POLICY AND PERFORMANCE STANDARD FOR THE MANAGEMENT AND CONTROL OF LEGIONELLOSIS INCLUDING LEGIONNAIRES DISEASE February 2005 S:\policies\files\water_hygiene.doc
Title Reference Number DOCUMENT HISTORY Issue Date Details 1 October 2004 Draft circulated for UoK initial consideration / adoption based on an original format supplied by Hydrop 2 8 th February 2005 Approved by SHEEC Author J.E.Burton Signature: J E Burton Reviewer N.H.Swinford Signature: N H Swinford Date: 10th February 2005 Date: 25 February 2005 Authorised by Chair of SHEEC Signature: P A Davies Date: 17 February 2005 Issued by Estates Department Signature: J E Burton Date: 25 February 2005 1
CONTENTS Section Title Page Nos 1. Policy 3 2. Introduction 4-5 3. Legislation and Guidance 6 4. General Responsibilities 7 5. Delegated Responsibility 8-12 6. Training Requirements 13-14 7. Audit 15 8. Appendix 1 Further Guidance 16-18 9. Appendix 2 - Letter of Appointment 19 2
1.0 POLICY It is University of Kent policy to manage the operation and maintenance of its Domestic Water and Air systems in line with current best practice, complying with all current and relevant guidelines and legislation relating to the management and control of Legionellosis including Legionnaires Disease. Measures to be taken to implement this policy include: A. The appropriate selection, design, installation and maintenance of plant. B. The appointment of Responsible Persons competent to: i. Liase with all other organisations that supply the University with services pertaining to Legionellosis Management & Control whether accommodation, facilities management, water treatment, consultancy etc. ii. Identify and assess the risk of Legionellosis resulting from work activities to include breakdowns and abnormal situations. iii. Develop, implement and maintain appropriate and suitable Management Systems, Personnel Training Programmes and plant treatment procedures. iv. Develop and maintain adequate records in order to demonstrate compliance with best practice and fulfil legal obligations. v. Ensure compliance with this policy. C. The regular monitoring, of all implemented Management Systems, Training Programmes and treatment procedures, to establish and ensure their continuing efficacy and legislation compliance. 3
2. INTRODUCTION 2.1 Management Statements and Aim The University of Kent (the University) recognises and accepts its responsibility under the Health and Safety at Work etc. Act 1974 and the Control of Substances Hazardous to Health Regulations 1999, to take all reasonable precautions to prevent or control the potential of Legionellosis to residents, staff and other persons working at or using its premises. The University recognises its responsibility to implement, in full, the Codes of Practice and all other relevant and associated documentation, particularly The Health and Safety Commission's Approved Code of Practice L8. The prime aim of this policy and procedural document is the proper care and maintenance of the University's water supply services, in the interests of residents, staff and other persons entering the University's premises. The University will: i. identify and assess sources of risk; ii. prepare a scheme for preventing, reducing or controlling the risk; iii. iv. implement and manage precautions; keep records of the precautions implemented and will do so for each of the premises within the University's control. 4
2.2 The Estate For the purposes of this Policy document, the Estate comprises all the buildings currently owned or occupied (under a full maintenance lease or otherwise) by University of Kent. 2.3 The University s Service Providers For the purposes of this Policy document, the Service Providers are organisations that supply the University with services pertaining to Legionellosis Management & Control, whether providers of accommodation, and or Facilities Management, Water Treatment, Consultancy, etc. 5
3. LEGISLATION AND GUIDANCE The University, in implementing this policy, will use, as a general source of practical help, the documents listed below: i. L8 The Control of legionella bacteria in water systems Approved Code of Practice & Guidance 2001. ii. Health and Safety at Work etc. Act 1974, Sections 2, 3 and 4 (HSW). iii. Control of Substances Hazardous to Health Regulations 1999, Regulation 6 (COSHH). iv. The Public Health (Infectious Diseases) Regulations 1988. v. The Water Supply (Water fittings) Regulations 1999. vi. BS 6700:1997 - Specification for Design, installation, testing and maintenance of services supplying water for domestic use within buildings and their curtilages. vii. Food Act 1990. Further information on the above guidance is included in Appendix 1. 4. GENERAL RESPONSIBILITIES 4.1 Employer s Duties The University as employer has a general duty under The Health and Safety at Work etc. Act 1974 to ensure so far as is reasonably practicable, the health, safety and welfare of all its employees. HSWA 2(1) requires employers to: i. provide and maintain plant and systems of work that are safe and free from health risks ii. make arrangements for ensuring safety and the avoidance of health risks in connection with the use, handling, storage and transportation of articles and substances (HSWA 2(2)b) iii. provide such information, instruction, training and supervision to 6
ensure the health and safety at work of their employees [HSWA 2(2)c] iv. provide a safe working environment [HSWA 2(2)e] v. those in control of premises must ensure that they are safe and that any plant or substance does not endanger health of any persons at work or the general public (HSWA 4) 4.2 Employees Duties Employees have a duty under Section 7 of the Health and Safety at Work Act etc. 1974 to take reasonable care for their own health and safety and that of others who may be affected by their acts or omissions at work. Towards this end, employees should use correctly all work items provided by their employers, in accordance with their training and their instructions they receive to enable them to use the items safely. Employees' duties under Section 7 also include co-operating with their employer to enable the employer to comply with statutory duties for health and safety. Employees or those they appoint (e.g. under Regulation 6) to assist them with health and safety matters therefore need to be informed without delay of any work situation which might present a serious and imminent danger. The danger could be to the employee concerned or, if it results from the employee's work, to others. Employees should also notify any shortcomings in the health and safety arrangements, even when no immediate danger exists, so that employers in pursuit of their duties under the HSWA Act and other statutory provisions can take such remedial action as may be needed. 7
5.0 DELEGATED RESPONSIBILITIES MANAGEMENT & CONTROL STRUCTURE COUNCIL Responsible for Health & Safety Policy Vice-Chancellor PVC (Health and Safety) SHEEC PVC (Estates) Responsible for standards Director of Estates Legionella Risk Management Team Responsible for implementing Assistant Director (Technical Services) Responsible Person Assistant Director (Campus Services) Maintenance Services Manager Deputy Responsible Person Direct Labour Manager Deployment of Direct & Contract Labour Indicates line management Assistant Services Manager (Standard & Compliance) Note: The Director of Safety, Health & Environment is a member of both SHEEC and the Legionella Risk Management Team The University delegates to the Pro Vice-Chancellor (Estates), responsibility for the implementation of this directive. 8
5.1 The Director of Estates shall i. Have overall responsibility for all aspects of the quality and management of water supplies within the University's buildings. ii. Nominate, in writing, a "Legionella Risk Management Team" the meetings of which he / she will chair, whose duties will be to monitor and advise the Pro Vice-Chancellor (Estates) on the Management & Control policy for Legionnaires disease. iii. Appoint, in writing, a Responsible Person and a Deputy Responsible Person (Legionella control) to manage the necessary procedures for the prevention of legionnaires, disease. These persons should possess a thorough knowledge of the control of Legionella. 5.2 The Responsible Person and Deputy Responsible Person shall i. Accept management responsibility for Legionella control. ii. Prepare and implement an Operational Policy on Legionella control. iii. Implement and maintain the University s Pre-planned Maintenance Programme for Legionella control. iv. Ensure that persons carrying out risk assessments are competent to do so. v. Ensure records of risk assessment and precautions implemented are maintained. vi Put in place arrangements for reporting an outbreak or suspected outbreak of Legionella. vii. Ensure that precautions on the Control of Legionella are audited annually. 9
viii. Assess the training needs for training of staff in Control of Legionella. ix. Liaise with suitable training establishments and Consultants etc to procure appropriate courses on Control of Legionella. x. Ensure personal training records are kept up to date. xi. Carry out Risk Assessments on water systems and air conditioning plant in line with the Guidelines and checklist in Section 2.6.0. xii. xiii. xiv. Keep permanent records of all risk assessments. Carry out remedial work highlighted during Risk Assessment. Put in place maintenance and inspection routines for the control of Legionella. xv. Keep maintenance and monitoring records that must be readily available for inspection. Written and computer records to be kept for 5 years. xvi. Ensure record drawings of systems are available and kept updated. xvii. Ensure the competence of staff or external contractors used for any aspect of monitoring and/or maintaining the precautions for Legionella. xviii. Ensure that new systems or systems worked-on are chemically disinfected to BS 6700. xix. Submit and discuss Risk Assessment results with the "Legionella Risk Management Team". xx. Only purchase materials for water systems and air conditioning plant that will not provide nutrients for Legionella bacteria. The Water Research Centre Water Fittings and Materials Directory may be used for this purpose. 10
5.3 University Director of Health, Safety & Environment shall i. Supply advice and assistance in all safety matters. ii. iii. If requested, participate in compliance audits. Notify reported incidents to the University s Safety Health and Environment Executive Committee and the Legionella Risk Management Team. 5.4 Legionella Risk Management Team shall i. Ratify the appointment of people into positions of Responsibility. ii. Approve all relevant Documentation, Works Specifications, PPM Programmes, Policies etc. (prepared by the team or by others for the team). iii. Monitor and report upon the efficacy of all implemented PPM Programmes and all other relevant procedures. iv. Monitor and report upon the efficacy of all contractors appointed to undertake work on Legionella related projects. v. Monitor and report upon the efficacy of all training programmes implemented for associated staff. The team should include persons able to represent the users of all types of University premises. The team will include the Director of Safety, Health and Environment and the Director of Kent Hospitality. The team will meet at intervals necessary to reflect the work load inhand, but termly meetings are considered to be appropriate initially during the implementation stages of the Legionellosis Management 11
& Control Programme. Thereafter six-monthly meetings may be appropriate. The team will advise the Pro-Vice-Chancellor on performance in monitoring infection control policy for the control of Legionella. 5.5 Reporting Line Council Vice-Chancellor Pro-Vice-Chancellor (Estates) Legionella Risk Management Team Members: Responsible Person Deputy Responsible Person (Maintenance Services Manager) Director of Estates (Chair) Assistant Director (Campus Services) Direct Labour Manager Assistant Services Manager (Standards & Compliance) Director of Kent Hospitality Director of Safety, Health & Environment Health & Safety Adviser Estates Department 12
6 TRAINING REQUIREMENTS The Legionella Risk Management Team and any competent staff who are chosen to deputise for them will be provided with regular appropriate training courses so that they are properly updated on new developments in the management and control of water services. In the absence of changed regulations or guidance making update training necessary, refresher courses will be undertaken annually to ensure the competent staff can fulfil the responsibilities of their specific duties. All managers responsible for University buildings and activities have a duty of care and will be given adequate training in order that they are aware of known hazards and the safe precautions to adopt to ensure their sites are safe. The University recognises that only with the assistance of all site managers can the "Legionella Risk Management Team" maintain a safe regime of care across the whole of the University's estate. The Director of Safety, Health and Environment, supported by The Responsible Person (Legionella), will arrange training for all managers within the University so that the procedures adopted to cope with high hazard activities in their areas / departments is understood. The location of all known types of hazards and current condition will be given to the managers. The training for all managers will incorporate a procedure to be adopted by them when their attention is drawn to any situation presenting an 13
unacceptable hazard. The procedure will be such that it avoids danger to any person s health and safety and arrangements for seeking the appropriate help from the "Legionella Risk Management Team" members. 14
7 AUDIT 7.1 The Responsible Person will procure an annual audit of operating arrangements to confirm or otherwise comment on compliance with this policy document. The audit report shall also advise whether the policy continues to meet both statutory requirements and best practice. 7.2 The Audit shall be undertaken by a suitably qualified person. 7.3 The content of the audit report shall be considered by the Legionella Risk Management Team and subsequently reported to the Safety, Health and Environment Executive Committee. 15
Appendix 1 Further Guidance 1. L8 The Control of legionella bacteria in water systems Approved Code of Practice & Guidance This Code of Practice gives practical guidance with respect to sections 2, 3, 4, and 6 of the Health & Safety at Work etc. Act 1974 and regulations 6, 7, 8, 9 and 12 of the Control of Substances Hazardous to Health Regulations 1999. This Code has been approved by the Health and Safety Commission and gives advice on how to comply with the Law. This Code has a special legal status in that, if you are prosecuted for breach of health and safety law, and it is proved that you have not followed the relevant provisions of the Code, a court will find you at fault, unless you can show that you have complied with the law in some other way. 2. Health and Safety at Work etc. Act 1974, Sections 2, 3 and 4 (HSW). Employers have a general duty, under the Act, so far as is reasonably practicable to ensure the health, safety and welfare of their employees and visitors. These duties are legally enforceable, and the Health and Safety Executive have successfully prosecuted occupiers of premises under this statute for outbreaks of Legionnaires Disease. It falls upon both owners and occupiers of premises to ensure that there is a management regime for the design, installation and maintenance of plant, equipment and systems. Failure to have proper system of work and adequate control measures can also be an offence even though an outbreak has not occurred. 16
3 Control of Substances Hazardous to Health Regulations 1999, Regulation 6 (COSHH). These regulations apply to micro-organisms, including Legionellae, which could create a health hazard. These regulations also apply to the chemicals which may be used to control the growth of organisms in water supply. 4. The Public Health (Infectious Diseases) Regulations 1988. These Regulations require that a proper officer (now usually the consultant in communicable disease control (CCDC)) shall inform the chief medical officer of any serious outbreak of any disease which has, to his knowledge has occurred in his district. 5. The Water Supply (Water Quality) Regulations 1989, Water Supply (Water Quality) (Amendment) Regulations 1991. These regulations apply to water stored and distributed within any site which is used for drinking and any domestic purpose. The Private Water Supplies Regulations 1991 (Statutory Instrument no 2790) cover private water supplies (Boreholes and Wells). 6. BS 6700:1997 Specification for Design, installation, testing and maintenance of services supplying water for domestic use within buildings and their curtilages. This standard specifies requirements for and gives recommendations on the design, installation, alteration, testing and maintenance of services supplying water for domestic use within buildings and their curtilages. It 17
covers the system of pipes, fittings and connected appliances installed to supply any building, whether domestic or not, with water for drinking, culinary, domestic laundry, ablutionary, cleaning and sanitary purposes. 18
Appendix 2 Letter of Appointment I nominate Mr N H Swinford as the Responsible Person" for Legionella Management for the University and Mr R S Watkins as his deputy, and approve the adoption of the Code of Practice which includes the following measures to be taken to attain this objective: 1. The appropriate selection, design, installation and maintenance of plant. 2. Identification and assessment of the risk of Legionellosis resulting from work activities; 3. Development, implementation and maintenance of appropriate and suitable Management Systems, Personnel Training Programmes and plant treatment procedures; 4. Development and maintenance of adequate records in order to demonstrate compliance with best practice and fulfill legal obligations, and; 5. Regular monitoring of Management Systems, Training Programmes and treatment procedures, to establish and ensure their continuing efficacy and legislation compliance. 6. Compliance with the University s Policy and Code of Practice. Issued by:. Director of Estates Date of Issue.. Received by.. (Responsible Person) Date.. Received by.. (Deputy Responsible Person) Date.. 19