the hazard is insignificant and any risk assessment will reflect this)

Physical surveys of the water systems in all premises for which they are responsible have will need to be carried out by a competent person (or will otherwise be assessed by competent persons) to determine if conditions are present which will favour colonization by Legionella bacteria; if any doubt exists as to whether a survey has been carried out, reference should be made to the Healthy and Safety File or the Health and Safety Officer.

In conjunction with the maintenance department, ensure any requisite physical modifications to the water systems and/or where necessary any appropriate water treatment regimes are carried out.

Such risk assessments are reviewed at least every one year or when there is reason to suspect it may no longer be valid, e.g:

• Changes to the water system or its use;
• Changes to the use of the building;
• Availability of new information/statutory requirements;
• Evidence that existing control measures are no longer effective;
• Where the water system (or part of it) has been shut down for more than 2 months and the re-commissioned – see also the section on “stagnation” in Appendix A: Guidance for the Control of Legionella;
• Upon confirmation that the water system has been colonized by Legionella bacteria at levels that require action (as set out in the ACOP); and
• Upon any confirmed case of Legionellosis (e.g. Legionnaires disease) which could possibly be related to the premises.

In the event of a confirmed case of Legionellosis, in liaison with the Health and Safety Officer, a contingency plan is implemented which will include:

• The identification of people who may have been exposed;
• Involvement of the public health authorities;
• Dissemination of information to employees, their union representatives and other interested parties of the nature of the risks; and
• Measures to rectify the situation.

Similar arrangements will need to be agreed with the landlord and other employers/agencies involved where there is joint occupancy of premises.

Arrangements are made for monitoring the implementation of this Policy in the homes to ensure that any risks are minimized or eliminated; resource allocation will need to be considered and agreed.

Retain records for at least five years.

Water systems in any premises that they are responsible for are appropriately managed in accordance with the guidance given in Appendix A: Guidance for the Control of Legionella.

The requirements specified in the responsibilities of chief Officers (above) are put into place in respect of locations within their control, so as to eliminate or minimize the risks of contracting Legionellosis.

Where they delegate water system management roles to Controllers of Premises at any particular home, they must ensure the Controller has sufficient understanding and resources to be able to carry out this function effectively.

They know the action to be taken if a suspected case of Legionella is reported at their premises, this will be communicated by means of a document and the relevant persons notified (Area Manager, Health and Safety Officer, Local Authority).

Personnel and Health and Safety Officer will ensure:

They are available to provide guidance to managers with the initial risk assessment to ascertain the risk of Legionellosis at a particular home.

As part of on-going training for managers and Controllers of Premises, that awareness of the risks associated with Legionella and their responsibilities in ensuring adequate controls are in place.

Home Managers must:

Ensure that a copy of the latest Water System Survey is held at the home.

Please ensure that they are aware of their expected duties in relation to Legionella control systems and the policy.

Employees must:

Adhere to advice given in relation to the control of Legionella. There they are concerned about the risk on an outbreak of legionellosis, they must report their concerns to either the Homes Manager, or the Personnel department and Health and Safety Officer so that appropriate measures can be taken to identify and eliminate or reduce the risks. Employees or others who have been exposed to significant occupational risk of infection will receive information about the nature of the risks, including advice on precautions and symptoms.

Appendix A: Guidance for the Control of Legionella

General

• Legionella bacteria are common in most natural watercourses, such as rivers and ponds, and as such may contaminate and grow in other water systems, such as hot and cold-water services. They survive low temperatures and thrive at temperatures between 20°C and 45°C;
• Legionella can cause a serious and potentially fatal pneumonia in susceptible persons known as Legionnaires’ disease. 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;
• Legionnaires’ disease is normally contracted by breathing deep into the lungs very fine droplets of water in aerosol form, which are contaminated by the bacteria. The risk increases with higher concentrations of the bacteria and the duration of the exposure. There is no evidence of person-to-person infection, and it cannot be contracted solely by drinking or washing in contaminated water;
• It should be appreciated therefore that the Legionella bacteria is the potential hazard, any risk to health being dependent on a susceptible person’s exposure to the inhalation of contaminated water vapour/aerosol, (e.g. from showers or other sources of spray);
• In practice most outbreaks have been connected with contaminated evaporative condensers and cooling towards associated with air conditioning systems, where the water aerosols were dispersed over a wide area. DMR Services currently has no such installations.

Avoidance of Stagnation

• Dead legs: (i.e. water service leading from the main circulation water system to taps or appliances which are not used at all or are used infrequently), and any other parts of systems, which may provide a stagnant reservoir for colonization should be eliminated where possible.

Minimization of Water Sprays

• Dissemination of contaminated aerosols should be reduced by careful design of equipment, use of drift eliminators to stop excessive circulation of potentially contaminated air, enclosure, etc.

System Maintenance

• Where a survey identifies a system with the potential for the proliferation of Legionella bacteria, in respirable water aerosols or mists, appropriate control and monitoring regimes must be put in place as soon as practicable. Water temperatures must be checked on a weekly basis;
• Guidance on these regimes is set out in the ACOP and compliance will require appropriate risk assessment, a written scheme including method statements, safe systems of working and appropriate levels of competence for those undertaking the work;
• Care must be taken to ensure that where water treatment is necessary, the chemicals are properly purged from the water systems before they are returned to normal use. Any biocides to be used must be approved by the Health and Safety Officer and subject to an appropriate Control of Substances Hazardous to Health (COSHH) Assessment;
• Where raising water temperatures is used as a control method, excess temperatures must be controlled or reduced, before water systems are returned to normal use;
• Equipment that produces water droplets (aerosols) for example showerheads must be dismantled, cleaned and de-scaled every three months by a competent person;
• Dead legs, including showers that are infrequently used, should be flushed through without creating spray aerosols at least once per week, and before use, for several minutes, or otherwise be decommissioned and removed. It would appear that DMR Services does not have any of these systems however this would need to be checked and identified in the risk assessment;
• Where a water system has not been used for a period of three months or more, and it is intended to be brought back into use, sampling should be carried out to determine the most appropriate method of dealing with the presence of Legionella bacteria;
• Similarly external hosepipes used for ground watering should be thoroughly flushed through, without generating spray, where they have been dormant or are infrequently used.

Sampling

• Where sampling is indicated as a control measure, periodic sampling for Legionella should be carried out to monitor the effectiveness of precautionary measures. This will require the services of an Approved Laboratory who specialize in the testing of water samples for Legionella;
• In the event of an outbreak or following sampling where results exceed the action levels for colony forming units as set out in the ACOP an immediate investigation and review of the control measures must be undertaken and corrective measures put in place;
• Clearance sampling will be required before the water system is returned to full use.

Appendix B: Model Premises - Specific Risk Assessment of Contracting Legionellosis Hazard

Description:

• Legionella Bacteria

Hazard Cause:

• The colonization of hot or cold water systems, including storage and distribution systems, with significant levels of Legionella bacteria (Ref ACOP L8);
• The release of Legionella in spray/water aerosols from showers and/or shower taps, ground watering hoses left unused for a period, etc.

Susceptible Persons Affected

• Older people, those suffering from chronic respiratory or kidney disease, those whose immune system is impaired, smokers, those with alcohol problems and young persons whose immune systems are still developing.

Hazard consequence:

• Legionnaire’s disease or other forms of Legionellosis.

Premises: Insert Name and Address

Responsible Person in Charge: Insert Name (Homes Manager and Health and Safety Officer)

Typical Current Controls:

Consider the following:

• Has a Water Survey been carried out?
• When was this – is it still relevant?
• Have the recommendations from the survey been implemented?
• Are ongoing control measures in place and being monitored?

Examples of typical control measures include:

• All hot water to be stored above 60°c, distributed (supply and return) at 50°c, or more and blended at point of use to not more than 43°c;
• All cold water to be stored and delivered at 20°c, or less;
• Chemical dosing systems in place if required i.e. Chlorine Dioxide units (these may not be used as homes are mains fed and may only apply if the home has a water tank fitted);
• Adequate preventative maintenance controls and records:
  • Annual testing of water samples are taken and if unsatisfactory a second sample is taken and if still unsatisfactory, the system is chlorinated and then a further sample taken to ensure the system is clear;
  • Monthly checks at sentinel taps to ensure hot water is at least 44°c, and cold water no more than 20°c;
  • Annual calibration of temperature gauges and boiler systems to ensure water storage of above 60°c;
  • Annual calibration of thermostatic mixer values to ensure hot water at 43°c or less;
  • Annual maintenance of all Chlorine Dioxide Units with checks to ensure that dosing levels do not exceed Water Authority standards (0.5mg/l). (may only be required if the home is fitted with a tank).

Likely Frequency of Harm occurring:

• Low i.e. harm is unlikely to occur where:
• The risk assessment (and water survey) processes have shown that respirable water in the form of aerosols cannot be released from the system;
• Where controls are necessary, all requirements are fully and properly implemented and monitored.

Likely Severity of Harm should it occur:

• Medium i.e.; Disease reportable as a biological agent to the Health and Safety Executive under RIDDOR. (It is not reportable under public health legislation, unless there are two or more cases occurring in the same locality within a six-month period).

Risk Rating:

• Low.

Further Recommendations: - might include:

• Monitor and maintain current controls;
• Notify the Maintenance departments and the Health and Safety Officer of any water discoloration that could indicate the presence of sludge, rust of scale, any redundant water outlets etc;
• Notify the Maintenance department and the Health and Safety Officer of any indicators that the control systems are not operating properly (including water temperatures at abnormally high or low levels).

Assessed by:

Name of Assessor (Block Capitals):

Signed:

Date:

Reviewed by:

Name of Assessor (Block Capitals):

Signed:

Date:

Procedure for de-scaling and disinfecting Showerheads and Hoses

Only Approved Contractors who specialize in the treatment of Legionella and DMR Services maintenance staff that are competent, that have been suitably trained, referenced the risk assessment and utilising the correct relevant Personal Protective Equipment (P.P.E) will carry out the procedure.

1. Dismantle the showerhead and hose (if hose fitted);
2. Dissolve the chemical agent (Showerhead plus) in water to the correct dilution;
3. Submerge the showerhead and hose in the chemical agent solution for a minimum of 3 minutes or longer until any scale has been dissolved;
4. Scrub each showerhead;
5. On completion drain and rinse each item in clean running water ensuring all traces of the chemical agent solution (Showerhead plus) has been removed;
6. Reinstate the showerhead and hose (if hose fitted).

Note: The chemical agent currently used is ?, which contains acid formulation with sanitizer. Building Services, Residences and contractors staff should ensure they have referenced the Data sheet for the product and adhere to any safety requirements identified.

Click here to view the Legionella Register.

End