Flushing Page 1 of 3 Version 1.0 October 2015

Standard Operating Procedure 1 (SOP1)

Flushing

Why we have a procedure?

The Trust accepts its responsibility under Health and Safety at Work etc. Act 1974 and Control of Substances Hazardous to Health Regulation 2002 (as amended), to take all reasonable precautions to prevent or control the harmful effects of contaminated water to residents, patients, visitors, staff and other persons working at or using its premises. The risk from water borne bacteria growing and proliferating in peripheral parts of the domestic water system, such as infrequently used outlets and dead legs off the re-circulating hot water system, may be minimised by regular use of these outlets. When outlets are not in regular use, regular and frequent flushing of these devices for several minutes can significantly reduce the risk of water borne bacteria proliferation in the system. Once started, this procedure has to be sustained and logged, as lapses can result in a critical increase in water borne bacteria at the outlet. Where there are high-risk patients more frequent flushing may be required as indicated by the risk assessment. Ward/ Department management appointed staff shall have the responsibility of identifying all infrequently used outlets (See Standard Operating Procedure 2 (SOP2) Reporting under Used Outlets) within their area and subjecting these to a prescribed flushing programme.

What overarching policy the procedure links to?

Water Management Policy

Which services of the trust does this apply to? Where is it in operation?

Group Inpatients Community Locations

Mental Health Services all

Learning Disabilities Services all

Children and Young People Services all

Who does the procedure apply to?

Departmental Heads

Ward/ Department management appointed staff

When should the procedure be applied?

When an under used outlet has been prescribed a flushing programme

Flushing Page 2 of 3 Version 1.0 October 2015

How to carry out this procedure

Systems or individual outlets that are not frequently used allow the development of stagnant water conditions, which increase the potential of bacterial growth and proliferation, including Legionella. In order to remove any stagnation that may have developed or to stop stagnation from occurring in the first place, it is important to introduce a "flushing" programme where necessary. Departmental Heads shall have the responsibility to ensure that this requirement is implemented and systematically audited to ensure adequate and correct implementation. The flushing programme shall be designed so that it allows for the whole dead-leg (section of stagnant water) to be removed. This is achieved by ensuring that the flushing is carried out at the specified system or outlet and for an appropriate length of time. The length of time of purging water from the system is important because it is vital to ensure that all the stagnant water has been expelled from the pipe-work and at least until "circulating" or "fresh" water is drawn from the outlet (water at temperatures exhibited throughout the rest of the system).

For all areas which are in "normal operating use", the responsibility for the Usage Evaluation and Flushing process shall be that of the "user"

For all areas which are "out of use", the responsibility for the Usage Evaluation and Flushing process shall be that of the Estates Department

Infrequently Used Outlets and Dead‐Legs Flushing Process The flushing programme shall follow the procedure outlined below:

Carry out the “Usage Evaluation” process in order to identify areas/outlets which are not used at least 3 x Weekly (daily in augmented care units) so that they can be flushed

Ensure that the system/ outlet can be flushed safely and in a tidy manner into an appropriate drain if not plumbed for drainage

Ensure that the purging of water from outlets does not create an unnecessary amount of aerosol at least no more than would be created when outlet is operated normally

Ensure that "splash-back" is minimised, where practicable, by placing a sponge or another material capable of absorbing some of the force of the water against the surface of the appliance

Purge the hot and the cold or the mixed water in turn for a minimum of 3 minutes or for a period of time necessary to draw water from the outlet at temperatures exhibited throughout the rest of the system

Where showers need to be flushed, it is important to ensure that, where practicable, the shower-head is removed in order to reduce the potential of aerosol production

Where the head is fixed, exposure to the aerosol produced must be minimised. One method that can be employed in this situation is the use of a transparent plastic bag, fixed around the shower- head, with one corner pierced to allow partial discharge of water

Consider whether the system/ outlet can be removed negating further flushing

Report the process via the Compass system. Detailed instruction and user guidance on the Compass system is included in Standard Operating Procedure 2 (SOP2) Reporting under Used Outlets

Flushing Page 3 of 3 Version 1.0 October 2015

Where do I go for further advice or information?

Estates Department Infection Prevention and Control Team

Training Staff may receive training in relation to this procedure, where it is identified in their appraisal as part of the specific development needs for their role and responsibilities. Please refer to the Trust’s Mandatory & Risk Management Training Needs Analysis for further details on training requirements, target audiences and update frequencies Monitoring / Review of this Procedure In the event of planned change in the process(es) described within this document or an incident involving the described process(es) within the review cycle, this SOP will be reviewed and revised as necessary to maintain its accuracy and effectiveness.

Equality Impact Assessment Please refer to overarching policy

Data Protection Act and Freedom of Information Act Please refer to overarching policy

Standard Operating Procedure Details

Review and Amendment History

Version Date Description of Change

V1.0 Oct 2015

New SOP created to support Water Management Assurance Policy; relevant information applicable to Trust Inpatient Staff taken from Water Management Plan

Unique Identifier for this SOP is BCPFT-COI-SOP-03-1

State if SOP is New or Revised New

Policy Category Organisational

Executive Director whose portfolio this SOP comes under

Executive Director of Nursing, AHPs and Governance

Policy Lead/Author Job titles only

Infection Prevention and Control Lead Nurse/ Estates Compliance Officer (Water)

Committee/Group Responsible for Approval of this SOP

Infection Prevention and Control Committee

Month/year SOP was approved October 2015

Next review due October 2018

Disclosure Status ‘B’ can be disclosed to patients and the public