maintenance & operational procedures for the control of legionella

Document name: Maintenance & Operational Procedures for the control of Legionella, water hygiene, ‘safe’ hot water, cold water, drinking water and non-drinking water.

Document type: Procedural

Staff group to whom it applies: All staff within the Trust

Distribution: The whole of the Trust

How to access: Intranet

Issue date: December 2012

Version: 1.05

Next review: October 2014 – Extended to December 2016 for full review by recently commissioned Water Safety Group

Developed by: Chris Curry, Specialist Services Compliance Manager & Authorising Engineer [Water].

Director leads: Alan Davis, Director of Human Resources & Work Force Development

Contact for advice: Chris Curry, Specialist Services Compliance Manager

Maintenance & Operational Procedures for control of Legionella, water hygiene, ‘safe’ hot water, cold water, drinking water and non drinking water. [Oct-2012 – version 1.05]

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ContentsSECTION 1 - MANAGEMENT REVIEW......................................................................4

1.1 Review.......................................................................................................41.2 Sampling and Monitoring...........................................................................4

1.2.1 Water Temperature Checks..............................................................41.2.2 General Microbiological/Legionella Sampling in potable Hot/Cold Water Systems............................................................................................7

1.3 Water Sampling (for drinking and non drinking water systems)................91.3.1 Sampling Containers........................................................................91.3.2 Sampling Procedure.......................................................................101.3.3 Action Regime Table.......................................................................111.3.4 Laboratory Competence.................................................................12

1.4 Records....................................................................................................131.4.1 Retention Period.............................................................................131.4.2 Record Keeping Forms....................................................................131.4.3 Incident Report Form......................................................................131.4.4 Schematics.....................................................................................13

SECTION 2 – Design, Operation & Maintenance..................................................152.1 Design Control.........................................................................................152.2 Water Supply [Water Fittings] Regulations 1999.....................................162.3 BS8558:2011 & BS EN 806 (parts 1 to 5)................................................16

2.3.1 Approved Materials........................................................................172.4 External Contractors................................................................................182.5 Maintaining control of systems during construction and testing.............182.6 Testing & Commissioning........................................................................182.7 Contaminated Aerosols............................................................................182.8 Other Health & Safety Issues...................................................................192.9 Operation of Premises............................................................................19

2.9.1 Occupation of New Premises..........................................................192.9.2 Procedure in the Event of Closure of Part or All of a Building.........192.9.3 Procedure in the Event of Re-occupation of an Indefinitely Closed Area. 21

2.10 Emergency and Outbreak Actions........................................................222.10.1 . .Guidelines for Investigating Single Hospital Cases of Legionnaires’ Disease......................................................................................................23

2.11 Operation of domestic water systems..................................................242.12 Domestic Cold Water Systems..............................................................25

2.12.1Cold Water Cisterns and Cold Feed Tanks......................................252.12.2Connections to Outside Services....................................................252.12.3Connections to Inside Services.......................................................252.12.4Pressurisation / Supply Pumps........................................................262.12.5Gravity Systems..............................................................................26

2.13 Domestic Hot Water Systems...............................................................272.13.1 ......................................Hot Water Storage and Distribution Temperatures

272.13.2DHW Generator Operation..............................................................272.13.3Domestic Hot Water Circulation Pumps..........................................282.13.4Electric Water Heaters....................................................................28

2.14 Air Conditioning Plant...........................................................................282.14.1 .................................................................................................................................General

28


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2.14.2 ....................................................................................Draining Traps and Pipework29

2.14.3 .........................................................................................................................Humidifiers30

2.14.4 ..............................................................................................................Heater Batteries30

2.14.5 Air Handling Plant Inspection....................................................302.15 Other Air Conditioning Units.................................................................30

2.15.1Portable A/C Units...........................................................................302.15.2 .........................................................................................................................Split Units.

302.16 Hydrotherapy Pools, Whirlpool Baths and Whirlpool Spas....................31

2.16.1General...........................................................................................312.16.2 .............................................................................................................................Guidance

312.17 Other Risk Systems...............................................................................312.18 Renal Dialysis Unit................................................................................312.19 Drinking and Non Drinking Water Systems...........................................32

2.19.1Drinking Water Systems.................................................................322.19.2Non Drinking Water Systems..........................................................32

2.20 Water Conditioning..............................................................................332.21 Cleaning and Disinfection.....................................................................34

SECTION 3: TECHNICAL PROCEDURES................................................................363.1 Domestic Cold Water Systems.................................................................36

3.1.1 Tank Cleaning Procedure................................................................363.1.3 Loss of Incoming Mains Cold Water Supply....................................40

3.2 Domestic Hot Water [DHW].....................................................................413.2.1 DHW Generator Flushing................................................................413.2.2 DHW Generator Maintenance..........................................................413.2.3 De-stratification Checks..................................................................423.2.4 Domestic Hot Water Temperature Less Than 45oC.........................42

3.3 Outlet Management................................................................................443.3.1 Showers..........................................................................................443.3.2 Thermostatic Mixing Valves [TMVs]................................................443.3.3 Little Used Outlets*.........................................................................443.3.4 Flexible Pipe Installations................................................................453.3.5 Safe Purging of Stagnant Water......................................................453.3.6 High Pressure Hoses.......................................................................453.3.7 Anti-Ligature Taps...........................................................................453.3.8 The Safe Operation of Mains Fed Chilled Drinking Water Units / Vending Machines / Ice Machines..............................................................46

3.4 Maintenance Checks for Other Water Systems.......................................473.4.1 Strainers.........................................................................................483.4.2 Cleaning Water Systems within Buildings.......................................483.4.3 Minor Plumbing Alterations.............................................................483.4.4 Major Plumbing Alterations [including work done through Procure21]

493.4.4 Certification....................................................................................493.4.5 Notifications....................................................................................49APPENDIX 1: LEGIONELLA RECORDS DOCUMENT MAP..............................51

APPENDIX 2: RECORD SHEETS............................................................................52APPENDIX 3: SENTINEL OUTLET MONITORING POINTS......................................110APPENDIX 4: NEW SYSTEM DESIGN CHECK LIST...............................................124


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APPENDIX 5: BIBLIOGRAPHY..............................................................................127


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SECTION 1 - MANAGEMENT REVIEW1.1 Review

Quarterly management review meetings shall be held in order to assess the progress with respect to management issues. Regular progress review meetings [at least quarterly] will be held to identify progress against the action plan in order to identify any problems with the implementation of specific remedial measures.

1.2 Sampling and Monitoring

System/Service Task Frequen

cyFile

Section*

Domestic cold water tank

Incoming mains cold water temperature

Tank water temperature

6 monthly

6 monthly

C

C

Domestic cold water outlets

Sentinel tap temperatures [mixed & non-mixed]

Temperature at representative number of taps on a rotational basis

Monthly

Annually

C

C

DHW Generators Flow and return temperature Monthly CDomestic hot water outlets

Sentinel tap temperatures [mixed & non-mixed]

Temperature at representative number of taps on a rotational basis

Monthly

Annually

C

C

Thermostatic mixing valves

Inlet temperature

Outlet temperature

6 monthly

6 monthly

C

C

* File section C – these are individual property files held in the Schematic/Drawing Office.

1.2.1 Water Temperature ChecksTemperature checks on the DHW generator and distribution system should be carried out as detailed below on a monthly, six monthly and annual basis. In the event of a non-compliance, the Authorised Person [Water] shall be informed immediately. Use of a digital thermometer with a touch and immersion probe is recommended. Although the HSE recommends spot temperature checks, the HTM04:01 requires a temperature excursion limit of less than 20 minutes, therefore continuous monitoring will be necessary in certain circumstances. The frequency of such monitoring to be based on a risk decision [i.e. balance risk, cost and difficulty for the system].Cold water storage tank temperatures should be checked during periods of high ambient temperatures [e.g. afternoons between June and August], water temperatures should be no greater than 20oC. At the same time, the furthest and nearest draw off points in the system should be checked to ensure that


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the water distribution temperatures are less than 20oC within 2 minutes of running the water [at full flow]. A similar temperature check regime should be undertaken during the winter months to identify the performance of cold water distribution systems and the impact of heat gain from heating systems.


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1.2.1.1 Hot and cold water distribution temperatures from sentinel taps: For domestic hot water services, these are the first and last taps on a re-circulating system. For cold water systems or non-recirculating hot water systems this is the nearest and furthest taps from the storage tank. For cold water outlets, the temperature should be below 20C after 2 minutes of running the water. For hot water outlets, the temperature should reach 55C within 1 minute of running the water.

1.2.1.2 Thermostatic mixer valves: Where fitted, the input temperatures to thermostatic mixer valves should be at least 55C within 1 minute of running the water. Outlets with TMV’s should be monitored on a sentinel basis as detailed above.

Where water temperatures fail to satisfy the criteria described (see table below), the Authorised Person [Water] shall be informed, and a full investigation must follow and Incident Report completed.

1.2.1.3 DHW generator flow and return temperatures:

The outgoing water from the DHW generator should be at least 60C, and water returning to the DHW generator should be at least 50C. These temperatures will be taken once a month direct from the domestic hot water generator and recorded on the monthly monitoring form. If temperature gauges are not fitted, then suitable surface temperature probes may be used.

1.2.1.4 Incoming mains cold water:Where there is a cold water storage tank, this should be measured at the ball valve outlet. The water should preferably be below 20C. However, during a prolonged hot summer the incoming water may rise above this temperature. Under the Water Supply [Water Quality] Regulations, water utilities are permitted to supply water to premises at temperatures up to 25C. If incoming water temperatures are above 20C, the water supplier should be advised to see if the cause of the high temperature can be found and removed.


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Monitoring should ideally be carried out so that one check takes place in the summer months and the other in the winter months.

1.2.1.5 Representative number of taps on a rotational basis:In order to ensure that the whole system is reaching satisfactory temperatures for Legionella control, the outlet temperatures should be taken from 20%of outlets other than sentinel taps. As such all other outlets will have their temperatures monitored once every 5 years. On a biannual basis all outlets with a TMV fitted have their temperature monitored and recorded. For cold water outlets, the temperature should be no greater than 20C within 2 minutes of running the water. For hot water outlets, the temperature should reach 55C within 1 minute of running the water.Where water temperatures fail to satisfy the criteria described, the Authorised Person [Water] shall be informed, and a full investigation must follow.


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1.2.2 General Microbiological/Legionella Sampling in potable Hot/Cold Water Systems

1.2.2.1 Circumstances under which samples are takenThe Infection Control Team will be advised of all water samples taken and reason for the sample. Samples for general microbiological testing i.e. total aerobic bacterial counts at 37oC, coliforms and E.coli will be taken for the following reasons:- One week following handover of a new building or water system, for one

month; As part of the tank cleaning and disinfection process; In response to taste or odour or sustained discoloured water complaints.When such samples are taken, a mains supply sample should be taken as a control, to verify whether the supply could be the source of any identified problems. The water supplier is also contacted for distribution zone water quality data, for the same reason. The Infection Control Team will certify the sample results are of a drinking water quality before the system is brought back into service.Samples for Legionella testing are taken:- Weekly from hot water systems where control levels of the treatment

regime, i.e. temperature in this case, are not consistently achieved – these samples should be taken until the system is brought back under control;

When an outbreak is suspected or has been identified; Regularly where a department specialises with services for ‘high risk’

patients.The Infection Control have identified all Trust properties can accommodate “high vulnerability” patients.

Typically the following minimum samples will be taken:-

Mains cold water control sample; Cold tank, nearest and furthest outlets; DHW generator flow, nearest and furthest outlet; Additional random samples.


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1.2.2.2 Action Levels for Legionella in Hot and Cold Water Systems (taken from L8)

Legionella Bacteria [cfu/litre]

Action RequiredFile

Section*

More than 100 but less than 1000

Either:If only one or two samples are positive, system should be re-sampled. If a similar count is found again, a review of the control measures and risk assessment should be carried out to identify any remedial actions.If the majority of samples are positive, the system may be colonised, albeit at a low level, with Legionella. Disinfection of the system should be considered but an immediate review of control measures and risk assessment should be carried out to identify any other remedial action required.

A.4

More than 1000 The system should be re-sampled and an immediate review of the control measures and risk assessment carried out to identify any remedial actions including possible disinfection of the system.

A.4


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1.3 Water Sampling (for drinking and non drinking water systems)

1.3.1 Sampling Containers Only sterile bottles should be used that have been provided by the

laboratory. Bottles should not be opened until the sample is to be taken. Bottles should have the following information.

o Batch code;o Date of expiry;

Bottles should ideally be used within 3 months of being sterilised. Any bottles outside of the ‘Date of Expiry’ should be returned to the

laboratory who supplied them. Bottles should be stored in clean and dry locations. Bottles should be adequately labelled with the following:

o Reference number;o Date & time of sampling;o Exact location of sampling point;o Type of water being sampled;o Reason for taking sample;o Identity of person taking sample;

Corresponding paperwork must be completed for each sample taken containing the same information as above.

Corresponding paperwork may also contain the following information:o Sufficient detail to enable sample to be taken from the same

location;o Unusual features when taking the sample, i.e. smell, appearance

or flow rates.


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1.3.2 Sampling Procedure Samples only to be taken using an un-tampered sterile bottle. Single use disposable gloves are to be worn. A new pair will be worn

for each sample taken and disposed of immediately after the sample has been taken. The disposable gloves shall be kept in their original supplied packaging until the time when they are required [ensure the user is not sensitive to the disposable gloves supplied].

Pre flush sample shall be taken (regardless of sampling for Legionella or bacteriological). The outlet will not be disinfected prior to taking the sample. The sample of water will be taken without letting any water run to waste. (This type of sample is most representative of the risk to individuals and is the only sample that should need to be taken from systems where there is evidence of adequate, sustained control and low risk).

Post flush samples shall be taken (regardless of sampling for Legionella or bacteriological).

Sample taps are disinfected before being sampled. Disinfection methods by using a 1 in 10 dilution of a commercial grade sodium hypochlorite solution (containing in the range 12% to 14% available chlorine Sodium hypochlorite solution.

The outlet shall be disinfected in accordance with BS7592:2008.

Flaming method is not to be used. When taking samples the bottle is held in one hand and the bottle cap

removed with the other hand, ensuring the top or the neck of the bottle doesn’t come in contact with hands or the outlet.

Do not rinse out the bottle or the cap. Do not place the cap on any surface, it should remain in your fingers. Turn on the water so a gentle stream is flow, fill the bottle leaving a

small air gap at the top, do not allow to over flow. Replace bottle cap immediately taking care not to touch the top or the

neck of the bottle. The bottle should then be placed into a cool, dark, insulated container

for transporting to the laboratory (see below for more detail). Sample delivery times to the laboratory:

Legionella samples within 24 hours but no more than 48 hours.

Bacteriological samples should be as soon as possible, not exceeding 24 hours if stored correctly (see below).

Transportation of sample: Legionella samples should be protected from heat and

sunlight, kept at ambient temperature not exceeding 20OC. Hot and cold samples to be packaged separately.

Bacteriological should be kept in dark, insulated storage containers which are regularly disinfected. The temperature of the sample should be kept at 2-8OC.

If during sampling accidental contamination is suspect the sample should be discarded and a fresh sterile bottle used to take a new sample.


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1.3.3 Action Regime TableOccupant

Susceptibility Category: Sample

Required:Where from:

Count above which action

required:

Required action:

VERY HIGH(Renal Dialysis, Cancer, AIDS, Respiratory

Illness, Imuno-compromised,

Elderly)

LEGIONELLA(species and

numbers)

Representative outlets as

agreed with the consultant (specify)

>20 a) If limited outlets or count 20-40 = Re-sample at once, and disinfect if repeated again.b) If more than 20% of outlets or counts 40+ disinfect at once, and review procedures.

TVC, E.coli , coliforms

Representative outlets as

agreed with the consultant (specify)

TVC = >100E.coli = >0Coliforms =

>0

a) If limited outlets give TVC counts of 100-500 then re-sample at once. If similar results from second sample then disinfect tank and system.b) If more than 20% of outlets give TVC counts 100+ disinfect at once, and review procedures.c) If TVC results give counts >500 sample the mains cold water unit a clear result is achieved. Then sample the cold water storage tanks, if these results are clean then no further action. If the results are returned positive then clean the cold water storage tank.d) If any outlet returns E.coli or coliforms of >0 disinfect.

SIGNIFICANT(All other

Healthcare areas)


numbers)

1 MCW1 of each Tank

2 TCW taps2 DHWS taps

>100

>1000

Re-sample. Disinfect if fail.

Disinfect at once and review systems.

TVC, E.coli, coliforms

1 MCW1 of each Tank



>0

a) If limited outlets give TVC counts of >100 = Re-sample at once, and disinfect if repeated again.b) If more than 40% of outlets give TVC counts 100+ disinfect at once, and review procedures.c) If TVC results give counts >500 sample the mains cold water until a clear result is achieved. Then sample the cold water storage tanks, if these results are clean then no further action. If the results are returned positive then clean the cold water storage tank.d) If any outlet returns E.coli or coliforms of >0 disinfect.


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LOW(e.g. staff

areas)


numbers)

1 MCW1 of each Tank


>100

>1000




1 MCW1 of each Tank



>0

a) If limited outlets give TVC counts of >120 = Re-sample at once, and disinfect if repeated again.b) If more than 40% of outlets give TVC counts 120+ disinfect at once, and review procedures.c) If TVC results give counts >500 sample the mains cold water until a clear result is achieved. Then sample the cold water storage tanks, if these results are clean then no further action. If the results are returned positive then clean the cold water storage tank.d) If any outlet returns E.coli or coliforms of >0 disinfect.

(*) These are for guidance. The risk assessment will indicate need to disinfect as a combination of factors may need to be considered.1.3.4 Laboratory Competence

Samples for Legionella shall be tested by a UKAS accredited laboratory that takes part in the HPA Water Microbiology External Quality Assessment Scheme for the isolation of Legionella from water.


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1.4 Records1.4.1 Retention Period

The following records will kept.

Record Retention PeriodThis policy and procedures document

Throughout the period for which they remain current and for at least two further years.

Risk assessmentsRisk minimisation scheme and details of its implementationMonitoring, inspection, test and check results, including details of the state of operation of the system

At least five years

1.4.2 Record Keeping FormsThe record forms are all included in Appendix 2.

1.4.3 Incident Report FormAn ‘incident report form’ is the record sheet used to record a non-compliant situation that has been discovered, either as part of routine monitoring and maintenance or as a result of a hot line call. All Incident Report Forms are kept file A.4.

The incident report form is an audit trail for ensuring all non-compliant situations are dealt with and closed down satisfactorily.

1.4.4 Schematics

Drawings and schematics are held in file B.3. This file allows specific schematics / drawings to be reproduced on request.Water system schematics are produced for all hot and cold water systems, with the exception of point of use water heaters and small tenanted domestic premises served by individual single-pipe water systems. The schematics show the storage systems in plant rooms and tank rooms. Distribution schematics show sentinel outlets on block plans [where available].For each water system that presents a risk from Legionella bacteria, a schematic or drawing shall be held, showing:-

Origin of water supply; General layout of the system; How the system operates; All associated storage and header tanks; All standby equipment; Any parts of the system that may be out of use temporarily; Any problem areas such as deadlegs; Regular operation and test points.


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These schematics/drawings may also show:- All system plant, e.g. water softeners, filters, strainers, pumps, non-

return valves and all outlets, for example showers, wash hand basins etc;

All associated pipework and piping routes.

Estates staff [maintenance & projects] ensure that any changes to the domestic water systems and associated equipment are recorded so that schematics / drawings held on file B are kept up to date.

Drawings/schematics shall be checked to coincide with risk re-assessment, to ensure that they are up to date.


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SECTION 2 – Design, Operation & Maintenance

2.1 Design ControlWater can’t be entirely free from aquatic organisms, therefore, measures have to be taken to guard against conditions that encourage microbial growth.

To reduce the risk of outbreaks the design of domestic water systems should eliminate:1) Direct contact of internal parts of pipes & structures by people, animals or birds.2) Backflow of contaminated water into a system conveying drinking water.

In order to avoid potentially costly remedial works, the design of new buildings and their water systems is controlled in order to “get it right first time”. The checklist provided in Appendix 4, is based on some of the questions contained within an audit checklist used by HSE Inspectors. This checklist should be used by relevant Estates staff and/or supplied to design consultants in order that they may check their own designs. This checklist is not a design brief and is not intended to deal with all potential design issues. It’s a management check. If these issues are incorrect it is likely that other aspects of the design are not compliant with good/best practice.

Hot & cold water supplies are considered drinking water. As such the design and installation of domestic hot and cold water services, and associated plant and equipment, in new, upgraded or refurbished premises will comply with documents details below:-

[a] The Water Supply [Water Fittings] Regulations 1999;

[b] BS8558:2011 - Guide to the design, installation, testing and maintenance of services supplying water for domestic use within buildings and their curtilages. Complimentary guidance to BS EN 806

[c] BS EN 806 "Specifications for installations inside buildings concerning water for human consumption" which consists of five parts:

Part 1: General Part 2: Design Part 3: Pipe sizing — Simplified method Part 4: Installation Part 5: Operation and maintenance.

These documents detail the minimum standards for domestic water storage for domestic use. For example, the design of pipework should ensure no possible cross connection between installations conveying drinking and non-drinking water or water from a private source.


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http://shop.bsigroup.com/en/ProductDetail/?pid=000000000030200074





The following documents (held by Estates Maintenance/Project Staff) will be consulted for guidance for the general design and operation of water systems on Trust premises:-

[a] HSE Approved Code of Practice and Guidance Document [L8] – “Legionnaires’ disease: the control of Legionella bacteria in water systems”

[b] HTM04-01: Water Systems – The control of Legionella, Hygiene, “Safe” Hot Water, Cold Water and Drinking Water Systems. Part A: Design, Installation and Testing;

[c] HTM04-01: Water Systems – The control of Legionella, Hygiene, “Safe” Hot Water, Cold Water and Drinking Water Systems. Part B: Operational Management.

When new designs are produced, consideration is given to the impact of new technologies/ techniques and their impact on water consumption, e.g. the use of alcohol hand-rubs significantly reducing the use of hand basin water supplies.

2.2 Water Supply [Water Fittings] Regulations 1999On 1 July 1999, the Water Supply [Water Fittings] Regulations replaced the Water Byelaws in governing the prevention of waste, misuse, undue consumption and contamination of public water supplies in domestic and commercial plumbing installations and represents important protection for public health and the environment. In Scotland these issues were implemented by the Scottish Water Byelaws [2000]. The Regulations are based on performance standards, e.g. British Standards or those European Standards being mandated under the Construction Products Directive. The Regulations are not retrospective and so will not apply to water fittings that were installed in accordance with the Byelaws before 1 July 1999.

The Regulations are enforced by water companies, and further advice should be sought from them or from the Water Regulations Advisory Scheme on 01495 248454 or from its website at www.wras.co.uk. The Scheme, has produced a guidance document to provide a more detailed explanation of the requirements

The Regulations introduced a new specification to prevent the backflow of water from 1 May 2000. This brings the UK into line with the emerging harmonised European Standard. The system consists of five fluid categories which reflect the potential toxicity of the downstream fluids. These categories relate to the risk posed to public health should fluids contaminate drinking water. The specification then equates each fluid category to the range of suitable backflow prevention devices. Particular reference should be made to the determination of fluid categories when considering alternative water treatment systems. The addition of a treatment chemical to drinking water may result in the need for a back flow device appropriate to the treatment added (subsequent fluid category).

2.3 BS8558:2011 & BS EN 806 (parts 1 to 5)BS 8558:2011 Guide to the design, installation, testing and maintenance of services supplying water for domestic use within buildings and their curtilages. BS 8558:2011 provides complementary guidance to BS EN 806. It is a guide to the design, installation, testing, operation and maintenance of services supplying water for domestic use within buildings and their curtilages.


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BS 6700 was withdrawn in July 2012. BS 8558 is now the lead document in the area of domestic water supply. The following parts of BS EN 806 include:

BS EN 806-1:2000Specifications for installations inside buildings conveying water for human consumption. ‘General’BS EN 806-2:2005Specifications for installations inside buildings conveying water for human consumption. ‘Design’BS EN 806-3:2006Specifications for installations inside buildings conveying water for human consumption. ‘Pipe sizing. Simplified method’BS EN 806-4:2010Specifications for installations inside buildings conveying water for human consumption. ‘Installation’BS EN 806-5:2012Specification for installations inside buildings conveying water for human consumption. ‘Operation and maintenance’

2.3.1 Approved Materials

Any materials that come into contact with the water in a hot and cold water installation must comply with the requirements of the Water Supply (Water Fittings) Regulations 1999. A list of products and materials that have been assessed for compliance with the requirements of these Regulations is given in the current edition of ‘Water Fittings and Materials Directory’, which is updated every six months.Materials of construction should be selected to take account of water quality and its potential corrosive properties.The materials generally used for the conveyance of water in healthcare premises are copper, steel, stainless steel and plastics. Lead is no longer allowed under the Water Supply (Water Fittings) Regulations 1999 for pipework or solders.Substances leached from materials of construction of pipes, cisterns or other water fittings in contact with water must not adversely affect the quality of water stored or drawn for domestic or food production purposes (Water Supply (Water Fittings) Regulations 1999).Jointing compounds or tape, which may be one of the many proprietary makes, should be used according to the manufacturers’ instructions. Compounds containing red lead must not be used because of the danger of contamination of the water. Jointing compounds must not support microbial growth, should comply with BS 6920-1:2000, and should be listed in the ‘Water Fittings and Materials Directory’Specific examples of materials not to be considered for use [unless where exceptions noted]

Hemp and paste Boss white –linseed oil based jointing compound Lead solder Natural rubber Generic fibre washers Flexible hoses (exemptions to this rule are PEX lined hoses which are

needed for non fixed appliances , ie high/low baths, basins ,washing machines etc)

Non WRAS approved fluxes( The only flux to be used is EVERFLUX which is a water based flux but must only used as per the manufacturer’s instructions and WRAS guidance installation method No.9-04-02:June 2012)

All other non WRAS approved materials


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2.4 External ContractorsA specification appertaining to new works will be produced. To include:-

[a] a standard form within the contract documentation to define roles, responsibilities and procedures of parties concerned;

[b] Submission where applicable of risk assessments and method statements with relation to compiled schedules.

[c] Evidence of competency. For the organisation they should be members of the LCA and be on WRAS ‘Approved Plumber Scheme’ register. Then evidence of competence of each member of staff who will working on the water systems.

2.5 Maintaining control of systems during construction and testingDuring the period of construction and testing, an appropriate biocide will be continuously applied to prevent the accumulation of biofilm. The system[s] will be regularly flushed to ensure the biocide reaches all parts of the system, particularly outlets.

2.6 Testing & CommissioningEstates maintenance and project managers will ensure that installation of hot and cold water services, carried out by contract, will be tested and commissioned in accordance with HTM.04-01.

2.7 Contaminated AerosolsThe disinfection procedures presented for cold water storage tanks, domestic hot water vessels and water systems are designed to minimise the risk to staff and others that may come into contact with water which may have been contaminated with Legionella sp. In all instances of draining, water should be drained in such a way as to avoid the creation of an aerosol. This also applies for the safe purging of stagnant water e.g. from unused outlets [see also Section 3 – Technical Procedures – 3.3 Outlet Management].

The appropriate protective clothing should be worn during such procedures. This can be a powered filter and hood, European Class TH3 [assigned protection factor of 40] or a power assisted filter and close fitting full face mask TM3 [assigned protection factor 40]. It should be borne in mind that the filter on these systems is liable to get wet and subsequent resistance to air can increase with consequent discomfort to the operator.

Alternatively, a hood or full-face mask fed with breathing quality compressed air may be used. The preferred equipment is a full-face close fitting airline mask with a positive pressure demand valve, under a hood or helmet protecting the rest of the head. The air supply should come from an oil free compressor drawing air through a filter from a location well upwind of any jetting operation or using cylinder supplies of compressed air. Further information on respiratory protective equipment [RPE] can be obtained from


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Respiratory Protective Equipment - legislative requirements and lists of HSE approved standards and type approved equipment and also HS[G]53: The selection, use and maintenance of respiratory protective equipment [2nd

Edition]. Personnel using RPE must be adequately trained to do so and equipment must be properly maintained.

Where possible, cleaning methods which create an aerosol [e.g. high pressure water jets] should be avoided. If this is not possible, the operation should be executed when the building is unoccupied, or in the case of permanently occupied building, windows in the vicinity should be closed and air inlets temporarily blanked off. As systems requiring cleaning will have high organic load the operator and others closely involved should wear suitable respiratory protective equipment. The high pressure jet wash must be feed from a drinking water supply with suitable air break to prevent back flow.

2.8 Other Health & Safety IssuesIf plant is located in confined spaces, reference on entry into confined spaces can be sought from Safe Work in Confined Spaces Approved Code of Practice, Regulations and Guidance [L101].

Because water treatment chemicals, including chlorine-containing chemicals and solutions, are often toxic or corrosive they should be used cautiously to ensure that they do not endanger the users or other occupants of the building. Caustic resistant gauntlet type gloves will be required. Water treatment should be carried out by, or under the direction of, people who are suitably qualified and experienced.

The use of water treatment chemicals should be subject to a COSHH assessment and permission would be required from the water authority prior to any discharge to sewers, storm water drains and watercourses. The Environment Agency should be contacted prior to direct discharge to water courses.

2.9 Operation of Premises

2.9.1 Occupation of New Premises2.9.1.1 Procedure until Occupation

This procedure is designed to prevent the risk of legionellosis developing in a new building/department through the interim period following construction, commissioning and hand over to occupancy.Once the system is in use and has been cleaned and chlorinated prior to hand over, a Competent Person shall be nominated to monitor and observe the system, and ensure that the system is operated in accordance with the Trust's 'Procedure in the event of closure of part or all of a building' [section 2.2] and the relevant record sheet completed.At the point of hand over all relevant information on system performance together with as-fitted drawings and design criteria of the domestic hot water systems and cold water services shall be submitted to the Senior Operations Manager & Authorised Person [Water] who will be Authorised for the premises. In addition, the certificates of chlorination and the testing & commissioning data.Occupancy of the new property should be as soon after hand over as possible to prevent further costs being incurred due to the need for re-chlorination of the water systems. From handover until the time at which the building is fully occupied, flushing any unused or little used outlets will be undertaken on a twice weekly basis.


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2.9.1.2 Routine Operation of Water OutletsIn all health care buildings water draw off will form part of the daily cleaning process. Written instructions for this practice will be issued to domestic staff by House Keeping / Hotel Services. Any areas that do not form part of the daily cleaning process must be informed to the Authorised Person [Water].

2.9.2 Procedure in the Event of Closure of Part or All of a Building2.9.2.1 Background

Where part or all of a building is going to close for a period of greater than one week, the relevant manager must notify the Authorised Person [Water] of the details.Following a closure decision, negotiations between the relevant manager and the Authorised Person [Water] must take place to ensure that the following procedure is established and documented, and to clearly define what actions named individuals shall perform.

2.9.2.2 Period of ClosureThe period of closure should be established at the earliest point in negotiations. The period for which an area is closed can play an important part on the cost implication and involvement of a closure.

2.9.2.3 Temporary ClosureWhere a closure is expected to not exceed 60 days a weekly PPM will be implemented by Estates Maintenance where a nominated individual shall be identified and every outlet will be run for 3 minutes twice a week and flush every toilet twice a week. The nominated individual should then complete the record sheet LEG26, signed by themselves and their relevant manager, the completed form being forwarded to the Authorised Person [Water]. [Vacant areas weekly outlet running record sheet]Before the closed area is re-occupied the Authorised Person [Water] shall carry out an inspection and test of the water systems to identify if any remedial works that may be required.At the end of the 60 day closure period then a review shall take place to identify if the area can be reoccupied. It is the responsibility of the relevant manager to notify the Authorised Person [Water] of their intention to re-open a temporarily closed area.If the area is to be reoccupied within the immediate future (within 30 days) then the twice weekly flushing shall continue.In the instance that part or all of a building is to remain closed with no planned re-opening date [this will be classed as ‘Indefinite Closure’], negotiations must be held as detailed above and funding be made available to the Authorised Person [Water] by the manager of the department that is closing, in order to disconnect and drain the water services within the affected area. The relevant manager should be aware that considerable cost for modifications could be needed to achieve this requirement in some large properties.

2.9.2.4 Indefinite ClosureIn the instance that part or all of a building is to close with no planned re-opening date, or where the closure period exceeds 60 days, negotiations must be held as detailed above, and funding made available to the Authorised Person [Water] by the manager of the department that is closing, in order to disconnect and drain the water services within the affected area. The relevant manager should be aware that considerable cost for


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modifications could be needed to achieve this requirement in some large properties.


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2.9.2.5 Detail of Works for an Indefinite ClosureWhere relevant - all water tanks associated with the affected area shall be drained, cleaned and dried out by a competent person.All pipework and devices shall be drained and where applicable DHW generator [or other storage vessels] shall be opened up, cleaned and left open to the atmosphere.Pipework shall be disconnected from the mains services and capped off, mains cold water services shall be isolated and capped off from the system and all relevant pipework drained.Notices shall be posted throughout the affected area stating that all water services are disconnected.The Competent Person shall be Authorised to ensure that an adequate water seal exists in unused toilets to prevent odours from the foul drain system entering the premises.Adequate records of actions, and amended water service schematic diagrams shall be produced by the Estates Department showing the relevant modifications and disconnections made to the water systems. The Completed Remedial Works Record Sheet shall be used for record keeping purposes.

2.9.3 Procedure in the Event of Re-occupation of an Indefinitely Closed Area.In the event of re-occupation of an indefinitely closed area, full negotiations must take place between the relevant manager and the Authorised Person [Water] prior to the re-occupation exercise.The Authorised Person [Water] will require the following information: The planned re-opening date; Any proposed changes of use of the area; Any areas which will not be used.The Authorised Person [Water] will provide the relevant manager with a cost to put the water systems [for which the relevant manager must provide funding] back in service.Before the water system is put back into service, any necessary modifications and maintenance shall be carried out prior to the cleaning of the system.


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2.10 Emergency and Outbreak ActionsThe contact details, both during office hours and out-of-hours, of the Authorised Person [Water], the Senior Operations Manager, Authorised Person [Water] and the Infection Control Officer [Water] are kept on the main switchboard and the major incident control room.An outbreak is defined by the Health Protection Agency [HPA] as 2 or more confirmed cases of legionellosis occurring in the same locality within a six month period.

The Trust will follow the guidance presented in Appendix 1 of the “Operational Management” volume of HTM.04-01.

The Authorised Person [Water] will be informed of a suspected case of legionnaires’ disease by the Infection Control Officer [Water]. An investigation will be carried out in association with the Health Protection Agency and the local Consultant in Communicable Disease Control [CsCDC].

It is essential that systems are not drained or disinfected before samples have been taken.

The investigation will concentrate upon all potential sources of Legionella contamination, including:-

[a] cooling towers[b] domestic hot and cold water storage and distribution systems;[c] showers or spray washing equipment;[d] drainage systems and traps;[e] whirlpool baths or hydrotherapy pools;[f] condensate trays and traps from air conditioning cooling coils;[g] humidification equipment;[h] ice-making machines and water coolers.

NOTE: South West Yorkshire Partnership NHS Foundation Trust & Wakefield PCT have no evaporative cooling towers.

The Authorised Person [Water] will be required to:-

[a] provide details of all pipe layouts and associated equipment;[b] provide adequate documentation detailing operation and

maintenance procedures;[c] assist the investigation team by locating outlets from which samples

can be taken. Easy access to these sampling points is essential;[d] identify water supplies to medical equipment such as orthodontics,

renal dialysis, respiratory therapy;[e] provide any off-site information e.g. local excavation or earthmoving

works, alterations to water supply or drainage systems.

If any relevant legislation has been infringed then the Trust may be subject to a formal investigation by the Police and/or Health and Safety Executive. Once the samples have been taken and the cause of infection identified, it is the responsibility of the Infection Control Officer [Water] and the Authorised Person [Water] to carry out disinfection procedures and implement any remedial action.


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2.10.1 Guidelines for Investigating Single Hospital Cases of Legionnaires’ DiseaseThese guidelines have been developed from “Guidelines for investigating single cases of legionnaires’ disease” published in Communicable Disease & Public Health journal Vol. 5 No. 2 June 2002. Authors - JV Lee and C Joseph of the Health Protection Agency [HPA].

These guidelines are produced for Consultants in Communicable Disease Control [CsCDC], microbiologists, clinicians, environmental health officers [EHOs] and other public health specialists involved in the control and prevention of legionnaires’ disease. It will be the responsibility of the hospital’s Infection Control Officer [Water] to lead the investigation into a single case in a hospital, it is essential that the local CsCDC is informed as soon as possible. The hospital’s Infection Control Officer [Water] will be Authorised for updating this procedure.

Local management of the investigation: Local Memorandum of Understanding [MoU] – this must be agreed between all relevant agencies [HSE, CsCDC, HPA laboratory, Environmental Health Departments]. Clinical diagnosis of legionnaires’ disease must be supported by confirmed or presumptive microbiological evidence. As soon as a laboratory diagnosis has been made by a microbiologist the case should be reported to the local CsCDC and local infectious diseases clerk. Investigation to be commenced following the pre-defined MoU. Investigations for Legionella infections may take place outside the residential area of the patient. If this is the case the suspected / confirmed diagnosis result should be immediately sent to the public health department in whose area the patient resides, the local CsCDC can commence follow up procedures. The CsCDC to obtain the patient’s movements for the two weeks prior to onset of illness. This will include full address and postcode of place residences, place of work, travel details, accommodation details [overnight stays]. This should also include details of possible hospitals visited and other potential common sites and exposure to Legionella. All cases should be reported to CsDSC in confidence, via telephone or encrypted fax to a named person. Once clinical, microbiological and exposure histories have been obtained for the case these should be detailed on the standard CsDSC reporting form. Investigations specific to hospitals will require reviewing the risk assessment for controlling Legionella and maintenance records by the incident control team in conjunction with the Authorised Person [Water]. The review of the risk assessment & maintenance records should identify if there are any deficiencies in controls as detailed by the HSE and NHS guidance. If any such deficiencies in the control are found these should remedied as soon as possible. Any precautionary disinfection of any part of the water system should only be completed after sampling. This sampling will be under the direction of the incident control team and carried out in accordance with BS7592:2008. A case search for other confirmed or presumptive cases of legionnaires’ disease associated with the hospital or community should be conducted.


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2.11Operation of domestic water systems System/Service Task Frequency File

Domestic cold water pressurisation pumps

Switch over pumps automatically, Or, manually.

DailyWeekly

N/APPM

Domestic water tanks

Where multiple tanks, operate in parallel. Where one or more tanks are drained,

ensure that all interconnecting pipework and mains cold feed are drained and vented.

Check tank temperatures and visually inspect and carry out remedial [where necessary].

Start-upAt

changeover

Biannually

PPM

B

C

DHW Generator Where multiple, operate in parallel. Where one or more DHW generators are

drained, ensure that all interconnecting pipework and cold feed are drained and vented.

Thermostat set to achieve minimum flow temperature of 60oC and a return temperature of at least 50oC.

In premises with high vulnerability occupants, DHW generator to operate 24 hrs per day, 7 days per week. In other premises operate by time clock, to achieve full temperature one hour before occupation and one hour after each day.

Start-upAt

changeover

Start-up

Start-up

PPM

B

C

PPM

DHW generator shunt pumps

Control by time clock. Alternatively, if data plot for one week

shows that DHW generator performance criteria are met under continuous pump operation.

1 hr / night N/A

Continuously C

DHW distribution pumps

In premises with high vulnerability occupants, distribution pumps to operate 24 hrs per day, 7 days per week. In other premises operate by time clock, to achieve full temperature one hour before occupation and one hour after each day.

Manual check that the distribution pump[s] are operating effectively [by temperature checks].

Start-up N/A

Monthly C

Air conditioning plant - humidifier

Set the fan to operate for 30 minutes before the humidifier starts up.

Set the humidistat to a maximum of 70% relative humidity.

Start-up

Start-up

C

C


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2.12 Domestic Cold Water SystemsNatural water sources such as borehole supplies may be contaminated with Legionella. There are no such supplies in use by the PCT. Sampling for Legionella shall be undertaken if such supplies are used in the future.

2.12.1 Cold Water Cisterns and Cold Feed TanksAll new domestic cold water storage cisterns and tanks shall comply with the requirements of the Water Supply [Water Fittings] Regulations 1999 & BS.8558:2011 & BS EN 806 (parts 1 to 5) for cold water storage [heating system header tanks - F&E are excluded]. The organisation is subject to a risk assessment every two years, as required by the ACoP L8. The findings of the risk assessments include prioritised recommendations; the actions necessary to bring existing tanks to the standards required by the Water Supply [Water Fittings] Regulations 1999 & BS.8558:2011 & BS EN 806 (parts 1 to 5). These prioritised recommendations have timescales which are tabled in the legionellosis risk minimisation scheme. Any completed actions are to be reviewed as part of legionellosis risk re-assessment.All domestic cold water storage tanks are to be examined and the temperature tested on a regular six monthly cycle and cleaned and disinfected as required as detailed in the Tank Cleaning Procedure. When a tank is inspected, the presence of a label stating its contents and capacity is verified. If it is lacking then a new label is to be fitted.

2.12.2 Connections to Outside ServicesThe existence of these connections and their necessity is checked on an annual basis and recorded on form C – LEG08, ensuring that an appropriate back flow prevention device has been installed applicable to the connections usage.

2.12.3 Connections to Inside ServicesVending machines, ice machines and chilled water dispensers will be checked annually and recorded on form C – LEG09 to ensure such units are connected to a drinking water supply (not softened). These connections will be via a double check valve and upstream of a regularly used outlet but not exceeding a distance of 3 metres in supply pipe length.


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2.12.4 Pressurisation / Supply PumpsWhere two or more pumps have been fitted for pressurisation systems, the lead pump shall be changed over at least weekly in order to avoid water stagnation.Dates and times of the manual pump change-over shall be recorded in the plant room log book. Print-outs of regimes for automatic systems will be adequate.Where pumps have not been in service for a period of four weeks or greater, or have been removed for any reason, the pump and associated pipework shall be thoroughly washed out and disinfected before being brought back into service. Disinfection of pumps shall be to 50ppm free residual chlorine for 1 hour and pumps shall be totally submerged during this period. Incident Report Form A.4 shall be completed giving details of why the pump was out of use. Details of any such action shall be recorded in the plant room log book.

2.12.5 Gravity SystemsSee table in section 2.11.


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2.13 Domestic Hot Water SystemsCalorifiers, direct gas water heaters, angelerys, plate heat exchangers, hot water cylinders & any associated buffer vessel are all a means of producing & storing domestic hot water and are subject to the procedures below. Hereafter the term "DHW Generator" is used to describe any of the above mentioned domestic hot water storage vessels. All new domestic hot water storage vessels shall comply with the requirements of the Water Supply [Water Fittings] Regulations 1999 & BS.8558:2011.

2.13.1 Hot Water Storage and Distribution TemperaturesThe storage of domestic hot water should be arranged to ensure that a water outflow temperature of at least 60oC is achieved. It is important to maintain temperatures at above this figure [Legionellae organisms will survive for only a short period of time above this temperature - approximately two [2] minutes].Permanent continuous monitoring of water temperatures via a building management system or data logger is recommended for higher risk premises in order to demonstrate performance.The outflow water temperature, under prolonged maximum continuous demand [at least 20 minutes] from DHW Generators should not be less than 60oC.While it is accepted that occasionally under peak instantaneous or prolonged demand that the water outflow temperature will fall, it is not acceptable if this occurs frequently [more than twice in any 24 hour period] and / or for long periods [exceeding 20 minutes].Under no circumstances shall the domestic hot water flow temperature fall below 50oC.It is recommended that disinfection by pasteurisation is undertaken if the water temperature of the DHW Generator falls below 45oC.The temperatures should be maintained 24 hours a day, seven days per week.A minimum domestic hot water circulation temperature of 55oC at outlets [and inlets to TMVs] shall be maintained.

2.13.2 DHW Generator OperationDHW generators in high risk premises such as healthcare are to be run 24 hours per day, 7 days per week, and the domestic hot water circulation pump kept running. Should it be necessary for interrupted operation or shut-down over night, then the DHW Generator should be allowed to maintain its water storage temperature and the domestic hot water pump should be started up to ensure full temperature through-out the distribution system for at least one hour prior to occupation of the premises.In other healthcare premises which do not operate through the night then the system will shut down one hour after closure and will come back on line for one hour before re-occupation on the next day.


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2.13.3 Domestic Hot Water Circulation PumpsDomestic hot water circulation pumps should perform in such a way to ensure a minimum water circulation temperature of 55oC throughout the system.Only one domestic hot water distribution pump should be installed near the DHW Generator, and a spare pump kept for immediate replacement in the event of pump failure.Multiple distribution pump arrangement is not prohibited within Trust domestic hot water systems.

It is not permissible to shut down the pumped circulation system. To do so will result in a loss of the required distribution temperatures.

2.13.4 Electric Water HeatersSuch units in the form of:

Instantaneous water heaters (i.e. no storage) Point of use water heater (limited storage between 5-50 litres) Combination water heaters (typical storage capacity between 12 to

150 litres)

The point of use and combination water heaters will operate a storage temperature of 60OC with outlet temperature of at least 55OC and will be subject to the sentinel outlet checks.

2.14 Air Conditioning Plant2.14.1 General

Air conditioning and ventilation plant and duct-work should be inspected at the access point[s] on a quarterly basis for critical ventilation plant and biannually for non critical ventilation plant in order to check cleanliness and general condition. After several years of service, even a correctly filtered system may contain dirt accumulation. It may be necessary to consider cleaning of the system. However, accumulation of dirt in a relatively short period of time is indicative of either:

poor filter arrangement and design; the use of incorrect filters; or failure of the filtration system.

In particularly polluted areas, it may be necessary to consider the installation of high grade final and pre-filters. The quality of filter housing design and in particular the seals are a critical factor in maintaining the efficiency of the filtration system by ensuring that air does not bypass the filter panels.All information on condition, cleanliness etc to be recorded in the plant room log book, with any non-compliance or incidents being identified to the Authorised Person [Water] immediately on identification, and an incident report record form completed.


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2.14.2 Draining Traps and PipeworkA drainage drip tray should be provided, to collect condensation collecting on cooling coils [including the return bends and headers], and for humidifiers, eliminators and, if necessary, heat recovery devices. The drainage drip tray should be constructed of a corrosion resistant material and be so arranged that it will completely drain - i.e. the drain connection should have no up stand in order to prevent 'pooling'. The drainage tray should be large enough to collect all the water produced by the device it serves. Provision should be made to allow for inspection of the drainage tray [i.e. viewing window / access panel]. Any jointing materials used to seal the drainage tray to the duct must be listed in the Water Fittings Directory and must not be capable of supporting bacterial growth. A slope of at least 1:20 in all directions towards the drain outlet position should be incorporated.Drainage drip trays should be connected to a drainage trap assembly which should discharge via a type A air gap as laid down in BS 6281:Part1:1988.The depth of any trap should be at least twice the static pressure head generated by the fan so that the water seal is not 'blown out' during plant start up.A trap need not be directly under the drainage drip tray which it serves, provided that the connecting pipework has a continuous fall. Each trap shall be made of the clear [borosilicate] glass or transparent plastic type in order to show clearly the integral water seal level, and should be fitted with a screw top cap to permit re-filling. The water seal level shall be permanently marked on the trap, to indicate the water seal levels when the fan is operational at its design duty. Each installation should incorporate quick release couplings to facilitate easy removal of the traps.Traps fitted to plant located outside or in unheated plant rooms may require trace heating to prevent freezing damage during the winter period. The trace heating system employed should not raise the temperature of the water in the trap to greater than 5oC. Similarly, it may be necessary to shield the trap from the direct sunlight of mid-summer in order to prevent heat gain and algal growth.The pipework from each trap should be constructed of thermoplastic, copper or stainless steel tube. Stainless steel may be particularly useful in instances where greater mechanical strength is required. The pipework shall have a minimum fall of 1 in 60 in the direction of water flow.Water from each trap should discharge over [at least 15mm gap between pipe and top of tundish] an open tundish connected to a drainage stack via a second trap, or a floor gully.Where the drainage pipework from the tundish outlet, which should be ventilated, discharges to a surface water drainage stack or a dedicated plant drainage stack, then the connection shall be in the form of an easy sweep tee.It may be necessary to employ chlorine or other chemicals in order to clean humidifiers and cooling coils etc. Under such circumstances it is necessary to discharge the plant effluent produced to the foul drainage system.Individual drainage systems should be separate wherever possible.


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2.14.3 HumidifiersThe steam supply connections to the humidifier should be provided with a dirt pocket and trap set installed as close as practicable to the humidifier.The water supply to the steam generating unit shall be designed as if drinking water supply right up to the device. The humidifier chamber should be inspected on a quarterly basis for critical ventilation plant and half yearly for non critical ventilation plant basis this is defined in the plant PPM schedule. Particular attention should be given to any pooling of water. The chamber interior should be clean, and free from any scale or other build-up on the walls. On occasion, cleaning and / or re-lining may need to be carried out by a specialist contractor. Form LEG05 to be completed.

2.14.4 Heater BatteriesInspection of the heater batteries is necessary in order to ensure free air flow and no build up of dirt, scale or other debris. Cooling coils should be examined on a quarterly basis for critical ventilation plant and half yearly for non critical ventilation plant in order to ensure that correct drainage is being achieved, and that there is no pooling of water or development of slime, algae or other deposit. Drainage drip trays should be removed [if possible] and cleaned on a regular basis. Form LEG05 to be completed.

2.14.5 Air Handling Plant InspectionPlant inspection is to be on a quarterly basis for critical ventilation plant and half yearly for non critical ventilation plant basis, and form LEG06 completed.

2.15 Other Air Conditioning Units2.15.1 Portable A/C Units.

From the date that this procedures document was accepted the Trust prohibits the use of such devices within any of the Trust properties. The Trust has prohibited the use of such devices on the grounds that HTM03:01 paragraph 5.28 states ‘units employing an internal water reservoir and wick to promote evaporative cooling must not be used in healthcare premises’. These units also require substantial frequent maintenance which is costly.

2.15.2 Split Units.These units incorporate internal recirculation air filters and a drainage system to remove condensate form the cooling coil. The systems used around the Trust properties are not in continuous use (i.e. 24/7) and a review of the condition of these systems has found that the units only require an inspection and clean every 6 months by an external contractor.


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2.16 Hydrotherapy Pools, Whirlpool Baths and Whirlpool Spas

2.16.1 GeneralHydrotherapy pools, whirlpool baths and whirlpool spas provide conditions which may favour the growth of Legionella. Whirlpool spas are particularly vulnerable because of the recirculation of a relatively small volume of water; careful maintenance and chemical water treatment is needed in order to maintain water quality. A detailed log must be kept detailing the treatment method, filter cleaning and results of tests for pH, free residual halogen and other key parameters.Whirlpool baths employ a single fill for each user, and do not present the same level of risk as spas, provided that the guidance recommended for hot and cold water systems is followed.

2.16.2 GuidanceHydrotherapy pools and spa pools should be operated to the guidance given in the following publications published by the HSE and HPA: ‘Legionnaires’ Disease: Controlling the risks associated with using spa baths’ [HSE Information Sheet] ‘Swimming Pool Water – Treatment and quality standards for pools and

spas' [PWTAG] 'Management of Spa Pools – controlling the risk of infection' [HPA]Copies of these publications should be held in the Estates Department, and used as the primary source of guidance for the management of such pools.All information on condition, cleanliness, servicing and monitoring to be recorded in a pool log book. Non-compliance or incidents to be identified to the Authorised Person [Water] immediately, and the incident report record form completed.

2.17 Other Risk SystemsFurther monitoring requirements for other risk systems should be based on the table section 3.4.

Internal ornamental fountains and features are not permitted within Trust properties. External ornamental fountains and features are the responsibility of building managers / unit managers to monitor and maintain them so as they do not present any hazard to health.

The Authorised Person [Water] must be informed of the existence of all external ornamental fountains and features for inclusion on the ‘Legionellosis Risk – Other Risk Systems Register’.

2.18 Renal Dialysis UnitThe water treatment plant is maintained under contract, reviewed annually by Estates maintenance.

Contractor’s service reports are held on file by the Estates Officer.

Disinfection of each plant is carried out in accordance with the PPM system.

Brine tank salt level and water filters [primary, charcoal, final] are checked accordance with the PPM system.


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2.19 Drinking and Non Drinking Water Systems 2.19.1 Drinking Water Systems.

Domestic hot and cold water systems are considered drinkable. The design of storage systems, pipework, valve arrangements and other fittings used on the system shall be such that they do not allow the contamination of the drinking water systems which could encourage microbial multiplication. These systems shall be configured in accordance with:

Water Supply (Water Fittings) Regulations 1999; BS EN 806 & BS8558. Water Fittings & Materials Directory.

All pipework carrying fluids which are non-drinking will be labelled according to British Standard. This action will assist in avoiding possible cross connections between installations conveying drinking and non-drinking water or water from private supplies.

Lead free materials for formation of capillary joints of domestic water systems must be used.

Vending machines, ice machines, cold water dispensers and high pressure jet hoses must all be fed from a drinking water supply with suitable back flow prevention device installed.

Treatment system used on drinking systems must not cause a breach of the requirements of the Water Supply (Water Quality) Regulations 2000.

Wet fire protection systems i.e. hoses, sprinklers, wet risers must be isolated from any drinking water supply by a method which is permissible by the Water Supply (Water Fittings) Regulations 1999. These supplies when feed from a drinking supply are very rarely used, stagnation occurs and conditions prevail which encourage microbial multiplication.

2.19.2 Non Drinking Water Systems.Rain water, surface runoff water, private water supplies, drainage of foul water, emergency use water tanks (currently there are no such tanks in use across the Trust) are classed as non-drinking water supplies and as such a potential source of pathogenic contamination. All non-drinking water systems should be colour coded or labelled as such.

Emergency use water tanks to be kept isolated from other water systems (drinking and non-drinking), by a suitable means which prevents back flow and microbial contamination. They should be treated regularly using Chlorine tablets to maintain water quality and checked with TVC samples periodically.


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2.20 Water ConditioningA temperature control regime is the method of water treatment used by South West Yorkshire Partnership NHS Foundation Trust as advocated in HTM04:01.

Should an alternative water treatment system regime be sought the onus shall be on the Trust to establish the efficacy of the system in its control of Legionella for each site, this shall be in the form of a trail. The trail will want to establish:

The control level; The ability to achieve the control level; The assurance that the control level will be maintained.


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2.21 Cleaning and DisinfectionWater systems will be cleaned and disinfected under the following circumstances:

System / Service

Circumstance Requiring Cleaning and Disinfection

Frequency

FileSectio

nDomesticcold watertank

New installations and small modification/ additions.

As required B.2

Empty tank re-commissioning. As required CTank temperature exceeds 20oC. As required A.4Tank contains moderate sediment, i.e. a complete covering of the tank base. As required C

Tank contains moderate corrosion. As required CContamination of tank by vermin or vermin faeces.

As required C

Gross organic contamination e.g. large number of dead insects. As required C

Regular programme for high risk healthcare category. Annually C

Regular programme for medium risk healthcare category. Annually C

Regular programme for non-healthcare premises [excluding small tenanted residential properties].

As requiredC

Consultant advice - interpretation of microbiological results As required A.4

Domestic cold waterdistributionsystem

New installations and small modification/ additions. As required B.2Contamination of system by vermin or vermin faeces.

As required A.4

Gross organic contamination e.g. large number of dead insects. As required A.4

Consultant advice - interpretation of microbiological results. As required A.4


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System / Service

Circumstance Requiring Cleaning and Disinfection

Frequency

File Sectio

nDomestic hot watergenerator

New installations and modifications / additions. As required BDHW Generator falls below 45oC. As required AEmpty DHW Generator re-commissioning. As required CContamination of header tank by vermin or vermin faeces. As required A

Regular programme [excluding small tenanted residential properties]. Annually A

Consultant advice - interpretation of microbiological results. As required A

Domestic hot waterdistributionsystem

New installations and modifications / additions. As required BContamination of system by vermin or vermin faeces. As required A

Consultant advice – interpretation of microbiological results. As required A

Air handlingunit

Contamination by vermin or vermin faeces. As required AGross organic contamination e.g. large number of dead insects. As required A

Chiller battery, drip trays, humidifiers and drainage pipework.

Quarterly*Biannually*

*CC

* Critical ventilation plant** Non critical ventilation plant


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SECTION 3: TECHNICAL PROCEDURES3.1 Domestic Cold Water Systems3.1.1 Tank Cleaning Procedure

Members of staff either of the Trust, or contract staff shall not be permitted to enter any water storage system [i.e. tank, DHW Generator, AHU] if they are suffering or have recently suffered from any gastric or other communicable illness, or a condition which may result in their increased susceptibility to legionellosis. It is the responsibility of the individual to inform their Authorised Person [Water] immediately if applicable.

All tanks are classified as drinking water tanks.The Supervising Officer shall notify all users of the proposed line of action, and of any disruption or modification to service. The Supervising Officer being the individual Authorised for the management of the task in question. The pre-maintenance authorisation record will be completed prior to any works commencing.All equipment and tools to be employed during the cleaning and disinfection process must be dedicated only to this task - this will include hire equipment. All equipment should be disinfected in a high concentration of chlorine solution prior to commencement of the process.

3.1.1.1 The Process Steps [Free Residual Chlorine]:[a] Isolate and shut down the cold water storage tank and remove the

cover or inspection hatch. The operator shall display warning labels in and around the plant room stating chlorination in progress;

[b] The tank shall be examined visually for signs of corrosion [if applicable], debris and biological growth. The water storage temperature and any such defects identified are recorded for report to the Estates department.

[c] The relevant water authority must be informed before dumping the tank contents. The relevant water authority will need to be informed of the volume to be discharged, any further quantities of chlorinated water to be dumped as a result of tank cleaning should be included. It may be necessary to neutralise the chlorine with sodium thiosulphate before dumping.

[d] Tank cleaning shall be performed using non-abrasive cleaning materials;

[e] Protective clothing, footwear, face goggles and masks are to be employed. These items must be specific to the task of cleaning and chlorination, and must not have been used for other activities;

[f] Where tanks are to be painted, only paints or coatings and materials that are recognised and approved by the WRAS and detailed in "The Water Fittings and Materials Directory" shall be employed. The specification for any such product must be submitted to the Senior Operations Manager and the Authorised Person [Water] for their approval prior to use;

[g] Details of all cleaning and painting materials shall be listed on the cold water tank inspection record form LEG07;


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[h] On completion of the cleaning / painting exercise, and after the necessary paint maturing period [if required], the tank shall be thoroughly flushed and washed out with water, refilled to the tanks normal working level and dosed to a level of 50mg/l of free residual chlorine. The tank shall be left to stand for a minimum period of one [1] hour. During this period the level of free chlorine shall be monitored and maintained at 50 mg/l to ensure adequate disinfection of the tank;

[i] On completion of the tank chlorination period, the tank contents shall be discharged as previously detailed in section [c]. The tank is then refilled to its normal operating level with fresh water. The free chlorine level in the tank water shall be monitored until it matches that of the incoming water supply;

[j] On completion of this exercise the tank shall be put back into service immediately, and water samples taken for analysis – Water samples should be taken from the mains supply (the control sample) and from the tank using sterile bacteriological techniques for deposit and examination at a UKAS accredited laboratory. The analysis shall include:Full Bacteriological

ExaminationUnit of measure Acceptable

parameterTotal coliforms / 100ml 0E coli / 100ml 0Colony Count @ 2 days (+/-4hrs) @ 37oC

/ ml No abnormal change*

* It is worth noting that colony counts can vary significantly between regions and seasons. The benefit of such data is the comparison for any indication of seasonal change and longer term changes in the general bacteriological quality of the water.

[k] On receipt of analysis results, these shall be submitted to the Authorised Person [Water] and the Infection Control Team. The Infection Control Consultant may be required to aid with the interpretation of the results, and the identification of remedial actions if necessary. The Infection Control Team shall certify if the water is of a drinking water quality.

[l] On completion of the tank cleaning or inspection exercise, it is recommended that details be entered onto a tank cleaning record label to be posted on or adjacent to the tank. Such a label must be robust, and able to withstand contact with water;

(m) Details of findings, actions taken and test results are to be entered onto the Domestic Cold Water Storage Tank Cleaning Record Form LEG07. Chlorination Certificates are to be obtained and held in file LEG07.

Any defects shall be reported immediately to the Authorised Person [Water].Once a system has been filled, the Trust and / or its Contractors will not drain that system unless full disinfection is to be undertaken. Before the tank can be brought into service the Infection Control Team must certify the water as being of drinking water quality. The only exception is in the case of an emergency and with the consent of the Authorised Person [Water], acting on the advice of the Infection Control team.


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3.1.2 Cold water tank contamination.This procedure is to be implemented if cold water tanks [domestic hot water header tanks or cold water outlet supply tanks] are found to be contaminated due to an occurrence of backflow or cross connection of drinking and non-drinking water systems.

For back flow contamination, this may sometimes be suggested initially, when water at greater than 20oC is supplied by cold water outlets, which normally supply water at a temperature of less than 20oC. The temperature of the relevant storage tank should be taken, and the following procedure followed if necessary.

Examples of back flow failures which may be responsible for tepid cold water [greater than 20oC]:

Mixing valve failure causing back feeding - non return valves are recommended.

Domestic hot water system venting over the tank. Failure of the primary heating coil.

Back flow failure which may be the cause for the tepid cold water [greater than 20oC]:

High ambient temperature and heat gain - may be accentuated by poor ventilation, glass windows above tanks, lack of or poor insulation.

Cross connection of a drinking and non-drinking supply i.e. rain water / surface runoff water system, private water supply or drainage of foul water, such occurrences may not be so obvious to tell at the outlet. Such an occurrence is more likely to be due to an error whilst completing remedial works or installation works.

3.1.2.1 Procedure for actioning tank contamination[a] The person identifying, or receiving report of a contamination occurrence

must notify the Authorised Person [Water] as soon as the problem is identified a Competent Person will be assigned to deal with the occurrence;

[b] The reason for failure must be identified and rectified as soon as possible;[c] Where the occurrence is due to a back flow issue. The Competent Person

shall verify the problem by taking the water temperature of the appropriate cold water storage tank. If the cold water storage temperature is greater than 20oC, the temperature of the incoming mains cold water should be taken; If the incoming water is 19oC or greater, and the tank water is no

greater than 2oC higher, no actions are necessary. If, the incoming water exceeds 25oC [the Authorised Person [Water] will contact the Water Supplier];

If the water temperature in the tank is greater than 2oC higher than the incoming water supply, the following actions should be implemented;

If the reason for warm water is found to be due to ingress of hot water [i.e. from DHW system or similar source], the Competent Person shall:

[I] Inform the users of the failed system that they must not draw off any cold water [and hot water if a single domestic hot water header] from the affected system until further notice;

[II] Disinfect the tank and distribution system in accordance with the tank cleaning/disinfection procedure;


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[III] The tank shall be brought back into service, as detailed in the tank cleaning/disinfection procedure;

[IV] The users shall be informed that the system is back in operation; [V] The Competent Person shall complete a Trust Incident Report Form

and filed in section A.4.

[d] If the occurrence of the warm water is identified as heat gain to the tank (no back flow or cross contamination), drain the tank contents and clean if necessary. A permanent solution, such as ventilation for the plant room or reducing the water storage volume must be implemented;

[e] If the occurrence is due to cross connection (this procedure also includes domestic hot water) the Competent Person shall verify the problem by confirming where the cross connection has occurred and the extent of the problem to the domestic distribution system. The reason for the cross connection shall also be identified, this may be due to:

Poor or incorrect labelling of the drinking and non-drinking water systems;

A lack of training or awareness in identification of drinking and non-drinking water systems of the person who completed work which resulted in the cross connection.

The Competent Person shall:

[I] Inform the users of the failed system that they must not draw off any cold water [and hot water if a single domestic hot water header] from the affected system until further notice;

[II] Disinfect the tank and distribution system in accordance with the tank cleaning/disinfection procedure;

[III] The tank shall be brought back into service, as detailed in the tank cleaning/disinfection procedure;

[IV] The users shall be informed that the system is back in operation; [V] Complete a Trust Incident Report Form and filed in section A.4.


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3.1.3 Loss of Incoming Mains Cold Water SupplyThis procedure must be followed in order to minimise risk to patients, staff and the public if any of the following occurs:

A cold water main bursts. Unplanned loss of supply. Contamination of cold water main. Suspected contamination of cold water main.

3.1.3.1 Procedure for dealing with the loss of incoming mains cold water supplyHospital/Site representative to inform Estates following preliminary investigation to confirm validity of problem.

Estates Management Representative to inform the following Departments: Health Protection Agency [HPA] -

Telephone: 01132 840606Out of hours - Telephone: as above.

Yorkshire Water Control Centre -Telephone: 0845 124 2424 (24 hours)

In the event of a burst it is the intention to use Yorkshire Water to carry out any repairs (telephone numbers as above). It should be noted that they will be working in the capacity of a Contractor to the Trust and as such they will require an appropriate Estates’ order number. Yorkshire Water will endeavour to undertake sampling on completion of repair under the direction of the Health Protection Agency.

ANY DECISION TO PUT SITES ON BOIL NOTICES OR BOTTLED WATER WILL BE MADE FOLLOWING A RISK ASSESSMENT CARRIED OUT BY THE HPA AND YORKSHIRE WATER.FOLLOWING CONSULTATION BETWEEN ALL PARTIES -

The HPA will inform the Authorised Person [Water] and the Building Manager of the results of the risk assessment and action to be taken.

The Authorised Person [Water] will be responsible for informing on-site staff of any precautions that need to be taken and keeping staff informed of developments.

The Authorised Person [Water] is to inform the local Fire Authority of any disruption to main water supply as well as any restrictions to the service roads caused by excavation works.

Conclusion

In order for the procedure to be effective it is important that continuous liaison is maintained between all parties. Incident Record form shall be completed stating full details and filed in section A.4


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3.2 Domestic Hot Water [DHW]3.2.1 DHW Generator Flushing

Each DHW generator should be flushed quarterly through its drain valve by opening the drain valve three [3] times, each time for a three [3] minute period. Precautions to be taken to minimise the release of any aerosol (i.e. direct to drain for hoses/fixed pipes).

DHW generator flushing should be carried out after temperature checks on the DHW generator and system have been completed. The DHW generator blow down record sheet and DHW generator monthly temperature record sheet should be completed and returned to the Authorised Person [Water].

3.2.2 DHW Generator MaintenanceThe cleaning procedure for DHW generator is as follows:[a] The DHW generator will be taken off line by isolating the service valves;[b] The DHW generator will be heated up until the contents have reached

70oC and held at this temperature for a period of at least one [1] hour;[c] The DHW generator will be drained. The inspection hatch will be

removed. The drain down time is recorded and a photo of the internal condition is to be taken and held with the record sheet;

The DHW Generator will be drained with the hose pipe outlet discharging below water level i.e. into a container of clean water.

[d] The DHW Generator will then be hosed out to remove any debris, scale or other deposit. Care will be taken to ensure that aerosols are kept to a minimum;

If the DHW generator does not have an inspection hatch, the pipework at the top of the vessel should be disconnected to allow the insertion of a high pressure water hose (fed from a drinking supply) to allow debris to be washed down off internal surfaces;

[e] The internal and external condition of the DHW Generator and pipework should be examined, any defects should be reported immediately to the Authorised Person [Water]. The safety valve should be checked, overhauled and re-set as necessary including temperature, altitude and pressure gauges to be checked;

[f] The DHW Generator can then be re-constructed, ensuring that only materials and compounds approved in the Water Fittings and Materials Directory are employed;

[g] On completion of DHW generator assembly, the following sequence must be undertaken:[I] Refill with cold water;[II] Drain the DHW Generator;[III] Refill with cold water, leave cold feed valve open;[IV] Run DHW generator at a temperature of 70oC for at least one [1]

hour. Test the operation of a high limit cut out system if fitted. Check the temperature of the DHW generator at the top and bottom with a touch thermometer;

[V] Allow the system to cool down to the operating temperature and put the system back on line immediately.

[VI] Adjust any controls as necessary;[VII] Complete DHW internal inspection record form.


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3.2.3 De-stratification ChecksDomestic hot water storage vessels should be subject to water temperature stratification checks on a bi-annual basis [i.e. every two years] for each DHW Generator. These checks should extend over a period of seven [7] days using a logging device. Logging should also be used where de-stratification pumps have been fitted to establish that such a pump will ensure that the water temperature at the base of the vessel achieves 50oC through the day and for at least one hour in the day achieve 60oC. All logging records will be held on file section C.Logging of DHW Generator temperatures is not undertaken in small domestic combi boiler which are single pipe water systems.

3.2.4 Domestic Hot Water Temperature Less Than 45oCThis procedure must be employed following a reduction of domestic hot water temperature to below 45oC for any reason.Such temperature reductions can result from system failures such as:

Primary heat source failure; DHW Generator water temperature controls failure; Domestic hot water distribution pump failure; System shut down for modification or repair; Poor circulation/pump failure; Blender passing cold water into the hot water system.

The procedure should be applied as follows:

Circumstance ActionTemperature under performance. Commence Legionella testing. Upgrade

the system to avoid future under performance. Full thermal disinfection.

Routine shutdown for refurbishment / upgrade, involving an outage of < 6 hours.OrMinor failure, involving and outage of < 6 hours.

Pasteurise hot water vessel only.

Major failure e.g. steam failure or power failure, resulting in an outage of >6 hours.

For power failure follow reset procedure. Full thermal disinfection of hot water vessel & system.


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3.2.4.1 Procedure for dealing with Domestic Hot Water <45oC

[a] In the event of a reduction in domestic hot water temperature to less than 45oC, the Authorised Person [Water] be notified immediately. It may be wise to fit the DHW generator with an alarm system. This should be relatively easy to achieve for vessels on a BMS system. The reason for failure must be identified and rectified as soon as possible;

[b] The Competent Person shall notify the users on the failed system that they must not draw off any hot water from the affected services until further notice;

[c] The user shall ensure that their staff members are aware of the situation, and that in turn shall prevent patients from using affected services;

[d] Thermal disinfection shall be carried out by raising the domestic hot water temperature of the contents of the DHW generator to 70oC, and then circulating this water throughout the affected distribution system for at least one [1] hour. Each tap or appliance should be run in sequence until full temperature is achieved [this should be measured]. To be effective the temperature in the DHW generator should be high enough to ensure that all distribution outlets receive water at a temperature of greater than 60oC. Ensure return flow to the DHW generator is a minimum of 60oC;

Care must be taken not to exhaust the DHW generator during this operation.

[e] The users shall be informed that the system is back in operation;

[g] The Competent Person shall complete an Incident Report Form and filed in section A.4, with an entry made into the relevant Plant Room Log Book;

NB – where hot water vessels are fitted with a de-stratification pump, the pump shall be running whilst thermal disinfection is taking place. This shall be stopped when the outlets are flushed.

The temperatures shall be maintained 24 hours / day seven days a week.

A minimum domestic hot water circulation temperature of 55oC at outlets [and inlets to TMVs] shall be maintained.


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3.3 Outlet Management3.3.1 Showers

This section does not apply to showers in small domestic properties which are the responsibility of tenants.

Showers are run daily as part of the daily cleaning procedure, including regular use as part of normal operation on the dept./ward.

The heads, roses and hoses of showers will be subject to quarterly clean and descale.

It is recognised that point-of-use shower head filters to 0.2um do not eradicate Legionella and risk seeding other parts of the system. Generally they will not be continually used in the long term. In all cases the Infection Control Officer [Water] will determine the necessity of such filters.

3.3.2 Thermostatic Mixing Valves [TMVs]Shall be operated in accordance with the temperatures outlined in 1.2.1.2.

All TMVs shall be checked every 6 months, where pre. TMV and outlet temperatures are checked including a failsafe check [LEG43].

On an annual basis each TMV will be subject a strip down and overhaul including temperature and failsafe check [LEG47].

3.3.3 Little Used Outlets*Normal daily operation on the dept. /ward by staff and patients of outlets and the daily cleaning procedure of outlets are considered regular use for an outlet.

Outlets which are rarely used (less than twice a week) should preferably be removed, or run twice a week for a 3 [three] minute period each occasion.

A memo is to be issued to all department heads outline their responsibility for ensuring daily use of all outlets through normal operational use by staff and


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patients and cleaning is be implemented. Where this is not the case the memo further advises the department head that alternative options to be taken to manage the risk of reducing stagnant water in the system will include placing the outlet on a twice weekly flushing programme including the completion of record form LEG26. OR, the department head must request the removal of the outlets and associated pipework and provide funding for the task to be completed.

* Outlets include the following types: showers, baths, wash hand basins, sinks, WCs, sluices, bidets, taps.

3.3.4 Flexible Pipe InstallationsWhen completing an installation all fittings will be made with fixed tails direct to the outlet. Flexible tails for installations shall only be used when fixed tail installation is not possible on the following appliances: Hi – Lo bath / wash hand basins, washing machines and dishwashers. When flexible tails have been installed then a check valve shall also be fitted pre flexible tail.

3.3.5 Safe Purging of Stagnant WaterStagnant water may potentially contain large numbers of legionellae. In order to avoid the risk of legionellosis, precautions are taken to avoid the creation of aerosols and to avoid the exposure of people to any unavoidable aerosols.The specific precautions may vary according to the particular circumstances, but typically include:-

Running a hose from the outlet into a container of clean water; Running hoses directly into a drain cover; Running fire hoses at a distance from occupied buildings; Closing windows and air conditioning intakes where aerosols are

created outdoors; Wearing respiratory protective equipment [remember this does not

protect nearby members of the public and others who are not wearing masks].

Care should be taken to avoid the possibility of back siphonage into mains water supplies.

3.3.6 High Pressure HosesThese units create considerable aerosol and as previously mentioned the use of such devices should be avoided. Where this is not possible then the water supply to such units must be from a drinking water supply and have a suitable air gap (i.e. the hose end of the device must not be inserted in a body of water whilst in or out of use) to prevent back siphonage.

3.3.7 Anti-Ligature TapsAnti-ligature taps include the following types:

infra red, tactile, push non-concussive.

These taps are installed for anti-ligature purposes. These types of taps bring with them water saving economies, which could impact on the turnover / through put of water being reduced when compared to a regular turn on / turn off tap. To ensure adequate through put of water from these taps each run time should be programmed for a minimum of thirty seconds


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whilst having the highest turnover possible (ideally turning over 6 litres of water in a minute).

As part of the cleaning regime the anti ligature taps outlet and shower head outlets are sprayed with a disinfectant solution (typically Milton solution) once a week. These fittings require specialist tools to remove the diffusers, the once a week spray of the outlets will assist with reducing any potential build up of dirt and contamination within the fittings. This process involves a contact time of 2 minutes on the outlet followed by 3 minute flush.

3.3.8 The Safe Operation of Mains Fed Chilled Drinking Water Units / Vending Machines / Ice Machines.

Mains fed chilled drinking water units, vending machines and ice machines should be used regularly on a daily basis.

Where it is suspected such a device has not been operated for periods greater than one week it should be discharged with the spray head under water to prevent the release of aerosols.

If the device is not required they should be isolated from use and removed. The supply feed pipe work will also be removed and cut back to the T joint of the main supply.

The installation of such devices should be from a drinking water supply, the water supply to the unit will not exceed 3 metres from a high use outlet.

Each cold water dispenser will:

1 The suppler / installer will provide a risk assessment and a work method prior to any installation.

2 Estates will be notified of the planned installation and they will then provide a connection for the suppler / installer of the device to connect too. The water supply to the device will not exceed 3 metres from a high use outlet.

3 The supply feed to the device shall not be exposed to heat sources i.e. heat exhaust vent at the rear of the device / radiator.

4 A chlorination certificate for each device installed will have to be supplied by the suppler / installer.

5 If a ward / dept. require such a device they will have responsibility to ensure a maintenance contract is in place.


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3.4 Maintenance Checks for Other Water SystemsBelow is a short check list for other systems that may cause risk of Legionella breeding and dispersion. If any of these systems are present, then a more comprehensive maintenance and testing regime and records will need to be created.

System/Service Task Frequency

File Sectio

nUltrasonic humidifiers/foggers and water misting systems

If equipment fitted with UV lights, check to ensure effectiveness of lamp [check to see if within working life] and clean filters

Six monthly or according to manufacturer’s instructions

To be defined

as req’d

Ensure automatic purging of residual water is functioning

As part of machinery shut down

To be defined

as req’d

Clean and disinfect all wetted parts

As indicated by risk assessment

To be defined

as req’d

Sampling for LegionellaAs indicated by risk assessment

To be defined

as req’d

Spray humidifiers, air washers and wet scrubbers

Clean and disinfect spray humidifiers / air washers and make-up tanks including all wetted surfaces, descaling as necessary

Six monthlyTo be

defined as

req’d

Confirm the operation of non-chemical water treatment [if present]

WeeklyTo be

defined as

req’dWater softeners

Clean and disinfect resin and brine tank – check with manufacturer what chemicals can be used to disinfect resin bed

As recommended by manufacturer C

Emergency showers and eye wash sprays

Flush through and purge to drain Weekly C

Sprinkler, wet riser and hose reel systems

When witnessing tests of sprinkler blow down, wet risers and hose reels ensure that there is minimum risk of exposure to aerosols

As directedTo be

defined as

req’d

Spa baths Check filters – sand filters should be backwashed daily Daily Users

Check water treatment – pools should be continuously treated with an oxidising biocide

Three times daily Users


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Clean and disinfect entire system Weekly Users


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3.4.1 StrainersStrainers should be positioned so as they are accessible, they should be cleaned, maintained and disinfected on a regular basis.

3.4.2 Cleaning Water Systems within BuildingsInstallations within buildings - All visible debris and scale shall be removed from the cistern. The cistern and distribution pipework shall be filled with clean water and then drained until empty of all water. The cistern shall then be filled with water again and the supply closed. A measured quantity of Sodium Hypochlorite solution of known strength shall be added to the water in the tank in order to give a free residual chlorine concentration of 50mg/l [ppm] in the water. The cistern shall be left to stand for one [1] hour, this being the minimum time period for existing cistern, ideally, it should be left for sixteen [16] hours for new installations. After this time period, each draw-off point shall be successively opened working progressively away from the cistern. Each tap and draw-off point shall be closed when the water discharge begins to smell of chlorine. The cistern shall not be allowed to become empty during this exercise. If necessary it shall be refilled and chlorinated as above. The cistern and pipes shall remain charged with chlorinated water for a further one [1] hour.

On completion of this period, the tap furthest from the tank shall be opened and the level of free residual chlorine in the water discharged from this tap shall be measured. If the concentration of free residual chlorine is less than 30 mg/l [30ppm] the disinfection process shall be repeated.

Distribution systems fed directly off the mains water supply shall have a chemical injection point fitted by others, then thoroughly flushed out with clean water until the free residual chlorine concentrations measured at the taps are no greater than that present in the supplier's mains water.

On completion of the cleaning exercise, a certificate of cleaning and chlorination shall be issued stating that the system has been cleaned and chlorinated in accordance with BS 8558 & BS EN 806.

It should be noted that in areas which are in use, the time scales detailed about maybe unachievable. As such any variations in time scales shall be agreed on site between the Contractor and Supervising Officer.

Full tank cleaning procedures are detailed in section 3.1.1.1.

3.4.3 Minor Plumbing AlterationsWhere small alterations or maintenance tasks on water systems have been carried out, then re-commissioning may require no more than thorough flushing of the systems. This can be followed by sampling and analysis of the water if considered necessary by the Supervising Officer, although this is not expected to be required after minor maintenance-related works such as replacement of individual water fittings.


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Disinfection should be completed for: New installations (except private dwellings occupied by a single

family); or Major alterations (except private dwellings occupied by a single

family); or Underground pipework (except localised repairs or insertion of

junctions); or Where it is suspected that contamination may have occurred, e.g.

fouling by sewage, drainage, animals or physical entry by site personnel for interior inspection, painting or repairs; or

Where a system has not been in regular use and not regularly flushed.

All fittings and pipe used on the installation are new and EITHER taken from the manufacturer’s sealed packing just before use, OR pre-chlorinated immediately before use.

Pre-chlorination can be simply achieved by immersing and agitating the fittings for 5 minutes in a 1,000ppm solution of sodium hypochlorite / chlorine dioxide. The COSHH Regulations apply to the use of such solutions at work – a Risk Assessment should be prepared and the appropriate physical precautions must be taken.

To avoid the need to disinfect large systems following relatively minor extensions and alterations, it is recommended that biocide injection points are provided at the point where the new pipework joins the existing system. Biocide injection points take the form of valves, tees and a drain valve or physically removable section of pipe. This enables biocide to be injected into the new section of pipework and circulated or drawn through all new fittings. The removable section must be taken out or the drain valve locked open to prevent any possibility of biocide [a Class 5 fluid] from contaminating the existing fresh water pipework during the disinfection process.

Work should only be undertaken by properly trained, experienced and qualified operatives or Contractors.

3.4.4 Major Plumbing Alterations [including work done through Procure21]On larger installations or where fittings have been re-used and are not new and sealed, the new or altered section of pipework must be cleaned and disinfected by a specialist Contractor using an approved biocide, in accordance with BS EN 806 & BS 8558.

Major extensions and new buildings must be disinfected before being brought into use, and in many cases it may be more convenient for a specialist Contractor to disinfect the entire buildings systems from the tank or source.

Notification must be made to the Water Undertaker in accordance with the Water Supply [Water Fittings] Regulations 1999. Work should only be undertaken by a competent person. A competent person is an ‘approved contractor’ who is accredited to the WRAS ‘Approved Plumbers Scheme’.

3.4.4 Certification


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In accordance with standard conditions of contract, the following Certificates should be obtained from the Contractor before new or significantly altered water systems are accepted at hand-over:

Certificate of Disinfection in accordance with BS EN 806 & BS 8558.Results of water analysis from UKAS-accredited Laboratory.

3.4.5 Notifications

Under the Water Supply [Water Fittings] Regulations 1999 if any of the following are to be done or installed, the Water Undertaking must be notified before commencing the work:

Erection of a building or other structure; Extension or alteration of a water system [other than in a dwelling]; Change of premises use; Installation of any of the following, other than as a like-for-like

replacement; Bath of over 230 litres capacity; Bidet; Shower unit of a specified type; Pump or booster; Reverse osmosis unit; Water treatment unit; RPZ valve or other mechanical device [category 4 or 5 fluids]; Garden watering system; Water system laid outside a building; Construction of a pond or swimming pool;

The Water Undertaking has 10 days to grant or withhold consent and/or impose conditions. After 10 days have expired and nothing has been heard, consent is deemed to have been given.

Approved contractors [members of WRAS ‘Approved Plumbers Scheme’] are exempt from certain of the above, but on completion of the work they must send a copy of the Contractors Certificate to the Water Undertaker.


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APPENDIX 1: LEGIONELLA RECORDS DOCUMENT MAP

FILE(location)

DESCRIPTIONPART CONTENT

AAP [Water]

Office

MANAGEMENT FILE1 Letters of appointment2 Policy & Procedures

1. Current2. Development document [work in progress]

3 Management and Communication1. Audit reports2. Minutes of management review meetings3. Communications e.g. emails to and from service providers

4 1. Incident Report Forms2. Microbiological / Legionella sample results

5 Contracts6 Competence

1. External Contractors2. Internal Training

BAP [Water]

Office

RISK ASSESSMENT AND SCHEMATICS1 Current Risk Assessment2 Risk minimisation scheme and evidence of works completed3 Current Site Schematics

C(Schematics / Drawing

office)

INDIVIDUAL PROPERTY FILELEG48 DHW generator blow down record sheet QuarterlyLEG45 DHW generator monthly temperature record sheet MonthlyLEG28 DHW generator internal inspection sheet AnnuallyLEG01 DHW plate heat exchanger strip down AnnuallyLEG29 DHW calorifier insurance inspection sheet Every 2 yearsLEG02 DHW generator de-stratification checks record sheet Every 2 yearsLEG37 Incoming mains water temperature record sheet Every 6 mthsLEG32 Tank inspection record sheet Every 6 mthsLEG07 Cold water tank pre maintenance authorisation sheet and cleaning

record sheetAs necessary

LEG39 Sentinel outlet monthly temperature [mixed and non-mixed] monitoring record sheet

Monthly

LEG04 20% Representative tap temperatures record sheet AnnualLEG26 Outlet flushing – Little used outlet / Vacant areas (<60 days) record

sheet2x Weekly

LEG41 Shower head & hose clean and descale record sheet QuarterlyLEG08 Outside connections record sheet AnnuallyLEG09 Inside connections record sheet AnnuallyLEG11 Ward / Dept. indefinite closure record sheet As necessaryLEG12 New TMV installation record sheet As necessaryLEG43 TMV / shower maintenance record sheet Every 6 mthsLEG47 TMV / shower maintenance record sheet AnnuallyLEG06 Non critical AHU ventilation supply plant cleaning and inspection

record sheetEvery 6 mths

LEG10 Split unit clean and inspection record sheet Every 6 mthsD

AP [Water] Office

OTHER RECORDS & TECHNICAL REFERENCES1 Templates [letters / forms etc.]2 Guidance Documents3 Other Technical Information

E(Schematics / Drawing

office)

ARCHIVE FILEN/A Previous documents e.g. Procedures manuals and letters of appointment.


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APPENDIX 2: RECORD SHEETS

Procedur INCIDENT REPORT RECORD SHEETMaintenance & Operational Procedures for control of Legionella, water hygiene, ‘safe’ hot water, cold water, drinking water and non drinking water. [Oct-2012 – version 1.05]

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e:Frequency:

As necessary Acceptance date:

Oct’12

File Ref: A.4 Next review date:

Oct’14

Property: Location:

System: Docket No:An ‘incident report form’ is used to record a non-compliant situation that has been discovered, either as part of routine monitoring and maintenance or as a result of a hot line call. The incident report form is an audit trail for ensuring all non-compliant situations are dealt with and closed down satisfactorily.

Nature of fault:

Fault Reported By: Department:Action taken:

Competent Person

Name: Signature: Date:

Authorised Person [Water]


Additional docket numbers issued:


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Procedure:

NON ROUTINE MICROBIOLOGICAL / LEGIONELLA SAMPLE RESULTS RECORD SHEET

Frequency:


Oct’12

File Ref: A.4 [page 1of 4] Next review date:

Oct’14

Sample results should be reviewed against the parameters detailed below and then attached to this form and filed in A.4.

Any action necessary needs to be recorded on an Incident Report and filed in A.4.

Please return this completed record sheet to the Authorised Person [Water].Highlight the type of sample result being reported on this form from the choice below.

MICROBIOLOGICAL LEGIONELLA

Reason for MICROBIOLOGICAL sample having been taken…… (delete as applicable)1) One week after handover of a new building/water system.2) Taste or odour or sustained discolouration

Reason for LEGIONELLA sample having been taken…….. (delete as applicable)1) Failure in treatment regime (temperature)2) Outbreak suspected3) Sample from specialist high risk user areas

Location of outlet

Unique Sample ID reference

Type of water(DHW / CWS)

Results attached to record sheet(Yes / No)

Results reviewed by (name)

Results acceptable(Yes / No)*

Action Taken(where results do not comply with the action regime table (overleaf) record the action you took to try and resolve and set up incident report form)

CONTROL MAINS COLD

I, the undersigned, have completed the works outlined above:Competent Person





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Procedure:


Frequency:


Oct’12

File Ref: A.4 [page 2 of 4] Next review date:

Oct’14

Sampling ProcedureSAMPLING PROCEDURE

Samples only to be taken using an un-tampered sterile bottle. Single use disposable gloves are to be worn. A new pair will be worn for each

sample taken and disposed of immediately after the sample has been taken. The disposable gloves shall be kept in their original supplied packaging until the time when they are required [ensure the user is not sensitive to the disposable gloves supplied].



o Sample taps are disinfected before being sampled. Disinfection methods by using a 1 in 10 dilution of a commercial grade sodium hypochlorite solution (containing in the range 12% to 14% available chlorine Sodium hypochlorite solution.

o The outlet shall be disinfected in accordance with BS7592:2008.o Flaming method is not to be used.

When taking samples the bottle is held in one hand and the bottle cap removed with the other hand, ensuring the top or the neck of the bottle doesn’t come in contact with hands or the outlet.

Do not rinse out the bottle or the cap. Do not place the cap on any surface, it should remain in your fingers. Turn on the water so a gentle stream is flow, fill the bottle leaving a small air

gap at the top, do not allow to over flow. Replace bottle cap immediately taking care not to touch the top or the neck of

the bottle. The bottle should then be placed into a cool, dark, insulated container for

transporting to the laboratory (see below for more detail). Sample delivery times to the laboratory:

o Legionella samples within 24 hours but no more than 48 hours.o Bacteriological samples should be as soon as possible, not exceeding

24 hours if stored correctly (see below). Transportation of sample:

o Legionella samples should be protected from heat and sunlight, kept at ambient temperature not exceeding 20OC. Hot and cold samples to be packaged separately.

o Bacteriological should be kept in dark, insulated storage containers which are regularly disinfected. The temperature of the sample should


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be kept at 2-8OC. If during sampling accidental contamination is suspect the sample should be

discarded and a fresh sterile bottle used to take a new sample.

Procedure:


Frequency:


Oct’12

File Ref: A.4 [page 3of 4] Next review date:

Oct’14

Occupant Susceptibility

Category:Sample

Required: Where from:Count above which action

required:Required action:



Elderly)


numbers)

Representative outlets as agreed

with the consultant (specify)





TVC = >100E.coli = >0

Coliforms = >0



Healthcare areas)


numbers)

1 MCW1 of each Tank


>100

>1000




1 MCW1 of each Tank


TVC = >100E.coli = >0

Coliforms = >0

a) If limited outlets give TVC counts of >100 = Re-sample at once, and disinfect if repeated again.b) If more than 40% of outlets give TVC counts 100+ disinfect at once, and review procedures.c) If TVC results give counts >500 sample the mains cold


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water unit a clear result is achieved. Then sample the cold water storage tanks, if these results are clean then no further action. If the results are returned positive then clean the cold water storage tank.d) If any outlet returns E.coli or coliforms of >0 disinfect.

Procedure:


Frequency:


Oct’12

File Ref: A.4 [page 4 of 4] Next review date:

Oct’14


Category:Sample



LOW(e.g. staff areas)


numbers)

1 MCW1 of each Tank


>100

>1000




1 MCW1 of each Tank


TVC = >150E.coli = >0

Coliforms = >0

a) If limited outlets give TVC counts of >120 = Re-sample at once, and disinfect if repeated again.b) If more than 40% of outlets give TVC counts 120+ disinfect at once, and review procedures.c) If TVC results give counts >500 sample the mains cold water unit a clear result is achieved. Then sample the cold water storage tanks, if these results are clean then no further action. If the results are returned positive then clean the cold water storage tank.d) If any outlet returns E.coli or coliforms of >0 disinfect.

(*) These are for guidance. The risk assessment will indicate need to disinfect as a combination of factors is to be considered.


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PPM: DHW GENERATOR BLOW DOWNPPM Ref: LEG48 Frequency: Quarterly

Examine valves for leaks, damage and corrosion.Clean and examine gauges and readings for accuracy.Examine controls and settings (60OC min). Clean strainer elements. Operate valves fully.Check operation of shunt pumps.

Safety valves:Examine / operate safety valve. Ensure valve re-seats correctly.

Pumps (Primary heating pumps):Examine differential gauges (if fitted) for correct pump operation. Clean gauge glasses.Examine duty pump for smooth running, for leaks, corrosion or damage to pump, housing, altitude gauges and associated pipework.Examine flexible couplings.Change over duty pump and make similar inspections, operate all valves fully and test for free travel.

Secondary domestic hot water pump: check for smooth running, for leaks, corrosion or damage to pump, housing and associated pipework.

If unvented domestic hot water system, check pressure in expansion vessels and re-pressure as required, check all associated pipework.

Sludge Test:If no sludge or debris noticed on initial draining, stop draining, no further action required.If sludge found, isolate, full drain down, re-fill and pasteurisation.

RECORD SHEET C – LEG48 MUST BE FILLED IN AND RETURNED TO THE AUTHORISED PERSON [WATER]


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Procedure:

DHW GENERATOR BLOW DOWN RECORD SHEET

Frequency:

Quarterly Acceptance date:

Oct’12

File & Form Ref:

C - LEG48[page 1 of 2]

Next review date:

Oct’14

Property: Location:

Date: Time:Item Work Description

Comply(Yes or

No)1 SAFETY CHECK: Before carrying out the procedures detailed below

complete a visual safety check of the area. Any defects should be reported immediately.

2 Before blow down procedure starts record temperatures below (pre).3 Examine valves for leaks, damage and corrosion.

Clean and examine gauges and readings for accuracy.Examine controls and settings (60OC min). Clean strainer elements.Operate valves fully.Check operation of shunt pumps.

4 Examine / operate safety valve. Ensure valve re-seats correctly.5 Examine differential gauges (if fitted) for correct pump operation.

Clean gauge glasses.Examine duty pump for smooth running, for leaks, corrosion or damage to pump, housing, altitude gauges and associated pipework.Examine flexible couplings.Change over duty pump and make similar inspections, operate all valves fully and test for free travel.

6 Secondary domestic hot water pump: check for smooth running, for leaks, corrosion or damage to pump, housing and associated pipework.

7 If unvented domestic hot water system, check pressure in expansion vessels and re-pressure as required, check all associated pipework.

8 Connect a hose pipe to each of the DHW Generator drain cock, where required, and run to a suitable drain position. Open the drain valve three [3] times over a three [3] minute period. The hose from the drain valve is to discharge direct to drain to minimise the release of any aerosol.

9 Once complete, shut off drain cock and disconnect hose pipe. Ensure all water is drained from hose before storing the pipe. If a large volume of debris has been flushed out, thought shall be given to flushing the hose pipe with chlorinated water in the work shop.

10 After blow down procedure record temperatures below (post).11 Clear up all spillages & remove all debris to waste. Scale or such debris

should not be flushed down the plant room drain, it shall be swept into a small area, allowed to dry and then disposed of into the waste skips.

12 Return completed document to the Authorised Person [Water].

Continued overleaf.....


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Procedure:

DHW GENERATOR BLOW DOWN RECORD SHEET

Frequency:

Quarterly Acceptance date:

Oct’12

File & Form Ref:

C - LEG48[page 2 of 2]

Next review date:

Oct’14

Property: Location:

Date: Time:Observations and Comments:

DHW generators online: No. 1. No. 2 No. 3 No. 4 Time

Pre

flu

sh:

Gauge reading (>60 Deg. C)Flow (>60 Deg. C)Return (>50 Deg. C)Cold feed (<20 Deg. C)

Post

flu

sh:

Gauge reading (>60 Deg. C)Flow (>60 Deg. C)Return (>50 Deg. C)Cold feed (<20 Deg. C)

Details of any corrective action taken:






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PPM: DHW GENERATOR MONTHLY TEMPERATURE PPMPPM Ref: LEG45 Frequency: Annual

Carry out temperature checks of DHW generators in accordance with HTM 04-01.

Using digital or non-contact calibrated thermometer for taking all required temperatures. The only gauge reading to be taken is that on the flow to ensure it matches the calibrated thermometer reading.

Check that the temperature is above 60OC for the flow pipe out of the DHW generators.

And is not less than 50OC for the return temperature to the DHW generators.

Manual check to confirm secondary hot water recirculation pumps are operating effectively.

Cold water service into the DHW generators is less than 20OC.

Visually inspect all controls, valves and pipework associated with the appliance and for defects noted please raise job sheets and a copy to be given to Authorised Person [Water]



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Procedure: DHW GENERATOR MONTHLY TEMPERATURE RECORD SHEETFrequency: Monthly Acceptance date: Oct’12File &Form Ref:

C - LEG45 Next review date: Oct’14

Property: Location:

Date: Time:Thermometer No.

Thermometer Calibration No.

System Reference & DHW generator No.

Gauge(>60 Deg.

C)

Flow(>60 Deg.

C)

Return(>50 Deg.

C)

Cold(<20 Deg.

C)

Secondary DHW pump

working OK?

All Acceptabl

e?(Y or N)

YES / NO YES / NOYES / NO YES / NOYES / NO YES / NOYES / NO YES / NOYES / NO YES / NOYES / NO YES / NOYES / NO YES / NOYES / NO YES / NOYES / NO YES / NOYES / NO YES / NOYES / NO YES / NOYES / NO YES / NOYES / NO YES / NOYES / NO YES / NO

Details of any corrective actions taken:







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PPM: DHW GENERATOR INTERNAL INSPECTIONPPM Ref: LEG28 Frequency: Annual

This will involve a drain-down of the calorifier and strip-down of gauges, valves, and safety valve.

Strip down all gauges and re-calibrate.

Strip down safety valve - clean and check, re-assemble and test.

Strip down control valve - examine seats, re-assemble, set and test.

Drain down calorifier, remove examination lids and check internal condition for sludge deposition and corrosion.

Clean all sludge and debris.

Non-return valves:

Clean strainers strip and check non-return valve.

Re-assemble calorifier and fill with mains cold water, re drain, refill.

Domestic hot water must remain isolated during pasteurisation.

Pasteurise the contents by raising the water temperature to 70 deg C or as close as possible and leave to stand for a min of 1 hours.

Allow water temp to fall back to 60 deg C before returning calorifier to service.

Ensure Legionella log book is filled in for each calorifier.

Restore the system to line



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Procedure: DHW GENERATOR INTERNAL INSPECTION RECORD SHEETFrequency: Annual Acceptance date: Oct’12File &Form Ref:


Property: Location:

System Reference:

DHW generatorId. No.:

Date: Time:

TASKCOMPLY

(YES or NO)Gauges working correctly YES / NOExamine controls - working correctly YES / NOIsolation valves operating correctly YES / NOSafety valve operating correctly YES / NOShunt pump operating correctly YES / NOD.H.W. secondary pump operating correctly YES / NOPrimary heating pump operating correctly YES / NOAll pipework & valves in plantroom in good condition YES / NOSafety valve overhaul working correctly YES / NOStrip & inspect heater battery working correctly YES / NOIf un-vented system - expansion vessel pressurised ok YES / NOCheck & strip check valves - working correctly YES / NODrain down time:Cleaned out by [initials]:

Sacrificial rod replaced?

Start up procedure by [initials]:

Yes / No

DHW generator held at 70oC by [initials]:

Hours DHW generator at 70oC:

DHW generator put back in service by [initials]:

Date DHW generator put back in service:

Observation and comments:






PPM: PLATE HEAT EXCHANGER MAINTENANCE PPMMaintenance & Operational Procedures for control of Legionella, water hygiene, ‘safe’ hot water, cold water, drinking water and non drinking water. [Oct-2012 – version 1.05]

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PPM Ref: LEG01 Frequency: Annual

Isolate all electrics and water services to plate and drain down.

Remove bolts and follower (front metal) plate.

Remove stainless steel plates carefully, keep in correct sequence of plates.

Carefully clean each plate 1 by 1 with a soft brush and a suitable detergent (washing up liquid is adequate)

NEVER USE A STEEL BRUSH, SCRAPPER, SAND PAPER OR ANYTHING OF THE LIKE

Rinse with cold water to remove the detergent.

Cleaning must be done carefully so as not to disturb the EPDM rubber gaskets.

If heavy deposits, then submerse in a bath of detergent.

Re-mount plates in same order and position as they were before.

Make sure all bolts are tightened equally attaining equal measurements across the plate at top, middle and bottom.

Refill and test for correct operation and working temperature as to HTM04-01.

Check safety valves and expansion vessel (as per calorifier 12 month check)



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Procedure: PLATE HEAT EXCHANGER MAINTENANCE RECORD SHEETFrequency: Annual Acceptance date: Oct’12File &Form Ref:

C – LEG01 Next review date: Oct’14

Property: Location:

System Reference:

Plate heat exchangerId. No.:

Date: Time:

TASKCOMPLY

(YES or NO)Gauges working correctly YES / NOExamine controls - working correctly YES / NOIsolation valves operating correctly YES / NOSafety valve operating correctly YES / NOShunt pump operating correctly YES / NOD.H.W. secondary pump operating correctly YES / NOPrimary heating pump operating correctly YES / NOAll pipework & valves in plantroom in good condition YES / NOIf un-vented system - expansion vessel pressurised ok YES / NOCheck & strip check valves - working correctly YES / NOUnbolt plates and clean (with detergent and soft brush) YES / NORe-bolt plate in order and tighten equally YES / NORefill and test - all ok YES / NOPlate held at 70oC by [initials]:

Hours the plate was held at 70oC:

Plate put back in service by [initials]:

Date plate put back in service:

Temperatures when put back into service:Flow temperature:Return temperature:Cold water temperatureObservation and comments:







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PPM: CALORIFIER INSURANCE INSPECTIONPPM Ref: LEG29 Frequency: Every 2 years

Carry out maintenance to prepare for insurance inspection of calorifier.

This will involve a drain-down of the calorifier and strip-down of gauges, valves, and safety valve.

Strip down all gauges and re-calibrate.

Strip down safety valve - clean and check, re-assemble and test.

Strip down control valve - examine seats, re-assemble, set and test.

Drain down calorifier, remove examination lids and check internal condition for sludge deposition and corrosion.

Clean all sludge and debris.

Non-return valves:

Clean strainers strip and check non-return valve.

Re-assemble calorifier and fill with mains cold water, re drain, refill.

Domestic hot water must remain isolated during pasteurisation.

Pasteurise the contents by raising the water temperature to 70 deg C or as close as possible and leave to stand for a min of 1 hours.

Allow water temp to fall back to 60 deg C before returning calorifier to service.

Ensure Legionella log book is filled in for each calorifier.

Remove safety valve and overhaul.

Remove heater battery.

Inspect battery, tube plate and cover.

Clean out calorifier shell.

Strip down and all gauges and re-calibrate.



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Procedure: CALORIFIER INSURANCE INSPECTION RECORD SHEETFrequency: Every 2 years Acceptance date: Oct’12File &Form Ref:


Property: Location:

System Reference:

DHW generatorId. No.:

Date: Time:

TASKCOMPLY

(YES or NO)Gauges working correctly YES / NOExamine controls - working correctly YES / NOIsolation valves operating correctly YES / NOSafety valve operating correctly YES / NOShunt pump operating correctly YES / NOD.H.W. secondary pump operating correctly YES / NOPrimary heating pump operating correctly YES / NOSafety valve overhaul working correctly YES / NOStrip and inspect heater battery working correctly YES / NOAll pipework & valves in plantroom in good condition YES / NOSafety valve overhaul working correctly YES / NOStrip & inspect heater battery working correctly YES / NOIf un-vented system - expansion vessel pressurised ok YES / NOCheck & strip check valves - working correctly YES / NODrain down time:Cleaned out by [initials]:Sacrificial rod replaced?Start up procedure by [initials]:

Yes / No

DHW generator held at 70oC by [initials]:

Hours DHW generator at 70oC:

DHW generator put back in service by [initials]:

Date DHW generator put back in service:








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PPM: DHW GENERATOR DE-STRATIFICATION LOGGING PPMPPM Ref: LEG02 Frequency: Every 2 years

Data logger to be installed.

Thermocouple sensors to be fitted to:Flow pipeReturn feed pipeCold feed pipe (pre TMV)Base of DHW generator

Data logger set to capture data over a 7 day period at 5 minute intervals.

The data to be downloaded from logger into spreadsheet for analysis and filtering of data.



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Procedure: DHW GENERATOR DE-STRATIFICATION LOGGING RECORD SHEETFrequency: Every two years Acceptance

date:Oct’12

File & Form Ref:

C – LEG02 Next review date:

Oct’14

Date logging commenced:

System Reference:

DHW generator Id. Nos.

Logging device used (detail S/N):

TASKCOMPLY

(YES or NO)Logging period covered 7 consecutive days? Yes / NoFlow temperature >60OC for 23 hrs & 40 minutes for every 24 hour period logged*?

Yes / No

Base of DHW generator is always 50OC or greater throughout the entire logging period*?

Yes / No

Base of DHW generator achieves 60OC for at least 1 hour in every 24 hour period*?

Yes / No

Hard copy logging data attached including copy of logging analysis report?All logging data should be held in 2.4 of the document management system.

Yes / No

Detail of corrective action taken to address any issues highlighted as a result of the logging exercise:

Observation and comments:* Analysis of data using a spreadsheet programme with autofilters applied will assist in this process.







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PPM: INCOMING MAINS COLD WATER TEMPERATURE RECORD SHEETPPM Ref: LEG37 Frequency: Biannually

Incoming mains.1. Lift manhole cover2. Check and record the temperature of incoming pipework at sensor point.3. Replace manhole cover.

All readings should be less than 20OC.

Where present take water meter readings and record.

Report any reading above 15OC.to a Authorised Person [Water] immediately.

Tools: Manhole keys, Calibrated digital thermometer, Second person to lift and replace manhole covers.

Manhole at entry point in grounds:

RECORD SHEET C – LEG37 MUST BE FILLED IN AND RETURNED TO THE RESPONS AUTHORISED IBLE PERSON [WATER]


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Procedure: INCOMING MAINS COLD WATER TEMPERATURE RECORD SHEETFrequency: Biannually Acceptance

date:Oct’12

File & Form Ref:


Oct’14

Property:Mains Water Manhole Location:

Date: Time:

TASK COMPLY[YES or NO]

Manhole inspection cover securely in place and not damaged or missing?

Yes / No

Manhole clear of debris and water? Yes / NoWater meter intact? Yes / NoMains cold water temperature (must be <20OC)?

........ OCWater meter reading? ....... M3

Manhole inspection cover replaced securely leaving no raised edges / trip hazards?

Yes / No








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PPM: DOMESTIC COLD WATER TANK INSPECTION PPMPPM Ref: LEG32 Frequency: Biannually

Check and record the temperature of;1. Mains incoming cold water temperature - entry point to building.2. The cold water feed3. The surface water of the tank4. The outlet water of the tank must be less than 20OC.5. Visually inspect general condition of tank, also signs of debris / sediment / stagnation.

Ensure all lids and covers are correctly aligned and in place.

Check overflows, warning pipes and vent pipes are not discharging and are free of obstructions.

Lids must be reinstated after work has been completed.

Enter the readings onto the appropriate section of the record sheet.

Report immediately to area facilities officer any abnormal readings.



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Procedure: DOMESTIC COLD WATER TANK INSPECTION RECORD SHEETFrequency: Biannually Acceptance

date:Oct’12

File & Form Ref:


Oct’14

Property: Location:

System Reference:

Tank Id. No.:

Date: Time:Incoming MCW TOC at point of entry to building:

Cold tank incoming MCW TOC:

Cold tank storage TOC:

Cold tank outflow TOC:

Ambient air TOC in tank room:

Ambient air TOC outside:

QUESTION COMPLY[YES or

NO]Tank room access locked? [if applicable] Yes / NoAdequate cover / inspection hatch fitted to tank? Yes / NoCover / inspection hatch secure? Yes / NoInsect screens & filters fitted? (if not record details) Yes / NoInsulation material for tank and pipe is adequate and in place? (if not record details)

Yes / No

External condition ok? Area free from debris / clutter & top of tank to be clear (if not record details).

Yes / No

Internal condition ok? Free from vermin / insects. Note the degree of sediment at % cover (if not record details).

Yes / No

Condition of water? Stagnant or turning over. Is there evidence of sufficient turnover? (if not record details)

Yes / No

Water level ok? Single and multiple linked tanks (if not record details). Yes / NoOperation of ball valve ok? (if not record details) Yes / NoOperation of isolation valves ok? (if not record details) Yes / NoPipework configuration correct (inlet and outlet at opposite ends)? (if not record details)

Yes / No

DHW vent not over drinking water tank? (if not record details) Yes / NoObservation and comments:







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PPM: DOMESTIC COLD WATER TANK CLEANING PPMPPM Ref: LEG07 [page 1 of 2] Frequency: As necessary

Tank cleaning will be undertaken by an approved specialist contractor.

The pre-maintenance authorisation record will need to be completed prior to any works commencing.

[a] Isolate and shut down the cold water storage tank and remove the cover or inspection hatch. The operator shall display warning labels in and around the plant room stating chlorination in progress;

[b] The tank shall be examined visually for signs of corrosion [if applicable], debris and biological growth. The water storage temperature and any such defects identified are recorded for report to the Estates department.

[c] The relevant water authority must be informed before dumping the tank contents. The relevant water authority will need to be informed of the volume to be discharged, any further quantities of chlorinated water to be dumped as a result of tank cleaning should be included. It may be necessary to neutralise the chlorine with sodium thiosulphate before dumping.

[d] Tank cleaning shall be performed using non-abrasive cleaning materials;[e] Protective clothing, footwear, face goggles and masks are to be employed.

These items must be specific to the task of cleaning and chlorination, and must not have been used for other activities;

[f] Where tanks are to be painted, only paints or coatings and materials that are recognised and approved by the WRc and detailed in "The Water Fittings and Materials Directory" shall be employed. The specification for any such product must be submitted to the Authorised Person or their nominated deputies for their approval prior to use;

[g] Details of all cleaning and painting materials shall be listed on the cold water tank inspection record form LEG07;

[h] On completion of the cleaning / painting exercise, and after the necessary paint maturing period [if required], the tank shall be thoroughly flushed and washed out with water, refilled to the tanks normal working level and dosed to a level of 50mg/l of free residual chlorine. The tank shall be left to stand for a minimum period of one [1] hour. During this period the level of free chlorine shall be monitored and maintained at 50 mg/l;

[i] On completion of the tank chlorination period, the tank contents shall be discharged as previously detailed in section [c]. The tank is then refilled to its normal operating level with fresh water. The free chlorine level in the tank water shall be monitored until it matches that of the incoming water supply;


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PPM: DOMESTIC COLD WATER TANK CLEANING PPMPPM Ref: LEG07 [page 2 of 2] Frequency: As necessary

The analysis shall include:Full Bacteriological

ExaminationUnit of measure Acceptable

parameterTotal coliforms / 100ml 0E coli / 100ml 0Colony Count @ 2

days (+/-4hrs) @ 37oC/ ml No abnormal

change** It is worth noting that colony counts can vary significantly between regions and seasons. The benefit of such data is the comparison for any indication of seasonal change and longer term changes in the general bacteriological quality of the water.

[k] On receipt of analysis results, these shall be submitted to the Authorised Person [Water] and the Infection Control Team. The Infection Control Consultant may be required to aid with the interpretation of the results, and the identification of remedial actions if necessary. The Infection Control Team shall certify if the water is of a drinking water quality.

[l] On completion of the tank cleaning or inspection exercise, it is recommended that details be entered onto a tank cleaning record label to be posted on or adjacent to the tank. Such a label must be robust, and able to withstand contact with water;

(n) Details of findings, actions taken and test results are to be entered onto the Domestic Cold Water Storage Tank Cleaning Record Form LEG07. Chlorination Certificates are to be obtained and held in file LEG07.

Any defects shall be reported immediately to the Authorised person or nominated deputies.

Once a system has been filled, the Trust and / or its Contractors will not drain that system unless full disinfection is to be undertaken. Before the tank can be brought into service the Infection Control Team must certify the water as being of drinking water quality. The only exception is in the case of an emergency and with the consent of the Authorised Person [Water], acting on the advice of the Infection Control team.



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Procedure: DOMESTIC COLD WATER TANK MAINTENANCE RECORD SHEETFrequency: As necessary Acceptance

date:Oct’12

File Ref: C - LEG07 [page 1 of 6] Next review date:

Oct’14

Property: Location:

System Reference:

Tank Id. No.:

Date: Time:Permit issued by:

Permits issued to:

Company carrying out work:

PRE MAINTENANCE AUTHORISATION RECORD

QUESTION NAME DATE TIME

Site manager notified of works?

Tank taken out of service and isolated by:

Contractor’s isolation locks fitted?

Warning labels displayed?

Chlorination periods? DURATION:Details of cleaning materials used:

Tank put back into service:

Permit cancelled by: I, the undersigned, have completed the works outlined above:

Competent Person






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Procedure: DOMESTIC COLD WATER TANK MAINTENANCE RECORD SHEETFrequency: As necessary Acceptance

date:Oct’12

File & Form Ref:

C - LEG07 [page 2 of 6] Next review date:

Oct’14

Property: Location:

System Reference:

Tank Id. No.:

Date: Time:Incoming MCW TOC at point of entry to building:

Cold tank incoming MCW TOC:

Cold tank storage TOC:

Cold tank outflow TOC:

Ambient air TOC in tank room:

Ambient air TOC outside:

QUESTION COMPLY[YES or

NO]Tank room access locked? [if applicable] Yes / NoAdequate cover / inspection hatch fitted to tank? Yes / NoCover / inspection hatch secure? Yes / NoInsect screens & filters fitted? (if not record details) Yes / NoInsulation material for tank and pipe is adequate and in place? (if not record details)

Yes / No

External condition ok? Area free from debris / clutter & top of tank to be clear (if not record details).

Yes / No

Internal condition ok? Free from vermin / insects. Note the degree of sediment at % cover (if not record details).

Yes / No

Condition of water? Stagnant or turning over. Is there evidence of sufficient turnover? (if not record details)

Yes / No

Water level ok? Single and multiple linked tanks (if not record details). Yes / NoOperation of ball valve ok? (if not record details) Yes / NoOperation of isolation valves ok? (if not record details) Yes / NoPipework configuration correct (inlet and outlet at opposite ends)? (if not record details)

Yes / No

DHW vent not over drinking water tank? (if not record details) Yes / NoPre chlorination to 50 PPM? Yes / NoPost chlorination @ 50 PPM? 1 hour minimum contact time. Yes / NoPost chlorination mains water TVC sample taken?* (See sampling procedure on page 2).

Yes / No

Post chlorination tank water TVC sample taken?* (See sampling procedure on page 2).

Yes / No

* The Authorised Person [Water] has responsibility for reviewing sample results. These should be reviewed against the parameters detailed on pages 4 & 5 of this form, the results should then attached to this form and filed in C. Any action necessary needs to be recorded on an Incident Report and filed in A.Details of cleaning /painting materials used:

I, the undersigned, have completed the works outlined above:


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Competent Person



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Procedure:

DOMESTIC COLD WATER TANK MAINTENANCE RECORD SHEET

Frequency:

Annually Acceptance date:

Oct’12

File & Form Ref:


Oct’14

Sampling ProcedureSAMPLING PROCEDURE

Samples only to be taken using an un-tampered sterile bottle. Single use disposable gloves are to be worn. A new pair will be worn for each

sample taken and disposed of immediately after the sample has been taken. The disposable gloves shall be kept in their original supplied packaging until the time when they are required [ensure the user is not sensitive to the disposable gloves supplied].



o Sample taps are disinfected before being sampled. Disinfection methods by using a 1 in 10 dilution of a commercial grade sodium hypochlorite solution (containing in the range 12% to 14% available chlorine Sodium hypochlorite solution.

o The outlet shall be disinfected in accordance with BS7592:2008.o Flaming method is not to be used.

When taking samples the bottle is held in one hand and the bottle cap removed with the other hand, ensuring the top or the neck of the bottle doesn’t come in contact with hands or the outlet.

Do not rinse out the bottle or the cap. Do not place the cap on any surface, it should remain in your fingers. Turn on the water so a gentle stream is flow, fill the bottle leaving a small air

gap at the top, do not allow to over flow. Replace bottle cap immediately taking care not to touch the top or the neck

of the bottle. The bottle should then be placed into a cool, dark, insulated container for

transporting to the laboratory (see below for more detail). Sample delivery times to the laboratory:

o Legionella samples within 24 hours but no more than 48 hours.o Bacteriological samples should be as soon as possible, not exceeding

24 hours if stored correctly (see below). Transportation of sample:

o Legionella samples should be protected from heat and sunlight, kept at ambient temperature not exceeding 20OC. Hot and cold samples to be packaged separately.

o Bacteriological should be kept in dark, insulated storage containers which are regularly disinfected. The temperature of the sample should be kept at 2-8OC.

If during sampling accidental contamination is suspect the sample should be discarded and a fresh sterile bottle used to take a new sample.


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Procedure:

DOMESTIC COLD WATER TANK MAINTENANCE RECORD SHEET

Frequency:

Annually Acceptance date:

Oct’12

File & Form Ref:


Oct’14

The Authoised Person [Water] has responsibility for reviewing sample results. These should be reviewed against the parameters detailed on pages 4 & 5 of this form, the results should then attached to this form and filed in 3.2. Where results do not comply with the action regime table record your action in the ‘ACTION TAKEN’ column when trying resolve and set up an incident report form.

Location of outlet

Unique Sample ID reference

Type of water(DHW / CWS)

Results attached to record sheet(Yes / No)

Results reviewed by (name)

Results acceptable(Yes / No)*

Action Taken

CONTROL MAINS COLD

I, the undersigned, have reviewed the sample results and attached them to this form. Any action necessary needs to be recorded on an Incident Report and filed in 1.5:Competent Person





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Procedure: DOMESTIC COLD WATER TANK MAINTENANCE RECORD SHEETFrequency: Annually Acceptance

date:Oct’12

File & Form Ref:


Oct’14


Category:Sample





Elderly)


numbers)







TVC = >100E.coli = >0

Coliforms = >0



Healthcare areas)


numbers)

1 MCW1 of each Tank


>100

>1000




1 MCW1 of each Tank


TVC = >100E.coli = >0

Coliforms = >0

a) If limited outlets give TVC counts of >100 = Re-sample at once, and disinfect if repeated again.b) If more than 40% of outlets give TVC counts 100+ disinfect at once, and review procedures.c) If TVC results give counts >500 sample the mains cold water unit a clear result is achieved. Then sample the


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cold water storage tanks, if these results are clean then no further action. If the results are returned positive then clean the cold water storage tank.d) If any outlet returns E.coli or coliforms of >0 disinfect.

Procedure: DOMESTIC COLD WATER TANK MAINTENANCE RECORD SHEETFrequency: Annually Acceptance

date:Oct’12

File & Form Ref:


Oct’14


Category:Sample



LOW(e.g. staff areas)


numbers)

1 MCW1 of each Tank


>100

>1000




1 MCW1 of each Tank


TVC = >150E.coli = >0

Coliforms = >0

a) If limited outlets give TVC counts of >120 = Re-sample at once, and disinfect if repeated again.b) If more than 40% of outlets give TVC counts 120+ disinfect at once, and review procedures.c) If TVC results give counts >500 sample the mains cold water unit a clear result is achieved. Then sample the cold water storage tanks, if these results are clean then no further action. If the results are returned positive then clean the cold water storage tank.d) If any outlet returns E.coli or coliforms of >0 disinfect.

(*) These are for guidance. The risk assessment will indicate need to disinfect as a combination of factors is to be considered.


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PPM: SENTINEL OUTLET MONTHLY TEMPERATURE [MIXED & NON MIXED]PPM Ref: C – LEG39 Frequency: Monthly

1) Check the incoming mains cold water temperature to ensure it is <20OC.

2) Run the cold water outlet at a moderate flow rate (do not fully open) and take the temperature to ensure it is <20OC within two minutes of running the outlet.

3) Run the hot water outlet at a moderate flow rate (do not fully open) and take the temperature to ensure it is at least 55OC within one minute of running the outlet. Those outlets with an electric water heater such as:

Instantaneous water heaters (i.e. no storage) Point of use water heater (limited storage between 5-50 litres) Combination water heaters (typical storage capacity between 12 to 150 litres)

With the point of use and combination water type heaters they will operate a storage temperature of 60OC with outlet temperature of at least 55OC. When taking the temperature of these units record the maximum temperature within the minute NB – running these units for a minute and then taking the temperature will exhaust the unit and give false readings.

4) Record all temperatures achieved. Where temperatures do not comply within the required time then keep the tap running and record the time taken to achieve the temperature (up to a maximum of 5 minutes).

5) Where temperatures do not comply investigate possible reasons why. Record your actions in the ‘ACTIONS TAKEN’ column with trying to resolve the non compliance.

NB – If a hot water outlet is supplied by an electric water heater then record the maximum temperature achieved.



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Procedure: SENTINEL OUTLET MONTHLY TEMPERATURE [MIXED & NON MIXED] RECORD SHEET

Frequency: Monthly Acceptance date:

Oct’12

File Ref: C – LEG39 [page 1 of 1] Next review date:

Oct’14

Details of the whereabouts of all sentinel outlets for each property can be found in Appendix 3 of the Procedures manual.

Property:System Reference:

Date & Time:Thermometer Serial No:

Location details Outlet detailsTOCcomply?[Yes or No]

Action TakenWard / Dept. & Room No.

Test PointNo.

WHB/SINK/ BATH etc.

HotT OC

Cold T OC

Mixer Fitted(tick)

Mixer T OC

Pipe TOC prior to mixer.






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PPM: 20% REPRESENTATIVE OUTLET TEMPERATURE MONITORINGPPM Ref: C – LEG04 Frequency: Monthly

1) Run the cold water outlet at a moderate flow rate (do not fully open) and take the temperature to ensure it is <20OC within two minutes of running the outlet.

2) Run the hot water outlet at a moderate flow rate (do not fully open) and take the temperature to ensure it is at least 55OC within one minute of running the outlet.

3) If the outlet is fitted with a TMV then take : The cold inlet temperature. The hot inlet temperature. The mixed outlet temperature.

4) Record all temperatures achieved. Where temperatures do not comply within the required time then keep the tap running and record the time taken to achieve the temperature (up to a maximum of 5 minutes).

5) Where temperatures do not comply investigate possible reasons why. Record your actions in the ‘ACTIONS TAKEN’ column with trying to resolve the non compliance.

NB – If a hot water outlet is supplied by an electric water heater then record the maximum temperature achieved.



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Procedure: 20% REPRESENTATIVE OUTLET TEMPERATURE MONITORING RECORD SHEETFrequency: Annual Acceptance

date:Oct’12

File Ref: C - LEG04 Next review date:

Oct’14

Property:System Reference:

Thermometer No.

Thermometer Calibration no.

Location details Outlet detailsTOC

Comply?[Yes or

No]

Action TakenWard / Dept. RoomNo.

WHB/SINK/ BATH etc.

HotT OC

Cold T OC

Mixer Fitted(tick)

Mixer T OC

Inlet TOC prior to mixer (hot and cold).

Yes / NoYes / NoYes / NoYes / NoYes / NoYes / NoYes / NoYes / NoYes / NoYes / NoYes / NoYes / NoYes / NoYes / NoYes / NoYes / NoYes / NoYes / NoYes / No

Competent Person






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PPM: OUTLET FLUSHING – LITTLE USED OUTLETS* / VACANT AREAS (<60 DAYS)PPM Ref: C – LEG26 Frequency: Twice Weekly

If outlets are not being used on an occupied dept. / ward for whatever reason e.g. a shower room being used as a store which is not cleaned by Hotel Services then the outlet needs to be flushed twice / week.

If an area e.g. ward is temporarily closed then all outlets in the affected area should be flushed / week.

1) The outlet[s] should be flushed twice a week for at least 3 minutes each time. If outlets have TMVs fitted then the flow of the water should be set to warm. WCs should be flushed.

2) All flushing procedures should be completed whilst trying to minimise the release of aerosol, if an outlet is being flushed without knowledge of when it was last run then the outlet should be flushed completing via the ‘safe purge’ method.

2) Use form C- LEG26 for both of the weekly flushes (Monday & Thursday).

3) The completed record sheet must be return to the Authorised Person [Water].

NB – should you discover any defects with the outlet contact Estates Helpdesk.

* Showers, baths, sinks, wash hand basins, sluice, WCs, tap, sprays etc.



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Procedure: OUTLET FLUSHING – LITTLE USED OUTLETS* / VACANT AREAS (<60 DAYS) FLUSHING RECORD SHEET

Frequency: Twice weekly Acceptance date: Oct’12File Ref: C – LEG26 Next review date: Oct’14

Property: Location:

System ID: Docket No:

OUTLET LOCATION

WEEKLYMONDAY FLUSHDATE &

TIME

WEEKLYMONDAYFLUSH

INITIALS

WEEKLYTHURSDA

YFLUSHDATE &

TIME

WEEKLYTHURSDA

YFLUSH

INTIALS

COMMENTS

* Showers, baths, sinks, wash hand basins, sluice, WCs, tap, sprays etc.I, the undersigned, have completed the works outlined above:

Operative Name: Signature: Date:





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PPM: SHOWER HEAD & HOSE CLEAN AND DESCALEPPM Ref: C – LEG41 Frequency: Quarterly

All correct PPE must be worn.

Disconnect shower head and hose.

Manually descale head, rose and hose.

Refit and flush through with clean water for 5 mins.



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Procedure: SHOWER HEADS & HOSES CLEAN & DESCALE RECORD SHEETFrequency: Quarterly Acceptance date: Oct’12File Ref: C - LEG41 Next review date: Oct’14Property: System ID:

LOCATIONMains

or tank fed?

Dismantled head, rose & hose?

[Yes or No]

Descaled head, rose &

hose?[Yes or

Replaced]

Adjustable spray

head

Refit & flushed

for 5 minutes?

Initial &

Date

MC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / NoMC/TC Yes / No Yes / Replaced Yes / No Yes / No








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PPM: OUTSIDE CONNECTIONSPPM Ref: C – LEG08 Frequency: Annually

The existence of outside connections and their necessity is checked on an annual basis and recorded on form C – LEG08, ensuring that an appropriate back flow prevention device has been installed applicable to the connections usage.

1) Complete external walk around each building, including any internal quad or garden areas to check the existence of any outside taps.

2) Where an outlet is found then record the location on form C – LEG08 and complete each of the questions on the form.



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Procedure: OUTSIDE CONNECTIONS RECORD SHEETFrequency: Annually Acceptance date: Oct’12File Ref: LEG08 Next review date: Oct’14Building: System ID:Thermometer No.

Thermometer Calibration no.

Location Is the outlet secure (tamper proof)?

Is the outlet in good working order?

Adequate protection from weather?

No hoses left attached?

Appears to be in regular use?

RPZ valve installed?

TOC







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PPM: INSIDE CONNECTIONSPPM Ref: C – LEG09 Frequency: Annually

This form is used to identify what inside connections exist on the drinking water system. The types of devices to be identified are: Vending machines with a water supply to them; Chilled cold water dispensers; Ice making machines.

All these devices should have a double check valve fitted to them to prevent back flow. The overall length of the supply pipe(s) from the machine to the next nearest high use outlet should not exceed 3 metres. Finally, the supply pipes to the device should not be subject to heat gain i.e. in contact with or in line with the heat exhaust vent from the device itself.

1) Complete internal walk around each building to check the existence of any such devices.

2) Where such a device is found then record the location on form C – LEG09 and complete each of the questions on the form.



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Procedure:

INSIDE CONNECTIONS RECORD SHEET

Frequency:

Annually Acceptance date: Oct’12

File Ref: LEG09 Next review date: Oct’14Location Type of

connection*Double check valve fitted?

Supply pipe <3meters in length?

Supply not affected from heat gain by vent heat from unit

VM / CD / IM Yes / No Yes / No Yes / NoVM / CD / IM Yes / No Yes / No Yes / NoVM / CD / IM Yes / No Yes / No Yes / NoVM / CD / IM Yes / No Yes / No Yes / NoVM / CD / IM Yes / No Yes / No Yes / NoVM / CD / IM Yes / No Yes / No Yes / NoVM / CD / IM Yes / No Yes / No Yes / NoVM / CD / IM Yes / No Yes / No Yes / NoVM / CD / IM Yes / No Yes / No Yes / NoVM / CD / IM Yes / No Yes / No Yes / NoVM / CD / IM Yes / No Yes / No Yes / NoVM / CD / IM Yes / No Yes / No Yes / NoVM / CD / IM Yes / No Yes / No Yes / NoVM / CD / IM Yes / No Yes / No Yes / NoVM / CD / IM Yes / No Yes / No Yes / NoVM / CD / IM Yes / No Yes / No Yes / No

* VM = Vending machine (plumbed in drinks machine), CD = Chilled water dispenser (plumbed in), IM = Ice Machine.

Observations & Comments:







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PPM: WARD / DEPT. INDEFINATE CLOSUREPPM Ref: C – LEG11 Frequency: As necessary

Where relevant - all water tanks associated with the affected area shall be drained, cleaned and dried out.All pipework and devices shall be drained and where applicable DHW generator [or other storage vessels] shall be opened up, cleaned and left open to the atmosphere.Pipework shall be disconnected from the mains services and capped off, mains cold water services shall be isolated and capped off from the system and all relevant pipework drained.Notices shall be posted throughout the affected area stating that all water services are disconnected.The Estates Department shall be Authorised to ensure that an adequate water seal exists in unused toilets to prevent odours from the foul drain system entering the premises.Adequate records of actions, and amended water service schematic diagrams shall be produced by the Estates Department showing the relevant modifications and disconnections made to the water systems. The Completed Remedial Works Record Sheet C – LEG** shall be used for record keeping purposes.



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Procedure:

WARD / DEPT. INDEFINATE CLOSURE RECORD SHEET

Frequency:


Oct’12

File Ref: C – LEG11 Next review date:

Oct’14

Property: Location:Closure date: Docket No:

Work carried out to disconnect and close down water services:

A modified schematic diagram must accompany this report.Work carried out by:Signature:REOCCUPATION OF THE ABOVE AREADate: Docket No:

Work carried out and detail of modifications:

Chlorination & cleaning completed? Yes / No.







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Procedure: NEW TMV INSTALLATION RECORD SHEETFrequency:


Oct’12

File Ref: C – LEG12 Next review date:

Oct’14

Property: Location:

Room No: Docket No:Description of TMV location:TMV Manufacturerand Type:TMV Asset No.

Work carried:

Approved temperatures for TMVs settings based on activity / area where the TMV is required.Note: All tactile taps/outlet where fitted, to achieve a 6 litres/minute [minimum] throughput, whilst in operationArea/activity Recommended

temperature (°C)

Staff bases, ward, consulting rooms, in-patient areas, out-patient areas and general areas to which staff and visitors may have access.

41

Paediatric bathsGeneral bathsAssisted baths

404346

Showers & Hair-wash facilities 41Bidets 38All sinks, kitchens, pantries, slop sinks 55Staff-only access i.e. Offices 43

TEMPERATURE TEST:1) Set temperature: __________________ Deg. C.

2) Flow temperature hot: __________________ Deg. C. (pipe temperature prior to mixer valve

3) Flow temperature cold: __________________ Deg. C. (pipe temperature prior to mixer valve)

FAIL TEST:Simulate a cold water supply failure by slowly turning off the cold supply.

1) Valve closes down: Yes / No

2) Time to shut off: _______________ seconds.I, the undersigned, have completed the works outlined above:Competent Person





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PPM: TMV / SHOWER MAINTENANCEPPM Ref: C – LEG43 Frequency: Every 6 months

For all TMV's carry out servicing using manufacturers service kit.

Inspect check valves & filters (clean or replace as necessary).

Re-instate and calibrate to correct temperatures detailed below:Area/activity Recommende

dtemperature (°C)


41


404346


Thermostatic mixing control valves (hot supply to be 55OC or greater, cold supply to be less than 20 OC to teat mixing valve fail safe).

Procedure for fail safe:1) Run the hot tap and check the water temperature with a calibrated thermometer

is at correct for the type outlet (according the table detailed above) (+ or - 1oC) with the control at hot.

2) Shut off the cold supply to the valve and ensure that the discharge shuts off within 2/3 seconds.

3) If a failure occurs:a. strip down,b. service,c. repaird. retest.

4) Reinstate the supply.

5) If fail safe does not work valves must be stripped & overhauled (parts replace as necessary).

6) The valves must then be commissioned to D08 specification.



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Procedure: TMV / SHOWER MAINTENANCEFrequency: Every 6 months Acceptance

date:31/03/10


31/03/11

Property: Location:

Docket No:Thermometer Serial No.:

BIANNUAL TEST:Check operation of mixer, set temperature (according to guide table below) and simulate fail test (see description below). Record the pipe temperature pre TMV, record the mixed outlet (hot & cold) and NON MIXED outlet (hot & cold) temperatures. Report any defects below.Fail Test:A simulated cold water fail test shall be carried out following the overhaul or calibration of each valve by SLOWLY turning off the cold water to the valve and observing the water flow stopping.A simulated hot water fail test shall be carried out following the overhaul or calibration of each valve by SLOWLY turning off the hot water to the valve and observing the water flow stopping.

Approved temperatures for TMVs settings based on activity / area where the TMV is required.Area/activity Recommended

temperature (°C)Staff bases, ward, consulting rooms, in-patient areas, out-patient areas and general areas to which staff and visitors may have access. 41Paediatric bathsGeneral bathsAssisted baths

404346

Showers & Hair-wash facilities 41Bidets 38All sinks, kitchens, pantries, slop sinks 55Staff-only access i.e. Offices 43*Where difficulty is experienced setting TMV temperature then a variation of +/- 1OC is acceptable.

Continued overleaf....


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Procedure: TMV / SHOWER MAINTENANCE File Ref:

C – LEG43 [page 2 of 2]

Ward / Dept. Room No.

Test done(tick)

Outlet dataTOC OK?

Fail Test OK

Initial & Date

6 M Ann WHB/Sink/ Bath/Shower etc.

TMV fitted (tick)

TMV Asset No.

Valve Type

Pre TMV TOC

Hot TOC

Cold TOC

Yes No

Comments:

I, the undersigned, have completed the works outlined above:Tradesperson Name: Signature: Date:


Name: Signature:

Additional Docket Numbers Issued:


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*** PLEASE PHOTOCOPY THIS FORM AS NECESSARY TO ACCOMMODATE ALL TMVs FOUND ON THE WARD / DEPARTMENT ***


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PPM: TMV / SHOWER MAINTENANCEPPM Ref: C – LEG47 Frequency: Annually

For all TMV's carry out servicing using manufacturers service kit.

Inspect, check, strip and overhaul all valves & filters (clean or replace as necessary).

Re-instate and calibrate to correct temperatures detailed below:Area/activity Recommende

dtemperature (°C)


41


404346


Thermostatic mixing control valves (hot supply to be 55oC or greater, cold supply to be less than 20 OC to teat mixing valve fail safe).

Procedure for fail safe:1) Run the hot tap and check the water temperature with a calibrated thermometer

is at correct for the type outlet (according the table detailed above) (+ or - 1oC) with the control at hot.

2) Shut off the cold supply to the valve and ensure that the discharge shuts off within 2/3 seconds.

3) If a failure occurs:a. strip down,b. service,c. repaird. retest.

4) Reinstate the supply.

5) If fail safe does not work valves must be stripped & overhauled again (parts replace as necessary).

6) The valves must then be commissioned to D08 specification.



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Procedure: TMV / SHOWER MAINTENANCEFrequency: Annual Acceptance

date:31/03/10


31/03/11

Property: Location:

Docket No:Thermometer Serial No.:

ANNUAL TEST:Check operation of mixer, set temperature (according to guide table below) and simulate fail test (see description below). Record the pipe temperature pre TMV, record the mixed outlet (hot & cold) and NON MIXED outlet (hot & cold) temperatures. Report any defects below.Strip down and overhaul. Fit new seals and parts as required. Reset temperature (according to guide table below) and simulate fail test (see description below). Record mixed outlet and NON MIXED outlet temperatures. Report any defects below.Fail Test:A simulated cold water fail test shall be carried out following the overhaul or calibration of each valve by SLOWLY turning off the cold water to the valve and observing the water flow stopping.A simulated hot water fail test shall be carried out following the overhaul or calibration of each valve by SLOWLY turning off the hot water to the valve and observing the water flow stopping.

Approved temperatures for TMVs settings based on activity / area where the TMV is required.Area/activity Recommended

temperature (°C)Staff bases, ward, consulting rooms, in-patient areas, out-patient areas and general areas to which staff and visitors may have access. 41Paediatric bathsGeneral bathsAssisted baths

404346

Showers & Hair-wash facilities 41Bidets 38All sinks, kitchens, pantries, slop sinks 55Staff-only access i.e. Offices 43*Where difficulty is experienced setting TMV temperature then a variation of +/- 1OC is acceptable.

Continued overleaf....


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Procedure: TMV / SHOWER MAINTENANCE File Ref:

C – LEG47 [page 2 of 2]

Ward / Dept. Room No.

Test done(tick)

Outlet dataTOC OK?

Fail Test OK

Initial & Date

6 M Ann WHB/Sink/ Bath/Shower etc.

TMV fitted (tick)

TMV Asset No.

Valve Type

PreTMVTOC

Hot TOC

Cold TOC

Yes No

Comments:

I, the undersigned, have completed the works outlined above:Competent Person Name: Signature: Date:


Name: Signature:

Additional Docket Numbers Issued:


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*** PLEASE PHOTOCOPY THIS FORM AS NECESSARY TO ACCOMMODATE ALL TMVs FOUND ON THE WARD / DEPARTMENT ***


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PPM: NON CRITICAL SERVICES VENTILATION SUPPLY PLANT CLEANING AND INSPECTION

PPM Ref: C – LEG06 Frequency: Every 6 monthsComplete an inspection of each AHU as detailed below and complete record form C – LEG06.

General check on overall condition of unit. Repair/renovate as required.Check all thermal and acoustic linings.Examine for any undue noise, vibration, lack of performance, etc. and report findings.Check flexible connections, examine security of retaining bands, replace damaged sections if necessary.Check security brackets and associated supports.Check tension, alignment and condition of fan drive belts; re-tension / renew (as a complete set) as required.Check condition of motor/drive casings and motor vent grilles and clean as required.Check electrical connections.Check safety guards are secure.

All procedures must comply with the Health and Safety at Work etc Act and COSHH regulations;

a) Notify all persons working in those areas served by the plant to be disinfected;

b) Switch off all ventilation systems containing devices to be disinfected;c) Close the plant isolating dampers;d) Open and remove the inspection covers/access doors on both sides of the

devices;e) Spray all internal surfaces of the humidifier section or cooler battery/cooling

coil with a 5 ppm chlorine solution until all surfaces are thoroughly wetted, also flood drip trays and drainage system with the same solution and allow to stand for a minimum of two hours;

f) Spray all internal surfaces of the humidifier and cooler battery/cooling coil with sufficient clean water to remove all traces of the chlorine solution from the device, its drip trays and drainage system;

g) Restore the plant to normal operation;h) If any suspicion arises as to the possible contamination of the system then

the microbiologist should be requested to take swab tests from all drain trays and cooler battery/cooling coil tubes and fins;

As an alternative to steps (f) and (g) detailed above, the surfaces may be steam cleaned;



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Procedure:

NON CRITICAL SERVICES VENTILATION SUPPLY PLANT CLEANING AND INSPECTION RECORD SHEET

Frequency:

Every 6 months Acceptance date:

Oct’12

File Ref: LEG06 [page 1 of 2] Next review date:

Oct’14

Building: Location:System ID:

Docket No:

Item Work description Y N1 Inform departments concerned that plant is to be shut down.2 Is the plant room secure (locked)3 Is the ventilation plant running upon entering the plant room?

4Is the ventilation plant adequate labelled with a unique reference / asset / plant No.

5 Is the ventilation plant safely accessible for inspection and maintenance?

6

Is the overall exterior condition of the ventilation plant in a good condition?If ‘NO’ detail reasons…

7 Are the principle ducts of the ventilation plant lagged?8 Are any pipework leading to the ventilation plant adequately lagged?

9Is the position of the air intake for the ventilation plant clear of any dirty, debris, build up of rubbish and unobstructed?

10

Is the position of the air intake for the ventilation plant at least 10 meters away from any extract or foul air from other sources i.e. gas scavenging outlets?

11Do internal lights work? (Replace faulty bulbs once isolated). Report other faults.

12 Electrically isolate power supplies to the plant and make safe and lock off.13 Do motorised dampers close on plant shut down?14 Remove access panels to all areas to be cleaned including batteries.

15With inspection plates open, using a torch, are the fins of heating and chilling batteries are clear and free of lint, dust & debris?

16

Having completed a visually inspect all heating & chilling batteries is there any sign of damage and leakage, including all local control valves etc?If possible rectify the fault, otherwise report to Authorised Person [Water] for further attention.

17Vacuum out all ducts of the ventilation plant, heating and chilling batteries including the areas around them?

18 Are the internal drainage drip trays stainless steel?

19Are the internal drainage drip trays fully accessible or capable of being removed for cleaning?

20Are the internal drainage drip trays below chillers and/or humidifiers clear of any corrosion of water i.e. there is no ponding of water?

21Are the duct work drainage drip trays clear and free flowing? (clear if required).

22

Spray chiller batteries and surrounding ductwork, drain areas and any other low points in the local ductwork with hypochlorite solution at 5ppm dilution.Ensure that both sides of the batteries are treated.

23 If a humidifier is present is it in operation?

24

Remove all glass traps, clean with a ‘bottle brush’, fill trap with clean water and then refit unit.Ensure there is an air break of at least 15mm between the trap and tundish.

25

Visually inspect and check mechanical drive to the plant including pulley belts, pulley tensions (where fitted) and bearings. Adjust and lubricate as required.


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26 Are manometers oil levels acceptable (fill with oil if required)

27Are all guards in a good condition and secure?Refix guards where necessary.

28Is the condition of associated control valves and pipework in good order?If ‘NO’ detail reasons…

Procedure:

NON CRITICAL SERVICES VENTILATION SUPPLY PLANT CLEANING AND INSPECTION RECORD SHEET

Frequency:

Every 6 months Acceptance date:

Oct’12

File Ref: LEG06 [page 2 of 2] Next review date:

Oct’14

Item Work Description Y N

29

Are all filters in place and in good condition (i.e. not need replacing).Where filters may need replace then report to Authorised Person [Water] for actioning.

30 Are the main filters correctly fitted with no air-bypass.31 Are all pre-filters correctly fitted with no air-bypass.32 Refit all access panels and check seals are intact.

33Remove locks and then restart plant, inspect the plant for any odd noises, leakage from any pipework, valve gear.

34 Did the ventilation plant restart satisfactorily?35 Record pre-filter differential pressure in comments box below.36 Record main filter differential pressure in comments box below.37 Record manometers readings in comments box below.38 Did the automatic change over operate satisfactorily?39 Have you cleaned down plant and wipe up all spills caused by your work.

40Have you cleared away any debris and redundant materials from the plant room.

41

Enter any comments or any faults and defects along with any actions you have taken in the area below and complete the box below.Sign and return this document to the Authorised Person [Water].

Observations & additional comments.

Pre Filter Diff:

Main Filter Diff:

Manometer:







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PPM: Split Unit Clean & InspectionPPM Ref: C – LEG10 Frequency: Quarterly

SPLIT UNIT INSPECTION AND CLEANING IS UNDER TAKEN BY ASPECIALIST CONTRACTOR.

CONTRACTOR TO ISSUE THEIR COMPLETE JOB SHEET FOR EACH UNITAND THESE MUST BE FILED IN C – LEG10.


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PPM: WATER SOFTENER CHECKSPPM Ref: C – LEG24 Frequency: Every 6 months

WATER SOFTENER INSPECTION AND CLEANING IS UNDER TAKEN BY ASPECIALIST CONTRACTOR.

CONTRACTOR TO ISSUE THEIR COMPLETE JOB SHEET FOR EACH UNITAND THESE MUST BE FILED IN C – LEG24


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Procedure:

MODIFICATION AND WORK RECORD SHEET TO RECTIFY DEFECTS FOUND [EITHER FROM THE LEGIONELLOSIS RISK ASSESSMENT OR AS FOUND / OCCUR]

Frequency:


Oct’12

File Ref: N/A Next review date:

Oct’14

Property: Location:

System ID: Docket No:

A description of the condition experienced:

Proposed solution / recommendation:

Target date for completion:

Who’s Authorised for completing:

Nature of work carried out:






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APPENDIX 3: SENTINEL OUTLET MONITORING POINTS


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Britannia WorksReference Point

Location Type of outletNearest Furthest

Hot Cold Hot ColdT1 T2 T3

The Dales UnitReference Point



Dean CloughReference Point



Elmfield HouseReference Point



Enfield DownReference Point



Folley HallReference Point




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Hebden Bridge Health CentreReference Point



Rushbrook HouseReference Point



Castleford and Normanton District HospitalReference Point



Field Head HospitalReference Point



Beckside CourtReference Point



Dewsbury Hospital – Ward 19Reference Point




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Ravensleigh CottageReference Point



Revensleigh Resource UnitReference Point



Castleford Health CentreReference Point



Crofton Health CentreReference Point



Eastmore Health CentreReference Point



Featherstone Health CentreReference Point




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Flemming Court (Unit 2)Reference Point



International HouseReference Point



Newstead HouseReference Point



Normanton Health CentreReference Point



21 North GateReference Point



Ossett Health VillageReference Point



Pontefract Health CentreReference Point



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POW Hospice -Macmillan ServiceReference Point



Stanley Health CentreReference Point



Star HouseReference Point



South Elmsall Health CentreReference Point



White Rose HouseReference Point




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Wrenthorpe Health CentreReference Point



Airedale ClinicReference Point



Baghill HouseReference Point



Beech HouseReference Point



Bridge HouseReference Point



Castle LodgeReference Point




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Cherry TreesReference Point



Flemming Court (Unit 11)Reference Point



Garden Street ClinicReference Point



Horbury Health CentreReference Point



Hyde ParkReference Point



Manygates ClinicReference Point




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Margaret StreetReference Point



Ossett Health CentreReference Point



Peterson RoadReference Point



Pomfret LodgeReference Point



The PoplarsReference Point



Receipt & DistributionReference Point




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Southmoor HospitalReference Point



South Kirby Health CentreReference Point



The SycamoresReference Point



WalkergateReference Point



170A Sheffield RoadReference Point



Birdwell ClinicReference Point




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Cudworth ClinicReference Point



Darfield Health CentreReference Point



DartonReference Point



Hilder HouseReference Point



Kendray HospitalReference Point



Keresforth CentreReference Point




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Lundwood Littleworth CourtReference Point



Mapplewell Health CentreReference Point



Mount Vernon HospitalReference Point



New StreetReference Point



Mount Vernon HospitalReference Point



Penistone ClinicReference Point




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Priory Day UnitReference Point



Regent StreetReference Point



Royston ClinicReference Point



29-31 Queens RoadReference Point



Silkstone Health CentreReference Point



StairfootReference Point




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Wombwell Health CentreReference Point




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APPENDIX 4: NEW SYSTEM DESIGN CHECK LIST


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Checklist for New Water System Designs or AlterationsFile: 9.1

Scheme: Project Manager: Yes/No Signed / DatedDesign and construction1 If altering an existing system, has the impact of the alterations on the

system been assessed to ensure safe systems at all times?2 If you are fitting a new system, do any of the materials or fittings used in

the water systems support the growth of micro-organisms?3 Are low corrosion materials used?4 Do materials and designs comply with the “Water Supply (Water Fittings),

Regulations”? Certificate to be supplied confirming so.5 If fitted, are thermostatic mixing valves [TMV’s] sited as close as possible

to the point of use?6 Are all water temperatures at all outlets greater than 55OC for hot water

outlets (un-mixed, or to the mixer) within 1 minute of running and at under 20C for cold water outlets within 2 minutes of running? Contractor to confirm.

7 Are all new systems commissioned appropriately in accordance with L8, HTM04:01 and BSRIA & CIBSE best practice? Is stagnation avoided? Contractor to certificate to this extent.

Design and construction: Cold water system8 Are low use outlets installed upstream of higher use outlets?9 Has cold water storage been assessed and minimised, i.e. holds enough

for a day’s use only?10 Is piping insulated and kept away from heat sources [where possible]?11 Is the cold water tank:

[i] fitted with a cover and insect screen[s] on any pipework open to the atmosphere?

[ii] located in a cool place and protected from extremes of temperature?[iii] accessible?

Design and construction: Hot water system12 Does the DHW generator storage capacity meet normal daily fluctuations

in hot water use while maintaining a supply temperature of at least 60oC at the DHW generator and at least 55oC at the outlets and 50oC at the return? **

13 Are the hot water distribution pipes insulated?14 If more than one DHW generator is used, are they connected in parallel?15 Does the DHW generator have the following fitted:

[i] a drain valve?[ii] a temperature gauge on the inlet and outlet?[iii] an access panel?[vi] Non return valves fitted to the cold and return feeds?[v] Are fitted with de-stratification loops which are set to run for 1 hr each day.

16 Have all return legs on the hot water circulation system been monitored to ensure they remain above 500C at all times?

17 Are all domestic hot water full temperature legs less than 1m in length.All reduced temperature legs less than 2m in length?


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** Each system to be logged to ensure that under prolonged continuous demand to ensure the following: the flow temperature does not fall below 60OC on more than two occasions for more than 20 minutes

in one 24 hour period. The return temperature should always be greater than 50OC. There should never be more than 10 Deg. Difference between flow and return temperatures. Cold water temperature should be <20OC.

The system must achieve 60OC for at least one hour each day throughout the entire vessel (base to top).


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APPENDIX 5: BIBLIOGRAPHY

Health Technical Memorandum 04-01: The control of Legionella, hygiene, ‘safe’ hot water, cold water and drinking water systems. Parts A and B :2006

Health Technical Memorandum 03-01: Specialised ventilation for healthcare premises. Parts A and B :2006

Approved Code of Practice, Legionnaires’ disease: the control of Legionella bacteria in water systems. [L8] :2000

The Health & Social Care Act 2008.

The Health and Safety at Work etc Act :1974

The Management of Health and Safety at Work Regulations: 1999

The Water Supply [Water Fittings] Regulations :1999

The Water Supply [Water Quality] Regulations :2000

The Control of Substances Hazardous to Health Regulations :2002

The Building Regulations :1992

BS 7592:2008 - Description: Sampling for Legionella bacteria in water systems. Code of practice

Water Regulations Advisory Scheme [WRAS] Water Regulations Guide :2004

Water Regulations Advisory Scheme [WRAS] Water Fittings and Materials Guide :2005

HSE - INDG253 - Controlling Legionella in nursing and residential care homes


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