WATER SAFETY POLICY. Assessment Completed

Transcription

1 WATER SAFETY POLICY Version Number 1 Version Date October 2013 Policy Owner Chief Finance & Commercial Officer Author Maintenance Manager First approval or date June 2011 last reviewed Staff/Groups Water Safety Committee Consulted Director of Infection Prevention and Control Infection Control Nurses Consultant Microbiologist Discussed by Policy Agreed by Chair of Policy Group October 2013 Group Replaced Ver 3 of the Legionella Policy Oct 13 Approved by HMT Approved through Water Safety Committee Next Review Due October 2016 Equality Impact August 2013 Assessment Completed

2 Table of Contents Water Safety Policy Rationale Aim Definitions The Estate The Trust's Service Providers Roles and Responsibilities Chief Executive Director of Estates and Facilities Specific Responsibilities Infection Control Doctor Infection Prevention and Control Team Responsible Person (Water) Deputy Responsible Person (Water) Maintenance Technician Contractor Contracting Supervising Officer/Project Manager Designer/Responsible Project Manager Legionella Control Consultants Water Safety Committee Wards/Departments Responsibility of Staff Training Requirements Actions in the Event of a Suspected or Confirmed Outbreak of legionella or Pseudomonas aerugisa infection.7 7. Limitations.7 8. Implementing, Monitoring and Evaluation References 8 Appendix 1- The management arrangement for outlet flushing 9 Appendix 2 - Summary of responsibilities for wards and departments..10 Annex A - The equality impact assessment tool 11 Page 2 of 11

3 WATER SAFETY POLICY 1. RATIONALE Yeovil District Hospital NHS Foundation Trust, hereinafter kwn as the Trust, accepts its responsibility under the Health and Safety at Work etc. Act 1974 and the Control of Substances Hazardous to Health Regulation 2002 (as amended), to take all reasonable precautions to prevent or control the harmful effects of contaminated water to residents, patients, visitors, staff and other persons working at or using its premises. This policy and associated procedure documents applies to all Trusts premises. The stated legislation and guidance documents (Health Technical Memorandum (HTM) and addendum and Health and Safety Commissions (2000) Approved Code of Practice (L8)), require individuals to be appointed to take responsibility for minimising the growth of legionella and Pseudomonas aerugisa bacteria in water systems, preventing infections resulting from any growth, and dealing with any outbreak that occurs. This policy defines the processes that ensure that this Trust in compliant with these requirements. 2. AIM The aim of this Policy is to introduce a structured Procedure and Reporting Schedule, for the Management and Control of Legionellosis, including Legionnaires Disease, and Pseudomonas aerugisa in compliance with current Guidelines (HTM s, Health Guidance Notes, Model Engineering Specifications and Approved Codes of Practice), Legislation and Water Supply Regulations. As required by L8 and the relevant HTMs, the Trust will undertake to: Identify and assess sources of risk; Prepare a scheme for preventing, reducing or controlling the risk; Implement the scheme, and manage and monitor the processes; Keep records of the measures implemented for each of the health care premises within the Trust's control. Appoint a person with management responsibility. Legionella bacteria grow in all water systems. If the growth is allowed to proliferate, and the water is dispersed in aerosol form which is breathed in, the result can be a severe form of pneumonia like infection (Legionnaires disease). In some cases, particularly in individuals such as hospital patients that have reduced immunity or ability to fight infection, the outcome can be fatal. Pseudomonas aerugisa is commonly found in wet or moist environments. It is commonly associated with the potential to cause infections in almost any organ or tissue, especially in patients compromised by underlying disease, age or immune deficiency. Pseudomonas aerugisa thrives in relatively nutrient-poor environments at a range of different temperatures and can become one of the species in biofilms. Management has the overall responsibility for the implementation of these procedures to ensure that safe, reliable hot and cold water supply, storage and distribution systems operate within the Trust. Page 3 of 11

4 The primary defence strategy for reducing the risk from Legionella and Pseudomonas aerugisa infection will be a maintained temperature control regime. This regime may be supplemented by the addition of chemical and other water treatments where considered necessary and appropriate. When it is proposed to carry out works on cold water distribution systems, the Trust shall ensure as is reasonably practicable, that the legal duty to tify the water undertaker is carried out and documented. 3. DEFINITIONS 3.1 The Estate For the purposes of this Policy, the Estate comprises all the buildings currently owned or occupied (under a full maintenance lease or otherwise) by the Trust. A full list of properties/buildings and status of occupation is available on request from the Trust s Head of Estates and Facilities. 4. ROLES AND RESPONSIBILITIES 4.1 Chief Executive The Chief Executive: Has overall responsibility for all aspects of the quality of water supplies within all the Trust properties. Shall minate, in writing, a Water Safety Committee (WSC) whose duties will be to advise on and monitor the Management & Control of Legionnaires disease and Pseudomonas aerugisa. The team will consist of relevant officers within the Trust and if necessary, outside consultants. 4.2 Director of Estates & Facilities The Director of Estates & Facilities is responsible for the overall provision of a compliant, effective and efficient Estates Service. This position fulfils the role of Designated Person (DP) for the Trust and provides an informed position at board level. Shall minate in writing, a Responsible person and a Deputy Responsible Person. 4.3 Specific Responsibilities Infection Control Doctor The Infection Control Doctor or Consultant Microbiologist is the person minated by management to advise on infection control policy and to have responsibility for the maintenance of the bacteriological quality of the water. The Infection Control Doctor shall attend the WSC Infection Prevention and Control Team Responsible for supporting the Infection Control Doctor in managing the bacteriological quality of the water. A member of the team shall attend the WSC Responsible Person (Water) The Responsible Person (Water) shall take overall responsibility for the development and implementation of legionella and Pseudomonas aerugisa prevention policy and procedures, in order to comply with all appropriate legislation, regulations, and Page 4 of 11

5 standards. Specific responsibilities shall be defined in Estates Department procedures. The Responsible Person (Water) shall appoint an independent Legionella Control Consultant to provide advice on legionella management processes, audit compliance, and carry out new system design and installation risk assessments and approvals Deputy Responsible Person (Water) The Deputy Responsible person (Water) shall assist with the development and implementation of legionella and Pseudomonas aerugisa control and associated procedures and processes, and oversee the day to day activities defined in these procedures. Specific responsibilities shall be defined in Estates Department procedures Maintenance Craftsmen and Assistants Maintenance Craftsmen and Assistants are members of the Maintenance Team who have sufficient technical kwledge and the experience necessary to carryout maintenance and routine testing of the water, storage and distribution system and shall undertake maintenance regimes as instructed and using best practice Contractor A contractor is a person or organisation designated by management to be responsible for the supply, installation, validation and verification of hot and cold water services, and for the conduct of the installation checks and tests. In relation to the control of Legionella and Pseudomonas aerugisa, it is essential to ensure that contractors have suitable qualifications (For example companies/individuals who are members of the Legionella Control Association) Contract Supervising Officer / Project Manager The person minated by management to witness tests and checks under the terms of contract. He/she should have kwledge, training and experience of hot and cold water supply, storage and mains services and understand the contents of this policy. All Contract Supervising Officers / Authorised Officers must undertake routine training on the prevention and control of legionella and Pseudomonas aerugisa Designer / Project Manager Designers and installers of hot and cold water distribution systems are required by law under the Water Supply (Water Fittings) Regulations 1999 to tify the water undertaker of any proposed installation of water fittings and to have the water undertakers consent before installation commences. The design, installation, and operation of all new water systems shall be reviewed for compliance by the Responsible Person (Water), and the Legionella Control Consultant. Completion of the project requires a documented Risk Assessment, and Certificate of Compliance Legionella Control Consultants The Trusts Legionella Control Consultant shall provide advice on legionella and Pseudomonas aerugisa management processes, audit compliance, and carry out new system design and installation risk assessments and approvals. Page 5 of 11

6 Water Safety Committee The Committee s membership shall consist of: Responsible Person (Water) (chair) Deputy Responsible Person (Water) Infection Control Doctor Infection Control Nurse A Nursing Manager (Matron) from SCBU and ICU Deputy Estates Manager Estates Admin Officer (Minutes) The Infection Control Doctor will liaise with the Medical Director on clinical issues raised by the group Wards/Departments Heads of Department (Ward Manager) shall have responsibility for: Obtaining approval from the Responsible Person or Deputy before any plant or equipment that uses or discharges (particularly aerosol droplets) water is purchased, installed, taken into use, modified, or removed. This includes water coolers, air conditioning units, evaporative type cooling fans, humidifiers, de-humidifiers, ice making machines, and any equipment that holds water or produces spray, mist or water vapour. Identifying all infrequently (defined as those outlets used less than three times a week for at least one minute) used outlets within their area and subjecting these to a thrice-weekly flushing programme or daily in critical care areas as described on the Outlet Flushing Log Sheet. The Deputy Responsible Person (Water) shall audit the logs regularly to ensure compliance. This process is depicted by flow-chart 1 on page 13 of this policy. Where infrequently used outlets are deemed by the ward/department staff to be longer required, they should tify the Estates Department in writing so that they can be removed. Where a building or sections of the system remain unused for long periods of time, steps shall be taken as follows: - Flush all water facilities (including toilet and urinal cisterns) thoroughly on a thrice-weekly basis whilst the building is t in use. - Flush all water facilities (including toilet and urinal cisterns) thoroughly at least one day prior to the building being used. If a ward / department / area is t under the jurisdiction of any specific department the Estates Management Department must be tified so that the above routines can be carried out. 4.4 Responsibility of Staff All YDH staff have a duty to take reasonable care for their own health and safety, and that of others who may be affected by their acts and omissions at work. They must also cooperate with their employer to enable compliance with health and safety statutory duties, by adhering to procedures, and performing all relevant tasks reasonably requested. Page 6 of 11

7 All Trust staff, particularly those with designated Legionella and Pseudomonas aerugisa responsibilities shall;- Carry out any Legionella and Pseudomonas aerugisa prevention duties as defined in procedures and training. Promptly inform the Estates Department of defects and issues with water systems or equipment that give rise to Legionella/ Pseudomonas aerugisa risk. Inform the Estates Department before purchasing any water system or equipment in order to allow a Legionella Pseudomonas aerugisa risk review to be undertaken. In the event of an outbreak of Legionella participate in any actions required by infection outbreak procedures to prevent further infections and identify the source of infection, ensuring that all actions undertaken are recorded. (Refer to the Trust s Outbreak Management Policy) 5. TRAINING REQUIREMENTS The Responsible Person shall ensure that the Maintenance Legionella Control Team and all other staff involved in or associated with the Management & Control of Legionnaires disease will undertake regular training courses to ensure they are kept updated on new developments in the management and control of water services. Refresher courses with be undertaken at 2 yearly intervals. Managers and staff in other departments shall attend legionella awareness training sessions as arranged by the Estates Department on a three yearly basis and will encourage other relevant staff to attend. Attendance will be recorded and maintained ready for inspection if required. 6. ACTIONS IN THE EVENT OF A SUSPECTED OR CONFIRMED LEGIONELLA OR PSEUDOMONAS AERUGINOSA OUTBREAK Staff who become aware of a suspected or confirmed case of Legionella or Pseudomonas aerugisa infection shall follow Infection Control Policy procedures for tification of Managers, the Infection Control Doctor / Committee, The Responsible Person (Water) and the Estates & Facilities Director. The WSC shall meet to agree and coordinate all actions and communications. Advice will be sought from the HSE and Public Health England. The Responsible Person (Water) shall instigate and coordinate action by Estates staff to assist in identifying the sources of infection, preventing use of any suspected source, and shutting down any system that could potentially be dispersing aerosols, whilst ensuring that system is flushed, disinfected, or treated in any other way that might prevent confirmation of the source by subsequent tests. The Estates Department shall define the detailed actions required to achieve the above safety assurance. 7. LIMITATIONS This policy will form part of the Standing Orders of the Trust and will be included in the Schedule to the written particulars of employment of all staff employed by the Trust. Page 7 of 11

8 8. IMPLEMENTING, MONITORING AND EVALUATION This policy will be implemented, monitored and evaluated in line with the Trusts Policy on Procedural documents. Responsibility for the implementation of this policy shall be monitored by the Water Safety Committee who shall assure the Infection Prevention & Control Committee of the following standards: Results from audits of flushing regimes Summary of results from routine temperature checks on sentinel outlets Summary of microbiological tests of outlets in high risk areas Confirmation of where HEPA filters are installed Summary of PPM activity Changes to Statutory and NHS Guidance Training statistics / status Risk Assessment Action Plan status 9. REFERENCES APPENDIX 1 The management arrangement for outlet flushing APPENDIX 2 Summary of responsibilities for wards and departments ANNEX A The Equality Impact Assessment Tool Page 8 of 11

9 APPENDIX 1 THE MANAGEMENT ARRANGEMENT FOR OUTLET FLUSHING Flushing by Wards/Departments carried out 3 times per week Form completed signed and dated by person carrying out the flushing and countersigned by Ward/Department Manager Deputy Responsible Person (Water) audits log books to check compliance Not Compliant Compliant Non Compliance discussed at Water Safety Committee Responsible Person sends warning to Manager. Repeat audit of n-compliant areas at next session Not Compliant Compliant Responsible Person informs Director of Infection Prevention and Control Page 9 of 11

10 APPENDIX 2 SUMMARY OF RESPONSIBILITIES FOR WARDS AND DEPARTMENTS Flush infrequently used outlets (used less than 3 times a week for one minute) Maintain Usage Evaluation and Outlet Flushing Regime (to ensure that infrequently used outlets are identified and flushed as above) If water outlets are longer required please tify the Estates Department for safe removal. Inform Estates Management of any failures in water system i.e. poor temperatures, discoloured water and poor flow. Inform the Responsible Person or Deputy (see policy) of any intention to purchase new equipment requiring water connection, or which uses or discharges water. No alteration to the water supply pipe work or outlets shall be made. This must be undertaken using the Trust s Estates Department to ensure compliance with the water supply (water fittings) regulations Ensure existing equipment is being maintained appropriately e.g. Birthing pools, Nebulisers, water coolers, air conditioning units, evaporative type cooling fans, humidifiers, de-humidifiers, ice making machines etc. Signed Page 10 of 11

11 ANNEX A EQUALITY IMPACT ASSESSMENT TOOL To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. Name of Document: Water Safety Policy Yes/No Comments 1. Does the policy/guidance affect one group less or more favourably than ather on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 5. If so can the impact be avoided? n/a 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? For advice or if you have identified a potential discriminatory impact of this procedural document, please refer it to The Equality & Diversity Lead, Yeovil Academy, together with any suggestions as to the action required to avoid/reduce this impact Signed: Dave Shire (Maintenance Manager) Date: 04/10/2013 n/a n/a Page 11 of 11