Legionella Risk Assessment - Our Lady of Lourdes Catholic ... · Legionella Risk Assessment RA/LCS/939 Site: The views and guidance expressed in this report are given in good faith

LCS/RA 939/Holy Cross Primary

Legionella Risk Assessment RA/LCS/939

The views and guidance expressed in this report are given in good faith and are based on LCSs interpretation of HSE ACOP L8 2001 – Legionnaires’ disease The Control of Legionella Bacteria in Water Systems, HSG274 Part 2 Hot & Cold Water Systems, HTM 04-01, the

scope of the survey and the information made available by the Client.

LCS cannot be held liable for any consequential loss as a result of any actions taken by a third party as a result of this report.

THIS REPORT MAY ONLY BE REPRODUCED OR INTERPRETED IN ITS ENTIRETY

For: Holy Cross Primary Catholic Voluntary Academy

Site: Leen Mills Lane Hucknall Nottingham NG15 8BZ

Surveyor: Brad Harrison Date: 13th April 2015

Assessor: Brad Harrison Date: 13th April 2015


Assessor: Brad Harrison / Brad Harrison Date: 11th September 2014

CONTENTS

1. INTRODUCTION 2.1 LEGAL REQUIREMENTS

2.2 MANAGEMENT PATHWAY STRUCTURE 3.1 GENERAL INFORMATION

3.2 SITE DESCRIPTION 4.0 RISK ASSESSMENT

5.0 COLD WATER SYSTEMS

6.0 HOT WATER SYSTEMS

7.0 MAINS COLD WATER SYSTEMS

8.0 SHOWERS

9.0 HOT AND COLD SERVICE OUTLETS

10.0 MANAGEMENT OF PRECAUTIONS

11.0 REMEDIAL ACTIONS

12.0 CHECKLIST OF PRECAUTIONS

13.0 REFERENCED PGOTOGRAPHS

14.0 SCHEMATIC DRAWINGS

15.0 RISK ASSESSMENT REVIEWS / AUDITS




1. INTRODUCTION

Holy Cross Primary Catholic Voluntary Academy have commissioned Legionella Consultancy Services Ltd to undertake a water management overview and Legionella Risk Assessment to the various domestic water systems at Leen Mills Lanes, Hucknall, Notts. The site survey works were undertaken by Brad Harrison of LCS Ltd Holy Cross Primary Catholic Voluntary Academy are responsible for the Management, Operation and Maintenance of the property and all water services within the building. Water to the buildings is served from the local town mains supply from which all other domestic water systems in the building are served. For each system identified there is a specific risk rating assigned. The risk rating is derived by assessing the potential for Legionella bacteria to colonize and proliferate; the potential for the Legionella to be disseminated in an aerosol form; and the potential for susceptible individuals to be exposed. The effectiveness of the control and preventative measures are also considered and along with the effect of out of line situations on the risk levels. The lines of communication and specific responsibilities are examined for the control of water services with regards to this site. From the risk assessment defined in this report, a recommended control scheme is identified and documented. The control scheme is the programme of actions required to control and minimize the risk of Legionella as required by the Health and Safety Commission’s Approved Code of Practice, L8 (ACoP L8). It is a requirement that all persons involved with the site water management regime have suitable training to understand their responsibilities and carry out their duties under the control scheme. Training in water management issues for site operatives needs to be reviewed and documented on a regular basis in order to meet legislative requirements. All actions undertaken should be fully documented and records retained on file for a minimum period of five years. The Management Pathway and Job Titles in Section 2.1 may vary depending on the individual site/customer structure. This section is completed to the best of our knowledge at the time of the survey.




2.1. LEGAL REQUIREMENTS

This risk assessment has been carried out in accordance with the following requirements:

2.1.1 Health & Safety at Work etc Act 1974 Duties under the Act extend to risks from Legionella bacteria which may arise from work activities.

2.1.2 Control of Substances Hazardous to Health Regulations 2002 These regulations provide a framework of actions designed to control the risks from a range of hazardous substances including biological agents. The essential elements of COSHH are:

• Risk assessment; • Prevention of exposure or substitution with a less hazardous substance if this is possible, or substitution of a process or method with a less hazardous one; • Control of exposure where prevention or substitution is not reasonably practicable; • Maintenance, examination and testing of control measures, e.g. automatic dosing equipment for delivery of biocides and other treatment chemicals; • Provision of information, instruction and training for employees; and • Health surveillance of employees (where appropriate and of there are valid techniques for detecting indications of disease) where exposure may result in an identifiable disease or adverse health effect.

2.1.3 Management of Health & Safety at Work Regulations 1999 These regulations provide a broad framework for controlling health & safety at work. As well as requiring risk assessments, they also require employers to have access to competent help in applying the provisions of health and safety law; to establish procedures to be followed by any worker if situations presenting serious and imminent danger were to arise; and for co-operation and co-ordination where two or more employers or self-employed persons share a workplace.

2.1.4 Interpretation of Requirements The views and guidance expressed in this report are given in good faith and are based on LCS’s interpretation of the following

HSE ACOP L8 2013 – Legionnaires ’ disease The Control of Legionella Bacteria in Water Systems,

HSG274 Part 2 - Hot & cold Water Systems 2014

HSG220 - Health & Safety in Care Homes 2014

HTM 04-01 - Health Technical Memorandum

Water Supply (& fittings) Regulations 1999 The information provided within the report is relevant the scope of the survey agreed and the information made available by the Client.




2.2. MANAGEMENT PATHWAY STRUCTURE

Site Name: Holy Cross Primary Catholic Voluntary Academy

Site Address Holy Cross Primary Catholic Voluntary Academy Leen Mills Lane Hucknall Nottinghamshire NG15 8BZ

Site Telephone No: 0115 953 4577

Name Position Address/Tel No

Statutory Duty Holder:

Mrs Snowdon Head Teacher Holy Cross Primary Catholic Voluntary Academy Leen Mills Lane Hucknall Nottinghamshire NG15 8BZ Tel: 0115 953 4577

Managerially Responsible Person

TBC Health & Safety Manager / Bursar

Holy Cross Primary Catholic Voluntary Academy Leen Mills Lane Hucknall Nottinghamshire NG15 8BZ Tel: 0115 953 4577

Nominated Responsible Person

TBC Site Manager Holy Cross Primary Catholic Voluntary Academy Leen Mills Lane Hucknall Nottinghamshire NG15 8BZ Tel: 0115 953 4577

and/or CONTRACTOR Trentside Plumbing Water Hygiene

Contractors

Trentside Plumbing Limited Kingfisher House 140 Nottingham Road Nottingham NG10 2EN Tel: -

Personnel Responsible for Weekly Mechanical

Maintenance / Monitoring: Note – there may be more

than one contractor responsible on site.

CONTRACTOR Brad Harrison

Legionella Consultancy Services Ltd

Risk Assessor LCS LTD Electric House Ninian Way Wilnecote Tamworth B77 5DE Tel: 01827 259346 Email: [email protected]

Service Providers: Note – there may be more

than one specialist contractor responsible on site i.e. Water

Treatment Company, Monitoring Companies etc.




3.1. GENERAL INFORMATION

CLIENT INSTRUCTIONS LCS was instructed by Holy Cross Primary Catholic Voluntary Academy to undertake a Legionella Risk Assessment, at the school at Leen Mills Lane, Notts. The Risk Assessment was undertaken on 13th April 2015 by Brad Harrison. This was carried out in accordance with the requirements of the Health and Safety at Work Act 1974, The Control of Substances Hazardous to Health Regulations 2002 and the relevant guidance as outlined in Section 2.14 above.

3.2. SITE DESCRIPTION SITE DESCRIPTION The site consists of 1 single storey building only. There are approximately 140 pupils and 15 members of staff on site.

Mains Water Isolation Valve The location of the stop valve for this system is in the Kitchen W.C in Building 50 Room 2. The system supplies cold water outlets as indicated in the site asset register. In addition it supplies the following equipment:

1 x Calorifier

1 x Pressurization Unit

1 x Tea Boiler

1 x Dish Washer

1 x MP Heaters

8 x LVWH Heaters

1 x Electric Shower

TMV as indicated in asset register

Hot Water Storage CAL01 – The calorifier is located in the Boiler Room in Building 1 Room 25. MP01 – Located in Building 1 Room 6&7 Class W.C – Heatrae Sadia Hotflo 50L - REMOVED MP02 – Located in Building 1 Room 33 Class – Heatrae Sadia Multipoint 30L. LVWH01 – Located in Building 1 Room 5 Washroom - Ariston 10L. LVWH02 – Located in Building 1 Room 5 Washroom –Newlec 10L. LVWH03 – Located in Building 1 Room 3 Caretakers - Heatrae Sadia Multipoint 10L. LVWH04 – Located in Building 1 Room 21 Cupboard - Heatrae Sadia Multipoint 15L. LVWH05 – Located in Building 1 Room 20 Class - Heatrae Sadia Multipoint 15L. LVWH06 – Located in Building 1 Room 19 Girls W.C. - Heatrae Sadia Multipoint 15L. LVWH07 – Located in Building 1 Room 18 Boys W.C. - Heatrae Sadia Multipoint 15L. LVWH08 – Located in Building 1 Room 28 Class - Heatrae Sadia Multipoint 15L.

Cold Water Storage

There are no Cold Water Storage Tanks Located on site.




3.2. SITE DESCRIPTION (CONT’D)

Showers During the site visit there were showers identified on site as follows:

1 x Electric shower located in Building 1 Room 11 - Disabled W.C The shower is infrequently used but site staff flush the shower weekly and record actions in the logbook.

Central Heating 1 x Gas Boiler located in Building 1 Room 25 Boiler house heats CAL01 indirectly during winter months and all wall mounted radiators. The system is supplied by a mains pressurization unit located beside the boilers and a quick filling loop for manual top up.

Meter Details / Readings No meters identified during the survey.




4.0 RISK ASSESSMENT

4.1 Rational Legionnaires’ disease is most commonly caused by the inhalation of water droplets contaminated with the Legionella bacteria. It is therefore important that systems susceptible to colonisation by Legionella and which incorporate a potential means for creating and disseminating water droplets should be identified and the risk they present assessed. This identification and assessment is required by ACOP L8. Assessments are required for all non-domestic water systems. The assessment must be completed for routine systems operation and also for circumstances such as breakdown, abnormal operation, commissioning or other unusual circumstances. Once the assessment has been completed, a strategy can be prepared for preventing or controlling the risk. The strategy will be based on a sound knowledge of the varying levels of attention required by the differing risk sources within the building. The assessment takes account of: A) The potential for formation of droplets. B) The condition of the water. C) Water temperature. D) The water turnover rate. E) The susceptibility of persons exposed to droplets. F) The population density exposed to droplets. Water droplets are normally created in various ways such as by spraying, bubbling and following impact onto hard surfaces. Large drops may be reduced to respirable size by further impact or evaporation. Smaller particles can remain airborne for long periods and will be carried on air currents. In undertaking the risk assessment and drawing up precautions, particular attention must be paid to situations where: 1) The population exposed contains a relatively high number of people susceptible to Legionella, for example in Hospitals and

Nursing Homes. 2) The destiny of population is high, and therefore the number of people at potential risk is high. The risk assessment should be reviewed whenever there is reason to believe that the original assessment may no longer be valid and ideally an annual review of all sources should be undertaken. The original assessment may be compromised if: 1) Changes are made to plant or water systems or its use. 2) Changes are made to building use in which the water system is installed. 3) New information about risks or control measures becomes available. 4) Results of checks indicate that control measures are no longer effective. Once the risk has been identified and assessed, a scheme should be prepared for preventing or controlling it. The risk is heightened when conditions are not monitored and control of the system is lost, thereby allowing Legionella to proliferate. The scheme should be implemented together with a planned preventative maintenance schedule in line with that contained within the general recommendations section of this report. This will meet the requirements of the ACOP. Log books must be compiled to demonstrate that risk assessments have been undertaken and that a management plan has been established to deal with any untoward elements. These Log books must be updated on an ongoing basis. Whilst there is currently no legal obligation for a company to follow the guidelines a company must demonstrate that all measures have been taken to the standard of the guide notes to prevent an outbreak of Legionella.




4.2 Method of Risk Assessment, legionella

The risk assessment takes account of the principle parameters which govern the risk associated with each water source in the building. Selective and planned water sampling may also be carried out in order to confirm absence of Legionella.

Risk Parameter Risk Rating Numerical Value

A) Formation of Droplets

Still water Low 10

Droplets Medium 20

Aerosol High 30

B) Water Condition

Chemical regime Low 10

Clean Low / medium 15

Contaminated Medium / high 25

Heavily contaminated High 30

C) Water temperature

Below 20oC Low 10

21oC – 25oC Medium 20

26oC – 45oC High 30

46oC – 50oC Medium 20

Above 50oC Low 10

D) Water turnover

Stagnant High 30

Low turnover Medium 20

Moderate turnover Medium / low 15

High turnover Low 10

E) Susceptibility of exposed persons

Average population Medium 20

Susceptible population High 30

F) Population density of exposed persons

Low density Low 10

Medium density Medium 20

High density High 30

For sources sampled and found Legionella positive an additional weighting factor shall be applied to the assessment. This allows the infected source to be immediately identified as high risk.

UPON IDENTIFICATION OF LEGIONELLA COLONISATION, IMMEDIATE STEPS MUST BE TAKEN TO ERADICATE THE INFECTION.




4.3 Source Risk Rating

Calculated by additional of numerical values for each of the risk parameters of each source and weighting factor if applicable.

Total Numerical Value Overall Risk Rating

70-106 Low

107-143 Medium

144-180 High

The overall risk rating for each source must be evaluated in conjunction with other influences observed during the course of the survey and with consideration for systems breakdowns, abnormal operations, commissioning and other unusual circumstances.




5.0 COLD WATER STORAGE SYSTEMS

There are no Cold Water Storage Tanks located on site.




6.0 HOT WATER SYSTEMS

Customer Details System Risk Assessment Details

Client: Holy Cross Primary Catholic Voluntary Academy Reference Number: CAL01

Address: Holy Cross Primary Catholic Voluntary Academy, Leen Mills Lane, Hucknall, Nottinghamshire, NG15 8BZ

Location: BDG 1 Room 25 – Boiler Room

Assessors Name: Brad Harrison

Date 13/04/2105 Time am

Is there safe access to the heater Yes

Is the heater supplied from mains or storage fed MCW

Ref. Name/No. of any cold water storage cistern related to this system N/A

Type of water heater e.g. calorifier, plate heat exchanger etc. Andrews – Unvented 300L

Is heater temperature raised to 60 0C for 1 hour before being used Yes

Is there pumped secondary hot water flow and return system Yes

If fitted with duty and standby pumps are they regularly changed Solo

Over what time period do the heater(s) operate Timer Operated

Are expansion vessels installed on Heater Internal

Are expansion vessels flushed on regular basis Not Possible

What material has been used to construct the heater(s) Glass Lined Steel

Dimensions (mm) 1.5 x 0.45 approx

Water capacity (litres) 300L

Is the volume of the vessel suitable for use (ie. Is it too large) OK

Is the primary method of heating Gas Fired

Secondary method of heating None

Is there an inspection hatch provided that would allow manual cleaning Yes

Can the base of the vessel be flushed and completely drained Yes

On what date was the heater vessel last inspected for scale/corrosion Not Known

Is the heater vessel insulated Yes

Is the insulation adequate and in a good state of repair Good

What is the size of the cold feed pipe Fully Insulated

What size is the hot water flow pipe work Fully Insulated

What size is the secondary return pipe work 22mm

Are there spray taps / showers fitted on distribution pipe work Spray Taps

Are there TMV’s fitted on distribution pipe work Yes

Are there Little use outlets on distribution pipe work None Identified

Are there Redundant branch pipes in distribution pipe work None Identified

Is the hot/cold water pipe work insulated Yes

Is the cold water supply to the heater softened No

Is there a shunt pump used for recirculating hot water around the vessel No

What is the set temperature of thermostat 0C No

Is there a temperature gauge on the hot flow No

Is there a temperature gauge on the hot secondary return 70°C

Actual temperature of cold inlet 0C No

Actual temperature at top of vessel 0C (should be at least 600C) No

Actual temperature at middle of vessel 0C -

Actual temperature at bottom of vessel 0C -

Actual temperature at outlet of vessel 0C Fully Insulated

Return water temperature 0C (should be >50 0C) 53.4°C

Are temperatures taken monthly and recorded Yes

Are records maintained of cleaning and disinfection. Yes

Is the biological quality of the water monitored Not Known

Sentinel temp 55.5°C




REMARKS: - CAL01 was operational as was the secondary recirculation pump. The units thermostat was set to 70°C although was

only achieving 55°C at the nearest outlet.

Risk Rating

A B C D E F TOTAL

20

15 10 15 20 20 90 Low




6.0 SMALL WATER HEATERS


Client: Holy Cross Primary Catholic Voluntary Academy Reference Number: MP01


Location: BDG 1 Room 6 – Classroom WC



Is there safe access to the heater N/A

Is the heater supplied from mains or storage fed N/A

Type (unvented, multi point, combination cylinder or point of use) N/A

Make and model N/A

Are expansion vessels installed on Heater N/A

Are expansion vessels flushed on regular basis N/A

Heater capacity N/A

Cistern capacity N/A

Method of heating N/A

Size of inlet N/A

Size of outlet N/A

Material used for distribution pipe work N/A

Cistern condition and conformity to Regulations N/A

Actual temperature at 1st outlet of heater 0C N/A

Is cold water supply treated and type N/A

Are there spray taps / showers fitted on distribution pipe work N/A

Are there TMV’s fitted on distribution pipe work N/A

Are there Little use outlets on distribution pipe work N/A

Are there Redundant branch pipes in distribution pipe work N/A

Is the hot/cold water pipe work insulated N/A

REMARKS: - This heater has been removed from service

Risk Rating

A B C D E F TOTAL

N/A N/A N/A N/A N/A N/A N/A






Client: Holy Cross Primary Catholic Voluntary Academy Reference Number: MP02


Location: BDG 1 Room 33 – Classroom


Date 13/04/2015 Date am



Type (unvented, multi point, combination cylinder or point of use) Multipoint

Make and model Heatrae Sadia Multipoint 30L

Are expansion vessels installed on Heater Yes


Heater capacity 30 litres

Cistern capacity -

Method of heating Elec

Size of inlet 15mm

Size of outlet 15mm

Material used for distribution pipe work Copper


Actual temperature at 1st outlet of heater 0C 70.1°C

Is cold water supply treated and type No/MCW





Is the hot/cold water pipe work insulated Not Known

REMARKS: - Supplies outlets located as follows:

Building 1 Room 33

Building 1 Room 34.

Building 1 Room 38. Heater is operating at recommended storage temperature of 60°C.

Risk Rating

A B C D E F TOTAL

20

15 10 15 20 10 90 Low






Client: Holy Cross Primary Catholic Voluntary Academy Reference Number: LVWH01


Location: BDG 1 Room 5 – Washroom





Type (unvented, multi point, combination cylinder or point of use) Low Volume

Make and model Ariston




Cistern capacity -


Size of inlet 15mm

Size of outlet 15mm



Actual temperature at 1st outlet of heater 0C Flow to TMV 55.3°C

Is cold water supply treated and type No

Are there spray taps / showers fitted on distribution pipe work Spray taps




Is the hot/cold water pipe work insulated No

Formerly known as POU1

REMARKS: - Supplies 1 x sink via a TMV and currently only operating at 55.3°C. The heater was heating water to recommended

temperatures during inspection (>50°C)

Risk Rating

A B C D E F TOTAL

20

15 10 15 20 10 90 Low








Location: BDG 1 Room 5 – Washroom






Make and model Newlec NLUV10

Are expansion vessels installed on Heater No – not vented



Cistern capacity -


Size of inlet 15mm

Size of outlet 15mm





Are there spray taps / showers fitted on distribution pipe work None


Are there Little use outlets on distribution pipe work No




REMARKS: - Supplies 1 x sink via a TMV and currently only operating at 55.2°C. The heater was heating water to recommended temperatures during inspection (>50°C)

Risk Rating

A B C D E F TOTAL

20

15 20 15 20 10 100 Low








Location: BDG 1 Room 3 – Caretaker






Make and model HS MP 10L




Cistern capacity -


Size of inlet 15mm

Size of outlet 15mm






Are there TMV’s fitted on distribution pipe work No


Are there Redundant branch pipes in distribution pipe work No



REMARKS: - Supplies 1 x bucket sink directly – no TMV. The heater was heating water to recommended temperatures during inspection (>50°C)

Risk Rating

A B C D E F TOTAL

20

15 10 10 20 10 85 Low








Location: BDG 1 Room 21 – Cupboard










Cistern capacity -


Size of inlet 15mm

Size of outlet 15mm











REMARKS: - Supplies 1 x SSS via TMV only. The heater was heating water to recommended temperatures during inspection (>50°C)

Risk Rating

A B C D E F TOTAL

20

15 10 15 20 10 90 Low











Is there safe access to the heater Yes – Panel Removed









Size of inlet 15mm

Size of outlet 15mm











REMARKS: - The heater was heating water to recommended temperatures during inspection (>50°C)

Risk Rating

A B C D E F TOTAL

20

15 10 25 20 10 100 Low








Location: BDG 1 Room 19 – Girls WC












Size of inlet 15mm

Size of outlet 15mm











REMARKS: - The heater supplies WHB via a TMV. The heater was heating water to recommended temperatures during inspection (>50°C)

Risk Rating

A B C D E F TOTAL

20

15 10 10 20 10 85 Low








Location: BDG 1 Room 18 – Boys WC












Size of inlet 15mm

Size of outlet 15mm










Formerly known as LVWH07

REMARKS: - The heater supplies WHB via a TMV. The heater was heating water to recommended temperatures during inspection (>50°C)

Risk Rating

A B C D E F TOTAL

20

15 10 10 20 10 85 Low















Are expansion vessels installed on Heater No

Are expansion vessels flushed on regular basis N/A




Size of inlet 15mm

Size of outlet 15mm











REMARKS: - The heater is failing to achieve recommended temperatures. The thermostat and/or timer to be adjusted to achieve >50°C.

Risk Rating

A B C D E F TOTAL

20

15 20 15 20 10 100 Low




7.0 MAINS COLD WATER SYSTEMS


Client: Holy Cross Primary Catholic Voluntary Academy Reference Number: MCW


Location: BDG 1 Room 2 – Kitchen WC



System Reference No. MCW

Location: Room 2

Material of incoming supply Plastic (Black)

Size of incoming supply 1” to 1”

Material used in Distribution pipe work Copper

Is the MCW distributed below 20 0C Yes

Is the distribution pipe work insulated No

Are there spray taps / showers fitted Yes

Are there TMV’s fitted Yes

Are there Little use outlets None Identified

Are there Redundant branch in system None Identified

Is there a F & E cistern fitted to system No

Is branch able to be flushed N/A

Is there a Pressurisation unit fitted to system Yes

Is branch able to be flushed Not Possible

Is there a central heating quick fill fitted to system Yes

Is quick fill connection being flushed Not Possible

REMARKS: - The system supplies the following water equipment:

All cold water outlet as identified in the asset register

1 x MP water heaters

8 x LVWH heaters

1 x Mains PU

1 x Calorifier (CAL01)

1 x Tea Boiler

1 x Dishwasher

1 x Washing Machine

1 x Triton Electric Shower

Risk Rating

A B C D E F TOTAL

30

15 10 20 10 10 100 Low




8.0 SHOWERS


Client: Holy Cross Primary Catholic Voluntary Academy Reference Number: ESH01


Location: BDG 1 Room 11 – Disabled WC



Type Showers Electric Comments

Number 1 Triton

How Supplied MCW

Type of Head Hose

Condition Good

Flushing Regime Yes

Are they metered No

REMARKS: - Shower is rarely used but is flushed weekly by the site manager with records kept.

Risk Rating

A B C D E F TOTAL

20 15 10 25 20 10 100 Low




9.0 HOT AND COLD WATER SERVICE OUTLETS

BDG NO.

Room No.

Usage Room/ Name

Fittings QTY & TYPE

Spray Tap Y/N

CW Supply Source

HW Supply Source

MCW Temp °

TCW Temp °

HWS Temp °

TMV outlet Temp °

TMV Inlet

Temp °

OTHERS INFO Sentinel (N) to

system:

Sentinel (F) to system:

1 5 Classroom

1 x SSS 1 x LVWH(01) 1 x TMV 1 x SSS 1 x LVWH(02) 1 x TMV

N - - N - -

MCW MCW MCW MCW MCW MCW

TMV - LVWH01 - TMV LVWH02

11.2°C 11.2oC

43.1°C 43.8°C

55.3°C 55.2°C

MP01 Removed Ariston 10L Newlec 10L

LVWH01 LVWH02

MP01

1 7 Classroom WC

2 x WHB 1 x TMV 3 x WC

Y - -

MCW MCW MCW

- CAL01 -

38.9°C 50.9°C

1 6 Classroom WC

2 x WHB 1 x TMV 3 x WC

Y - -

MCW MCW MCW

- CAL01 -

29.8°C 50.9°C

1 33 Classroom

1 x Sink 1 x TMV 1 x MP(02)

Y - -

MCW MCW MCW

TMV MP02 -

11.7°C 43.8°C 70.1°C

HS MP 30L

MP02

1 34 Classroom W.C

2 x WHB 1 x TMV

Y -

- MCW

TMV MP02

42.2°C 69.78°C

1 38 Class Kitchen

1 x SSS 1 x W/Mach

Y -

MCW MCW

MP02 -

11.0°C 71.0°C Bosch

MCW / MP02





BDG NO.

Room No.

Usage Room/ Name

Fittings QTY & TYPE

Spray Tap Y/N

CW Supply Source

HW Supply Source

MCW Temp °

TCW Temp °

HWS Temp °

TMV outlet Temp °

TMV Inlet

Temp °


system:


1 3 Caretakers

1 x BFT Sink 1 x LVWH(03)

N -

MCW MCW

LVWH03 -

11.4°C 58.9°C HS MP 10L

LVWH03

1 40 Classroom

1 x SSS 1 x TMV

Y -

MCW MCW

TMV CAL01

11.6°C 39.8°C 53.4°C

1 24 Classroom 1 x SSS Y MCW TMV 14.3°C 42.9°C TMV in Room 21 LVWH04

1 23 Staff Ladies W.C

1 x WHB 1 x TMV 1 x WHB 1 x TMV 2 x W.C

Y - Y - -

MCW MCW MCW MCW MCW

TMV CAL01 TMV CAL01 -

14.1°C 14.1°C

41.2°C 43.8°C

55.6°C 55.6°C

1 22 Staff Gents W.C

1 x WHB 1 x TMV 1 x W.C

N - -

MCW MCW MCW

TMV CAL01 -

13.2°C 39.8C 54.1°C

Thermo Tap CAL01

1 21 Cupboard

1 x LVWH(04) 1 x TMV

- -

MCW MCW

- LVWH04

53.4°C

HS MP 15L Supplies room 24

1 20 Classroom

1 x Sink 1 x TMV 1 x LVWH(05)

Y - -

MCW MCW MCW

- LVWH05 -

12.3°C 38.4°C HS MP 10L

LVWH05 MCW





BDG NO.

Room No.

Usage Room/ Name

Fittings QTY & TYPE

Spray Tap Y/N

CW Supply Source

HW Supply Source

MCW Temp °

TCW Temp °

HWS Temp °

TMV outlet Temp °

TMV Inlet

Temp °


system:


1 19 Girls W.C

1 x WHB 1 x TMV 1 x WHB 1 x TMV 1 x WHB 1 x TMV 1 x LVWH(07) 3 x W.C

Y - Y - Y - - -

MCW MCW MCW MCW MCW MCW MCW MCW

TMV LVWH07 TMV LVWH07 TMV LVWH07 - -

37.9°C 38.6°C 40.0°C

54.9°C

HS MP 15L

LVWH06

1 18 Boys W.C

1 x WHB 1 x TMV 1 x WHB 1 x TMV 1 x WHB 1 x TMV 1 x LVWH(06) 2 x UR 2 x W.C

Y - Y - Y - - - -

MCW MCW MCW MCW MCW MCW MCW MCW MCW

TMV LVWH06 TMV LVWH06 TMV LVWH06 - - -

46.5°C 47.6°C 48.9°C

61.0°C

HS MP 15

LVWH07

1 16 Staff Room

1 x SSS 1 x T/Boiler 1 x D/Washer

Y - -

MCW MCW MCW

CAL01 - - -

12.4°C 52.7°C HS Supreme I55 Indisett

1 28 Classroom 1 x Sink 1 x TMV 1 x LVWH(08)

Y - -

MCW MCW MCW

TMV LVWH08

11.3°C 37.6°C 46.7°C

HS Hot Flo 10

LVWH08

1 11

Disabled W.C & Shower Room

1 x WHB 1 x TMV 1 x WHB 1 x TMV 1 x W.C 1 x E/Shower

Y - Y - - Y

- MCW MCW MCW MCW MCW

TMV CAL01 TMV CAL01 - -

12.9°C

40.7°C 42.1oC

50.3°C 50.1oC

Triton

CAL01





BDG NO.

Room No.

Usage Room/ Name

Fittings QTY & TYPE

Spray Tap Y/N

CW Supply Source

HW Supply Source

MCW Temp °

TCW Temp °

HWS Temp °

TMV outlet Temp °

TMV Inlet

Temp °


system:


50 1 Main Kitchen

1 x SSS 1 x WHB 1 x BFT Sink 1 x SSS 1 x S/Sink 1 x R/Sink

Y Y N Y N N

MCW MCW MCW MCW

- MCW

CAL01 CAL01 CAL01 CAL01 CAL01 CAL01

11.8°C 11.1°C 11.6°C 12.2°C - 12.2°C

56.3°C 57.1°C 56.5°C 55.7°C 55.1oC

Sterilizer sink Rinser sink

50 2 Kitchen Wash 1 x WHB N

MCW

CAL01

12.1°C 54.7°C MCW CAL01

50 3 Kitchen W.C 1 x W.C 1 x MCW SV

- -

MCW ST WATER

- -

1 25 Boiler Room 1 x CAL(01) 1 x MPU 2 x Boiler

- - -

MCW MCW MPU

- - -

Andrews 300L Hoval

1 - New Extension 1 x WHB 1 x TMV

Y -

MCW MCW

- CAL01

11.9°C 43.9°C 50.1°C





Frequency Check Checks are carried out, signed, dated and are

satisfactory.

Remedial actions

recorded Faults and Action required

Weekly

Flush infrequently used outlets and showers, emergency showers and eyewash sprays for at least 2 minutes without creating an aerosol. Any toilet not used within a 7 day period must be flushed (ensure the lid is closed to avoid contact with any water droplets/aerosols)

Yes Yes Work is currently carried out by the Site Manager and details recorded in the Site Logbook. Currently just the Electric Shower and bib taps on the regime.

Weekly Add salt to the softener brine tank and measure the water hardness

N/A

Monthly

Sentinel taps The water temperature should be below 20oC after running the water for up to two minutes The water temperature should be at least 50o C within a minute of running the water

Yes Yes Up until April 2015 MDB Plumbing were the water treatment contractors responsible for this work. A company called Trent Side Plumbing have been contracted to take over from April 2015.

Monthly

Inlet to TMVs on a sentinel basis The water supply to the TMV temperature should be at least 50oC within a minute of running the water


Monthly

Water leaving and returning to calorifier or water heater Outgoing water should be at least 60oC, return at least 50oC


Monthly Check the log book for errors or omissions.

Yes Last log book entry unknown.






satisfactory.

Remedial actions


Quarterly Descale and disinfect shower heads and hoses Yes N

Up until April 2015 MDB Plumbing were the water treatment contractors responsible for this work. A company called Trent Side Plumbing have been contracted to take over from April 2015.

Quarterly

Are quarterly review meetings being undertaken

No No evidence of this check being carried out.

Six Monthly

Cold water storage tank incoming cold water inlet ( at least once in the winter and once in the summer) The water should be preferably be below 20oC at all times but may be supplied at 25oC by the supplier as permitted under regulations

N/A All formerly identified tanks now removed.

Six Monthly

Carry out planned maintenance of rainwater harvesting systems “Stormsaver” or equivalent

N/A

Six Monthly Service water softener

N/A

Six Monthly Small water heater checks


Six Monthly Other system check being carried out ie filters, air conditioning unit etc

N/A






satisfactory.

Remedial actions


Annually

Representative number of taps on a rotational basis The water temperature should be 20oC after running the water for two minutes The water temperature should be at 50oC within a minute of running


Annually

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

N/A

Annually

Inspect cold water storage tanks for the presence of sediment or biological material

N/A All formerly identified tanks now removed.

Annually

Arrange for samples to be taken from hot water calorifiers, in order to note condition of drain water


Annually

Carry out maintenance on calorifiers and water heaters in accordance with manufacturers’ maintenance


Annually

Carry out servicing of thermostatic mixing valves fitted to washbasins, sinks and showers

No No Up until April 2015 MDB Plumbing were the water treatment contractors responsible for this work. A company called Trent Side Plumbing have been contracted to take over from April 2015.






satisfactory.

Remedial actions


2 yearly / as required

Carry out a review of the risk assessment every 2 years or following material changes to the systems or personnel

Yes Last risk assessment dated April 2012.

As required Arrange for cleaning and disinfection of the cold water tanks following recommendations from an inspection, following remedial or project works or if the tank has been entered for some reason

N/A

As required Arrange for the hot water system to be thermally pasteurised if the system has been below 50oC for more than one week, if it has been out of operation or drained or following remedial or project works. Chlorination may be considered as an alternative

REMARKS: TRENTSIDE PLUMBING have taken over the water treatment contract from MDB PLUMBING commencing April 2015





Item Apparatus Recommend remedial action

for Approved Code of Practice Compliance Priority Allocated to Date rectified

11.1

There are in total 8 x Low Volume Water Heaters and the following were found to be operating outside recommended temperatures:

LVWH08 – BDG 1 Room 28 Classroom (HS MP 10L) – 46.0°C

It is recommended that LVWH heaters are achieving 50°C for one hour before use and that the heater maintains 50°C at all outlets throughout the day.

It is recommended that the thermostats and / or timer clocks are raised to 500C. The water heaters should be checked on a regular basis and maintained in accordance with manufactures recommendations. The outlet temperatures from these heaters must be above 50 0C prior to the thermostatic mixing valve which must reduce the outlet temperature to a maximum of 430C as described in page 42, temperature regime 169 and 170, of the Health and Safety Commission, Legionnaires disease, Approved Code of Practice and Guidance

MEDIUM





Item Apparatus Recommend remedial action

for Approved Code of Practice Compliance Priority Allocated to Date rectified

11.2

Thermal Mixing Valves located throughout the site as detailed in the Asset Register. TMV’s in following locations were operating outside the recommended temperatures:

BDG 1 Room 18

BDG 1 Room 17

It is recommended that, once CAL01 is operating at recommended temperatures, TMV’s operate between 38°C-43°C. Once the Water Heaters have had the thermostats adjusted checks should be made to the TMV’s listed and then adjusted accordingly to operate at recommended temperatures.

It is recommended that all TMV’s are failsafe tested and where necessary recalibrated on an Annual basis with actions should be recorded within the sites log book.

A service of TMV’s should include the cleaning of all filters if fitted with suitable isolation valves.

LOW




11.0 REMEDIAL ACTIONS CONTINUED

Item Maintenance and Monitoring Issues

Recommend remedial action for Approved Code of Practice Compliance

Priority Allocated to Date Rectified

11.3 Risk Assessment And Logbooks

As part of this assessment, Severn Trent Select has drawn up an asset register of the water systems to update the records held on the P2 property management system. The site responsible person must notify the Water Officer of any changes or modifications carried out.

MEDIUM

11.4 Responsibility Structure And Training

No training records were seen for the Site responsible person or Site Manager but he was fully aware of his responsibilities.

The Site Manager is responsible for weekly flushing of infrequently used outlets. The site responsible person must ensure that all named site staff are suitably trained for the tasks they are assigned. Contact the Water Officer to arrange for training to be carried out.

LOW

11.5 Site Monitoring

No records of Calorifier servicing in the Site Logbook

The site responsible person must ensure that all maintenance, inspection and testing activities are carried out and that records are kept up-to-date and properly stored on site. Records must be kept for at least five years.

MEDIUM

Priority Rating

Emergency Risk

Take immediate action to reduce risk

High

Action within one month

Medium

Action within 3 months

Low

Action within 12 months

Best Practice

Carry out when funds available or as part of more wide-ranging works




12.0 CHECKLIST OF PRECAUTIONS – DOMESTIC HOT & COLD WATER SYSTEMS The Approved Code of Practice for the Control of Legionella Bacteria in water systems requires that precautions are carried out to reduce the risk of exposure to legionella. The risk assessment survey has concluded that the following checks are required. Records of tests and checks undertaken must be kept for a minimum of 5 years.

Frequency Check Standard to meet

Cold water Standard to meet

Hot water Responsibility Notes

Weekly Flush infrequently used outlets and showers, emergency showers and eyewash sprays for at least 2 minutes without creating an aerosol. Any toilet not used within a 7 day period must be flushed (ensure the lid is closed to avoid contact with any water droplets/aerosols)

- - Water left standing in pipework can aid biofilm formation that can result in colonisation by Legionella bacteria. Flushing weekly, particularly during the summer holiday period can help to maintain safe conditions.

Weekly Add salt to the softener brine tank and measure the water hardness

Hardness should be <5ppm

-

Monthly Sentinel taps The water temperature should be below 20oC after running the water for up to two minutes

The water temperature should be at least 50o C within a minute of running the water

This check makes sure that the supply and return temperatures on each loop are unchanged, ie the loop is functioning as required

Monthly Check the inlet temperature to TMVs on a sentinel basis

- The water supply to the TMV temperature should be at least 50oC within a minute of running the water

One way of measuring this is to use a surface temperature probe

Monthly Water leaving and returning to calorifier or water heater

- Outgoing water should be at least 60oC, return at least 50oC

Failure to achieve these temperatures may indicate a problem with the power to the pump, the pump itself, electric immersion elements




12.0 CHECKLIST OF PRECAUTIONS – DOMESTIC HOT & COLD WATER SYSTEMS




Quarterly Set up quarterly review meeting with relevant parties

- -

Quarterly Descale and disinfect shower heads and hoses There should be no visible scale or biological material

- Inspection may show that this clean may need to be carried out more frequently.

Six Monthly

Cold water storage tank incoming cold water inlet ( at least once in the winter and once in the summer)

The water should be preferably be below 20oC at all times but may be supplied at 25oC by the supplier as permitted under regulations

- The most convenient place to measure is usually at the ballvalve to the cold water storage cistern

Six Monthly

Carry out planned maintenance of rainwater harvesting systems “Stormsaver” or equivalent

- - The site is responsible for setting up a maintenance contract.

Six Monthly

Service water softener Maintains the quality of the softened water and prevents

scale formation

- The site is responsible for setting up a maintenance contract.

Six Monthly

Small heater check Check heater is working and is discharge water at

above 60 oC

Six Monthly

Other system as shown in logbook Maintain in accordance with manufactures

recommendations








Annually Representative number of taps on a rotational basis The water temperature should be 20oC after running the water for two minutes

The water temperature should be at 50oC within a minute of running the water

Ensures that the whole system is reaching satisfactory temperatures for legionella control

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

- - The site is responsible for setting up a maintenance contract.

Annually Inspect cold water storage tanks for the presence of sediment or biological material

There should be no undue warming of water

-

Annually Arrange for the sludge and silt in water harvesting tanks to be sucked out

- - The site is responsible for placing an instruction

Annually Arrange for samples to be taken from hot water calorifiers, in order to note condition of drain water

- - Where the water heater has a clean-out opening, internal inspection

Annually Carry out maintenance on calorifiers and water heaters in accordance with manufacturers’ maintenance. Drain down and inspect internally where practicable


Annually Carry out servicing of thermostatic mixing valves fitted to washbasins, sinks and showers

- Mixer temperatures Shower 41oC Washbasin 41oC Un-assisted Bath 44 oC Assisted Bath 44 oC

The site is responsible for setting up a maintenance contract.








2 yearly / as required

Carry out a review of the risk assessment - - Reviews must be carried out every 2 years or following material change to the water systems or personnel

As required Arrange for cleaning and disinfection of the cold water tanks and down services following recommendations from an inspection, following remedial or project works or if the tank has been entered for some reason


As required Arrange for the hot water system to be thermally pasteurised if the system has been below 50oC for more than one week, if it has been out of operation or drained or following remedial or project works.

- - Chlorination may be considered as an alternative. The site is responsible for placing an instruction

As required Remove redundant pipe connections as described in schedule 2, section 4, paragraphs 8 to 13 of the Water Regulations guide.





13.0 REFERENCE PHOTOGRAPHS

MCW Stop valve located in BDG 50 Room 03 Kitchen WC CAL01 – Andrews 300L unvented, gas fired and located in

Room 25 Boiler Room

View of front panel display of CAL01 View of secondary return pump and expansion vessel of CAL01

located in Boiler Room





1 X Electric Shower located in BDG 1 Room 11 Disabled WC 1 x Mains Pressurisation Unit supplying boilers located in

Room 25 Boiler Room

2 x HOVAL Boilers located in Room 25 Boiler Room supplying all central heating in the school





Drinking water outlets are labelled MP02 – HS MP 30L located in Room 33 Class

LVWH01 – Ariston 10L located underside east side sink in Room 05

LVWH02 – Newlec 10L located underside west side sink in Room 05. Vent appears to be capped and requires further

checks





LVWH03 – HS MP 10L located in Room 03 Cleaners LVWH05 – HS MP 15L located in Room 20 Classroom

LVWH07 – HS MP 15L located in Room 19 Girls WC. Identical to LVWH06

LVWH08 – HS MP 10L located in Room 28 Classroom





View Room 05 New Separated Wash Rooms

View Room 19 & 18 New Wash Rooms





1 x Tea Boiler located in Room 16 Staff Room 1 x Dishwasher located in Room 16 Staff Room

Typical TMV




14.0 SCHEMATIC DRAWINGS




15.0 RISK ASSESSMENT REVIEWS / AUDITS

Documents

Legionella Risk Assessment - Our Lady of Lourdes Catholic ... · Legionella Risk Assessment RA/LCS/939 Site: The views and guidance expressed in this report are given in good faith