STANDARD PROCEDURE FOR THE CONTROL OF LEGIONELLA BACTERIA IN

WATER SYSTEMS

FOR

THE UNIVERSITY OF BRADFORD

Revision 3: May. 2010.

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LEGISLATION

HSC L8 (2000) Control of legionella Bacteria in Water Systems is the Approved

Code of Practice and Guidance for the control of Legionella bacteria in water systems
sets out the statutory requirement for dealing with risk. This applies to all premises with
a water system/s. This document includes consideration of the development of new
control technologies and takes account of a number of points that have arisen in the
practical application of HSG 70. This document has “special legal status” and is
considered as being law.

Health and Safety at Work Act 1974 is the statutory instrument that underwrites and
legally enforces HSC L8 (2000).

Notification of Cooling Towers and Evaporative Condensers Regulations 1992

requires all owners of cooling towers and evaporative condensers to formally notify
Local Authority of location and type.

The Control of Substances Hazardous to Health Regulations 1999 relates to the

risk from hazardous micro organisms, including Legionella and chemicals such as
biocides and disinfection agents. Under these regulations, risk assessments and the
adoption of appropriate control measures are required to be put in place.

RIDDOR Regulations 1995 is the legal reporting mechanism by which dangerous

incidents/occurrences including outbreaks of legionnaire’s disease are notified to the
Health and Safety Executive.

SUPPLEMENTARY DOCUMENTATION

C.I.B.S.E. TM13 (2000) this Technical Memoranda offers collective advice on how to
minimise the risk of Legionnaires disease from engineering services in buildings and
complements and enhances HSC L8 (2000).

Health Technical Memorandum’s 2040 and 2027 (Healthcare Premises) provides

recommendations, advice and guidance on controlling legionella and good practice in
healthcare premises. It is applicable to new and existing sites and is for use at various
stages during the inception, design, upgrading, refurbishment, extension and
maintenance of a building. Although not legislative (apart from where applicable to
healthcare premises) it sets good practice.

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BS 6700: 1997 Specification for design, installation, testing and maintenance of
services supplying water for domestic use within buildings and their curtilages.

SPECIFICATION

Specification for the Identification and assessment of risk of legionellosis in buildings

owned by the University of Bradford.

• HSC L8 (2000)

• COSHH Regulations 1999

• Health and Safety at Work Act 1974

• Health Technical Memorandum’s 2040 and 2027 [Healthcare Premises]

A suitable and sufficient assessment should be carried out to identify and assess the
risk of Legionellosis from work activities and water sources on the premises and any
necessary precautionary measures.

The purpose of the assessment is to enable a valid decision to be made about

a) The risk to health, ie whether the potential for harm to health from exposure is
reasonably foreseeable unless adequate precautionary measures are taken.

b) What measures for prevention, or adequate control to minimise the risk from
exposure to legionella, should be taken.

INTRODUCTION

The procedure for the control of Legionella bacteria in water systems within University
of Bradford buildings and properties shall be in accordance with the Approved Code of
Practice HSC L8 (2000). This document has special legal status and should be
considered as law.

Legionellosis is the term used for infections caused by Legionella pneumophila and
other bacteria from the family of Legionellaceae. Legionnaires disease principally
affects those who are susceptible due to age, illness, immunosuppressant, smoking etc
and in some circumstances may be fatal. Legionella is widespread in natural sources of
water.

Infection is attributed to inhaling Legionella in droplet form small enough to penetrate

the lungs – normally aersol. Most outbreaks of legionella have been attributed to water
services in buildings, cooling towers, hot water systems and spa baths.

The majority of the University of Bradford properties house some form of water storage
system which is susceptible to bacteria, therefore deeming it necessary to have
procedures to minimise the risk of Legionellosis.

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MANAGEMENT

Director: Duty and budget holder.

• The Director of Estates and Facilities is the designated person responsible for
ensuring the identification and assessment of a risk programme for the
prevention of Legionellosis and is the budget holder for the Department. The
Director of Estates and Facilities shall have the co-operation of all University staff
in controlling the risk of legionella.

Deputy Director: Deputy Duty and budget holder health & safety manager.

• The Deputy Director of Estates and Facilities is the designated deputy

responsible person and is tasked with the management of compliance of HSC L8
(2000) and has overall responsibility for Health and Safety in the department.
The post is responsible for ensuring adequate budget allocation and resources to
achieve compliance.

Estates Manager Engineering and Building: Operation, design/ capital works and
compliance manager.

• The Estates Manager Engineering and Building is responsible for maintenance

and operations of the estate. Acting on information received, ensuring resources
is correctly allocated and planned. Ensuring remedial work is indentified, as well
as carrying out detailed investigations of exceptions and emergencies.

Mechanical Maintenance Officer: Operations manager.

• The Mechanical Maintenance Officer is responsible for day-to-day management

of the Water Quality Technician, overseeing and periodic checking of the
database and risk assessments. Transmitting information up the managerial
chain from the Water Quality Technician. Acting on information received,
organising initial investigations of exceptions and emergencies.

Water Quality Technician: Compliance operative

• The Water Quality Technician has day-to-day responsibility for the management
of the computerised database ensuring all information is up-to-date and
maintained in orderly manner. Taking and recording temperatures and inputting
them into the database. Checking and investigating exceptions. Undertaking
routine activities including flushing and cleaning items such as shower heads.

Refer to the Organogram for line management responsibilities

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In the event that Water Quality Technician is absent through leave and/or sickness
essential duties are carried out by a member of either the plumbing team or a Shift Plant
attendant.

General Management Procedures

No work on water systems shall be carried out unless under of the direction/knowledge
of the Department of Estates and Facilities. This will allow the University to comply in
full with HSC L8 [2000] with constant auditing of work in progress, planned maintenance
procedures and monitoring regimes, it is essential all log books are up dated and are
current.

In the event of a LEGIONELLA POSITIVE water sample returning from the laboratory or
any untoward findings, the said reporting procedure shall be adhered to. All information
received shall be forwarded to the Director of Estates and Facilities or one of the
nominated deputies for immediate action. If no instruction has been received to carry
out remedial works within 24 hours, the request shall again be made in writing, with a
copy to the Universities Health and Safety Adviser and to the Director of Estates and
Facilities or to any of the nominated deputies.

In the event of the either the Director and/or the Deputy Director of Estates the Estates
Manager (Engineering and Building) Services being unavailable, the Reporting
Procedure shall be adhered to (see Appendix)

Communication in reporting shall be FAIL SAFE.

PROPERTIES

All buildings that have water services are susceptible to colonisation by Legionella.

After the initial risk assessments, a scheme shall be established to follow the
procedures set out in L8 (2000), which shall include the following; this will vary from site
to site depending on the risk assessments. This is not an authoritative list and L8 (2000)
shall be consulted to provide a comprehensive set of actions.

a) Inspection of water storage tanks every six months

b) Visual inspection of the hot water calorifiers annually
c) Visual checks of temperatures and settings of calorifiers every month
d) Temperatures of hot and cold-water outlets every month (Sentinel taps)
e) Legionella water samples to be taken annually (where appropriate)
f) Cooling towers to be monitored on a minimum of a weekly basis, to ensure
biocide levels are acceptable, towers to be cleaned and chlorinated at least every
six months. Legionella water samples to be taken quarterly.
g) Cleaning and disinfect ion of shower heads (quarterly)
h) Flushing of infrequently used outlets (weekly)

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i) Checking other outlets on a rotational basis over a 12 month period recording
temperatures in log book.

The Water Risk Assessments and logbooks are computer based. Information regarding
assessments and the buildings’ logbooks are recorded and filed on this programme
which is accessible by Estates and Facilities Department. Monitoring and inspections of
water systems is recorded in the logbook and the water risk assessment is updated
following any works, alterations or subsequent re-assessments. Tight control shall be
established with the use of in-house staff. This will entail monitoring, as set out in the
individual log book/risk assessment.

In the event of a building either not used or put into “hibernation” control regimes will be
maintained until such time the building can be properly drained down and
decommissioned into a safe state. When the building is brought back into operation a
new risk assessment will be commissioned, all water services checked and chlorinated
to the standard as indentified in this document. It is incumbent on all departments and
schools to advise Estates and Facilities when buildings or parts of building are not being
used so the appropriate risk prevention can take place.

TRAINING

Lack of training and poor communication has all been identified as a contributory factor
in outbreaks of Legionella. It is the responsibility of The Department of Estates and
Facilities that all communication is properly defined and clearly set out.

Staff shall be trained to understand the need for measures to control Legionellosis and
the need for care in the recording and reporting procedure. Basic instruction on record
keeping and monitoring techniques shall be taught, with health and safety aspect in
mind. Members of staff shall be trained so that if one trained member of staff is absent
or leaves, the line of communication is unbroken, ensuring all staff are trained
adequately and have basic awareness relating to water quality and Legionnaires
disease.

Staff will be trained to carry out the following basic tasks of:

a) Visual checks of temperature readings of water storage vessels

b) Take and monitor temperatures of hot and cold-water outlets
c) Run showers or any potential dead leg that are not used on a regular basis - in
accordance with any prevailing risk assessment. All results shall be recorded in
the log book and signed.
d) Disinfect and clean shower heads or any other ‘outlet’ device that requires this
action.

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AUDITING

It is essential that “the responsible person” ensures the continuous auditing of all log
books and the monitoring of all risk assessments is being carried out.

After all risk assessments have been completed and the monitoring programme is
established, the records shall be continually updated in accordance with the programme
for the individual building and all documentation shall be kept in an accessible location
for auditing. The Risk Assessment and logbook will be reviewed a minimum of once
every two years.

DISINFECTION

Water services shall be disinfected for any of the following reasons:

i) New installations before being taken into use to remove contamination which
may have occurred during construction
ii) If a routine inspection shows it to be necessary
iii) If the system or part of it has been substantially altered or entered for
maintenance purposes in a manner that may lead to contamination
iv) Following an outbreak or suspected outbreak of legionellosis or any other water
borne infection/disease.

Disinfection shall be carried out in accordance with BS6700.

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 RISK ASSESSMENT FOR LEGIONELLOSIS

AT

UNIVERSITY OF BRADFORD

SCHEME

The scheme shall consist of a risk assessment for the control of Legionella in water
systems in identified properties.

a) ASSESSMENT

A risk assessment shall be undertaken of all water storage cisterns, calorifiers,

cooling towers and associated pipework which are susceptible to colonisation by
Legionella. The risk assessment shall follow the Procedure set out in the
Approved Code of Practice for the prevention of Legionella. The assessment
shall follow the guidelines in HSC L8 (2000).

b) DISCRETION

Total discretion shall be adhered to by any contractor on any untoward findings

during a risk assessment and also on results of any water samples taken.

All findings to be reported through the REPORTING PROCEDURE (refer to the

appendix)

c) WATER SAMPLES

Total Viable Cell Counts and/or Legionella samples shall be taken if during either
the risk assessment or routine inspection of the condition of the water service
gives rise to concern. The contractor shall obtain two 1litre water samples in a
sterile container, one from the hot water distribution system and one from the
cold-water distribution system. The samples to be sent away to an independent
UKAS accredited laboratory for analysis, within 24 hours.

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d) CERTIFICATES

Chlorination and Legionella test certificates shall be sent to the Department of

Estates and Facilitates to enable the legal documentation to be updated and the
asset register to be altered accordingly.

e) MONITORING/AUDITING REGIME

Monitoring shall be carried out as prescribed by HSC L8 (2000).

On completion of a risk assessment a monitoring regime shall be formatted and

shall then be inserted into the site logbook. It is proposed that all properties be
audited annually. All results from the monitoring regime shall be inserted into the
site logbook; the assessor shall sign and date the logbook on every site visit.

Estates and Facilities personnel competent to do so can carry out the weekly,
monthly, and quarterly monitoring regimes in-house. However, water-sampling
and the tasks requiring engineering skills shall be done by an approved and
competent contractor.

f) SITE LOG BOOK

Risk assessment on completion shall be formatted and delivered to the

Department of Estates and Facilities.

The site logbook shall contain:

i) Full site address

ii) Name of site contact (managerial)

iii) Name of risk assessor and the company name

iv) Name of responsible person for the University of Bradford

v) Date of assessment

vi) Schematic drawing of water storage tanks and associated pipe work

vii) Detail of operation, relevant to the controlling the risk

viii) Controls to be implemented, complete with schedule

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i) PHOTOGRAPHIC EVIDENCE

Photographs shall be taken during a risk assessment, to highlight any pipe work
defects, condition of water storage cisterns, calorifiers, evaporative humidifiers ,
showers etc.

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