WATER QUALITY (Legionella) WRITTEN SCHEME April 2018 .../file/waterpolicy.pdf · The RP(Water) has responsibility for the effectiveness of the water/legionellarisk management system

EFM Integrated Management System.

WATER QUALITY (Legionella) WRITTEN SCHEME

April 2018

Version One (Reviewed Annually and Updated Every Two Years)

Consisting of:

Section 1 – The Policy Section 2 – Procedures Section 3 – Work Instructions Section 4 – Log Book

SECTION 1: THE POLICY IMS Reference OPP_WC 001

UNIVERSITY OF SHEFFIELD – WATER QUALITY (LEGIONELLA) WRITTEN SCHEME Issue Number Page

SECTION 1: POLICY OPP_WC 001 2 of 30

SECTION 1: POLICY

Page

DUTY HOLDER:

Policy statement – Water Management 3

RESPONSIBLE PERSON (WATER):

Responsibility, Authority and Resources 4

Duty Holder 5

Responsible Person (Water) 6

Deputy Responsible Person (Water) 7

Water Compliance Manager 8

Authorised Person (Water) – Maintenance 9

Authorised Person (Water) – Projects/Design 10

Competent Person (Water) 11

Authorising Engineer (Water) 12

Responsibility of Other University Staff 13

Risk Assessment 14

Water System Schematics 15

Employee Consultation 16

Risk Minimisation Scheme 17

Design Control 18

Training, Competence and Contractors 22

Risk Management Audit 24

Emergency and Outbreak Actions 25

Drinking Water 28

Documents and Records 29



POLICY STATEMENT – WATER MANAGEMENT

The University is committed to meeting its legal obligations with respect to all of the quality, health, safety and environmental aspects of water. This encompasses issues such as drinking water provision, legionella and other bacteria prevention and protection from scalding.

The University takes account of the latest guidance and is committed to doing all that is reasonably practicable to manage the risks associated with water and to follow the steps laid out in its Policy, Procedures and Work Instructions. The judgement of reasonably practicability will be based on the balance of risk, cost and difficulty.

The University will provide and maintain safe and healthy working conditions, equipment and systems of work for all staff, visitors and the public. It will apply such resources, information, training and supervision as may be needed for this purpose.

The management of water and its associated risks will be a continual commitment by the University involving regular management/progress meetings and a risk assessment programme. Re-assessments will also fulfil many of the monitoring, inspection and record-keeping requirements (including programme implementation, and system condition).

The Duty Holder is the Director of Estates and Facilities Management and the Head of Engineering and Maintenance has been appointed as the Responsible Person (RP Water). The RP(Water) maintains an effective water management system, based on a detailed policy document which supports this policy statement.

Records of all actions involved with Universities commitment to follow procedures are kept electronically and are available for viewing by those who have an interest in their own independent areas and responsibilities.

To ensure good practice this document complies with the requirement of ISO 14001 Environmental Policy.

The University has commissioned an external and independent Authorising Engineer (Water) whose duties include an annual audit of the water management system for the Responsible Person and an assurance statement for the Duty Holder, as evidence of the verification of the effectiveness of the management system.

This policy statement is formally accepted by the Duty Holder, on behalf of the University.

Signed: ..........................................................

Print Name: .......................................................... (Duty Holder)

Date: ..........................................................



POLICY – RESPONSIBILITY, AUTHORITY AND RESOURCES

The following is a brief overview of the responsibility, authority and resources aspects of each role in the water/Legionella risk management system: -

NAMED APPOINTMENTS CAN BE FOUND IN SECTION 4 PAGE 4

The Legionella Training Register will provide information on individual qualification

DUTY HOLDER DIRECTOR OF ESTATES AND

FACILITIES MANAGEMENT (EFM) EXTERNAL

AUTHORISING ENGINEER (WATER)

RESPONSIBLE PERSON (WATER) HEAD OF ESTATES ENGINEERING

AND MAINTENANCE

LOCATION COMPETENT

PERSONS (CP) WATER

HEAD OF ESTATES DEVELOPMENT

AUTHORISED PERSON (AP)

LOCATION MANAGER

AMRC

DEPUTY RESPONSIBLE PERSON (DRP)

WATER COMPLIANCE

MANAGER


LOCATION MANAGER

WEST CAMPUS


LOCATION MANAGER

EAST CAMPUS

AUTHORISED PERSON (AP) DEPUTY HEAD

OF ESTATES DEVELOPMENT

LOCATION COMPETENT

PERSONS (CP) WATER

LOCATION COMPETENT

PERSONS (CP) WATER

PROJECT MANAGER

COMPETENT PERSONS (CP)

WATER DEVELOPMENT

WATER TEAM

4 X ENGINEERS

RP TECHNICAL



POLICY – DUTY HOLDER

By Who? Frequency

The following is a brief overview of the responsibility, authority and resources aspects of the Duty Holder’s (DH) role in the water/legionella risk management system: -

Duty Holder

The Duty Holder has accountability under the Health and Safety at Work etc Act to protect the health, safety and welfare of staff, visitors and the public, in relation to hazards arising from its activities. This duty cannot be delegated.

The Duty Holder appoints a competent person to manage responsibility. Title of this appointment is Responsible Person (RP) (Water).

The Duty Holder owns, signs and implements the Water/Legionella Risk Policy Statement.

The Duty Holder reads the Assurance Statement from the Authorising Engineer (Water) and acts on it.

The Duty Holder ensures that sufficient resources are available to the RP(Water) in order that he/she may fulfil his/her obligations.

DH

DH

DH

DH

As required

Annually/ Substantial Change

Annually

As required



POLICY – RESPONSIBLE PERSON

By Who? Frequency

The following is an overview of the responsibility and authority of the Responsible Person(Water)’s role in the water/Legionella risk management system: -

Responsible Person (Water)

The RP(Water) produces, implements, manages and monitors a water/legionella risk management system.

This includes: -

• Identifying and assessing sources of risk;

• Preparation of a Written Scheme for preventing or controlling the risk;

• Implementing and managing the precautions, including monitoring and auditing;

• Keeping records of precautions implemented.

• Liaise with other professional services and disciplines.

• Shall attend Legionella Key Risk Review meetings

The RP(Water) has responsibility for the effectiveness of the water/legionella risk management system.

The RP(Water) appoints an external, independent, qualified Authorising Engineer(Water).

The RP(Water) appoints at least one deputy to whom delegated responsibility may be given. The deputy acts on behalf of the RP in his/her absence.

The RP(Water) appoints Authorised Persons(Water).

The RP(Water) has responsibility for all issues related to water hygiene and safety, including all of those covered by HSE ACoP L8, HSG 274 Parts 1 to 3.

Attend updated management training every three years or sooner if identified by training needs analysis. The RP(Water) liaises with interested parties as required including departmental representatives, Health and Safety, Authorising Engineer, other auditors, etc.

RP

RP

RP

RP

As required

As required

As required

As required



POLICY – DEPUTY RESPONSIBLE PERSON (MAINTENANCE AND DESIGN/PROJECTS)

By Who? Frequency

The following is an overview of the responsibility and authority aspects of the Deputy Responsible Person(Water) – role in the water/legionella risk management system: -

Carry out the duties of the Water Compliance Manager as identified on the next page.

Be responsible for the implementation of the Water Quality Written Scheme and ensuring compliance with ACoP L8, including HSG 274 Parts 1, 2 and 3.

Assist with the implementation of water quality Legionella control measures and ensuring records are maintained.

Carry out and assist others with audits.

Shall attend Legionella Key Risk Review meetings.

Attend updated management training to Responsible Person level every three years or sooner if identified by training needs analysis. Deputises for the Responsible Person (Water) in his/her absence.

DRP

As required



POLICY – WATER COMPLIANCE MANAGER

By Who? Frequency

The following is an overview of the responsibility and authority aspects of the Water Compliance Manager’s role in the water/legionella risk management system: -

Water Compliance Manager

• Undertakes or commissions Legionella risk assessments for all University buildings to the frequency identified in the Legionella Risk Assessment register.

• Oversees the production and revision of the Legionella Written Scheme for each building.

• Implements the Written Scheme.

• Co-ordinates record keeping.

• Keeps the Responsible Person informed of implementation and progress of the Written Scheme.

• Attends the Legionella Key Risk Meeting and feeds back on matters arising to the DRP(Maintenance).

• Provides advice to Authorised Persons (Water), Estates and Facilities Management staff and other University departments of Faculties regarding all water issues.

• Provide advice on specialist water systems that are not described and domestic water services but are used within areas that are University responsibility

• Advises the Legionella Key Risk Review group of any changes to ACoP L8 and HSG 274 Parts 1 to 3 and Water Regulations.

• Manages the University Water Management team

• Liaising with the water undertaker and ensure that equipment that is permanently connected to the water supply is correctly installed and where applicable maintained.

• Co-ordinates training of all relevant staff members – RP, DRPs, APs, CPs and awareness delegates.

• Attend updated management training to Responsible Person level every three years or sooner if identified by training needs analysis.

WCM

As required



POLICY – AUTHORISED PERSON (WATER) – MAINTENANCE

By Who? Frequency

The following is an overview of the responsibility, authority and resources aspects of Authorised Person (Water) - Maintenance’s role in the water/Legionella risk management system: -

This role is normally undertaken by the Estates and Facilities Management (EFM) Location Manager.

Authorised Person(Water) - Maintenance

The AP(Water) Maintenance: -

• Owns the water system from handover through to de-commissioning or handover to the “AP (Water) - Projects/Design” team for refurbishment or decommissioning.

• Ensures that the operation, maintenance and monitoring of water systems follows the Water/Legionella Risk Procedures.

• Issues all relevant PPM work orders to Competent Persons and to ensure all PPM works are completed and recorded on the University Planon system.

• Ensure non-compliant occurrences or issues identified in periodic PPM tasks are reviewed and reported to the Water Compliance Manager and then actioned in a timely manner.

• Has responsibility for the water/Legionella risk associated with the operation, maintenance and monitoring of the water system.

• Appoints only Competent Persons (Water) to carry out small installations and maintain, repair, refurbish, monitor existing water systems.

• Ensures any consultant, professional service or contractor are suitably qualified and competent to undertake the respective work instruction.

• Authorises works undertaken by contractors, or affecting the water distribution system.

• Ensures that the work will be the subject of a risk assessment and a method statement produced prior to undertaking any work on the water systems takes place.

• Attend updated management training to Authorised Person (AP) level every three years or sooner if identified by training needs analysis.

AP

AP

AP

AP

As required

As required

As required

As required



POLICY – AUTHORISED PERSON (WATER) – PROJECTS/DESIGN

By Who? Frequency

The following is an overview of the responsibility, authority and resources aspects of the “AP(Water) - Projects/Design role in the water/Legionella risk management system: -

For each single project the AP (Water) for Projects and Design will delegate the responsibility to each appointed project manager.

AP(Water) – Projects/Design (Delegated Project Manager): -

• Owns the water system from feasibility through to handover.

• Follows the Water/Legionella Risk Procedures and ensures that the design, project management, construction, testing, commissioning and handover of water systems takes into consideration current guidance.

• Considers elimination/substitution of water systems/components at the feasibility/design stage.

• Appoints Competent Persons to undertake construction, installation, commissioning and testing.

• Has responsibility for the water/legionella risk inherent in the design of the water system and the risks associated with its construction, installation, commissioning and testing.

• Authorises works undertaken by contractors, or affecting the water distribution system.

• Ensures any consultant, professional service or contractor are suitably qualified and competent to undertake the respective work instruction.

• Ensures that the work will be the subject of a risk assessment and a method statement produced prior to undertaking any work on the water systems takes place.

• At handover ensures that the Water Compliance Manager and AP (Water)- Maintenance is provided with documented evidence of the design, construction, installation, commissioning and testing.


AP

AP

AP

AP

AP

As required

As required

As required

As required

As required

As required



POLICY – COMPETENT PERSON (WATER)

By Who? Frequency

The following is an overview of the responsibility, authority and resources aspects of the Competent Person’s role in the water management system: -

A Competent Person (CP) is described as a trades person, technician or other status who works with water or on water systems and has attended CP training.

Competent Person(Water)

The CP(Water): -

• Ensures that his/her operation, maintenance and monitoring of water systems follows the Water Management Logbook.

• Has responsibility for the water/legionella risk associated with his/her operation, maintenance and monitoring of the water system.

• Only use WRAS approved materials when working on water systems

• In the prevention of contaminating systems and outlets maintain good hygiene practices with tools, equipment, components and materials to be used.

• Ensure good personal hygiene (including clothing and footwear) practices and reporting any communicable diseases to the AP before working on any water system.


CP

As required



POLICY – AUTHORISING ENGINEER (WATER)

By Who? Frequency

The University retains an Authorising Engineer (Water) as its source of competent help.

The AE(Water): -

• Acts as an independent professional adviser to the organisation.

• Appraises and make recommendations for the appointment of Responsible Persons

• Attends a quarterly review meeting with the Water Compliance Manager and provides a record of the event.

• Provides advice on positive sample results and other non-compliant issues

• Reviews and revises the water and legionella policy/procedures. The objective is to ensure the document remains compliant and up to date with necessary guidance.

• Undertakes an annual audit of the University water and legionella risk management system in order to assess its suitability and effectiveness.

• Identify where improvements are necessary to meet the current requirements of HSE ACoP L8 and HSG 274 Parts 1, 2 and 3.

• Evaluate management, operation, training and record-keeping status.

• Compile and issue a formal water and Legionella risk management audit report detailing where key issues are not up to standard and how these can be made compliant.

• Provide update training for Competent Persons.

RP As required



POLICY – RESPONSIBILITY OF OTHER UNIVERSITY STAFF: -

Laboratory Technicians, Engineers and Others who may have an involvement with water and water systems within the University

Other Staff

All staff as identified above, including temporary and agency staff, are responsible for

Compliance with relevant process documents Co-operating with the development and implementation of policies and procedures and as part of their normal duties and responsibilities

There is a duty on all Staff to report any potential biological hazard or anything that is not normal with the water systems that could introduce harmful bacteria such as Legionella or Pseudomonas Aeruginosa.

Such examples are: -

• Water temperature, this could be warm cold water or cold hot water.

• Extreme hot water from any outlet where full immersion is possible, i.e. shower or bath

• Any discolouration of water from the outlet

• Loss of pressure to both hot and cold supplies

• Scaling or unclean water outlets including shower heads

• Any outlet that may be producing a fine spray. Typical example and often found is a loose joint where a shower hose meets the shower head.

• Stagnating water, this could be a tap or outlet that is no longer used or somewhere where water is ponding. Legionella can be found in any water system including medical equipment used in an operating theatre.

• Little used outlet including showers. If due to operational requirement the outlet cannot be removed, then the risk needs to be managed by flushing.

• Attend Legionella awareness training.

Any reported incident will be investigated by the University water team, plumber or mechanical engineer



POLICY – RISK ASSESSMENT

By Who? Frequency

All current Legionella Risk Assessments and associated Water Schematics are listed by building code on the University of Sheffield MiCad Website.

As shown in the Risk Assessment Register (Document OPP_WC 005), each building has been identified by level of risk.

Based on the assessed risk of the building, these Risk Assessments and Schematics are reviewed at the frequencies listed below

Water System Risk

Frequency

High Every 2 Years Moderate Every 2 Years Low Every 3 Years

Buildings identified as High Risk may have in place additional monitoring procedures to eliminate the need for increased frequency reviews. The University will undertake and review legionella risk assessment under the following circumstances: -

• On a regular basis, frequency dependent on risk as described above

• Change of building use or occupation

• After refurbishment

• As part of remedial works to the identification of Legionella or other harmful bacteria

At the time of each risk assessment, schematics of hot and cold water systems and other specialist systems are checked to show that they are up to date and the existence of water connections to outside services is checked.

Risk Assessment: -

• Is undertaken employing competent help

• Identifies and evaluates potential sources of risk

• Encompasses all buildings and all water systems

• Takes account of healthcare requirements and high susceptibility populations

RP

WCM

WCM

As required



POLICY – WATER SYSTEM SCHEMATICS

By Who? Frequency

Under the control of the Water Compliance Manager (WCM) Water system schematics are produced for all hot and cold water systems.

The schematic layout drawings will generally show a representational view of the distribution pipe work, storage systems in plant and tank rooms and sentinel outlets.

For each water system that presents a risk from Legionella bacteria, a schematic or drawing shall identify: -

• Origin of water supply • General layout of the system, i.e. piping routes • Location of the system within and around the premises • How the system operates • All associated storage and header tanks • Calorifiers, hot water heaters and other generators • Relevant items of plant, generally to include water

softeners, supplies to laboratory equipment, pumps, expansion vessels and thermostatic mixer valves (TMV)

• Any problem areas such as dead legs; • Any main control valves and test points.

These schematics/drawings may also show: -

• All outlets, for example showers, normal and emergency, wash hand basins, external bib taps, irrigation points and so on.

• All associated pipework.

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

WCM

DRP/RP

As required

2-3 years and as required



POLICY – EMPLOYEE CONSULTATION

By Who? Frequency

Employees are consulted regarding the assessment and control measures.

This is done through the Legionella Key Risk Review meeting and generated down the Health and Safety Committee structure.

The University employs its own water management engineers and through these members of staff building users are provided with a narrative of control procedures and any issues.

RP/WCM

Continuous



POLICY – RISK MINIMISATION WRITTEN SCHEME

By Who? Frequency

The Health and Safety Executive refers to the need for a “Written Scheme” to manage the Legionella risk.

The Written Scheme is considered to consist of all elements within this policy document under the headings of: -

Section 1 - Policy

Section 2 - Procedures

Section 3 – Work Instructions

Section 4 – Log Book

More specifically, a Risk Minimisation Scheme is produced as a result of the risk assessments and is a costed, prioritised programme of remedial works, based on the concept of ALARP (as low as reasonably practicable).

The Risk Minimisation Scheme is the “Master Defects List” which is maintained by the Water Compliance Manager and located on the M Drive under the Estates “Water Management Team” Folder.

All maintenance tasks containing any work element, which help to prevent the proliferation of Legionella; are contained in the Planned Maintenance System, “Planon” and also on Annual Monitoring Temperature Sheets and periodic tasks and inspections that are also found on the M Drive as identified in the paragraph above.

WCM

As required



POLICY – DESIGN CONTROL

Who? Frequency

Water cannot be entirely free from aquatic organisms. Therefore, measures have to be put in place to prevent conditions that would encourage microbial growth. To reduce the risk of outbreaks, the design of potable 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 potable water.

No new water systems shall be introduced and no changes shall be made to water systems unless they have first been authorised by the Authorised Person – Development Team.

To avoid potential costly remedial works, the design of new buildings and their water systems is controlled in order to “get it right first time”. The RP and WCM provide the Development Team AP with a standard specification and examples of design preferences to a standard “As Low as Reasonable Practicable” (ALARP) shown on the next page. These guides are not a design brief and not intended to deal with potential design issues.

Hot & cold water supplies are maintained as potable. As such the design and installation of hot and cold water services, and associated plant and equipment, in new, upgraded or refurbished premises will comply with documents details below: - [a] Water Supply (Water Fittings) Regulations 1999 [b] BS8558:2015 Guide to the design, installation, testing and

maintenance of services supplying water for domestic use within buildings and their curtilages – Complementary guidance to BS EN 806

[c] Building Regulations 2010, Approved Document G. (New in 2015)

These documents detail the minimum standards for potable water storage for domestic use. For example, the design of pipework should ensure no potential for cross connection between installations conveying potable and non-potable water or water from a private source. All pipe work conveying a liquid other than that provided by the utility company should be clearly labelled.

The University’s policy is to comply with Building Regulations Part G and install thermostatic mixing valves (TMVs) for baths, showers and where a documented risk assessment by the designer or University has shown a TMV to be necessary.

RP

As required



The following documents will be consulted for guidance for the general design and operation of water systems on all premises: -

HSE Approved Code of Practice (L8) – “Legionnaires’ disease: the control of Legionella bacteria in water systems”.

HSE HSG274 Legionnaires’ Disease, Parts 1-3: Part 1 – Control of Legionella Bacteria in Evaporative Cooling Systems Part 2 - Control of Legionella Bacteria in Hot and Cold Water Part 3 – Control of Legionella Bacteria in Other Water Systems



POLICY – DESIGN CONTROL (CONT’D) ALARP MATRIX:-(As Low as Reasonably Practical)

Yellow (Conventional Practice)

Green (Good Practice) Blue (Best Practice)

Drinking water Stored mains water. Mains water. Mains water. Cold water storage Single or multiple

tanks with conventional ball valve(s).

Single tank with delayed action inlet valve.

No storage (for smaller buildings). Single tank with delayed action inlet valve (for larger buildings).

Water saving devices None. Fitted to existing with attention to pipe sizing eg fitted only in very high use areas.

Fitted to new build or major refurbishment.

Grey water (rain water) systems

Present, with PPM, labelling, UV treatment with cartridge filtration, transmission detector/alarm, quartz sleeve wiper mechanism.

Absent. Absent.

Small hot water systems

Combi cylinder. Point of use water heater.

Instantaneous water heater.

Conventional domestic cylinder.

Combi boiler.

Solar pre-heating Large hot water generation

Conventional calorifier.

Plate heat exchanger with buffer.

Plate heat exchanger.

Gas fired water heater Vented or unvented hot water.

Unvented with WRAS approved cul-de-sac diaphragm vessel.

Unvented with WRAS approved flow-through diaphragm vessel.

Unvented with WRAS approved flow-through diaphragm vessel. Vented.

Large hot water distribution

Single pipe. Flow and return recirculating system.

Single pipe trace heating.

Recirculating loop.

Showers Conventional showers ie on flow and return system.

Self-purging showers on flow and return system.

Electric showers.

Rain/massage multi-function heads.

Single function shower heads.

Single function shower heads.



POLICY – DESIGN CONTROL (CONT’D)

Yellow (Conventional Practice)

Green (Good Practice) Blue (Best Practice)

Water temperature monitoring

Calibrated gauges. Calibrated BMS sensors. Calibrated BMS sensors.

Scalding protection ("vulnerable user group" defined as nursery children, healthcare patients/visitors and others where identified in specific documented risk assessment. "Less vulnerable" means anyone not in the vulnerable user group).

TMVs on baths, showers and whb for vulnerable user group.



Separate hot/cold taps on whb with plug for less-vulnerable.

Monobloc tap on whb for less-vulnerable.

Monobloc tap on whb for less-vulnerable.

TMVs on baths/showers only if new, for less vulnerable group.

TMVs on all baths/showers.

TMVs on all baths/showers.

No TMVs on sinks in kitchens, laboratories, cleaners rooms.

No TMVs on sinks in kitchens, laboratories, cleaner’s rooms.

No TMVs on sinks in kitchens, laboratories, cleaner’s rooms.

Cooling Evaporative cooling Dry cooling Passive/natural ventilation

Dry/wet cooling

Humidification Adiabatic None None

Steam



POLICY – TRAINING, COMPETENCE AND CONTRACTORS

Who? Frequency

Legionella risk management training is provided to staff, appropriate to the responsibilities of each staff member in accordance with the training matrix below. General awareness is carried out by the Water Compliance Manager who also maintains Legionella training records located on the University M Drive. All other training is conducted by external consultant. The competence of the Responsible Person and Deputy Responsible Person is assessed by the Authorising Engineer (Water). The competence of Competent Persons is assessed by the Authorised Persons. Assessment is based on a combination of knowledge, experience, qualification and ability to perform the duty.

RP AE/RP/DRP AP

As required Every 3 years, as required At start

Training Matrix: -

Role Training Course Duration Frequency

Duty Holder “Water and Legionnaires’ Disease: An Executive Briefing” with AE

15 minutes One-off

Responsible Person (RP), Deputy Responsible Person (DRP)

“Legionnaires’ Disease: Role of the Responsible Person” - Management

One day Every 3 years

RP, DRP and Authorised Person

“Legionnaires’ Disease: Role of the Authorised Person” - Technical

One day Every 3 years

Competent Person “Legionnaires’ Disease: Role of the Competent Person”

Half day Every 3 Years

Other staff involved in Risk Control Technical Services other trades, Faculty Technicians, Facilities Managers, Cleaner Operatives, Porters and others who may have a responsibility to water and water systems

“Legionnaires’ Disease: Awareness”.

1 hour Every 3 Years



POLICY – TRAINING, COMPETENCE AND CONTRACTORS (CONT’D)

Who? Frequency

Contractor competence/code of conduct The roles and responsibilities of contractors involved in the Legionella control regime shall be agreed in writing and form part of contract documentation. Any deviation from the initial contract documents must be agreed in writing after review of the process. The competence of such contractors is continually assessed by the Water Compliance Manager. For Legionella testing laboratory competence, the Laboratory must be independent have UKAS accreditation and be on the University approved supplier/contractor list. Unplanned Maintenance Tasks Prior to the commencement of any reactive maintenance or minor projects by an external contractor which involve any invasive works to the water systems or which require isolation of the water systems will be subject to the following: -

• Contractor must be a University approved contractor. • All contractor’s workforce must have an induction prior to

working on site unescorted. This induction is carried out at the Estates and Facilities Management Help Desk.

• Each contractor employee must have a valid UKATA Asbestos certificate or other approved certificate.

• Any other contractors required for urgent attendance must be escorted by a suitable University member of staff at all times during the period on site.

• A Method Statement and Risk Assessment shall be provided by the contractor and agreed. Copies will be held in the individual site or incident folder on the University M Drive.

• All details of the work including flushing or disinfection to be recorded including the name of contractor and/or persons working on the system. These will be recorded on the M Drive as stated above for Method Statement and Risk Assessments.

• The requirements for disinfection or flushing will be assessed on a job by job basis. However, as a minimum requirement, any pipe work or fittings to be installed in the system shall be pre disinfected.

Contractors Specialist Contractors are used to supplement the University Water Team to carry out: -

• One off system chlorination because of alterations to systems or poor test or check results in any area.

• Contractors are appointed in accordance with the University Control of Contractors Policy.

WCM and AP’s

As required



POLICY – RISK MANAGEMENT AUDIT

Who? Frequency

An annual water management audit is undertaken by the Authorising Engineer (Water) in order to ascertain the effectiveness of the overall Legionella control and aspects of water quality management arrangements. The methodology for audit may vary from year-to-year in order to ensure a fresh outlook on each occasion and to ensure compliance with HSE latest guidance and other statutory requirements. The audit report includes recommendations for improvement and forms part of the water management system. A quarterly audit of site log books is also undertaken. All details and records of audits can be found on the University M Drive

AE/WCM

AE/WCM

Annually

Quarterly



POLICY – EMERGENCY AND OUTBREAK ACTIONS

Who? Frequency

Contact details, both during office hours and out-of-hours, of the Responsible Person, Deputy and other key people, including on-call are kept at the Security Control Centre. Major Plant Failure Whilst emergency procedures are covered in this procedures document, all of the incidents described below are part of the University Emergency Plan. Chemical System Failure There are two water systems for which this is relevant: -

• Swimming pool at the Leisure Centre, Goodwin North. • Cooling towers at AMRC Catcliffe

The response to chemical system failures for the cooling tower is the responsibility of the relevant department and Estates and Facilities Management. Primary Heat Source Failure Heat is provided under contract by Veolia. In the event of failure of the heating system supply, the Water Compliance Manager through the Responsible Person and Location Manager will assist with the provision of temporary boilers, until the heating supply is reinstated. Electrical Power Failure This will affect domestic hot water circulating systems. The action to be taken is as follows: -

• Shut down the source of heat transfer. • Provide water for use at below 20oC. • Monitor temperatures and take samples for Legionella

testing. • Notify users and keep them updated. • Depending on the duration of the failure, which may

involve draining the system down, consider disinfection (see procedure “DHW Temperature Below 45oC”).

If the building is supplied by a boosted cold water system: -

• Reduce building occupancy or close the building. When power is restored, the Building Management Services MS (BMS) Team will respond when systems don’t reset. Where remedial actions are required, the BMS Team will inform Technical Services and or the WCM.

RP

DRP/WCM/Location Manager

Location AP

As required

As required

As required



POLICY – EMERGENCY AND OUTBREAK ACTIONS (CONT’D)

Who? Frequency

Water Supply Quality/Quantity Failure The action to be taken is as follows: -

• Monitor temperatures and take samples for Legionella testing.

• Notify users and keep them updated. • Depending on the duration of the failure, which may involve

draining the system down, consider disinfection. If a failure of the supply quality occurs: -

• Isolate the water supply at the first stop valve to prevent further contamination.

• Identify the areas affected. • Notify users with instructions and guidance on affected plant

and equipment (including research and animal welfare). • Draw up a programme of loss through to re-instatement. • Investigate alternative supplies such as nearest toilets,

drinking water, and consider the provision of mobile tanks. • Advise on further instructions for reinstating supplies, issue

instructions for reconnection and by whom. • Take samples for microbiological testing (including Legionella

where relevant) throughout this process. If there is a water supply quantity failure: -

• If the building is mains fed without storage or is supplied by a boosted cold water system, reduce building occupancy or close the building.

Records For water quality testing the University takes samples using bottles provided by an appointed independent UKAS laboratory who then conducts the sample analysis. All certificates and interim or out of specification reports are filed on the M Drive. Where an occurrence has been recorded as an incident; all records, in addition to the above will be recorded under that incident report and recorded in a separate folder located on the M Drive. This will assist in problem solving and to provide a background for “Lessons Learnt”

WCM/AP Location

WCM/AP Location

WCM/AP Location

WCM

As required

As required

As required

As required



POLICY – EMERGENCY AND OUTBREAK ACTIONS (CONT’D)

Who? Frequency

Outbreak of Legionella

The following actions apply in the following circumstances: -

• An outbreak, suspected or confirmed as being centred at a University premises;

• An outbreak, the source of which has yet to be confirmed, but which is believed to be centred in area which includes a University premises.

An outbreak is defined as 2 or more confirmed cases of legionella occurring in the same locality, closely linked in time (weeks rather than months). An outbreak is declared by the Consultant in Public Health Medicine [CPHM] / Consultant in Communicable Disease Control (CCDC). The CPHM/CCDC invokes an Outbreak Committee, involving all the relevant agencies. The Health and Safety Executive (HSE) or Environmental Health Office (EHO) may be involved in the outbreak investigation. The organisation will follow the guidance presented in Appendix 2.3 of HSG274 Part 2.

The CPHM/CCDC, EHO and/or HSE may make a site visit. The enforcing authority, either HSE or local authority may make the following requests and recommendations: -

• Shut down aerosol producing processes until sampling, cleaning, other remedial work and clearance to restart are have occurred.

• Water sampling before disinfection.

• Provide staff health records and help prepare case histories of people affected.

• Co-operate fully with the investigation of any suspect plant e.g.: - Tracing pipework; Scrutiny of operational records; Statements from plant operatives and managers; Statements from water treatment contractors or

consultants. If any relevant legislation has been encroached on, then the organisation may be subject to a formal investigation by the HSE or EHO.

On conclusion of the investigation, the outbreak control team will submit a public report on its findings. The original report will be located on the M Drive under Health and Safety.

RP/WCM

WCM

WCM/RP

As required

As required



POLICY – DRINKING WATER

Who? Frequency

Staff members draw off water for drinking from identified as Drinking Water outlets. Drinking water outlets are provided in convenient locations and clearly identified if not from a kitchen sink or water fountain. Drinking water for meetings and events is provided in jugs or bottles filled from the tap. These may be cooled in a fridge beforehand. Free-standing bottle water coolers are generally discouraged from University buildings. Where existing units are found, removal is considered. In some circumstances plumbed-in water coolers are provided for students in heavily used buildings that used for day and night studying. Subject to approval by the WCM. A programme of maintenance and monitoring of water systems and quality is undertaken to assure water is potable at Drinking Water Outlets. Testing of water is undertaken in response to taste, odour or discoloured water complaints. ACS provides chilled bottled tap water for students at meal times.

WCM/RP

WCM/RP

WCM

WCM

ACS

As required

As required

As required

As required



POLICY – DOCUMENTS AND RECORDS

The document structure is as follows: -

Document:- Implemented by: -

Interaction with Authorising Engineer(Water):-

Section 1 Policy Statement Duty Holder

Responsible Person (Water)

Water Compliance Manager/Deputy Responsible Person

Assurance Statement Audit Report, Risk Assessment Reports, Review Meeting Minutes

Section 2 Procedures Water Compliance Manager

Authorised Persons

University Water Team

Risk Minimisation Scheme

Section 3 Work Instructions University Water Team Competent Persons

Update Training

Section 4

Log Book

University Water Team

Competent Persons

Update Training

All of the above form the University of Sheffield Policy Document for the Control of Legionella and Water Quality. A copy can be found on the University Website.

The following records are kept: -

Record Retention Period

Policy statement, policies, procedures and work instructions Throughout the period for which they remain

current and for at least three further years and a total minimum of five years.

Risk assessments

Risk minimisation scheme and details of its implementation

Monitoring, inspection, test and check results, including details of the state of operation of the system

At least five years

All of the above records can be found on the University M Drive.



POLICY – DOCUMENTS AND RECORDS (CONT’D)

Who? Frequency

REVIEW The Responsible Person and Deputy Responsible Peron (DRP) (Water) will ensure that each policy document is reviewed in accordance with the timescale specified at the time of approval. No policy or procedure, including Terms of Reference will remain operational for a period exceeding three years without a review taking place. Staff who become aware of changes in practice, changes to statutory requirements, revised professional or clinical standards and local/national directives that affect, or could potentially affect policy documents, should advise the Responsible Person or Deputy Responsible Person (RP/DRP) as soon as possible, via line management arrangements. The RP/DRP will then consider the need to review the policy or procedure outside of the agreed timescale for revision. If the review results in changes to the document, then the initiator should inform the Policy manager who will renew the approval and re-issue under the next “version” number. If, however, the review confirms that no changes are required, the title page should be renewed indicating the date of the review and date for the next review and the title page only should be re-issued. For ease of reference for reviewers or approval bodies, changes should be noted on the “Document History” table. Archiving

The Water Compliance Manager under the direction of the RP (Water) will ensure that archived copies of superseded policy documents are retained in accordance with the above table.

RP/DRP/WCM

RP/DRP

WCM

As req’d and at least every 3 years

As required

As required