UNIVERSITY OF BRISTOL · Web viewHSP32 Control of Legionella Bacteria within water systems Health...

$: UNIVERSITY OF BRISTOL · Web viewHSP32 Control of Legionella Bacteria within water systems Health and Safety Policy – Capital Maintenance & Infrastructure Group I:\Operations\Capital$
ESTATES OFFICE

CAPITAL MAINTENANCE & INFRASTRUCTURE GROUP

HEALTH & SAFETY POLICY & PROCEDURES HSP32

CONTROL OF LEGIONELLA BACTERIA WITHIN WATER SYSTEMS

POLICY AND PROCEDURES

ISSUE RECORDRevision Description Review

DateCompiled/revised by

Checked by

Next review date

05 Modified Dec 2014 J Cummins S Hyde Dec 1504 Modified Mar 2013 J Cummins/S Hyde S Hyde Mar 1403 Modified Nov 2012 J Cummins S Hyde Aug 13 02 Updated Mar 12 J Cummins S Hyde Mar 13 01 Modified Jan 11 J Cummins S Hyde Jan 12

Contents:

1. Purpose of Document/tt/file_convert/5ad0ddca7f8b9a86158b6ade/document.docx

2. Commitment Statement

3. Organisation and Responsibilities3.1 Management and Responsibility Chart3.2 The Responsible Person

4. Risk Assessment

5. Control Methodology

6. Training and Record Keeping

7. Audit

8. Control areas of risk - New equipment, replacement equipment and alterations

9. Control areas of risk - Cooling Towers and Evaporative Condensers

10. Control areas of risk - Showers

11. Control areas of risk - Domestic Hot Water Systems

12. Control areas of risk - Cold water systems

13. Control areas of risk - Infrequently used outlets

14. Control areas of risk - Air washers

15. Control areas of risk- Humidifiers

16. Control areas of risk - Ornamental water fountains

17. Control areas of risk - Residences

18. Control areas of risk – Fire Protection

/tt/file_convert/5ad0ddca7f8b9a86158b6ade/document.docx

HSP32 Control of Legionella Bacteria within water systems Health and Safety Policy – Capital Maintenance & Infrastructure Group

Control of Legionella bacteria within water systems in the University

1. Purpose of the Document

To define how the Director of Estates (Duty Holder) intends to manage the risk from exposure to legionella bacteria in water systems in a manner that adopts the principles of legislation and good practice.

This Policy applies to all areas of the University without exception.

The University’s recommended standards to be held in this policy have been prepared on the interpretation, understanding and practical application of the HSE Approved Code of Practice ACOP L8 – “The control of legionella bacteria in water systems” and Technical Guidance HSG274.

Estates Capital Maintenance and Infrastructure group implement this Policy through Works Instruction WI-3 and the University of Bristol Generic Projects Requirements.

2. Commitment Statement

2.1 The University intends to adopt as far as reasonably practicable the principles of control and management identified in the current edition of the H.S.E Approved Code of practice and Guidance Document L8 “The Control of Legionella Bacteria in Water Systems” (ACOP L8 ).

2.2 To comply with its duties the University will:a) Identify and assess sources of risk. This includes checking whether conditions are

present which will encourage bacteria to multiply, is there a means of creating and disseminating breathable and if there are susceptible people who may be exposed to the contaminated aerosols.

b) Prepare a scheme for preventing or controlling the risk

c) Implement, manage and monitor all precautionary control measures identified

d) Keep records of precautionary measures

e) Identify responsibilities of employees and contractors within the University establishment.

University of Bristol Page 2 of 16Estates – Capital Maintenance & Infrastructure Group Document updated: December 2014

DIRECTOR OF ESTATES

DUTY HOLDER

Senior Engineer

RESPONSIBLE PERSON

EmployeesFacilities Managers

Heads of Department

Accommodation Managers/Wardens

Contractors

Consultation & Advice

Compliance Officer

DEPUTY RESPONSIBLE PERSON

Capital Projects Office

Capital Project Managers

Capital Projects Officers

Design EngineersSurveyors

Contracts Supervisors

Reactive Maintenance Managers

Langford / PrecinctResidences

Specialist Water Treatment Contractors

Reactive Maintenance Services Operatives


3. Organisation and Responsibilities



3.1 The University has appointed the Director of Estates to be the Duty Holder. The Duty Holder has appointed the Senior Engineer to be the Responsible Person to manage Legionella control within its estate.

3.2 The University responsibilities are listed below:

The Director of Estates- To be the duty holder- To appoint a responsible person and delegate total authority to allow compliance

Senior Engineer- To be the Responsible Person- Manage the compliance policy and system. (Utilising water treatment and

environmental specialists as necessary)- Order works from providers as necessary- Audit performance

Compliance Officer:- To be the Deputy Responsible Person - Ensure compliance with University of Bristol control of legionella bacteria within

water systems policy and procedures- Ensure the monitoring regime is adhered to- Ensure the Inspection regime is adhered to- Cost any remedial work identified and provide costs to the Senior Engineer- Order works from providers as necessary- Audit performance- Update records as appropriate- Maintain database

Maintenance Managers - Ensure compliance with University of Bristol control of legionella bacteria within

water systems policy and procedures- Ensure any tasks allocated are completed on schedule and remedial jobs created

as necessary, with response category appropriate for task- Ensure the monitoring regime is adhered to- Ensure the Inspection regime is adhered to- Cost any remedial work identified and provide costs to the Senior Engineer- Order works from providers as necessary- Facilitate any monitoring or inspection work- Facilitate and ensure completion of any remedial work identified- Ensure all necessary documentation is completed and returned to the Compliance

Office- Ensure all maintenance works comply with the ACOP L8 documents. The

University Control of Legionella Policy, the Estates Works Instruction WI-3 and the GPR.



Design Engineers, Surveyors, Contracts Supervisors, Project Managers and Project Officers:- Ensure compliance with University of Bristol control of legionella bacteria within

water systems policy and procedures- Ensure systems are designed and installed to ensure compliance with the ACOP

L8 document and the Estates GPR- Ensure all necessary documentation is completed and returned to the Compliance

Office

Specialist Water Treatment Contractors/ Environmental Service Company:- Carry out Risk assessments in accordance with BS8580- Carry out any inspection/tests/monitoring as instructed on water systems and in

accordance with the Works Instruction WI-3.- Carry out investigations and remedial works as instructed- Ensure all necessary documentation is completed and returned to the Compliance

Office

Maintenance Services/Residences Operatives and Operators:- Carry out any inspection/monitoring/maintenance tasks as instructed on water

systems and in accordance with the Works Instructions WI-3.- Ensure all necessary documentation is completed and returned to the Compliance

Office

Residence Managers and Wardens;Facility/ Building Managers and Heads of Department:- Ensure compliance with University of Bristol control of legionella bacteria within

water systems policy and procedures, permitting access to Departmental areas or Residences to complete works

- Ensure departmental or Residential equipment is maintained in house or by contractors to standards necessary for the control of Legionella and in accordance with the Works Instruction WI-3

- Keep records of departmental or Residential equipment servicing and maintenance

- Facilitate and co-ordinate with Estates Compliance Officer over the infrequently used outlets policy

- Facilitate any monitoring or inspection work- Facilitate any remedial work identified- Ensure flushing of infrequently used outlets is carried out, as required and records

kept- Ensure that NO modifications/alterations or additions to water systems are

carried out unless approval is obtained from the Compliance Office - Notify Estates Compliance Officer of any equipment not on testing schedule- Ensure all necessary documentation is completed and returned to the Compliance

Office for tasks carried out by Departmental or Residential staff



Contractors:- Ensure compliance with University of Bristol control of legionella bacteria within

water systems policy and procedures and the Estates Works Instruction WI-3 and GPR

- Ensure all necessary documentation is completed and returned to the Compliance Office

Employees:- Ensure compliance with University of Bristol control of legionella bacteria within

water systems policy and procedures

The Director of Health & Safety:- Reporting incidents under RIDDOR- Undertake Policy audits

4. Risk Assessment

4.1 The University will conduct suitable and sufficient risk assessments in respect of legionella bacteria and have them reviewed regularly or when refurbishment takes place, or when a new building is commissioned, or whenever there is reason to believe that the current assessment may no longer be valid.

4.2 The University will employ professionally qualified and competent companies to carry out the risk assessment on its behalf, and ensure they are competent under the duty of care. The risk assessments are held centrally by the Compliance Office.

4.3 The risk assessments shall be in accordance with BS 8580 and ACoP L8 and consider the individual nature of each site and system as a whole. A schematic diagram will be produced for each site/system.

5. Control Methodology

5.1 Estates Capital Maintenance and Infrastructure group will schedule, design, order and monitor all controls necessary to reasonably practicably manage water systems within the University.

5.2 Estates Capital Maintenance and Infrastructure group will implement, procure, advise and report on controls necessary to manage water systems within the University.

5.3 Individual University departments and Institutions will ensure that departmental equipment is serviced (including inspection, flushing, cleaning and disinfecting) and maintained to the standard required to control legionella bacteria within water systems. Individual University departments and Institutions will ensure records of servicing and maintenance are kept.



5.4 Estates Capital Maintenance and Infrastructure group will retain the information required for a Water Systems logbook for each building (or Group of buildings) that will contain records of control measures implemented.

These will be held within Estates Capital Maintenance and Infrastructure group and contain the following:-- Risk Assessment for the system- Schematic diagrams of the system- Records of control checks taken- Chlorination record certificates- Records of any remedial work carried out

5.5 As a policy the University adopts a temperature regime for Legionella Control. However where historically problems have been encountered in maintaining temperature control and cost prohibits an engineered solution then the additional control measure of Biocide treatment in the form of Chlorine Dioxide dosing plant will be utilised and monitored.

5.6 As a policy the University adopts a temperature regime for Legionella Control. However, on review of risk assessments and monitoring records, in certain areas that are low risk, less energy intensive solutions can be installed that maintain lower temperatures. These solutions can only be installed on written authorization by the Responsible Person, providing the solution is equipped with automatic, regular pasteurisation at 600C or above at least weekly, and that this solution produces evidence of this pasteurisation.

5.7 The latest up to-date inspection test sheets and log sheets can be obtained from Estates Capital Maintenance and Infrastructure group. The Estates Works Instructions WI-3 “Control and Inspection of Plant Susceptible to Infection by Legionella” contains procedural information and can be found on the Estates web-pages.

5.8 Specific information on System Design and Equipment Specification can be found in the University Estates Generic Project Requirements.

6. Training and Record Keeping

6.1 Staff involved in the management of water systems will be trained by a competent person to carry out their responsibilities.

6.2 The services of specialist water treatment/environmental services companies will be retained to advise as appropriate.

6.3 Estates Capital Maintenance & Infrastructure Group will record all risk assessments and the steps taken to prevent exposure, along with records of examinations, tests and repairs of control measures. These records will be retained for five years.



7. Audit

7.1 The Responsible Person will audit this policy on a regular basis.

The audit will be undertaken at least once every 12 month and more frequently as required by exception.

The Audit will be managed and recorded by the Responsible Person and will include:-- Training (Staff and Contractors)- Risk Assessments- Testing reports- Review of Trends - Residences and Non-residences- Review of specific projects and tasks during period- Review of monitoring and Compliance Officer audits- Review of actions from previous audits- Review of action from exceptions/incidents during audit period- Conclusions and summary of actions/advice to Duty Holder

7.2 The Responsible Person will pass a copy of the audit to Duty Holder who will confirm actions and advise on resources and findings if necessary. A copy of final report and actions to be passed to the Director of Health & Safety.

8. Control of Areas of Risk - New Equipment, Replacement Equipment and Alterations

8.1 All new systems, replacement equipment or alterations should be designed and installed to minimize the risk of legionella bacteria and in accordance with the ACOP L8 document, Guidance Documents HSG274 University of Bristol control of legionella bacteria within water systems policy and procedures, University of Bristol Generic Projects Requirements, WRAS and current British Standards.

8.2 All operatives, working on water systems on all University sites will be required to be suitably competent and trained.

8.3 All University departments to have all proposed alterations to water systems approved by the Compliance Office or Design Engineers or the Responsible Person prior to works commencing.

8.4 Hot water systems are stored at 600C to overcome bacterial proliferation. However the risk of scalding increases rapidly above 450C. Thermostatic mixing valves can be installed ONLY where there are vulnerable people, very old or young, or for other Health and Safety reasons. TMV3 category valves shall then be used. The location of all TMV’s must be identified to the Compliance Officer.

8.5 All Project Managers to ensure approval obtained before work commencement.



8.6 All projects are to instruct risk assessment or re-assessments on completion of their project works. All projects are to include costs for updating risk assessments and schematic drawings and issuing to the Compliance Officer.

8.7 Information required for records for the water systems will be provided to the Compliance Office and will contain the following:-

Risk Assessment for the system Schematic diagrams of the system Records of control checks taken Chlorination record certificates Records of any remedial work carried out Idenfification of and location of any TMV’s or RPZ valves

In addition, on handover of a new system, a log of recorded temperatures at every outlet shall also be provided.

8.8 If a system is taken out of use for alterations or an area is unused for over 7 days the Departmental Representative or Project manager must ensure that one of the following options are taken:

Completely drain the system down followed by cleaning and disinfection prior to re-use.

Instigate a regime of regular flushing of the water systems during the out of use period followed by cleaning and disinfection prior to re-use.

8.9 If an area or building has been isolated at the mains for longer than 7 days, Departmental Representatives or Project Manager must ensure that the mains is adequately flushed through before re-connecting to the area or building.

8.10 If a system has been wetted through commissioning activities for example, it is the Projects responsibility to flush the system through at least once every 7 days until handover.

9. Control of Areas of Risk – Cooling Towers and Evaporative Condensers/Evaporative Cooling Systems

There are currently NONE of these units in the University. N.B cooling towers of this type are NOT PERMITTED to be used in conjunction with any new build or refurbishment project. Dispensation for their use can only be granted by written authorisation of the Director of Estates, following written approval from the University Responsible Person.

All wet cooling towers and evaporative condensers must be notified to the local authority on an approved form under the Cooling Towers and Evaporative Condensers Regulations 1992.



10. Control of Areas of Risk – Showers

Each showerhead and associated hose should be chemically cleaned and de-scaled on a routine basis. A Water Treatment/Competent Service Contractor or the Maintenance Services staff or Residences staff should carry out the work and complete the record sheets. This includes electric showers.

Records are to be returned to the Compliance Office.

Emergency/drench showers will be included in the cleaning/de-scaling regime.

11. Control of Areas of Risk – Domestic Hot Water Systems

11.1 Legionella control, as a policy the University adopts a temperature regime, domestic hot water is stored at 60ºC and is distributed with a flow return temperature of 50ºC minimum.

11.2 If more than 15 litres of hot water is stored, then the generator is classed as a Calorifier. If 15 litres or less of hot water is stored, then the generator is classed as a Water Heater.

11.3 The storage calorifiers should be designed and installed to ensure that the total volume of stored water is heated and maintained at 60ºC with no/minimal possible stratification. Water heaters should be designed and installed to ensure that water at 50oC is delivered within one minute to the outlets.

11.4 Instantaneous water heaters and low volume (less than 15 litres) storage water heaters.

11.5 Calorifiers and water heaters are inspected annually by Maintenance Services staff or Specialist Contractors.

12. Control of Areas of Risk – Cold water systems

12.1 Legionella control, as a policy the University adopts a temperature regime that requires that cold water storage does not exceed 20ºC. All outlets should be capable of delivering cold water that is as close to the incoming water temperature within two minutes of running.

12.2 Storage tanks are inspected six monthly by Maintenance Services staff or Specialist contractor. The volume of stored cold water should be minimised and not exceed a nominal 12 hours total usage.

12.3 All drinking water outlets and drink dispensers should only be attached to the mains cold water supply or a dedicated portable water supply.



12.4 Any department buying in equipment, required to be connected to the existing service, MUST inform the Compliance Officer or the Responsible Person.

13. Control of Areas of Risk – Infrequently used outlets

Water outlets that are unused for a week or more should be flushed through on a weekly basis and this should be recorded. This includes showers.

Water outlets that are unused for a week or more, that are not possible to flush on a weekly basis should be disconnected from the system leaving no (or minimum) dead leg, and only be returned to use after purging, and this should be recorded.

When flushing or purging the outlets, any difficulties or problems encountered should be reported to Maintenance Services Helpdesk and a remedial job created.

Special consideration should be given to accessible toilets as these are used less frequently and during vacation periods when usage drops.

13.1 Refer to University of Bristol HSO document ‘The Control of Legionella Bacteria in infrequently used Water Systems (current version 1.0 January 2012)

The identification and management/control of infrequently used outlets

requires the support of building users. The Estates Office, through the ‘Duty Holder’ and ‘Responsible Person’ will

undertake to notify building users of the need to co-operate with Estates to identify infrequently used outlets and management recording regime which reasonable and acceptable to both parties.

This notification and the response to it will be recorded against records for

each building and included in RP audits. Testing/Control/Management records will be maintained by Estate and

where actions are undertaken by ‘School’/Users, data will be passed to Estates for the purpose of recording, within an agreed time frame.

A condition of NON-COMPLIANCE will be assumed when action records and associated data fails to be returned to the Estates Compliance team within the agreed time frame. This will be reported to Health and Safety Office as a situation hazardous to health.



14. Control of Areas of Risk – Air Washers

There are currently NONE of these units in the University of Bristol N.B air washers are NOT PERMITTED to be used in conjunction with any new build or refurbishment project. Dispensation for their use can only be granted by written authorisation of the Estates Director following written approval from the University Responsible Person.

15. Control of Areas of Risk – Humidifiers

15.1 The University generally only installs and operates steam generating humidifiers. Any department or institution requesting a different type of humidifiers to be installed must get written authorisation from the University Responsible Person.

15.2 Departments and institutions must notify the University Compliance Office of the locations of all existing spray humidifiers, ultrasonic humidifiers, fogging systems and water misting systems.

15.3 All of these types of systems must be regularly inspected, cleaned, disinfected and maintained.

15.4 It is the responsibility of the individual departments and Institutions to arrange for the inspection, cleaning, disinfecting and maintenance of all spray humidifiers, ultrasonic humidifiers, fogging systems and water misting systems to the standard necessary for the control of Legionella.

15.5 It is the responsibility of the individual departments and Institutions to maintain risk assessments for the operation, maintenance and control of all of these types of systems.

16. Control of Areas of Risk – Ornamental Water Fountains (Internal or External)

16.1 In view of publicised cases of Legionnaires disease attributable to self-circulating water features/ornamental fountains, it is University policy to actively remove any existing and prohibit the installation of any new.

17. Control of Areas of Risk - Residences

17.1 A suitably trained residence attendant/Maintenance Services staff employee or competent contractor undertakes the maintenance/monitoring tasks. Specific attention must be made to vacation periods when the population at risk charges; usage changes; and infrequently used outlet increase.

17.2 The Residences Maintenance Manager must ensure that the completed log sheets/report sheets are returned to the Compliance Office.



18. Control of Areas of Risk – Fire Protection

18.1 It is University policy to actively remove any existing Fire hose reels and prohibit the installation of any new. Replacement Fire extinguishers should be installed.

18.2 It is University policy to actively remove any existing wet risers and replace with dry risers. No new wet risers shall be installed.

18.3 Sprinkler systems shall only be installed where absolutely necessary. They shall be installed on a mains cold water supply with double check valve and not connected into building system to prevent any possible contamination between the two systems. Alternative fire fighting systems must always be considered in preference.



P olicy & Procedures produced by:-

Name Title DateTony Harvey Works Officer September 2004

Comments received and incorporated into policy from:Chris Griffin Assistant Director of Maintenance Services September 2004Health and Safety Office October 2004Steve Neck Chair Trade Union Health and Safety

Committee November 2004

Policy and procedures reviewed and amended by:Tony Harvey Works Officer September 2005

Policy and procedures reviewed and amended by:Tony Harvey Works Officer April 2006

Policy and procedures reviewed and amended by:Tony Harvey Works Officer August 2006

Comments received and incorporated into policy from:Health and Safety Office August 2006

Policy and procedures reviewed and amended by:Tony Harvey Works Officer February 2007

Policy and procedures reviewed and amended by:Tony Harvey Maintenance Services Manager August 2007

Policy and procedures reviewed and amended by:Tony Harvey Maintenance Services Manager February 2009

Policy and procedures reviewed and amended by:Jeni Cummins Senior Mechanical Engineer December 2009

Jeni Cummins Senior Engineer January 2011

Jeni Cummins Senior Engineer March 2012

Steve Hyde } Head of Capital Maintenance &Infrastructure Group March 2013

Jeni Cummins } Senior Engineer



Estate Office – Capital Maintenance & Infrastructure

Control of Legionella Bacteria within water systems Policy & Procedures

Post-holder and Contact Numbers

Title Name Contact DetailsDirector of Estates(Duty Holder)

Patrick Finch 0117 331 7278

Head of Capital Maintenance & Infrastructure Group

Steve Hyde 0117 928 8050

Senior Engineer(Responsible Person)

Jeni Cummins 0117 928 8800

Compliance Officer (Deputy Responsible Person)

Dan Paterson 07786 548776

Reactive Maintenance Manager

Tony Spencer 0117 331 7489

Director of Health & Safety Peter Adams 0117 928 8781

Estate Services Help Desk 0117 928 9898


UNIVERSITY OF BRISTOL · Web viewHSP32 Control of Legionella Bacteria within water systems Health...

Documents

Transcript of UNIVERSITY OF BRISTOL · Web viewHSP32 Control of Legionella Bacteria within water systems Health...