The Newcastle upon Tyne Hospitals NHS Foundation Trust Water Safety Policy Version No.: 2.0 Effective From: 09 February 2018 Expiry Date: 09 February 2021 Date Ratified: 09 November 2017 Ratified By: Infection Prevention & Control Committee 1 Introduction The Newcastle upon Tyne Hospitals NHS Foundation Trust is committed to minimising the risk of waterborne pathogens, including legionella and pseudomonas, to provide a safe environment for patients, staff and visitors. As a provider of specialist acute healthcare services we know the risk that these waterborne pathogens pose to our patients is high. In order to deliver this commitment the Trust will follow the guidance contained within Health Technical Memorandum 04-01 Approved Code of Practice L8. This policy links directly to the Trust s first strategic goal, from our Vision and Values, in putting patients first and providing care of the highest standard focusing on safety. 2 Scope This policy covers all premises owned, occupied or managed by the Trust. It also applies to the activities of the Private Finance Initiative (PFI) service providers, other employers, contractors and volunteers sharing or working on any of the Trust s sites. 3 Aims This policy aims to minimise the risk of patients, staff and visitors acquiring an infection from waterborne pathogens in Trust owned or occupied premises. 4 Duties (Roles and responsibilities) For a detailed explanation of roles and responsibilities, including governance arrangements with regards to water safety, please see the Water Safety Plan (a detailed procedures document maintained by the Trust Water Safety Group). 4.1 Trust Board The Trust Board has overall accountability for the activities of the organisation, including water safety. The Trust Board delegates the responsibility for water safety through the Chief Executive. 4.2 Chief Executive Page 1 of 7
The Chief Executive will, on behalf of the Board, be responsible for ensuring that duties required by the Health & Safety at Work etc Act 1974, and Control of Substances Hazardous to Health 2002 (as amended), are fulfilled. The Chief Executive is the duty holder with regards to water safety, including legionella and pseudomonas management and control. The Chief Executive delegates the day-to-day operational responsibility for water safety to the Director of Estates. 4.3 Board Level Director The Director with water safety responsibility must ensure that water safety issues are highlighted at Board level. This responsibility has been delegated to the Director of Estates by the Chief Executive. 4.4 Water Safety Group The Water Safety Group (WSG) is responsible for the strategic risk management of water quality and water safety across Trust owned and occupied premises. The WSG is accountable to the Trust Board via the Infection Prevention & Control Committee (IPCC). The WSG is chaired by the Director of Infection Prevention & Control (DIPC) and membership consists of nominated representatives from Estates, Infection Prevention & Control (IPC), Nursing, Hotel Services, Health & Safety and the Trust s independent external Authorising Engineer for Water. The group will review terms of reference annually to ensure that the WSG remains fit for purpose, with any amendments ratified by the IPCC. 4.5 Independent Authorising Engineer (Water) As per Health Technical Memorandum (HTM) 00: Policies and Principles of Healthcare Engineering and HTM 04-01: Safe Water in Healthcare Premises the Trust will appoint an Authorising Engineer for Water, AE(W), as an independent professional adviser to the organisation on all matters relating to water quality management and control. The AE(W) will advise on all projects involving water systems in Trust owned and occupied premises, carry out compliance audits with regards to statutory water quality management and control requirements and also assess competence of those taking on the role of Responsible Persons. 4.6 Estates Responsible Persons (Water) Key Estates staff will be designated with the role of Trust Responsible Persons and Deputy Responsible Persons by the Director of Estates. The Responsible Persons (Retained Estate), and Responsible Person (PFI Estate), will work with the DIPC and WSG Nominated Persons to consider each water quality risk assessment report and ensure all necessary remedial work are discussed, agreed and acted upon to minimise or control the level of risk. The Deputy Estates Responsible Persons (Water) will support the Responsible Persons in taking a lead on the implementation of agreed Page 2 of 7
remedial work and the day-to-day management and control of water quality as per the Trust Water Safety Plan. 4.7 Directorate Managers and Heads of Department Directorate Managers and Heads of Department are responsible for ensuring this policy, and the procedures outlined in the Water Safety Plan, are followed within their respective areas. These responsibilities include, but are not limited to: informing Estates when an area containing water outlets is vacant for more than 4 days and ensuring outlets are flushed regularly in accordance with the Water Safety Plan. 4.8 All members of staff All members of staff, including volunteers, are responsible for ensuring they take reasonable care pertaining to safety of themselves and others who may be affected by their omissions at work. Members of staff must complete mandatory IPC training in accordance with the Mandatory Training Policy, this training includes legionella awareness. All members of staff are responsible for reporting under-used, or faulty, water outlets to the Estates Service Desk in order to reduce the risk of stagnation and waterborne bacteria proliferation. 4.9 Contractors All contractors working on Trust water systems must comply with this policy. Contractors shall be members of Constructionline and, where applicable, the Legionella Control Association. All contractor staff need to demonstrate, and provide evidence of, training and competence appropriate to their responsibilities with regards to work on Trust water systems. Where a specialist contractor is required to carry out emergency remedial works and does not meet the membership criteria listed above, they may be employed by the discretion of the Chair of the WSG. 5 Definitions None 6 Water Quality Management and Control The key requirements to ensure effective water quality management and control are documented procedures (Water Safety Plan), documented risk assessments (legionella and pseudomonas) and accurate maintenance records (log books). 6.1 Water Safety Plan A water safety plan, as per HTM 04-01, will be documented and approved by the Trust Water Safety Group and made available to all staff via the intranet. This plan will outline the governance arrangements, standard procedures, checklists and proformas to enable the Trust to deliver compliant and effective Page 3 of 7
water quality management and control practices across all Trust owned and occupied premises. The water safety plan will be reviewed, at least annually, by the Water Safety Group and be subject to external independent audit. 6.2 Risk Assessments The Trust will ensure documented legionella and pseudomonas risk assessments are held, and maintained, all Trust owned premises. The Trust will also make arrangements to have sight of the relevant risk assessments for premises occupied by Trust staff to ensure staff, patients and visitors are not exposed to high levels of risk from poorly managed third party premises. Progress towards remedial action plans, generated from risk assessments, will be monitored by the WSG and be subject to independent external audit. 6.3 Record Keeping To ensure that water quality management and control precautions take place, records must be maintained and kept for at least five years, as per the Trust Water Safety Plan (accessible to all staff via the Infection Prevention & Control intranet page). Precautionary measures and treatments, monitoring results and remedial work must be logged and signed by the person authorised to carry out the work. Sufficient information must be recorded to clearly identify what measures were taken and how they were monitored. A logbook system should be maintained to improve efficiency and effectiveness of the water system and also to provide a record of various tasks so that a history can be reviewed at any time. The logbook structure and required contents is stipulated in the Trust Water Safety Plan. 7 Training 7.1 All staff All staff are made aware of waterborne pathogen risk, and the means of controlling the risk, via the Mandatory Training for Infection Prevention & Control. This basic training takes place at induction and is repeated annually in refresher form. 7.2 Estates Responsible Persons (Water) Estates Responsible Persons (Water), and Deputy Estates Responsible Persons (Water), are required to undertake regular accredited water quality management and control training courses, at least every two years, to ensure they are kept up-to-date on new legislation and developments in water quality management and control. 7.3 Water Safety Group Nominated Persons Page 4 of 7
Members of the Water Safety Group, along with other key stakeholders such as Microbiology and Infection Prevention & Control staff, are required to undertake awareness training commensurate with their role. A best practice module has been created on the Trust s e-learning platform for this purpose. 7.4 Hotel Services staff Specific training, in support of this policy, is provided to Hotel Services staff by Hotel Services management. This includes, but is not limited to, the importance of regular outlet flushing and the correct method for cleaning sanitary fittings so as to minimise the proliferation of bacteria (most notably pseudomonas). This training is mandated for all hotel services domestic staff and is refreshed regularly. 7.5 Contractors All contractors, and agency staff, working on water systems in Trust owned or occupied premises must be competent and trained in water quality management and control commensurate with their role. 8 Equality and Diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This document has been appropriately assessed. 9 Monitoring Compliance Standard / process / issue Independent assessment of Water Quality Management and Control procedures and legal compliance Authorising Engineer (Water) combined HTM compliance and governance audit Water Quality Management Update Compliance with the WSG terms of reference Monitoring and audit Method By Committee Frequency Audit (Main Hospital sites) Audit (Trustwide) Report Report External independent water safety expert Authorising Engineer (Water) Responsible Persons (Water) Director of Infection Prevention Control (WSG Chair) WSG WSG Trust Board via IPCC IPCC Six-monthly Annually Monthly Annual Page 5 of 7
10 Consultation and review This policy was developed in consultation with, and approved by, the Trust Water Safety Group. The policy is then passed to the Infection Prevention & Control Committee (IPCC) for final ratification. 11 Implementation (including raising awareness) This should include any specific requirements (in addition to the implementation in accordance with this strategy/policy/procedure) e.g. staff briefings, newsletters, team brief, divisional meetings. This policy, and the more detailed Water Safety Plan procedural document, is available on the Trust intranet for all staff to access. Awareness of this policy, the Water Safety Plan and the governance work of the Water Safety Group is raised via Infection Prevention & Control Forums 12 References Health & Safety Commission Approved Code of Practice & Guidance 2013 - The Control of Legionella bacteria in water systems (L8) Health and Safety at Work etc., Act 1974 The Management of Health and Safety at Work Regulations 1992 and The Health and Safety (Miscellaneous Amendments) Regulations 2002 Control of Substances Hazardous to Health (COSHH) Regulations 2002 (as amended) The Public Health (Infectious Diseases) Regulations 1988 The Water Supply (Water Fittings) Regulations 1999 The Water Supply (Water Quality) Regulations 2000 Health Technical Memorandum (HTM) 00: Policies and Principles of Healthcare Engineering Health Technical Memorandum (HTM) 04-01: Safe Water in Healthcare Premises 13 Associated documentation Healthcare Acquired Infections Prevention and Control Strategy Water Safety Plan (available on the IPC Intranet page) Page 6 of 7
Appendix 1 Trust Organogram (Water Safety) Page 7 of 7
The Newcastle upon Tyne Hospitals NHS Foundation Trust Equality Analysis Form A This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. PART 1 1. Assessment Date: 26.09.17 2. Name of policy / strategy / service: Water Safety Policy 3. Name and designation of Author: James Dixon (Head of Environmental Management) and Dr Ashley Price (DIPC and Chair of Water Safety Group) 4. Names & designations of those involved in the impact analysis screening process: Water Safety Group members 5. Is this a: Policy X Strategy Service Is this: New Revised X Who is affected Employees Service Users Wider Community 6. What are the main aims, objectives of the policy, strategy, or service and the intended outcomes? (These can be cut and pasted from your policy) The minimisation of risk of waterborne pathogens, including legionella and pseudomonas, to provide a safe environment for patients, staff and visitors. 7. Does this policy, strategy, or service have any equality implications? Yes No X If No, state reasons and the information used to make this decision, please refer to paragraph 2.3 of the Equality Analysis Guidance before providing reasons: The policy has considered the needs of all people including those who have protected characteristics and ensures any groups of people with protected characteristics are not disproportionately advantaged or disadvantaged.
8. Summary of evidence related to protected characteristics Protected Characteristic Race / Ethnic origin (including gypsies and travellers) Evidence, i.e. What evidence do you have that the Trust is meeting the needs of people in various protected Groups The policy is designed to support the highest levels of patient care and staff safety. Does evidence/engagement highlight areas of direct or indirect discrimination? If yes describe steps to be taken to address (by whom, completion date and review date) Sex (male/ female) As above No No Religion and Belief As above No No Sexual orientation including As above No No lesbian, gay and bisexual people Age As above No No As above No No Disability learning difficulties, physical disability, sensory impairment and mental health. Consider the needs of carers in this section Gender Re-assignment As above No No Marriage and Civil Partnership As above No No Maternity / Pregnancy As above No No 9. Are there any gaps in the evidence outlined above? If yes how will these be rectified? No No Does the evidence highlight any areas to advance opportunities or foster good relations. If yes what steps will be taken? (by whom, completion date and review date) 10. Engagement has taken place with people who have protected characteristics and will continue through the Equality Delivery System and the Equality Diversity and Human Rights Group. Please note you may require further engagement in respect of any significant changes to policies, new developments and or changes to service delivery. In such circumstances please contact the Equality and Diversity Lead or the Involvement and Equalities Officer. Do you require further engagement? Yes No X 11. Could the policy, strategy or service have a negative impact on human rights? (E.g. the right to respect for private and family life, the right to a fair hearing and the right to education? No
No PART 2 Name: James Dixon Date of completion: 17/10/17 (If any reader of this procedural document identifies a potential discriminatory impact that has not been identified, please refer to the Policy Author identified above, together with any suggestions for action required to avoid/reduce the impact.)