Management Standard: Control of Legionella

Transcription

1 OHSS: H&S Management Standard 103 Control of Legionella Management Standard: Control of Legionella 1. Legal Framework This policy is produced to ensure compliance with; 1.1. the Health and Safety at Work Act 1974; 1.2. the Management of Health and Safety at Work Regulations 1999; 1.3. the Control of Substances Hazardous to Health (COSHH) Regulations 2002 (as amended); 1.4. the Approved Code of Practice and Guidance L8, The Control of Legionella Bacteria in Water Systems Purpose and Scope The purpose of this management standard is to ensure, so far as is reasonably practicable, the health and safety of staff, students and others working with or using water systems within the University. 3. Standards and Responsibilities The following table sets out the standards that all University staff and students must adhere to. The Occupational Health and Safety Service will monitor compliance with this management standard and the University will engage a competent contractor to carry out a management audit on a regular basis according to the University Audit Programme. Page 1 of 8

2 Although roles and responsibilities are provided in the following table, the following management structure is provided to clearly define where accountabilities are held for managing the potential risks of legionella bacteria. The following also provides definitions for role holders: Duty Holder The Vice Chancellor is the Duty Holder and has overall responsibility for health and safety. The Duty Holder should specifically appoint a competent person or persons to take day-to-day responsibility for controlling any identified risk from legionella bacteria, known as the responsible person. Responsible Person Someone with day-to-day responsibility for controlling any identified risk from Legionella bacteria. The Vice Chancellor, through the Faculty Pro Vice Chancellors and Registrar, has nominated each Unit as the Responsible Person for their specific area(s). Appointed Person The person who has been given responsibility for carrying out activities specified within risk assessments for the control of legionella bacteria. Deputy Appointed Persons The person who will assist or provide a replacement service for the Apointed Persons. Standard 3.1 Vet and Engage a Competent Water Hygiene Provider a) To ensure that a single contractor, hereafter referred to as the Water Hygiene Provider, is procured for the University to carry out water hygiene services in respect to legionella bacteria To vet and engage a competent water hygiene provider Provide the water hygiene provider with asset registers and schematic drawings of the University s domestic hot and cold water system up to the point of use Provide Unit based responsible and appointed persons with the contact details of the water hygiene provider so they can arrange contractor visits to assess, maintain and monitor Faculty/Unit owned water systems Unit To provide ESS and water hygiene provider with asset register details of all plant and equipment using water systems contained within areas of responsibility. This will include all equipment used after the point of use designated by ESS. To co-ordinate and agree who takes the lead for shared water systems, e.g. Page 2 of 8

3 Standard 3.2 Definitive Point of Transfer a) There must be understanding and agreement for what part of the water system people are responsible for. b) ESS are responsible for the water system up to a definitive point. c) Units are responsible for the water system after the definitive point. 3.3 Risk Assessment and Written Scheme a) Suitable and sufficient risk assessment must be carried out. b) Risk assessments should be reviewed every 2 years or immediately if there reason to believe it is no longer valid, if there is a significant change in the work activity to which it relates of if the results of health surveillance or monitoring indicate it to be necessary. de-ionised water systems, and provide details to ESS Arrange contractor visits to assess, maintain and monitor Unit owned water systems Provide a definitive point of transfer, schematic drawings, of responsibility between building, plant and equipment to Units as well as Faculties. Faculty To provide a list of identified people, Responsible Person and Appointed Person those performing tasks, to ESS and Strategic Water Safety Group. This will include all those who require access to the records for buildings database. Unit To ensure that documented arrangements are recorded when working with others to ensure accountabilities and responsibilities for the control of legionella are agreed. Water Hygiene Provider and ESS Visits to be organised with Units so access and supervision can be organised. Risk assessments and written scheme undertaken by Water Hygiene Provider and provided to ESS. To facilitate a central University Legionella management data recording system. ESS to monitor progress and actions of all Units (including ESS) in relation to water management and raise alerts with Heads of Unit as necessary. Page 3 of 8

4 Standard 3.4 Selection and Implementation of Control Measures a) To ensure that all water systems are included in the written scheme and risk assessments b) To ensure that the control measure are achievable c) To implement the requirements of the University Legionella guidance d) To implement the control specified within the legionella risk assessments Ensure that risk assessments are carried out and remedial actions implemented for all water systems within their control Ensure assessments are reviewed according to this management standard. Heads of Unit Ensure that risk assessments are carried out for work activities under their supervision and reviewed according to 3.2 Communicate the findings of the risk assessment to staff who have been given responsibility for carrying out control measures. Staff will be competent to perform their tasks. Faculty/Unit based Responsible and Appointed persons Staff and Students Heads of Unit, Upload risk assessments, and schemes of examination along with maintenance and inspection records onto the central University Legionella management data recording system. Follow information given by Managers/University Representative. Ensure the risk assessment provided by the Water Hygiene Provider cover all water systems within their area of control. To provide information to line managers in respect to equipment and facilities within their area of control. To ensure that specified control measures are achievable and practical Ensure the implementation of control measures to reduce the risk of exposure to hazardous substances. Page 4 of 8

5 Standard 3.5 Monitoring a) The requirement for monitoring should be determined by risk assessment. See section 3.3. and OHSS: H&S Guidance for further information. Appointed Person ESS, Unit and Appointed Persons Appointed Person To ensure the necessary resource support and oversight is provided. To implement the control measure as provided in the risk assessments for their locations. To ensure records are maintained, either locally or on the records for building database, as required by University guidance. Monitor whether risk assessments are being carried out within their units and actions are being implemented. This will be done by using the records for buildings database. To provide an annual report on the control of legionella via the University health and safety reporting system. To provide access, to records for buildings database for Faculties and Units. ESS to monitor progress with risk assessments and actions of all Units (including ESS) in relation to water management and raise alerts with Heads of Unit as necessary. To organise, implement and maintain suitable control measures identified in risk assessments or University H&S Management Standard and Guidance for their equipment. This would include actions to be taken by the Water Hygiene Provider. Upload details and records e.g. weekly flushing of showers or laboratory hoses onto the central University Page 5 of 8

6 Standard 3.6 Information, Instruction and Training a) Employees working with water systems must be provided with information, instruction and training to ensure safe working practices and competency. b) Employees should be supervised until they are deemed competent. c) Training records should be kept. 3.7 Emergency Procedures a) Please refer to the OHSS guidance Legionella management Faculty Estates Co-ordinator. Duty Holder, OHSS & data recording system. Respond to alerts raised by ESS regarding controls or actions that haven t been taken within relevant timescales To monitor and pursue Units when actions have not been undertaken and to seek assurance via the records for buildings database for completed actions. Where actions are not complete Faculty to inform Heads of Units that action must be taken. To train Responsible Person and provide awareness training for appropriate Unit staff Heads of Unit Identify the training needs of all those with responsibilities under this standard and make arrangements for the provision of training, instruction, information and supervision to ensure safe work practices and competency. Appointed Person Heads of Unit, Provide local training courses and inductions and maintain records. Ensure adequate emergency arrangements are in place within their unit Page 6 of 8

7 APPENDIX A Newcastle University acts as the managing agent for accommodation within the private sector. The following information will be documented as clauses within contracts between Accommodation and Hospitality Services (AHS) and Landlords providing services to Newcastle University students: 1.1 Landlord and Newcastle University: Ensure a proportionate legionella risk assessment is carried out and control measures identified are implemented. Shower Heads will be removed and disinfected during annual inspections or as required by the risk assessment The water system will be flushed prior to new occupations and at quarterly inspections undertaken (AHS will monitor this activity) To manage the risks during non-occupancy, consideration should be given to implementing a suitable flushing regime or other measures if the property is unoccupied for extended periods of time, e.g. student accommodation left empty over the summer vacation Carry out checks required by the risk assessment, e.g. califorier (boiler) temperature / cleaning of shower heads Check that cold water storage is maintained at < 20 Centigrade and be at or below this temperature at the point of use within two minutes of turning on cold tap Hot water storage is maintained at a minimum of 60 Centigrade at calorifier, it will circulate the system and return to the calorifier at not less than 50 Centigrade, the temperature at the point of use should achieve not less than 50 C within one minute of turning on tap. Thermostatic mixing valves will reduce the water temperature at the outlets to prevent scalding Making sure any redundant pipework identified is removed 1.2 Tenants: Clean and disinfect shower heads regularly Where water outlets have not been used for a week, flush them for 2 minutes and the toilet twice Contact the managing agent if the water is not heating properly Do not adjust the temperature setting of the calorifier. Page 7 of 8

8 APPENDIX B Overview Flow Chart for Legionella Management Process & Responsibility Units to provide asset register to ESS. ESS to vet and arrange contract with a Water Hygiene Provider Unit based Responsible/Appointed person to arrange contractor visits for risk assessment, remedial actions, inspections and monitoring. Unit based Responsible/Appointed person to upload Risk assessments and scheme of examination and all associated records onto the central University Legionella management data recording system ESS to alert Unit based Responsible/Appointed persons when risk assessments and actions haven t been carried out to relevant timescales ESS to escalate issues within Units that haven t been actioned to Unit Page 8 of 8