How to - Manage legionella | Falkirk Council

Legionella bacteria is quite common but usually exists in relatively low numbers. If allowed to grow and multiply it has the potential to become a health concern. Inhaling contaminated water droplets suspended in the air can cause the potentially fatal, pneumonia-like Legionnaires' Disease. It can also cause the similar but less serious conditions of Pontiac Fever and Lochgoilhead Fever.

Under certain conditions any building's water system could be a potential source for legionella growth. Poorly managed, they can provide an environment where legionella bacteria can flourish.

To effectively manage the risks from legionella Falkirk Council will:

assess the risks from legionella in all Council properties
ensure systems are in place to manage the risks from legionella
audit management systems to ensure they are effectively implemented
provide employees with appropriate information, instruction and training to safeguard themselves and others
appoint competent person(s) to provide specialist and technical advice on the management of legionella in Council properties

This How To supports the implementation of the Council's Wellbeing policy and is part of the Council's safety management system.

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Risk Assessment

The Building Design Manager will ensure a current legionella risk assessment is available for all Council workplaces. The legionella risk assessment will be made available to workplaces through the SHE Assure system.

The Property & Asset Manager will ensure a current legionella risk assessment is available for all Council housing stock, which includes sheltered housing.

Where Falkirk Council has leased a non-domestic property to another party the Manager (Asset Management) will ensure that any responsibilities regarding legionella risk assessments are clearly defined in the lease.

A risk assessment is current if it has been reviewed in the last 24 months unless the risk assessment states it should be reviewed more, or less, frequently. For the purposes of this document the duty holder is anyone identified by legislation or the Council who has a specific responsibility for legionella management.

The risk assessment process will include:

an appraisal of the maintenance records to confirm that the water system(s) have been serviced at appropriate intervals and any remedial actions completed within a reasonable timescale
an appraisal of how effectively duty holder responsibilities have been allocated
an appraisal of the competence of individuals with any involvement in legionella management on the premises
an appraisal of the legionella management activities routinely carried out at the premises (see Management Controls)
a visual inspection of the system to identify possible sources of contamination

The findings of the risk assessment will be detailed in a report and include:

the scope of the risk assessment and a description of the premises, its occupancy and the system(s) assessed
the qualifications and experience of the assessor(s)
details all duty holders responsible for, and those who carry out, routine legionella management activities
a schematic diagram of the hot and cold water system(s) identifying:

mains water inlets and drinking water supplies
cold water storage tanks
hot water generation and storage vessels
hot and cold water outlets
little used outlets
drinking water outlets
sentinel points on each system
showers and any aerosol generation
dead legs
external taps

a summary of risks identified, their risk rating and recommendations for remedial or corrective actions
practical, prioritised recommendations for any additional controls or improvements needed to existing controls to reduce any risks identified to as low a level as is reasonably practicable
a recommendation for whether microbiological monitoring is required and, if so, the frequency of sampling
training requirements for those responsible for carrying out regular legionella management activities; including the frequency for refresher training
a recommendation for how often the risk assessment should be reviewed

Risk assessments will initially be carried out by an external contractor but subsequent reviews may be carried out by a suitably competent employee.

The Building Design Manager is responsible for appointing competent person(s) to provide specialist and technical advice on the management of legionella at Council workplaces. If a competent employee is not available an external contractor will be used. For all Council housing stock this will be the responsibility of the Property & Asset Manager who may appoint a competent person(s). Where the Council has leased a non-domestic property to another party the Manager (Asset Management) will ensure that similar responsibilities are clearly defined in the lease.

The risk assessment will be reviewed every 24 months unless the original risk assessment recommends a different review period. The risk assessment should be formally reassessed by an external contractor where there are:

modifications to the water system(s)
changes in the use of the building which will affect how water is used
any indications that control measures (see Management Controls) have not been effectively carried out
there has been an incident involving legionella, water quality or any damage to the water system(s)

At Council workplaces the Premises Manager will ensure that a current legionella risk assessment is available for their property on the SHE Assure system. If they do not have a current legionella risk assessment available they should request that one is conducted by Facilities.

Where the risk assessment identifies remedial or corrective actions an action plan will be put in place to ensure they are carried out within recommended timescales. For Council workplaces this will be the responsibility of the Building Design Manager. For all Council housing stock this will be the responsibility of the Property & Asset Manager.

Remedial and corrective actions must be completed within the recommended timescale. Service Directors will ensure adequate resources are made available for all remedial or corrective actions to be carried out.

Management Controls

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Design

Any modifications to water systems will be designed, managed and maintained to comply with:

The Construction (Design and Management) Regulations 2015
The Building Regulations 2010 (and associated amendments)
The Water Supply (Water Fittings) (Scotland) Byelaws 2014
The Private Water Supplies (Scotland) Regulations 2006
BS EN 806 (Parts 1–5) – Specifications for installations inside buildings conveying water for human consumption
BS 8558 – Guide to the design, installation, testing and maintenance of services supplying water for domestic use within buildings and their curtilages
CIBSE Guide G Public Health and Plumbing Engineering

For Council workplaces this will be the responsibility of the Building Design Manager. For all Council housing stock this will be the responsibility of the Property & Asset Manager. Where the Council has leased a non-domestic property to another party the Manager (Asset Management) will ensure that any responsibilities in relation to modification of water systems are clearly defined in the lease.

Planned preventative maintenance

Maintaining the condition of water systems is important to prevent legionella bacteria from flourishing. A programme of planned preventative maintenance will be put in place. Records of planned preventative maintenance carried out will be maintained and readily available (see record keeping).

For Council workplaces this will be the responsibility of the Building Design Manager. For all Council housing stock this will be the responsibility of the Property & Asset Manager. Where the Council has leased a non-domestic property to another party the Manager (Asset Management) will ensure that any responsibilities in relation to planned preventative of water systems are clearly defined in the lease.

Routine premises checks

At Council workplaces the Premises Manager will ensure arrangements are in place to carry out the following regular checks of the water systems, as detailed in the Premises Manager Handbook:

weekly flushing of little used outlets
monthly temperature checks at hot and cold sentinel points
monthly temperature checks at calorifier(s)

The Premises Manager will also ensure records are maintained on the SHE Assure system and any faults or where temperatures are not being consistently achieved are reported to property.repairs@falkirk.gov.uk as detailed in the Premises Manager Handbook.

The risk of legionella multiplication increases in schools during holiday periods when buildings are closed, or their use is greatly reduced. Children's Services' Senior Asset Officer will ensure arrangements are in place to carry out temperature checks and flush little used outlets at appropriate intervals during holiday periods.

The risks identified by the risk assessments for residential settings are likely to be low; in which case no further action may be necessary. Where the risk assessment identifies that a system of routine checks is required the Property & Asset Manager will ensure these are put in place.

Where the Council has leased a non-domestic property to another party the Manager (Asset Management) will ensure that any responsibilities in relation to routine checks of water systems and remedial actions are clearly defined in the lease.

Microbiological monitoring

Microbiological monitoring will be carried out:

where there is any indication that management controls are not being carried out effectively
if appropriate temperatures are not being consistently achieved throughout the system
if there has been an incident involving legionella, water quality or any damage to the water system(s)
as recommended by a legionella risk assessment
at least once in a 12 month period; except for housing stock unless stated otherwise in the risk assessment

An external contractor will be appointed to carry out any microbiological monitoring required and recommend any remedial or corrective actions.

Issues with the operation and management of the water system will be identified through an audit programme (see Auditing).

For Council workplaces the Building Design Manager is responsible for ensuring microbiological monitoring is carried out when required, appointing an external contractor and ensuring any remedial or corrective actions are completed. For all Council housing stock this will be the responsibility of the Property & Asset Manager. Where the Council has leased a non-domestic property to another party the Manager (Asset Management) will ensure that any responsibilities in relation to microbiological monitoring of water systems are clearly defined in the lease.

More information on microbiological monitoring is available in The Control of legionella Bacteria in Hot and Cold Water Systems (HSG 274 - Part 2).

Information, instruction and training

All employees with responsibilities for legionella Management should have a clear understanding of their role. The Building Design Manager and Property & Asset Manager Appropriate will ensure that appropriate training is made available to employees who require it.

Line Managers will ensure relevant information, instruction and training is provided to any employee whose role is likely to involve any aspect of legionella management.

At Council workplaces the Premises Manager will ensure that those responsible for the carrying out the regular legionella management activities (see Routine premises checks) complete the training as detailed in the premises' legionella risk assessment. The Premises Manager will also ensure refresher training is carried out at appropriate intervals.

Auditing

The Senior Health, Safety and Wellbeing Adviser will implement a programme of audits to monitor whether legionella management control measures are being effectively implemented.

The Senior Health, Safety and Wellbeing Adviser will identify any remedial or corrective actions needed where any failures in legionella management control measures are identified. Remedial and corrective actions will be recorded on the SHE Assure system.

Service Directors will ensure remedial or corrective actions are completed.

Record keeping

Line managers will ensure that records of all initial and refresher training, and their dates, are maintained and are readily available.

Records of legionella risk assessments, monitoring, maintenance and repairs of water systems are maintained and are readily available. For Council workplaces the Building Design Manager is responsible for ensuring arrangements are in place for maintaining records. For all Council housing stock this will be the responsibility of the Property & Asset Manager.

The Premises Manager will ensure that records of routine premises checks (see Routine premises checks) are maintained and are readily available. These checks will be recorded in the SHE Assure System.

The Senior Health, Safety and Wellbeing Adviser will ensure that records of Premises Manager Handbook audits are maintained on the SHIELD Audit and Inspection system and are readily available.

Records will be held for at least 5 years.

Planned preventative maintenance requirements

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Calorifier

Task	Instructions	Frequency
Blowdown of calorifier	Run drain until clear or for minimum of 2 minutes and note condition of water Provide photograph of water sample	6 months
Service calorifier with inspection hatch	Drain it and remove the inspection cover Withdraw the heater elements and clean them thoroughly. Inspect them for damage and replace any that need to be replaced Clean the shell and inspection cover removing all traces of scale Refit the heater elements and inspection cover using new seals of an approved type. Reconnect any pipework that has been disconnected using approved materials (eg PTFE tape, not hemp) Refill and thermally disinfect the entire hot water system	12 months
Service calorifier without inspection hatch	Purge any debris in the base to suitable drain Collect initial flush from base to inspect clarity, quantity of debris and temperature Carry out internal inspection by borescope Check the operation of the safety and/or temperature & pressure relief valve Check and, if necessary, repair the lagging	12 months

Combi Water Heater

Task	Frequency
Inspect internal cold water tank and carry out cold water storage tank checks (see below) Carry out chemical disinfecting according to specification and check temperature profile for control and cut out operational if applicable.	12 months

Direct Water Heater

Task	Frequency
Draw-off water from drain cock and check for water clarity and temperature Isolate both gas and electrics, isolate out flow if possible and flush through boiler to drain Check temperature gauges on flow and return Fire up boiler once system has been restored to normal check flow and return temperatures and controls Carry out internal inspection by borescope	12 months

Temperature Gauges

Task	Frequency
Check accuracy of temperature gauges and thermometers on hot water system	12 months

Cold Water Storage Tanks

Task	Frequency
Check operation of float operated ball valve, water level and shut off. Replace washer if necessary. Check float for leakage and security	3 months
Check temperature of cold water storage tanks. Temperature at ball valve should be <3°C of the incoming supply to the building. Storage should be <3°C of temperature at ball valve.	6 months
Visually inspect cold water storage tanks and carry out remedial works where necessary Check all valves associated with the tanks and repack or replace as necessary Check the connections and pipework for rust and deterioration Check the tanks for damage and deterioration Check overflow and warning pipes are unobstructed, ends are conspicuous and well above the flood over level of a gully Repair as necessary Carry out turnover test	12 months

Shower Heads, Hose and Spray Taps

Task	Frequency
Dismantle, clean and descale spray taps, shower heads and hoses Examine all taps & heads for scale build-up or other deposits and descale any which are not clean Chemically disinfect by removing and immersing in a solution of sodium hypochlorite for one hour	3 months

Hot and Cold Water Taps

Task	Frequency
Carry out temperature checks on all the hot and cold sentinel taps. Temperature of hot taps should be >50°C. Temperature of cold taps should be <20°C.	6 months
Examine all taps outlets for scale build up or other deposits and descale any which are not clean	12 months

Pipework

Task	Frequency
Check all accessible pipework for corrosion, damage, leaks and security of fittings and attachments Check correct materials used in compliance with Water Regulations Advisory Scheme specification	12 months

Thermostatic Mixer Valves

Task	Frequency
Strip down & clean mixer valves Replace strainers Carry out cold water shut-off test	12 months

Point of use Water Heaters (<15 litres)

Task	Frequency
Check water temperatures to confirm heater operates at 50 – 60°C or Check installation has a high turnover	6 months

Expansion Vessels

Task	Frequency
Where possible, flush through and purge to drain Change bladders according to manufacturer's guidelines	6 months

Cleanse and Disinfection

Task	Frequency
Cleanse and disinfection to be carried out as required by HSG 274 Legionnaires’ disease, Part 2: The control of legionella bacteria in hot and cold water systems guidelines	As required (see notes below)

Hot and cold water services should be cleansed, flushed and disinfected in the following situations:

on completion of a new water installation or refurbishment of a hot and cold water system
following installation of new components, especially those which have been pressure tested using water by the manufacturer (see the manufacturer's instructions)
where the hot and cold water is not used for a prolonged period and has not been flushed as recommended or the control measures have not been observed
where routine inspection of the water storage tanks shows evidence of significant contamination or stagnation
if the system or part of it has been substantially altered or entered for maintenance purposes
following water sampling results that indicate evidence of microbial contamination of the water system
during, or following an outbreak or suspected outbreak of legionellosis linked to the system
where indicated by the risk assessment