Support services - Estates: Legionella policy (U01d)

1.1. This is a new joint SOP for Essex Police and Kent Police.

2.1 The policy of Essex Police and Kent Police is to follow the guidelines given in L8 by the Health and Safety Commission (HSC), to manage the water systems such that conditions under which legionella can proliferate are designed out of systems. The policy of Essex Police and Kent Police is to use the control of water temperatures as the main control measure for the prevention of Legionellosis together with good system design; maintenance and proactive management of water temperatures to prevent the proliferation of legionella within systems. Regular weekly/monthly checks of water temperatures and systems to comply with L8 must be made by the facilities assistant of each site. Quarterly/annual inspections and two-yearly updates to the site risk assessment, to comply with L8 are carried out by the Essex Police and Kent Police, Estate Services department or by a specialist (legionella) contractor employed by Essex Police and Kent Police. Where it is considered that there are vulnerable persons e.g. custody suites etc. monitoring by a specialist contractor is performed on a quarterly basis in addition to the regular monitoring performed by the site.

2.2 This procedure/SOP will apply, without exception, to all buildings and individuals employed and/or engaged by Essex Police and Kent Police.

2.3 Ultimately, the responsibility for the implementation of the policy and procedures, along with the compliance with the requirements of L8, will rest with the force chief constable. The implementation of the policy however will be delegated to the responsible person (legionella). Individual site managers will be responsible for maintaining site log books. In line with the force health and safety policy, this will be the area commander or head of department but normally delegated to the admin/facilities/property supervisors. Where more than one establishment is located on the same site, it is preferable that a single duty holder serves all establishments.

Compliance with this procedure/SOP and any governing policy is mandatory.

3.1.1 Essex Police and Kent Police are committed to managing water systems to prevent the proliferation and spread of legionella to comply with the terms of L8.

3.1.2 For those Essex Police and Kent Police buildings where the Estate Services department has the responsibility and funding for repairs and maintenance, the Estate Services department will ensure that:

• for all properties there is a comprehensive survey and risk assessment of water systems to comply with L8. The survey will contain details of all hot and cold cisterns, calorifiers, water temperatures (hot and cold) measured during the site survey, HVAC systems, any other specialist equipment installed, photographs, schematics and a site plan
• all properties will have a site management log book wherein details of checks required will be listed and have log sheets for the recording of the checks to be made by sites. A co-coordinated centralized database will be kept by the Estate Services department. The site admin/facilities/property supervisors shall arrange for site personnel (facilities assistant) to inspect tanks/check water temperatures etc. to comply with L8 and will countersign that the regular inspections have been completed
• in the event of non-compliances being discovered, these must be noted along with any remedial measures implemented at the time, and a copy of this faults/defects sheet passed to the responsible person (legionella)
• a quarterly visit to each site will be made by a specialist contractor to ensure that sites are carrying out their duties in regard to L8 and to advise on any matters that the site personnel are unsure of. This will ensure that a qualified professional checks all sites and ensures that sites are carrying out the regular checks required by L8
• all risk assessments will be updated at a maximum interval of two years, unless building modifications or alterations have taken place where an intermediate risk assessment may be required. Water outlets and items of plant will be checked and the risk associated with legionella reassessed
• surveys and assessments will be reviewed immediately if there is reason to suspect that the assessment is no longer valid or if there has been a significant change to the water systems within the premises
• where evaporative cooling tower systems exist they shall be subject to individual assessment and maintenance by a specialist water treatment company. All towers shall be registered under the Notification of Cooling Towers and Evaporative Condensers Regulations 1992 as a ‘notifiable device’ (at the time of writing there are no known cooling towers within the force). Where new cooling plant is required, the use of evaporative cooling tower systems shall only be considered if there is no other possible cooling media
• humidifiers within air-handling plants shall be subject to inspection where they exist. Generally humidifiers used will only be of the steam-generating type with a “blow down” facility that is intrinsically safe from legionella. Spray-type humidifiers shall not be used
• where spa, whirlpool baths or tank fed drench showers exist within premises, they will have been installed as a tenant item. The Estate Services department as the landlord is not responsible for these items, as they are not deemed to be fixed equipment. The tenant is fully responsible for these items and the risk assessment/action to comply with L8
• where freestanding drinking water supplies using bottled water are provided these will have been installed by the tenant, and are not covered by the risk assessment. The tenant is fully responsible for these items and the risk assessment/action to comply with L8. The provision of drinking water by this means is not endorsed by the Estate Services department, as there is the potential for the growth of legionella/algae within the water system due to the exposure to ultra-violet light
• ornamental ponds or fish tanks within premises are not covered by the water risk assessment. The tenant is fully responsible for these items and the risk assessment/action to comply with L8
• cases of legionellosis are reportable under RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995). Where a case of legionellosis is reported to the site management then:
  • the responsible person for the management of the site will immediately report the incident to the estate services department and the force health and safety advisor
  • formal reporting of an incident will be in compliance with force policy early notification of incidents being reported to the HSE by the force health and safety advisor following consultation with the state Services department
  • the Estate Services department will arrange to have carried out an assessment of the risk caused by exposure to legionellosis in the particular situation, as appropriate
• staff will be given sufficient training to enable them to perform their duties with regard to legionella. Refresher training will be given when appropriate

3.1.3 To comply with legal duties, the forces shall:

• identify and assess sources of risk this includes checking whether conditions are present which will encourage bacteria to multiply, e.g. is the water temperature between 20ºC and 45ºC, is there a means of creating and disseminating breathable droplets e.g. the aerosol created by a shower or cooling towers; and if there are susceptible people who may be exposed to the contaminated aerosols
• prepare a scheme for preventing or controlling the risk
• implement, manage and monitor precautions if control measures are to remain effective, then regular monitoring of the systems and the control measures is essential
• keep records of the testing and precautions taken
• appoint a person to be managerially responsible. The duty holder has appointed the joint head of Essex and Kent Estate Services

3.2. Works where the Estate Services department are not involved

3.2.1 This procedure will also apply where establishments order work, directly from contractors without reference to the Estate Services department. Examples of this are work that is an alteration or addition to water systems, including any new provision. The establishment must inform the Estate Services department of their intention to carry out any such work.

3.2.2 The Estate Services department acts as the landlord for premises owned by Essex Police and Kent Police. Certain establishments do not use the services of the Estate Services department as an agent for new construction, extensions modifications, repairs and maintenance, being autonomous in this respect. Under the terms of L8 these establishments are responsible for the compliance with L8 in these properties. These establishments must follow the policy of Essex Police and Kent Police as above. The Estate Services department is available to give advice as required and those responsible for premises are strongly advised to contact the estate services department as soon as any concerns arise.

3.3 Roles and responsibilities

The chief constable – duty holder

3.3.1 Will take overall responsibility and ensure that the procedure for the control of legionella is implemented and that appropriate funding is made available. In practice the duty holder will delegate the day-to-day implementation of the procedure to the nominated responsible person.

The Joint Head of Essex and Kent Estate Services – (responsible person)

3.3.2 This person is specifically charged with:

• providing advice on legionella matters to colleagues and to establishments within Essex Police and Kent Police
• advising on training for appropriate staff
• implementation and delivering of legionella awareness training seminars by specialist consultants
• ensuring that all companies used for legionella surveys and risk assessments have the appropriate insurance and accreditation from certification bodies
• updating this procedure to take into account changes in legislation
• ensuring the forces remain at the forefront of best practice in legionella control and management
• maintaining centralised records
• providing compliance with the requirements of the ACOP 
• performance monitoring measures
• establishing competence of delegated staff
• ensuring that planned works for which they are responsible take into account the requirements of L8 such that conditions that encourage the proliferation of legionella do not exist and that the works comply with any water authority local conditions or requirements, and seeking advice where necessary
• ensuring that designs take into account the guidelines of L8 and that appropriate test and chlorination certificates are provided by the contractors
• ensuring that any changes to the water systems (including additions/extensions) are notified so that an inspection of the changes may be made and the risk assessment and legionella site management log book can be updated
• ensuring, by means of audits, that procedures are being followed
• providing advice on legionella to sites for inclusion within the health and safety manual

The Estate Services department building services engineer (deputy responsible person)

3.3.3 This person is specifically charged with:

• programming the surveys and annual monitoring and ordering surveys etc. from specialist contractors
• checking on receipt, the legionella survey and risk assessment for high priority items requiring remedial work and ensuring that remedial work is implemented or programmed and added to the condition survey information for the site
• being a point of contact for reports of problems with temperature control/foreign bodies etc. in water systems and arranging remedial action
• visiting those sites that are not checked by a specialist contractor on an annual basis to ensure that these sites are carrying out their responsibilities to comply with L8, to countersign the log and to give advice as required by the site
• updating and producing legionella surveys and risk assessments for properties in accordance with L8, updating existing surveys/risk assessments, all in accordance with the programme
• reporting problems found whilst making site visits and ensuring timely remedial work for items classed as high risk is put in hand, with other items being reported as lower risk are added to the condition survey information for the site
• inspecting any changes to the water systems and updating the risk assessment and legionella site management log book
• establishing competence of contractors

The admin/facilities manager and admin/facilities/property supervisor on site

3.3.4 They are specifically charged with:

• ensuring that the nominated person(s) (facilities assistant) carry out the checks detailed in the legionella site management log book and the Essex Police and Kent Police Written Scheme for controlling the risk of exposure to legionella bacteria and countersigning that the requisite checks have been carried out
• ensuring that any problems noted during the regular inspections are reported to the estate services department or to their appropriate consultant used for repairs and maintenance
• ensuring that any changes to the water systems (including additions/extensions) not initiated by the Estate Services department are notified to the estate services department or to their appropriate consultant used for repairs and maintenance so that an inspection of the changes may be made and the risk assessment and legionella site management log book can be updated
• carrying out such work on all tenant items to ensure that the proliferation of legionella is prevented

The premises managers, staff, officers etc. at sites

3.3.5 They are specifically charged with:

• carrying out the checks detailed within the legionella site management logbook and the Essex Police and Kent Police Written Scheme for controlling the risk of exposure to legionella bacteria and ensuring that the responsible person on site countersigns that the checks have taken place
• ensuring that any problems are reported as above
• co-operating with the estate services department staff or specialist nominated contractors during annual checks and risk assessment updates

General contractors and sub-contractors

3.3.6. They are specifically charged with:

• ensuring that new works or modifications to existing systems are installed such that conditions that encourage the proliferation of legionella do not exist and that the works comply with any water authority local conditions or requirements. A certificate of compliance should be issued after modification works as set down in the Water Supply (Water Fittings) Regulations 1999
• providing certificates of chlorination for modifications/new works as required by the works specification
• prior to any works being undertaken on Essex Police and Kent Police sites, a full site specific method statement will be supplied to the responsible person for approval

Legionella survey contractors

3.3.7 They are specifically charged with:

• producing the site risk assessment and legionella site management logbook to comply with L8. The site management logbook is to be delivered to site and required procedures explained to the duty holder and nominated persons on site
• advising the building services engineer as soon as reasonably practicable of problems found on sites that need immediate resolution
• ensuring that surveys cause the minimum disruption to the site
• acting in a professional manner at all times whilst on site
• providing specialist advice on legionella matters
• contributing to an action/rectification plan with the duty holder etc.
  The reporting structures for both forces can be found on the extranet version of this procedure

3.4 Risks

3.4.1 The approved code of practice and guidance (L8) require that all systems susceptible to colonization by legionella and which may create water droplets must be identified and risk assessed.

3.4.2 Police buildings and plant are considered to fall into three categories for the purposes of precautions against legionella infection, these are:

1. class A – cooling towers associated with air conditioning systems. There are currently none of these units in the force
2. class B – large premises, usually with a large feed tank fed by either gravity or circulation pump to a storage calorifier with a pumped distribution circuit including flow and return
3. class C – small residential/domestic premises, including large complexes with self-contained units. Typically here the water systems are of the “domestic” type, i.e. with gravity cold water feed tank to a conventional copper storage cylinder, distribution may or may not be pumped

3.4.3 The Estate Services Department will conduct risk assessments in respect of legionella bacteria and have them updated every two years, or when any refurbishment takes place, or when a new building is commissioned, or indeed whenever there is reason to believe that the risk assessment is no longer valid.

3.4.4 The Estate Services Department 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.

3.4.5 The risk assessments are to be held at each premises with a copy kept centrally by the Estate Services department.

3.5 High-risk conditions

3.5.1 Water temperatures between 20º and 45ºC promote growth of legionella. The optimum temperature for growth is 37ºC. Therefore these water temperatures must be avoided wherever practicable. Organisms may be present at temperatures below 20ºC but remain dormant until suitable temperatures are achieved.

3.5.2 Sediment, sludge, rust, scale and organic material will provide nutrients for legionella proliferation. Should such deposits become evident in storage cisterns then cleaning may be required.

3.5.3 The use of some rubbers, jointing compounds, mastics, wood and certain plastics must be avoided as these too will provide a nutrient source for legionella proliferation.

3.5.4 Other organisms in water such as bacteria, amoeba etc. may also indicate the presence of legionella. Cleaning may be required when sampling indicates this necessity.

3.5.5 Biofilms will also provide nutrients and safe “harborage” for legionella. A biofilm is a layer of microorganisms which forms a surface slime.

3.5.6 Stagnant water will also encourage microbiological proliferation.

3.6 Preparation of a written scheme

3.6.1 On completion of the risk assessments, the responsible person will ensure the following are carried out:

• develop schemes for risk minimization in order of priority, giving due consideration to cost, risk and resources
• develop a management programme. This programme should detail resources and timescales for any remedial measures to be completed
• implement the above programme on receipt of budget approval, taking any necessary remedial action where required
• review the programme annually and record the progress of implementing the work. All changes to the water systems should be recorded and evaluated

3.7 General methods of prevention

• remove all facilities that are no longer required or implement a weekly flushing regimen to simulate moderate usage
• ensure calorifiers discharge at 60ºC with an associated return temperature of 50ºC
• ensure any pipework carrying blended water at temperatures below 50ºC is as short as possible. The use of common mixer valves whereby one mixer supplies a range of wash hand basins is to be avoided
• remove any dead legs found to be greater than 0.5m
• avoid stagnation
• maintain storage cisterns in a clean condition
• ensure correct level of maintenance to ensure safe operation and compliance with statutory regulations
• reduce storage capacity where required to ensure adequate turnover of water
• keep all storage cisterns secure to minimize external contaminant ingress

3.8 Monitoring - cooling towers associated with air conditioning equipment

3.8.1 There are currently none of these units within the force. N.B. unless exceptional circumstances exist which prevent the use of alternative plant; cooling towers of this type are not permitted to be used in conjunction with any new build or refurbishment project.

3.8.2 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.

3.9 Domestic hot and cold water

Sentinel outlets

3.9.1 The facilities assistant will be instructed to take temperature readings of the sentinel taps monthly in each building.

3.9.2 All results are to be recorded on the issued water distribution temperature log sheet and returned to the local admin/facilities/property supervisor for filing in the building logbook.

3.9.3 Cold water shall be below 20°C after running for two minutes, hot water above 50°C after running for one minute, with a maximum temperature of 62°C.

3.9.4 Anomalies are to be reported immediately to the Estate Services department.

Annual temperature profile

3.9.5 Annually representative tap temperatures are to be taken by a specialist contractor. The outlets should include all areas of the building and a full range of the facilities.

3.9.6 All results are to be recorded on issued record log sheet and returned to the local admin/facilities/property supervisor for filing in the building logbook.

3.9.7 Cold water below 20°C after running for two minutes, hot water above 50°C after running for one minute, with a maximum temperature of 62°C.

3.9.8 It is the Estate Services departments policy to actively remove any existing spray emission type taps and prohibit the installation of any new. Taps that produce a spray emission as a result of lime scale should be identified to the Estate Services department for repair/replacement.

3.9.9 Anomalies are to be reported immediately to the Estate Services department.

Scale removal

3.9.10 Scale will provide nutrients for microbiological growth. It is also an excellent insulator and as such can shield legionella from pasteurization temperatures. All outlets should be cleaned and descaled annually as part of a planned preventative maintenance routine.

Showers

3.9.11 Each shower-head and associated hose should be cleaned and de-scaled on a quarterly basis. 

3.9.12 Records are to be returned to the local admin/facilities/property supervisor on the issued record sheet for filing in the building logbook. A method statement for all such work by contractors should be issued and filed in the logbook.

3.9.13 Emergency/drench showers will be included in the maintenance regime.

Cold water storage cisterns

3.9.14 Wherever possible, new tanks are to be partitioned or a bypass installed to allow for the chlorination and cleaning of the tanks without interrupting the cold water/hot water service to the building.

3.9.15 Tanks are to be fitted with delayed action float valves or in the case of pumped services conductivity rod operated switches to allow for positive water displacement in the tank.

3.9.16 The incoming feed to the tank shall be at the opposite end to the outgoing connections.

3.9.17 Where new tanks are to be installed, GRP sectional tanks externally flanged with integral insulation and a dished bottom drain for ease of cleaning are to be fitted.

3.9.18 All new tanks shall be fitted with 54mm drains to waste to ease the process of tank cleaning and draining.

3.9.19 Where partitioned tanks are installed the policy is to operate both tanks together except for chlorination and maintenance.

3.9.20 Each cistern is to be inspected annually by a specialist contractor and details of the following inspections recorded:

• condition inside/outside
• condition of thermal insulation
• storage and ball valve temperature
• is lid fitted correctly?
• is water clean and debris free?
• ball float valve operating correctly?
• condition of overflow pipe
• condition of lid vents and overflow screens
• general compliance with the Water Supply (Water Fittings) Regulations 1999

3.9.21 Report to be issued to the local admin/facilities/property supervisor for filing in the building logbook.

Calorifiers

3.9.22 The Estate Services department adopts a temperature regime as primary method of risk control; domestic hot water is stored at 60ºC and is distributed with a minimum return temperature of 50ºC. Anomalies are to be reported immediately to the Estate Services department.

3.9.23 The storage calorifiers may be fitted with a shunt pump set to operate via time switch to pasteurize the internal surfaces for one hour per day. The necessity of a shunt pump will depend on the units design and should be noted in the risk assessment.

3.9.24 Each system should be fitted with the circulation pump on the return leg where required.

3.9.25 Each system should have sensors fitted to the flow and return legs attached to the BMS system, from which a daily log can be taken to confirm the correct operation.

3.9.26 Water temperatures entering and leaving calorifiers are to be checked weekly via the building management system by the building services engineer where these are fitted.

3.9.27 Monthly temperatures are to be taken and recorded on the water storage temperature log sheet and returned to the local admin/facilities/property supervisor for filing in the building logbook.

3.9.28 An annual internal maintenance inspection of each domestic calorifier is carried out, during which microbiological sampling of the drain water for legionella should take place. The calorifier is isolated from the building circuit, the shell is drained down and the internal surface is inspected and cleaned.

3.9.29 Immediately prior to the calorifier being returned to service a full pasteurization process is carried out and the operative records the process on the issued maintenance sheet which is then returned to the local admin/facilities/property supervisor for recording in the building logbook.

Water heaters

3.9.30 The term water heaters is applied to hot water generators with a storage capacity of less than 15 litres.

3.9.31 Temperatures are to be taken monthly and recorded on the water storage temperature log sheet which is then returned to the local admin/facilities/property supervisor for recording in the building logbook.

Infrequently used outlets

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

3.9.33 Water outlets that are unused for a week or more, that are difficult to flush should only be returned to use after purging and this should be recorded.

3.9.34 Special consideration should be given to disabled toilets as these are used less frequently.

3.9.35 A shower, including emergency/drench showers, which may be unused for a week or more, must be flushed through on a weekly basis and this should be recorded.

Pressure vessels

3.9.36 Pressure vessels connected to the domestic systems should have a drain valve installed to allow for regular monthly flushing. Pressure vessels will otherwise act as a blind end, creating a stagnant area ideal for microbiological proliferation.

3.9.37 Thermostatic mixer valves

• service in accordance with the manufacturer’s recommendations and method statement detailed in appendices
• check operation of non-return valves
• clean strainers where fitted
• descale all components
• test mixing valve for failsafe and reset to maintain safe hot water temperature as set down in Health Technical Memorandum HTM04-01

3.10 Drinking water distribution

General

3.10.1 As a policy all drinking water outlets should be serviced from a separate supply pipe direct from the mains service.

3.10.2 Drinking water and drink dispensers should only be attached to the rising main.

3.10.3 Drinking water outlets to be located in designated areas only.

3.10.4 All taps which are supplied and positioned for potable water use are labelled “drinking water”.

3.10.5 No alterations or additions to the drinking water supply are to be made without written authorisation from the Estate Services department.

3.10.6 All plumbers working on the Forces sites will be required to be a member of the Water Industry Approved Plumber Scheme.

3.10.7 Any department buying in equipment, required to be connected to the existing service, must inform the Estate Services department.

Water analysis

3.10.8 Routine sampling of the domestic water systems is not required by ACoP L8. Sampling is only recommended in the following instances:

• if systems are chemically treated as a means of control
• if the control regimen (i.e. temperature) is not consistently at the required levels
• when an outbreak is suspected or has been identified

3.10.9 All samples must be analysed by a UKAS accredited laboratory.

3.10.10 All sampling certificates must be returned to the local admin/facilities/property supervisor for filing in the building logbook. Copies must also be provided to the responsible person (legionella).

3.10.11 The water treatment/environmental service contractor shall provide a standard of service described in the code of conduct for service providers produced by the British Association for Chemical Specialities and the Water Management Society and hold a current registration certificate issued by the same organisation.

Tests control limits

3.10.12 Bacteria (total viable colony count):

• one day at 37ºC < 10 cfu/ml
• three days at 22ºC < 100 cfu/ml
• coliform/E.coli < 1 cfu/ml

3.10.13 All results should be interpreted by an experienced consultant/microbiologist, but elevated results may indicate the need for cleaning, disinfection and a review of the system and control methods.

3.10.14 Legionella:

• first action level 100 cfu/litre to 1000 cfu/litre
• second action level >1000 cfu/litre

3.10.15 Any detection at the first action level shall cause a retest and a review of the system and control methods. If there are detections at the second action level the building services engineer must be informed and remedial action implemented. The system shall also be reviewed and control methods checked.

3.11 Air washers

3.11.1 There are currently none of these units within the force. N.B. Unless exceptional circumstances exist which prevent the use of alternative plant; air washers are not permitted to be used in conjunction with any new build or refurbishment project.

Humidifiers (ultrasonic humidifiers, fogging systems and water misting systems)

3.11.2 No new spray humidifiers may be installed.

3.11.3 Departments must notify the estate services department of the locations of all existing spray humidifiers.

3.11.4 Existing spray humidifiers must be regularly inspected, maintained, cleaned and disinfected.

3.11.5 Departments must notify the estate services department of the locations of all ultrasonic humidifiers, fogging systems and water misting systems.

3.11.6 It is the responsibility of the individual departments to arrange for the inspection, cleaning, disinfecting and maintenance of all Ultrasonic humidifiers, fogging systems and water misting systems to the standard necessary for the control of legionella.

3.12 Ornamental water fountains (internal or external)

3.12.1 In view of publicised cases of Legionnaires disease attributable to self-circulating water features/ornamental fountains. It is the forces’ policy to actively remove any existing and prohibit the installation of any new.

3.13 Fire hose reels

3.13.1 It is the forces ‘policy to actively remove any existing fire hose reels and prohibit the installation of any new. Replacement fire extinguishers should be installed.

3.14 New equipment and alterations

3.14.1 System design: all new systems or alterations should be designed and installed to minimize the risk of legionella bacteria and facilitate compliance with the ACOP L8 document:

• only non-spray emission water taps are to be installed
• only shower-heads that are designed to give large droplets should be installed
• all installed pipework to be insulated, including cold-water services
• water systems are to be designed so that there are no dead legs or pockets created
• all hot water systems must be designed with a return on them or suitable trace heating provided

3.14.2 Modifications to existing pipework, including removal of branches must include cutting back to the main, as it is totally unacceptable to leave pipework capped at the end and unused.

3.15 Only Water Research Centre approved water fittings and materials are to be used

3.15.1 Jointing materials such as natural rubber, hemp and linseed oil-based jointing compounds and fibre washers are excluded from use.

3.15.2 Control regime: all departments shall have all proposed alterations to water systems approved by the building services engineer prior to works commencing.

3.15.3 All projects to include costs for updating schematic drawings and issuing them to the Estate Services department for inclusion in the logbook.

3.15.4 If a system is taken out of use for alterations or an area is unused for over seven days the 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 risk systems during the out of use period followed by cleaning and disinfection prior to re-use

3.16 Residences

3.16.1 The logbook for the systems will be held within the Estate Services department 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

3.16.2 A suitably trained specialist contractor will undertake the maintenance/monitoring tasks.

3.16.3 A planned maintenance docket is issued identifying the areas where the maintenance activities are to be undertaken and the appropriate log sheet/report sheet is then completed, dated and signed. The docket will be directed to the local admin/facilities/property supervisor to expedite.

3.16.4 The local admin/facilities/property supervisor must ensure that the completed log sheets/report sheets are returned to the Estate Services department.

3.17 Sports facilities

3.17.1 The logbook for the systems will be held within the Estate Services department 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

3.18 Emergency action to be taken in the event of legionella contamination

3.18.1 The maintenance contractor or water treatment specialist must inform the responsible person of the serotype and number of bacteria by phone and confirm by facsimile or email.

3.18.2 In the event the responsible person cannot be contacted the deputy should be contacted: refer to responsibility structure for full details of contact names, telephone and facsimile numbers that should be used on an escalating emergency basis.

3.18.3 The responsible person will then instruct a qualified contractor to shut down the specific systems if appropriate, and/or to take further samples followed immediately by a clean and disinfection (or pasteurisation) of the affected systems.

3.18.4 The site specific shutdown procedure must be provided by the maintenance contractor and must be included in this section giving method statements and location descriptions of all relevant fan, pumps, shut-off valves and drain points and other plant and equipment associated with the affected.

3.18.5 The maintenance contractor must ensure that an emergency shut-down procedure is drawn up as soon as reasonably practicable i.e. within three weeks of commencing the maintenance works.

3.18.6 The affected systems shall be retested for legionella contamination seven days following the clean and disinfection.

3.18.7 The routine maintenance regime, system design and risk assessment should be reassessed by a competent and independent person. A full report to be inserted into the water hygiene log book and policy document.

3.19 Outbreak of legionnaires disease

3.19.1 In the event of an outbreak of legionnaires disease in the vicinity of the property the maintenance contractor or water treatment specialist must inform, and confirm in writing, to the force’s responsible person and the local admin/facilities/property supervisor of the possibility that the property’s water system might be implicated. Should the responsible person be un-contactable the maintenance contractor or water treatment specialist must refer to the responsibility structure and inform the next available manager.

3.19.2 The force building services engineer must liaise with the environmental health officer/Health and Safety Executive and ask for their advice and assistance.

3.19.3 It is normal for them to send in a team to investigate. It is important for them to be able to trace where the infection came from. Therefore, do not drain down any systems until told to do so, but do isolate them from service. They may request water samples are taken prior to any emergency disinfection being instructed.

3.19.4 The force building services engineer subject to 2 above will then instruct the maintenance contractor or water treatment specialist to carry out appropriate analytical action and disinfect the systems in accordance with the emergency procedures in this document.

3.19.5 Do not speak to anyone about the problem other than the force’s responsible person or building services engineer. Do not make any comments to the media.

3.19.6 Note: - An ‘outbreak of legionnaires disease’ is defined by the Health Protection Agency as two or more confirmed cases of legionellosis occurring in the same locality within a six-month period.

3.20 Training

3.20.1 Appropriate training will be provided for all Estate Services department staff that may require information about legionella and changes to relevant legislation in the course of their duties.

3.20.2 Training for facilities assistants etc. in the taking of water temperatures, the use of log books will be given at the time that the log books are delivered, either by contractor's staff or by the estate services department building services engineer. More general information on the requirements of legislation will be provided through seminars organised by the Estate Services department.

3.20.3 Refresher training will be provided by the Estate Services department and records of all initial and refresher training will be documented. Refresher training should be undertaken on at least a two-yearly basis.

4.1. This SOP has been assessed with regard to its impact on equality. As a result of this assessment it has been graded as having a low potential impact.

5.1 ACoP L8 requires employers and others to undertake assessments to establish the risk of legionella. The responsibility to ensure that these are carried out rests with the responsible person (legionella), supported by the nominated person (legionella).

5.2 The assessment must take into account a number of parameters that will directly affect the proliferation and dissemination of the bacteria.

These parameters are:

1. the potential for droplet formation
2. the condition of the water
3. water temperature
4. the turnover rate of the water
5. the susceptibility of those exposed to the water
6. the population density of those exposed to the water

5.3 The assessment must be completed for routine system operation and also for circumstances such as breakdown, abnormal operation, commissioning or other unusual circumstances.

5.4 Once the assessment has been completed, a strategy can be prepared for preventing or controlling the risk. The strategy will be based on a sound knowledge of the varying levels of attention required by the differing risk sources within the building.

5.5 As part of the risk assessment process, schematic diagrams of the water systems must also be provided. The schematic must detail all items of plant, main pipework runs, pumps, valves and all terminal equipment and facilities.

5.6 Persons at risk

5.6.1 Risk assessments have identified that forces staff; visitors and the general public using adjacent buildings and thoroughfares may be at risk. Persons at higher risk include those with the following risk factors:

• sex (males are at greater risk)
• age (middle aged persons at increased risk)
• smoking
• respiratory illness
• aids or other immune suppressed condition
• cancer
• renal patients

5.6.2 Areas of risk where control is necessary are:

• cooling towers
• showers
• domestic hot water systems
• tank-fed cold water systems
• infrequently used outlets
• drinking water distribution
• air washers
• humidifiers
• ornamental water fountains
• new equipment/alterations
• residences
• sports facilities
• any other area or equipment that may create a tiny droplet water spray
• any possible dead legs in pipework