ࡱ> g 2Qbjbj x jx jVCI 5581tp(8Vd4tttttttLx{tt&.@&&t55t&R5"t&t>dWr_rF$xixktt0t+j4v{tv{_r_rv{sr&&&&&&&ttz>&&&t&&&&v{&&&&&&&&& Y :  Corporate Health & Manual  3.7 THE CONTROL OF LEGIONELLA IN WATER SYSTEMS Guidance and Procedures  Summary Appointment of Duty Holder. Ensure adequate resources are allocated to manage the risk of legionella. Any problems arising in connection with the management of legionella risk are raised and adequately managed. Ensure those responsible for managing buildings maintain up to date property registers / records and water risk assessments. Ensure adequate processes and procedures are in place to manage legionella risk across the organisation. Audit checks are completed regularly and recorded. Ensure adequate processes and procedures are followed in relation to procurement of contractors and suppliers. Ensure sufficient information, instruction and training is carried out. Legal Requirements The Code of Practice L8 Legionnaires Disease (The Control of Legionella in Water Systems) came into effect on 8 January 2001 the current Fourth Edition was published in 2013 and gives guidance on compliance with regulations 6, 7, 8, 9 and 12 of Control of Substances Hazardous to Health Regulations 2002. HSG274 Part 2 The control of legionella bacteria in hot and cold-water systems provides guidance gives practical advice on the legal requirements of the Health and at Work etc Act 1974, the Control of Substances Hazardous to Health Regulations 2002 concerning the risk from exposure to Legionella and guidance on compliance with the relevant parts of the Management of Health and at Work Regulations 1999. Important Definitions Legionella Bacteria is common and can be found naturally in environmental water sources such as rivers, lakes and reservoirs, usually in low numbers. Legionella bacteria can survive under a wide variety of environmental conditions and has been found in water at temperatures between 6C and 60C, water temperatures in the range 20C to 45C seem to favour growth. The organisms do not appear to multiply below 20C and will not survive above 60C. They may, however, remain dormant in cool water and multiply only when water temperatures reach a suitable level. Bacteria held at 37C has greater virulence than the same Bacteria kept at a temperature below 25C. Legionnaires disease was first identified following a large outbreak of Pneumonia among people who attended an American Legion Convention in Philadelphia in 1976. A previously unrecognised bacterium was isolated from lung tissue samples, which was subsequently named Legionella Pneumophila. Not everyone exposed will develop symptoms of the disease and those that do, do not necessarily develop the full blown disease. The incubation period is between 2 10 days (usually 3 6 days). The initial symptoms of Legionnaires Disease include high fever, chills, headache and muscle pain. Patients may develop a dry cough and most suffer breathing difficulties. About one third of patients infected also develop diarrhoea or vomiting and about half become confused or delirious. Infection with Legionella Bacteria can be fatal in approximately 12% of reported cases. This rate can be higher in a more susceptible population; for example, immuno-suppressed patients or those with other underlying disease. Certain groups of people are known to be at higher risk of contracting Legionnaires Disease; for example, men appear more susceptible than women, as do those over 45 years of age, smokers, alcoholics, diabetics and those with cancer or chronic respiratory or kidney disease. It is normally contracted by inhaling Legionella Bacteria, either in tiny droplets of water (aerosols), or in droplet nuclei (the particles left after the water has evaporated) which is contaminated with Legionella, deep into the lungs. Procedures Organisation and Responsibilities STC recognises its duty under The Control of Substances Hazardous to Health Regulations 2002 (COSHH) and its associated Approved Code of Practice (ACOP L8) and has developed these arrangements to ensure that the risk of Legionella is managed in its own property portfolio and properties where it has an interest by agreement, i.e. where a Service Level Agreement (SLA) exists to provide a service back to a school or tenant. To comply with COSHH and ACOP L8 STC will: Identify properties where it has a duty to manage Legionella. Identify duty holders for their respective property portfolio. Ensure that Legionella is managed in their respective property portfolio. Make notifications to the Health and Executive where applicable. Ensure any work where an employee could be at risk from exposure to Legionella is assessed. Review and audit the management of Legionella in water systems. Record all of the above. Provide training to appropriate staff who have responsibilities for water management and refresh this training every 3 years. This excludes persons who hold a relevant risk assessment qualification. Ensure resources are available to provide competent staff to manage Legionella in Water systems. Duty Holder (Corporate) The Nominated Duty Holder (Corporate) for the STC property portfolio where a duty exists is the Chief Executive. However, this duty is delegated to the Designated Responsible Person Director of Place Strategy and Director of Community Operations, and their deputy responsible person Head of Strategic Housing and Assets and Assistant Head of Service Compliance and Customer . The corporate duty holder has the responsibility to ensure adequate resources are available for the following: The effective management of Legionella in STC property portfolio properties where it has an interest by agreement including domestic properties. That Initial risk assessments of Water Systems are carried out in all of the above properties and are reviewed as and when required, i.e. change to the water system or management structure triggering a review of the Water Management Risk Assessment / Water Management Plan. Ensure through the s Procurement Process contractor competence to carry out Water Management Risk Assessments and maintenance of water systems. Notification to the Health and Executive of any Cooling Towers or Evaporative Condensers. Director of Place Strategy and Director of Community Operations, (Responsible Persons), the Head of Strategic Housing and Assets and Assistant Head of Service Compliance and Customer (Deputy Responsible Person) Have the following responsibilities: To provide contractors with historical information regarding installed systems in STC buildings. To instigate initial Legionella Risk Assessments in accordance with HSE Publication HSG274 Legionnaires Disease Technical Guidance Parts 2 and keep them under review. To be a first line contact for all water management advice. Provide and maintain a database for non-domestic buildings including risk assessments and reports. To provide an emergency response service. Notify the National Legionella Surveillance Team (Newcastle) of an outbreak of legionella. To appoint and manage competent contractors who carry out Water Risk Assessment and maintenance of water systems. (Statutory Compliance Officers) Ensure risk assessments are reviewed and acted upon as required. Ensure an effective water management regime is in place to control the risk of Legionella. Monitor performance of water management contractor. Ensure contractors management system is maintained. Where applicable the PIMSS compliance system is maintained; Carry out audits across STC buildings. Ensure all actions have been allocated and completed in a timely manner. Ensure internal and external data records are maintained. To be a first line contact for all water management advice. Provide, facilitate or source training for staff with responsibilities for water management; Ensure all servicing requirements are up to date. Respond in an efficient manner to out of spec results. Carry out domestic water risk assessments as per procedures; Ensure domestic risk assessment programme data is maintained. Ensure void property procedure is adhered to. Persons with water management duties (Head Teacher), (Facilities Manager), (Care Home Manager), (Building Officers), (Housing Plus Officers), (Caretakers) and (Empty Homes Team). Persons identified with water management duties have a responsibility to: Report any concerns regarding water management. Carry out any simple tasks e.g., flushing infrequently used outlets etc. and record Facilitate access for approved contractors who carry out the water management programme. Identify Blind ends and Dead legs in void properties, which should also be identified in water management risk assessment. Flush or isolate water systems in void properties. All records of maintenance visits to non-domestic properties are now recorded electronically and held centrally. For domestic buildings all records are held within the Subcontractors portal. Responsibilities of All Employees Employees have a general duty under the health and safety at work etc act 1974 as follows: To take reasonable care for the health and safety of themselves and of other persons who may be affected by what they do or fail to do. To cooperate with STC as an employer in their efforts to comply with the act. Not to interfere or misuse anything provided for the purposes of health, safety or welfare. PLANNING AND IMPLIMENTATION Building Risk Assessment The basis for the management of Legionella risk in any building is an initial Risk Assessment carried out in accordance with ACOP L8 which identifies the type of water system installed in a building and whether a detailed assessment is required. The following criteria are to be used in all instances: Source of system water supply, e.g. whether from a mains supply or not. Possible sources of contamination. to the supply water in the premises before it reaches the cold-water storage tank, calorifier, cooling tower or any other system using water that may present a risk of exposure to legionella bacteria. The normal plant operating characteristics. Unusual, but reasonably foreseeable operating conditions, e.g. breakdown. Any means of disinfection in use. The review of any current control measures. The local environment. Once this initial Risk Assessment has been completed, it will identify whether a more detailed assessment of the buildings water system is required. Where the assessment demonstrates there is no reasonably foreseeable risk or that risks are insignificant and unlikely to increase, and are properly managed, no further assessment or measures are needed. If an initial Risk Assessment identifies that a more detailed assessment is required, the Water Management Compliance Officer will instigate the assessment from an approved contractor who is Legionella Control Association accredited. The aim of the assessment is to identify the controls required to: Avoid water temperatures and conditions that favour the growth of legionella bacteria and other microorganisms. Avoid water stagnation which may encourage the growth of biofilm. Avoid the use of materials that harbour bacteria and other microorganisms or provide nutrients for microbial growth. Control the release of water spray, maintaining the cleanliness of the system and water in it. Use water treatment techniques. Take action to ensure the correct and safe operation and maintenance of the water system. Methods of Controlling Legionella Risk Once the risk has been identified and assessed, a written scheme will be prepared to control the risk. and will identify the following: The physical treatment programme e.g. using temperature control for hot and cold-water systems: The chemical treatment programme, including a description of the manufacturers data on effectiveness, the concentrations and contact time required. Health and safety information for storage, handling, use and disposal of chemicals. System control parameters (together with allowable tolerances); physical, chemical and biological parameters, together with measurement methods and sampling locations, test frequencies and procedures for maintaining consistency. Remedial measures to take in case the control limits are exceeded, including lines of communication. Cleaning and disinfection procedures. Identify specific persons to carry out the above. Dealing with an Outbreak of Legionella If a Legionella Outbreak is Declared in any STC owned Property, the Protocol below will be followed                On receiving a notification of and outbreak of legionella from the National Legionella Surveillance Team is expected to establish an Outbreak Control Team (OTC) which carries out the following functions: Coordinates the investigation. Advises on Control measures. Establishes a means of recording and communicating information. Declaring an End of Outbreak and deals with aftermath. Overview from Public Health England Guidance on Investigating Cases, Clusters and Outbreaks of Legionnaires Disease page 32 See HYPERLINK "https://assets.publishing.service.gov.uk/media/602bad20d3bf7f031745a025/guidance_on_investigating_cases_clusters_and_outbreaks_of_legionnaires_disease.pdf"Here      InvestigationControl MeasuresCommunicationsEnd of Outbreak 1. Descriptive epidemiology 2. Environmental investigation 3. Microbiological investigation 4. Analytical study  1. Source identified and controlled 2. Revised risk assessment of systems 3. Assurance that ongoing control measures are effective  1. Communication flows and protocols 2. OCT minutes 3. NIRP protocols 4. Media and press statements 1. No further cases 2. No public health risk requiring investigation 3. Declare outbreak over 4. Debrief, lessons learned 5. Produce outbreak report and case summary  Record Keeping Where any works are carried out on any installed system (e.g., removal of dead legs, storage tanks), a review of the Water Management Risk Assessment will be carried out and the details of those works will be included in the Water Management Plan. The local Duty holder will sign for the Water Management Plan and will maintain the following within it: A list of contacts. The sign over document. (The duty holder acceptance) The following are held online and centrally via Docia or PIMSS compliance system: A record of service visits as identified by the Water Management Plan The Water Management Risk Assessment also available on the Sub-Contractors portal Where Schematic diagrams or floor plans are not held on the Docia system they will be held within onsite logbooks and the sub-contractors portal Domestic property risk assessments are held within the (domestic) Compliance Team database. Information, Instruction & Training STC will ensure that employees receive appropriate information, instruction and training to enable them to safely carry out their duties regarding water management. The responsibility for identifying training requirements lies with all Heads of Service, Senior Managers and Team Leaders having control of such employees. Governance and Monitoring Water management compliance reports are prepared for non-domestic housing buildings and domestic properties which are presented to the (Domestic) Compliance Group on a monthly basis. Any risk or poor performance issues are raised and discussed at the group. Links to Guidance Health & Executive - Legionella and Legionnaires' disease -  HYPERLINK "https://www.hse.gov.uk/legionnaires/" https://www.hse.gov.uk/legionnaires/ The Control of Legionella Bacteria in Water Systems Approved Code of Practice (ACOP) L8  HYPERLINK "http://www.hse.gov.uk/pubns/priced/l8.pdf" http://www.hse.gov.uk/pubns/priced/l8.pdf HSG274 Part 2 HYPERLINK "https://www.hse.gov.uk/pubns/books/hsg274.htm"https://www.hse.gov.uk/pubns/books/hsg274.htm The Health and at Work Etc. Act 1974  HYPERLINK "http://www.legislation.gov.uk/ukpga/1974/37" http://www.legislation.gov.uk/ukpga/1974/37 The Control of Substances Hazardous to Health Regulations 2002 (COSHH) (As Amended)  HYPERLINK "http://www.legislation.gov.uk/uksi/2002/2677/contents/made" http://www.legislation.gov.uk/uksi/2002/2677/contents/made The Notification of Cooling Towers and Evaporative Condensers Regulations 1992,  HYPERLINK "http://www.legislation.gov.uk/uksi/1992/2225/made" http://www.legislation.gov.uk/uksi/1992/2225/made Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 -  HYPERLINK "https://www.hse.gov.uk/riddor/" https://www.hse.gov.uk/riddor/ Legionella Plan Appendix G - HYPERLINK "https://intranet.southtyneside.gov.uk/article/20668/Legionella-health-and-safety-plan"https://intranet.southtyneside.gov.uk/article/20668/Legionella-health-and-safety-plan Review These guidance and procedures will be reviewed on an annual basis. Document approved by: H&S Policy Review Group Last updated/reviewed: September 2024 Date issued: October 2024 Date of next review: September 2025       Occupational Health & Team, People and Organisational Change Page  PAGE 1 of  NUMPAGES 2 Building and Compliance Team Leader / Compliance Manager will notify Local Duty Holder in charge of affected building and instruct them to isolate the affected area immediately Building and Compliance Team Leader / Compliance Manager will notify Environmental Health Team (local enforcing authority). Environmental Health Team should then notify the National Legionella Surveillance Team and Local Health Protection Team (Newcastle); The appropriate Statutory Compliance Team to supply all water management information to Environmental Health Team and await further instruction; Building and Compliance Team Leader / Compliance Manager to assist with implementation of control measures following the investigation by the relevant organisations such as cleaning and disinfection of hot/ cold water systems. The appropriate Statutory Compliance Team will review Water Risk Assessment for the affected building following implementation of control measures: The appropriate Statutory Compliance Team Await instruction from Environmental Health Team that the affected system and/ or area is safe for reoccupation. 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