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Purpose - This document is intended to assist in checking compliance with the LCA Code of Conduct and

to audit LCA Members. It is also available for Members to use as the questions for their internal audit and
Assessor auditing a Member and the Member responding to the LCA. The same steps and process shoul
LCA involvement.

Structure - This document is broken down into tabs for audit details, non-conformity tracker, Code of Cond
coloured yellow where an audit of that standard or code has been completed. Do NOT hide, delete or c

Audit Details - The audit details tab includes administrative details such as name, date etc and other item
record when the audit was done.

There is a status drop down for noting the stage at which the audit is at the time the record is saved. This
LCA), SoC signed off (end of the first stage of application to join the LCA), Audit actions (an audit has been
completed), audit follow up (a Member has responded to the identified actions but the Assessor cannot sig
the Assessor and confirmed as complete).

There is a short explanation of what is required as an action for non-conformances and for observations. T

At the bottom of the Audit Details tab there is a section on each of the different Service Delivery Standards
area of interest. If a service category is registered for the member this should be used for recording an ind
assessments, xxx members of staff work in that area, etc. Exact numbers are not critical but the record of
registered as an area of interest for a Member the Assessor will question if this service has been delivered
conformance and a recommendation made to register the service or stop providing it.

Non-conformity Tracker - this tab is the action plan for the member to see in one place what needs to be
taken to close them out with references to evidence. When a Member has been audited and sends their re
Non-Conformity Tracker tab to see what the Member has done to correct the non-conformance and the de
The LCA assessor should then note any further comments, date and complete or not the audit in the follow
this should be shown in the next set of blue columns with the assessor response following that. Any furthe
clear which lines have been completed or not.

The non-conformances are numbered with a prefix for Code, or specific Service Delivery Standard and rep
P&E-1.
Code - this tab contains structured questions that explore compliance with the LCA Code of Conduct and i

Column A has the reference back to the requirements of the Code.

Column B includes the Code of Conduct requirement text.

Column C contains structured questions, prompts and embedded explanatory notes to explore compliance

Column D is for recording answers to the questions in Column C, to describe process and reference evide
achieved and where this is detailed in procedure the answer should reflect the content of the Members Sta
actual practice, example records of actual practice are checked, a note is made of what was checked and

Column E is for recording non-conformances from answers in column D. The non-conformances are num
replicated on the non-conformance tracker.

The Service Delivery Standard tabs are numbered 1-8 and include the specific questions on the individu

At the top of this tab in cell D2 there is a space to record the work being audited. Use quote, job, etc. refer
the audit could be replicated.

Column B references the clause in the standard that underlies the audit question. If unsure of the meaning

Column D is for answers to the audit questions based on templates, procedures and master documents - t
system in place deliver work to the required standard. Answers in column D should be regarding the proce

Column E is for recording non-conformances from answers in column D. The non-conformances are num
replicated on the non-conformance tracker.

Column F is for answers to the audit questions based on the evidence from actual work being checked - th
performance, has the system in place delivered work to the required standard. Answers in column F shou

Column G is for recording non-conformances from answers in column F. Often if there is a column D/E no
because the management system flaw has led to an output flaw. A single corrective action common to bot
consecutively throughout the audit report and replicated on the non-conformance tracker.

LCA Document reference: 006.1.3 02-24


This document is the copyright and intellectual property of the Legionella Control Association made available for LCA
Audit details

Company Name: All Counties HVAC


Registration Reference:

Audit Date:
Audit issue Date:
Assessor response Date:
Audit status:

Auditor:

Signature:
Present/Assisted by:

Audit method

Audit Explanation
This audit is detailed under these sections (Please read carefully)
Code Audit - Statement of Compliance (SOC) and Management procedures/process audit
Checklists to evidence operational compliance with each applicable LCA Service Standard &
Service standard check lists -
utilisation of the member's procedures/processes.
Non-conformity tracker - Non-conformity tracker with corrective actions required, actions taken and closure.

Bold All non-conformances raised are highlighted in bold with red fill, issued a Non-conformity reference
and require a response on the Non-conformity tracker tab.

OBS
In addition to the non-conformances, the assessor has given a number of Recommendations for
Improvement, observations (OBS) these are optional suggestions for the member.

Please use the Non-conformity tracker tab to record your response to the non-conformities raised.
The company is to write to the assessor via the LCA secretariat admin@legionellacontrol.org.uk within 6 weeks indicating the steps which have
been taken to address these non-conformities providing, where applicable, evidence in the form of completed documents. Amendments to
procedures should be highlighted. All Non-conformities in the Non-conformity tracker must be completed satisfactorily within 3 months of the
date of the Report for existing members (the initial 6 week period allowing sufficient time for any negative assessor responses and still achieve
final completion within 3 months). Applicant members should aim for satisfactory completion of non-conformities within 12 months from date of
application acceptance. In the event of non-completion by this date, then the existing Member will be at risk of being suspended from the LCA
website and ultimately have membership withdrawn, and new applications will be cancelled.

Additional comments from


the assessor:

Service standard Assessor's comments on relative activity, numbers staff operational, sub-contractors used
1 Legionella Risk Assessments
Hot & cold water
Evaporative cooling systems
Other systems
Healthcare
2 Water Treatment services
Hot and cold water
Evaporative cooling systems water
treatment
Process & Other systems water
treatment
Hot and cold water monitoring
3 and inspection
4 Cleaning and disinfection
Hot & cold water
Evaporative cooling systems
Other systems
Independent Consultancy
5 Services
6 Training services
7 Legionella monitoring services
Sampling
In field analysis
Laboratory analysis (In house)
Audit details

Company Name: All Counties HVAC


Registration Reference:

Interpretation of analysis
8 Plant and equipment services
Design and supply
Installation
Service and Maintenance
Refurbishment
Action plan
Non-Conformity Tracker
Please use the Non-conformity tracker tab to record your response to the non-conformities raised.
The company is to write to the assessor via the LCA secretariat admin@legionellacontrol.org.uk within 6 weeks indicating the steps which have been taken to address these non-conformities providing, where applicable, evidence in the form of
completed documents. Amendments to procedures should be highlighted. All Non-conformities in the Non-conformity tracker must be completed satisfactorily within 3 months of the date of the Report for existing members (the initial 6 week period
allowing sufficient time for any negative assessor responses and still achieve final completion within 3 months). Applicant members should aim for satisfactory completion of non-conformities within 12 months from date of application acceptance. In
the event of non-completion by this date, then the existing Member will be at risk of being suspended from the LCA website and ultimately have membership withdrawn, and new applications will be cancelled.

Target
Allocated Description of action taken to correct the Evidence of Date / (complete / Not
NC Ref Action required Response Assessor follow up comments
to non-conformity completion/reference complete)
Date

Page 5 of 74
LCA Management Process audit

LCA Code of Conduct Audit


For required actions see Non-Conformity tab
Procedure and related process references/suitability and evidence Non-Conformity
Section Code of Conduct requirement Related audit questions
provided by the member Ref
Scope CoC section 3.1 The AOI, Website and SOC scope all match
Sub-contract & in-house correctly defined for each
AOI
Current version of the Statement of Compliance
(‘SOC’)
Procedure referenced in SOC under 1.1 and briefly
1.1
described.
The procedure/process relevant to this requirement is
Provide guidance to the service user on The Procedure/Process details the actions required
what they need to do to comply with the and was found to be in-line with actual practice
Law in respect of Legionella control. Forms/Master documents used by process

Legislation & Guidance provided matches


AOI/Website/Scope
Procedure referenced in SOC under 1.2 and briefly
1.2 Formalise a written agreement described.
identifying those services covered by The procedure/process relevant to this requirement is
the LCA Member and indicate those
The Procedure/Process details the actions required
which should be provided by the service
and was found to be in-line with actual practice
user to comply with the Law, Regulation,
ACoP and the LCA standards for Forms/Master documents used by process
service delivery.
Confirmation of agreement achieved
Procedure referenced in SOC under 2.1 and briefly
2.1
described.
Having a system to identify initial The procedure/process relevant to this requirement is
training needs and arrange training for
The Procedure/Process details the actions required
their staff associated with the control of
and was found to be in-line with actual practice
Legionella.
Forms/Master documents used by process

Procedure referenced in SOC under 2.2 and briefly


2.2
described.
The procedure/process relevant to this requirement is
Having a system for assessing and The Procedure/Process details the actions required
maintaining the competence of their and was found to be in-line with actual practice.
staff, establishing their ongoing training Does the system for assessing training and
needs. competence identify the job aspects of the Surveyor,
Designer, Planner, Technician, Reporter and Auditor?
Forms/Master documents used by process

Procedure referenced in SOC under 2.3 and briefly


2.3
described.
Maintaining records of training, The procedure/process relevant to this requirement is
competence assessments and annual The Procedure/Process details the actions required
competence validity checks. and was found to be in-line with actual practice
LCA Management Process audit
Maintaining records of training,
competence assessments and annual Procedure and related process references/suitability and evidence Non-Conformity
Section Code of Conduct requirement Related audit questions
competence validity checks. provided by the member Ref
Forms/Master documents used by process

Procedure referenced in SOC under 2.4 and briefly


2.4
described.
Having a system to ensure that The procedure/process relevant to this requirement is
developments in industry standards and
The Procedure/Process details the actions required
good practice are identified and
and was found to be in-line with actual practice
disseminated to all appropriate staff.
Forms/Master documents used by process

Procedure referenced in SOC under 3.1 and briefly


3.1 Register all Legionella control services described.
they offer with the LCA and in their The procedure/process relevant to this requirement is
written agreement with the service user
The Procedure/Process details the actions required
confirm that all the legionella control
and was found to be in-line with actual practice
services being offered are registered
with the LCA. Forms/Master documents used by process

Procedure referenced in SOC under 3.2 and briefly


3.2
described.
The procedure/process relevant to this requirement is
The Procedure/Process details the actions required
and was found to be in-line with actual practice
Is there a suitable process for matching the complexity
Have a management system to gather of the work with the competence of the individual
information, assess the requirements carrying out the work?
Are there suitable procedures to check that required
and ensure an appropriate service is
tasks are completed for a proportional sample of
designed, implemented, monitored and
visits?
maintained that satisfies as a minimum Are there suitable procedures to check that the correct
the LCA Standards for Service Delivery. control limits have been employed for a proportional
sample of all visits?
Are there suitable procedures to check that test
results have been interpreted correctly for a
proportional sample of all visits?
Forms/Master documents used by process

Procedure referenced in SOC under 3.3 and briefly


3.3
described.
The procedure/process relevant to this requirement is
Have a system for checking that any The Procedure/Process details the actions required
recommended corrective, preventive and was found to be in-line with actual practice
and improvement actions are completed Are there suitable procedures to check for recording
and effective. and tracking to conclusion any significant non-
conformances?
Forms/Master documents used by process
LCA Management Process audit

Procedure and related process references/suitability and evidence Non-Conformity


Section Code of Conduct requirement Related audit questions
provided by the member Ref
Procedure referenced in SOC under 3.4 and briefly
3.4
Have a calibration and validation described.
procedure to ensure that any testing The procedure/process relevant to this requirement is
equipment used in the field is operating The Procedure/Process details the actions required
correctly. and was found to be in-line with actual practice
Forms/Master documents used by process
Procedure referenced in SOC under 4.1 and briefly
4.1
described.
Agree with the service user who the The procedure/process relevant to this requirement is
appropriate contacts are for routine and
The Procedure/Process details the actions required
emergency communication and who the
and was found to be in-line with actual practice
duty holder and responsible persons are
Forms/Master documents used by process

Procedure referenced in SOC under 4.2 and briefly


4.2
described.
The procedure/process relevant to this requirement is
Have procedures to communicate The Procedure/Process details the actions required
appropriately when non-conformance and was found to be in-line with actual practice
from normal control limits or safe Are there suitable procedures to check that
operation is identified. appropriate corrective actions have been discussed
with the agreed contacts for a proportional sample of
all visits?
Forms/Master documents used by process

Procedure referenced in SOC under 4.3 and briefly


4.3
Bring to the service user’s attention any described.
matters affecting the control of The procedure/process relevant to this requirement is
Legionella of which they have become The Procedure/Process details the actions required
aware beyond the responsibilities of and was found to be in-line with actual practice
their service provision. Forms/Master documents used by process

Procedure referenced in SOC under 4.4 and briefly


4.4 Have a staged escalation procedure to described.
ensure that significant matters of
Procedure/Process reference
concern are escalated, as necessary, to
the responsible person, the duty holder The Procedure/Process details the actions required
and, as a last resort, to the relevant and was found to be in-line with actual practice
enforcement agency. Forms/Master documents used by process
Procedure referenced in SOC under 5.1 and briefly
5.1
described.
Identify what records need to be The procedure/process relevant to this requirement is
maintained to provide evidence of The Procedure/Process details the actions required
Legionella control. and was found to be in-line with actual practice
Forms/Master documents used by process
LCA Management Process audit

Procedure and related process references/suitability and evidence Non-Conformity


Section Code of Conduct requirement Related audit questions
provided by the member Ref
Procedure referenced in SOC under 5.2 and briefly
5.2
described.
Agree with the service user in writing The procedure/process relevant to this requirement is
which records should be kept by each The Procedure/Process details the actions required
party, where and how. and was found to be in-line with actual practice
Forms/Master documents used by process

Procedure referenced in SOC under 5.3 and briefly


5.3
Maintain their own records, including all described.
detail recorded in site records, for a The procedure/process relevant to this requirement is
minimum of five years following delivery The Procedure/Process details the actions required
of service provision and make them and was found to be in-line with actual practice
available to the service user. Forms/Master documents used by process

Procedure referenced in SOC under 6.1 and briefly


6.1
described.
Review formally, at least annually, all The procedure/process relevant to this requirement is
aspects of the service provision with the The Procedure/Process details the actions required
service user. and was found to be in-line with actual practice
Forms/Master documents used by process

Procedure referenced in SOC under 6.2 and briefly


6.2
described.
Assist the client to assess training The procedure/process relevant to this requirement is
needs of staff and then, where
The Procedure/Process details the actions required
requested, advise as to how these can
and was found to be in-line with actual practice
be met.
Forms/Master documents used by process

Procedure referenced in SOC under 7.1 and briefly


7.1 Audit their own management system at described.
least once per year to ensure it complies The procedure/process relevant to this requirement is
with the requirements of the LCA Code
The Procedure/Process details the actions required
of Conduct and Service Delivery
and was found to be in-line with actual practice
Standards and keep a record of that
audit. Forms/Master documents used by process

Procedure referenced in SOC under 7.2 and briefly


7.2 Audit a representative sample of output / described.
records to ensure the management
system is effective and being correctly The procedure/process relevant to this requirement is
applied. This should include auditing The Procedure/Process details the actions required
records of all aspects of service delivery and was found to be in-line with actual practice
(internal processes and on-site activity),
training records, competence
assessments, sub-contractor
performance, survey information,
quotations, service delivery reports,
reviews, etc., and keep a record of that
audit.
Audit a representative sample of output / LCA Management Process audit
records to ensure the management
system is effective and being correctly
Procedure and related process references/suitability and evidence Non-Conformity
Section applied.
Code This
of should
Conductinclude auditing
requirement Related audit questions
records of all aspects of service delivery provided by the member Ref
(internal processes and on-site activity),
training records, competence
assessments, sub-contractor
performance, survey information, Forms/Master documents used by process
quotations, service delivery reports,
reviews, etc., and keep a record of that
audit.

Procedure referenced in SOC under 7.3 and briefly


7.3
Establish a corrective action programme described.
so that any non-compliance identified is The procedure/process relevant to this requirement is
corrected in a timely manner including The Procedure/Process details the actions required
addressing procedures where failings and was found to be in-line with actual practice
are systemic Forms/Master documents used by process

Procedure referenced in SOC under 7.4 and briefly


7.4
described.
Ensure the current version or issue of The procedure/process relevant to this requirement is
any document is in use (have a The Procedure/Process details the actions required
document control system). and was found to be in-line with actual practice
Forms/Master documents used by process

Procedure referenced in SOC under 8.1 and briefly


8.1 Check that every non-LCA registered described.
sub-contractor has procedures to carry The procedure/process relevant to this requirement is
out adequate task Risk Assessments
The Procedure/Process details the actions required
and produce suitable Method
and was found to be in-line with actual practice
Statements that comply with the LCA
service delivery standards. Forms/Master documents used by process

Procedure referenced in SOC under 8.2 and briefly


8.2
Review the competence assessments of described.
subcontractor staff working for them The procedure/process relevant to this requirement is
prior to engagement. The Procedure/Process details the actions required
and was found to be in-line with actual practice
(LCA registered companies are required
to carry out competence assessments
and provide them on request and would
be subject to the complaints procedure
where these cannot be readily provided.
Subcontractors should not be used Forms/Master documents used by process
where there is no evidence of
competence
from the review of these competence
assessments.)
LCA Management Process audit

Procedure and related process references/suitability and evidence Non-Conformity


Section Code of Conduct requirement Related audit questions
provided by the member Ref
Procedure referenced in SOC under 8.3 and briefly
8.3 Conduct a documented assessment of described.
the sub-contractor’s staff competence to
carry out the work where records cannot The procedure/process relevant to this requirement is
be provided as per 8.2. This must follow The Procedure/Process details the actions required
requirement 2.2 above and be validated and was found to be in-line with actual practice
at least annually or at any point where
there is reason to doubt the sub-
contractor’s performance.
Forms/Master documents used by process
(Requirement 8.3 should only need to
apply to non-LCA registered
companies.)

Include sub-contractor activity in the Procedure referenced in SOC under 8.4 and briefly
8.4
evidence examined in their internal described.
audits under requirement 7 to ensure The procedure/process relevant to this requirement is
that all aspects (scoping, quotation and The Procedure/Process details the actions required
delivery) are compliant with the LCA and was found to be in-line with actual practice
Code of Conduct and Service Delivery Forms/Master documents used by process
standards.
Procedure may be defined in the SOC under 9.1 and
9.1
A copy of the LCA Code of Conduct and briefly described.
proof of Registration are made available Procedure/process relevant to this requirement if
to all Legionella control service users. separate
This can be achieved either by providing
The SOC/Process details the actions required and
them with hard copies, electronic copies
was found to be in-line with actual practice
or making them available as
downloadable files from their website or Forms/Master documents used by process
links to the LCA website.

Number of Actions 0
Number of Observations 0
Check list 01 - Legionella Risk Asses
Brief description of the work(s) being audited:
- Quote(s) & Dates
- Job/Works(s) Ref & Date:

Clause Question

A) What does the standard cover


What is the scope of service for Risk Assessment - does this align with the LCA
1
registration?
B) Competence of staff
Does the system for assessing training and competence identify the job aspects of
5
the Surveyor, Designer, Planner, Technician, Reporter and Auditor?
Is there a suitable process for matching the complexity of the work with the
7 & 15A
competence of the individual carrying out the work?
Is there a process for assessors to seek more competent help or to decline
8
completion of the risk assessment and detail it's limitations.
9 Is a template or proforma used to guide the risk assessor (a valuable aide memoire)?
C) Service Delivery
Does the agreement for Legionella Risk Assessment define:
13a The premises and/or buildings to be included in the risk assessment?
13b Which water systems are to be assessed and any that are knowingly excluded.
13c Whether the assessor will have access to previous risk assessments?
13d The requirement for schematic diagrams and asset registers?
13e The extent of the written scheme of control to be supplied.
13g The format in which the final report is to be presented?
13h To whom the final report will be sent?
Access needed and assistance that may be required to understand the water
13i
systems?
13j Specific safety and other requirements?
13k Contacts to report issues of immediate concern?
13l Define how any areas of repetition will be assessed (% sample).
How to record any unavoidable omissions, the effect they may have on the
assessment of risk, whether the required information can be obtained by other means
13m
and what provision should be made to provide access on a subsequent occasion and
any additional implications.
How any reported information (not directly observed by the assessor) in the risk
13n
assessment will be presented.
If the executive summary is to be for individual sites, or for multiple sites, an overall
13o
project summary.
Is there a record of a formal agreement between the member and their client defining
14
the above points?
Does the member have a suitable process to describe and manage -
Preparing for the work?
15b
- Including provision of equipment to carry out the risk assessment survey
12 &
Carrying out the risk assessment?
15d
A process to transfer information to work instructions that identify all the systems
16
included in the in the risk assessment scope?
Does the risk assessment process-
17a Review the previous risk assessment where one has been conducted?
17b Review asset registers where available, comment on their accuracy and suitability or
17c supply an asset register?
Include inspection and assessment of the design, construction, and condition of the
17d
water system and accessible equipment?
Include appraisal of system operation (Historic results) and the adequacy of site
17e
records?
Where it is not possible to inspect all parts of the system does the assessment:
- Determine the system condition from other evidence, or
17f
- Indicate that the assessment is not fully complete, or
- Postpone the assessment and return at a later date when access can be arranged
Provide an assessment of the inherent risk presented by the system before any
17g
controls are applied (worst case)?
Provide assessment of the residual risk presented by the system with the controls in
17h
place applied (current level of risk)?
Provide an assessment of any risk gap between residual risk and ALARP (as low as
17i
reasonably practicable)?
Does the members risk assessment include checking the purpose and scope detail
18 &
within the written scheme of control (proportional to the identified risk)
19a
If there is no written scheme of control in place, is there a high priority in the risk
IB2
assessment recommendations that one needs to be produced?
Check that the written scheme has been written to address the actual risks identified
19b
on previous risk assessment?
Does the risk assessment - Check that notification of any cooling towers or
19c
evaporative condensers is recorded in the written scheme (if applicable)?
19d Record the management structure documented in the written scheme of control?
Does the risk assessment - Include checking the description in the written scheme of
19f
correct operation and any controls in place to minimise risk?
Include checking the start up and shut down procedures, plant rotation and flushing
19g
for little used outlets in the written scheme of control?
Does the members risk assessment include assessing the detail in the written
19h
scheme of control for any plant or equipment brought onto site by third parties?
19i Include assessment of task method statements in the written scheme?
Include an assessment of the written scheme of control schedule of monitoring,
19j operational checks, inspections and calibrations that are to be carried out including
the frequency of tasks and the control limits to be employed?
19k Assess the planning/completion of corrective actions in the written scheme of control?
19i Assess the incident plans in the written scheme of control?
20a A check of the effectiveness of the control measures as detailed in the records?
20b Include a check of the maintenance history as detailed in the records?
Check the records for history of past issues and where these are found does it ask:
i. if the correct actions were taken
ii. were the actions taken within a timely fashion
iii. were results rechecked after remedial actions
20c
iv. if the actions did not result in better control, was an escalation procedure invoked
to ensure conditions were eventually controlled? If not, is there an escalation
procedure in place?
v. were there lessons learned or a new procedure put in place to prevent recurrence?
20d Check the records for significant deviations from operating procedures?
Assess the management responsibilities that are in place including:
The duty holder, the responsible person and any deputies are clearly identified
Where applicable (healthcare or other settings where a WSG is in place), there is an
appropriately comprised multi-disciplinary water safety group
21(a-f)
The responsibility for tasks to be undertaken by each individual or party are outlined
clearly with the necessary frequency of the tasks
Lines of communication and the reporting structure are clearly stated in the written
scheme of control
Assess and comment on the evidence within the site records for the competence of
22
the individuals involved in legionella control?
Does the risk assessment procedure or method statement include a mechanism for
IC4
reporting matters of immediate concern?
Does the risk assessment report contain -
24a i An executive summary
The scope of the assessment, including clear identification of buildings, systems
24a ii
assessed and their use?
The identification of which systems can present a risk from Legionella and those
24a iii
which may not/are excluded?
Analysis and evaluation of risk for each system including an explanation of how the
24a iv
risk rating is derived?
24a v Consideration of elimination or substitution of the risk?
Identification of key personnel, both staff and contractors, and an assessment of their
24a vi
competence based on the training and operational records available?
Asset registers (if they have been produced)?
24a viii or reference to them (if they have been reviewed);
or recommendation that they be produced or updated, as appropriate.
The results of condition surveys including operating parameters, temperatures,
24a ix system inspections (if third party information is used it should be clearly identified in
the assessment)?
24a xii Any specific limitations of the assessment?
Does the risk assessment report contain - Any matters or areas of evident concern
24a xiii
identified which fall outside the scope of the assessment?
24a xiv Details of the competence of the assessor?
(Where risks are identified)
- Recommendations prioritised for remedial/corrective actions to eliminate or reduce
24b I, iii
the risk?
& iv
- Any short term control measures to be applied until completion of
remedial/corrective actions?
IC5
- Control measures to be applied (longer term) following completion of
remedial/corrective actions?
Is the risk assessment report concise without reproducing large sections of guidance
23
or using unnecessary repetition?
Does the report identify that the existing control measures are adequate?
or does it give recommendations for site and system specific control measures
24b ii
(monitoring, inspection and treatment, etc.)
including identification of sentinel outlets and/or other sample and inspection points?
Subject to scope, offer recommended precautions to be taken when testing,
24b v maintaining or operating typically low risk systems, such
as fire sprinkler systems, closed heating and chilled water systems, for example.
Does the risk assessment report contain - A recommended review date based on the
site and anticipated risk?
24b vi
- Including guidance regarding the circumstances under which a reassessment is
likely to be required.
Does the risk assessment report contain - Details of any sources of reference and
24a xvi
guidance utilised, e.g., bibliography?
For healthcare settings, does the report include clarification of the scope, specifically
26
a legionella risk assessment, or includes other water pathogens.
Does the members risk assessment report contain - Details of the person involved in
24a xv
QA reviewing the assessment report (if different)
Are there suitable procedures to check that the survey, risk assessment and reporting
28a has been completed to the scope agreed for a proportional sample of all risk
assessments completed?
Are there suitable QA procedures - For checking that appropriate recommendations
28b have been made to achieve ALARP risk?
(for a proportional sample of all risk assessments completed).
Does the member have a suitable process to describe and manage - Recording and
28c tracking to conclusion any significant non-conformances?
(Where there is an ongoing relationship with the client)
Does the provided or assessed schematic diagram include detail to assist
implementation of the written scheme of control:
Source of makeup water
19e
Cooling towers, evaporative condensers, heat exchangers and chillers
24a vii
Water softeners and other pre-treatment plant, Water treatment equipment
35(a-n)
Storage and header tanks, Calorifiers and water heaters
&
Piping relationships including significant branches and hot water returns
39
Pumps, Strainers, TMVs, All outlets
Deadlegs, Dead ends
Any other detail relevant to the communication of risk
D) What you need to tell your customer

The member should inform the client that it is the responsibility of the duty
holder/responsible person to:
a. Ensure there is a Legionella risk assessment record that includes all systems
where water is stored/used in any premises controlled by the duty holder, and that it
is reviewed regularly to ensure it is valid and reassessed when required.
b. Clearly define the scope of any required Legionella risk assessment.
c. Make reasonable enquiries of proof of competence of the Legionella risk
assessor.
d. Ensure any schematic diagrams and asset registers are available to inform and
help the risk assessor.
30 e. Ensure the findings of the legionella risk assessment including the required
corrective actions and control measures are implemented, or if not implemented
recorded as to why they were not.
f. Ensure a written scheme of control is produced and maintained and the output
from the scheme of control is recorded and used in any subsequent review of risk.
g. Ensure regular reviews of the effectiveness of Legionella control activities are
carried out to verify the written scheme of control remains adequate and if they are
not to carry out a review of the legionella risk assessment.
h. Have change management procedures and or regular review procedures to
determine if the existing risk assessment is still valid, suitable, and sufficient. If it is
not, then a reassessment of the risk is required.
heck list 01 - Legionella Risk Assessment

For required actions see Non-Conformity tab

Observations/Comments service standard


Non-Con Observations/Comments on evidence
compliance
Ref (E.G. RAMS/Reports/Certificates).
(E.G. Procedures/Processes/Templates)
Non-Conformity tab

Non-Con
Ref
Check list 02 - Water Treatmen
Brief description of the work(s) being audited:
- Quote(s) & Dates
- Job/Works(s) Ref & Date:

Clause Question

A) What does the standard cover


What is the scope of service for Water Treatment - does this align with the LCA
1
registration?
B) Competence of staff
Does the system for assessing training and competence identify the job aspects of
4
the Surveyor, Designer, Planner, Technician, Reporter and Auditor?
Is there a suitable process for matching the complexity of the work with the
6
competence of the individual carrying out the work?
C) Service Delivery
Are there suitable procedures that cover design, execution and management of the
7
required water treatment programme?
Does the member have a suitable process to describe and manage -
Survey/Information Gathering?
Is there a site survey or other suitable process to gather information?
Including obtaining make up water analysis?
Including water system mechanical details?
Including water system operational details?
8 & 9 Including environmental restrictions?
Including a review of the fitness for purpose of any existing water treatment
equipment?
Including looking at the existing legionella risk assessment and management
processes?
Including looking at any other information relevant to design of the water treatment
programme?
Does the member have a suitable process to describe and manage - Design of water
11
treatment to achieve the desired outcomes?
11 Does the procedure consider the compatibility of products when dosed together?
Does the procedure consider any limitations of products or processes that may affect
11
the performance of the programme?
Does the water treatment programme design procedure include selection of water
12a
treatment products or control techniques
Does the water treatment programme design procedure include consideration of the
12b suitability of existing pre-treatment and dosing and control equipment for the
proposed treatment programme?
Does the water treatment programme design procedure include selection of chemical
12c i
tests to be used for monitoring and testing of particular products or services?
Does the water treatment programme design procedure include how to identify
12c ii
sampling points for monitoring and testing of water treatment programmes?
Does the water treatment programme design procedure include selection of microbial
12c iii monitoring points and tests for monitoring and testing of water treatment
programmes?
Does the water treatment programme design procedure include the test methods
12c iv
appropriate for monitoring and testing of water treatment programmes?
Does the water treatment programme design procedure include control limits and
12c v
desired outcomes for the testing and monitoring of the water treatment programme?
Does the water treatment programme design procedure include the testing / servicing
12c vi
frequency for monitoring and testing of water treatment programmes?
Does the water treatment programme design procedure include the cleaning and
12d disinfection regime design and scheduling where it is required as part of an overall
water treatment programme?
Does the member have a suitable process to describe and manage - Agreeing the
scope of work?
The premises and/or buildings to be included in the scope?
- Identification of water systems to be treated?
- Treatment techniques to achieve the desired outcomes?
13
- Products and services to be supplied?
- The monitoring analysis and inspection programme?
- Confirmation of the agreement of the lines of communication and reporting?
- Reporting format and delivery method?
- Access needed and times of access?
14 Is the service user given instruction in the areas they may need to implement?
Is there documented allocation of responsibilities between the LCA Member and the
14a
service user?
14c Initial instruction for the service user and identification of training needs?
14d Agreement over success criteria for the programme?
15a Did the individual sent to site have the appropriate competence for the task?
15b ii Did the individual sent to site have a suitable method statement/work instruction and
16c is there evidence this was checked prior to commencing work?
15b v / Did the individual sent to site have suitable monitoring, testing and inspection
16d equipment and is there evidence this was checked prior to commencing work?
Did the individual sent to site have a job reporting system (e.g. a paper or electronic
15b vi
record of the work when completed)?
Is there evidence that all tasks on the water treatment programme allocated to the
17a
LCA member have been completed?
Is there evidence of a detailed report of work outcomes for each service visit and
17b
does it contain all the detail in the site records?
Where there are non-conformances are they brought to the attention of the client on
17c
the report with recommended corrective actions?
Do the reports bring to the attention of the client any other areas of concern identified
17d
which could impact on Legionella risk?
Are there suitable procedures to check that all scheduled service visits have been
18a
completed (missed visit control)?
Are there suitable procedures to check that all required monitoring, analysis and
18b inspection tasks have been completed for a proportional sample of all water treatment
visits?
Are there suitable procedures to check that the correct control limits have been
18c
employed for a proportional sample of all water treatment visits?
Are there suitable procedures to check that test results have been interpreted
18d
correctly for a proportional sample of all water treatment visits?
Are there suitable procedures to check that appropriate corrective actions have been
18e discussed with the agreed contacts for a proportional sample of all water treatment
visits?
Are there suitable procedures to check for recording and tracking to conclusion any
18f
significant non-conformances?
D) What you need to tell your customer
The member should inform the client that itis the responsibility of the duty
holder/responsible person to:
a. Have a legionella risk assessment, written scheme of control and schematic
diagram in place which includes a programme of treatment, monitoring, and
inspection (and may include legionella sampling) and make this available to us.
b. Provide sufficient information to allow us to design an appropriate treatment
programme, including a legionella sampling plan if appropriate.
20
c. Make the systems available for the agreed work, with safe access, and adequate
notice to ourselves to schedule and execute the agreed work.
d. Provide us with any information on known risks and safety requirements in the
areas we will be working.
e. Ensure the control scheme tasks you are responsible for are completed and
recorded.
f. Participate in the agreed review process.
Check list 02 - Water Treatment

For required actions see Non-Conformity tab

Observations/Comments service standard


Non-Con Observations/Comments on evidence
compliance
Ref (E.G. RAMS/Reports/Certificates).
(E.G. Procedures/Processes/Templates)
Non-Conformity tab

Non-Con
Ref
Check list 03 - Hot & Cold Water Mo
Brief description of the work(s) being audited:
- Quote(s) & Dates
- Job/Works(s) Ref & Date:

Clause Question

A) What does the standard cover


What is the scope of service for Hot and Cold Water Monitoring and Inspection - does
1
this align with the LCA registration?
B) Competence of staff
Does the system for assessing training and competence identify the job aspects of
3
the Surveyor, Designer, Planner, Technician, Reporter and Auditor?
Is there a suitable process for matching the complexity of the work with the
4
competence of the individual carrying out the work?
C) Service Delivery
Does the member have a suitable process to describe and manage -
Survey/Information Gathering?
Including asking for copies of system schematic diagrams to identify location of
components?
6&7
Including asking for existing Legionella risk assessment and written scheme of control
(or access to same)?
Including determination of monitoring and inspection points?

Identifying relevant site-specific requirements?


- Preliminary task risk assessment
- Safe access and egress to complete the work
- Induction procedures
7(d)
- reporting any emergencies during the work
- Access permits and permits to work
- Security and safety restrictions
- Avoid cross contamination of services from the monitoring activity
Design of programme of hot and cold water monitoring and inspection?
- Including any existing written scheme of control including a review of its suitability?
8&9
- Including a monitoring regime detailed in HSG274 part 2/HTM04-01 as applicable,
based on survey information and risk assessment?
Does the programme design include suitable detail?
- Where applicable, does the monitoring programme include temperatures at sentinel
10 and representative points in the hot and cold water?
- Where there is recirculating hot water are subordinate loops included in the
monitoring programme?
Does the programme design include suitable detail?
- Where applicable, does the inspection programme for water tanks include checking
internal/external condition, water condition, lid condition and fit, condition of vermin
10
screens, condition of insulation, etc.?
- Where applicable, does the inspection programme include appropriate inspection of
calorifiers with internal access/blown down where there is no access?
- Have standard method statements/procedures for routine monitoring and inspection
11
tasks within the programme?
Agreeing the scope of work?
- Including the premises and/or buildings to be included in the scope?
- Identification of water systems?
- The monitoring and inspection points included in the scope?
- Frequency of monitoring and inspection?
12(a-h)
- Allocation of responsibility for tasks covered by the LCA Member and those which
should be provided by the service user?
- Confirmation of the agreement of the lines of communication and reporting?
- Reporting format and delivery method?
- Access needed and times of access?
Section 4: Preparation
Does the member have a suitable process to describe and manage - Sending the
13b i / 14c individual to site with the appropriate method statements and the individual checking
the method statement and work instruction is valid?
Does the member have a suitable process to describe and manage sending the
individual to site with the appropriate resources?
- Including emergency procedures (e.g. first aid, accident reporting, incident reporting,
13biii / iv
chemical handling/safety and environmental protection, etc.)?
- Including PPE/RPE and other safety/access equipment that may be required by the
site rules or task risk assessment/method statement?
Does the member have a suitable process to describe and manage - Sending the
individual to site with suitable monitoring, testing and inspection equipment?
13(bv &
- Including calibration where applicable?
bvi)
- Including a job reporting system (e.g. a paper or electronic record of the work when
completed)?
Section 5: Carrying out the Work
Is there a process for completing a pre-work risk assessment or review and, if
14(a-c) necessary, amending the preliminary task risk assessment where risks have
changed?
Is there evidence of a detailed report of work outcomes for each service visit and
15b
does it contain all the detail in the site records?
Where there are non-conformances is there a process for them to be brought to the
15c
attention of the client on the report with recommended corrective actions?
Section 6: Verification and Quality Control
Is there a process to ensure all service visits are completed and have all the
16a & 17
scheduled service visits been completed for the evidence examined in this audit?
Is there a process to check that all required monitoring and inspection tasks have
16b & 17 been completed for a proportional sample of all service visits and have all the
required tasks been completed for the evidence examined in this audit?
Is there a process to check that the correct control limits have been employed for a
16c & 17 proportional sample of all monitoring and inspection visits and have the correct control
limits been applied for the evidence examined in this audit?
Is there are process to check that monitoring and inspection results have been
16d & 17 interpreted correctly for a proportional sample of all visits and have they been
correctly interpreted for the evidence examined in this audit?
Is there a process to check that appropriate corrective actions have been discussed
16e & 17 with the agreed contacts for a proportional sample of all visits and is it evident that
this has occurred for the evidence examined in this audit?
Is there a process for identifying, recording and tracking to conclusion any significant
16f & 17 non-conformances that arise from the work? If these occurred in the evidence
checked as part of this audit, was the process followed?
D) What you need to tell your customer
The member should inform the client that it is the responsibility of the duty
holder/responsible person to:
a. Have a legionella risk assessment, written scheme of control and schematic
diagram in place which includes a programme of treatment, monitoring, and
inspection (and may include legionella sampling) and make this available to us.
b. Provide sufficient information to allow us to design an appropriate treatment
programme, including a legionella sampling plan if appropriate.
18
c. Make the systems available for the agreed work, with safe access, and adequate
notice to ourselves to schedule and execute the agreed work.
d. Provide us with any information on known risks and safety requirements in the
areas we will be working.
e. Ensure the control scheme tasks you are responsible for are completed and
recorded.
f. Participate in the agreed review process.
eck list 03 - Hot & Cold Water Monitoring

For required actions see Non-Conformity tab

Observations/Comments service standard


Non-Con Observations/Comments on evidence
compliance
Ref (E.G. RAMS/Reports/Certificates).
(E.G. Procedures/Processes/Templates)
Non-Conformity tab

Non-Con
Ref
Check list 04 - Cleaning & Disinfec
Brief description of the work(s) being audited:
- Quote(s) & Dates
- Job/Works(s) Ref & Date:

Clause Question

A) What does the standard cover


What is the scope of service for Cleaning & Disinfection and does this align with the
LCA registration?
1 - Hot and Cold Water Systems
- Evaporative Cooling Systems
- Process and Other Risk Systems
B) Competence of staff
Does the member have a suitable process to describe and manage - That individuals
5 & quoting, planning, conducting, reporting and auditing C&D services are trained and
16(a) competence assessed?
Staff/sub-contractor has the appropriate assessed competence?
C) Service Delivery
Does the member have a suitable process to describe and manage -
Design, execution and management of the cleaning and disinfection processes?
7
Including the design or selection of an appropriate cleaning and disinfection process?
Gathering physical information about the equipment prior to works commencing?
8, 9(a) Including appraising current system condition conditions before works commence?
& 9(c) Including any restrictions imposed by equipment manufacturers that may impact the
disinfection technique?
Identify waste disposal options/requirements prior to works commencing?
9(b) Including agreement issued to the client?
Including the agreed waste disposal method in the RAMS and reports?
Identification of the location and isolation points for dosing, control or sensitive
equipment, drinks dispensers where applicable?
9(d)
Including being defined in the work instruction?
Evidence the requirements were carried out.
For requesting copies of system schematic diagrams to identify dead legs, redundant
9(e)
pipe-work or equipment, outlets, etc.?
Agreeing the scope of work?
Agreement on the premises and/or buildings to be included in the scope?
Agreement includes identification of water systems to be cleaned and disinfected?
14(a-e) Agreement identifies the water systems to be cleaned and disinfected?
Agreement identifies the service users responsibilities?
Agreement confirms responsibility for lawful waste removal?
Agreement on the time required and system availability?
Is there evidence for acceptance/acknowledgement from the service user of the
15
scope e.g. purchase order or go-ahead from the client.
11 & Selecting or producing standard or bespoke method statements to ensure known (or
16(bii & anticipated) conditions of the system to be cleaned are applied?
iii) Risk assessment and method statement provided to staff?
Does the method statement cover -
12c Pre-work disinfection of the system consideration?
12d Disinfection process, including selection of the disinfectant?
12e Disinfectant concentration (or temperature) with the appropriate contact time defined?
12f & Consider the effect of pH on the selected disinfectant?
16b vi Does the report - Provide evidence of pH recorded as appropriate?
Define the residual disinfectant required at the end of the process?
12g
Test equipment and reporting system supplied to operative?
16(bvi)
Does the report - Provide evidence of residual disinfectant as required?
Define neutralisation and flushing requirements of the system following disinfection?
12h & Does the report - Evidence that the remaining disinfectant was neutralised and
IB4 flushed from the system if necessary, or if a thermal disinfection the temperature of
the system was reduced and flushed to outlets to reduce risk of scalding?
Include isolation or disconnection of any sensitive equipment identified during
12i
agreement?
12j Inform the operative of the effluent and waste disposal arrangements?
Inform the operative of the PPE/RPE to be used or any other special precautions to
12k be followed during the work?
Emergency procedures and equipment supplied to operatives?
If the system was disinfected while in normal use are appropriate instructions
IB1
available to deliver a disinfection and maintain safe usage?
28 Does the method statement include a suitable test method for disinfectant reserves?
Are the reported results actual results that are possible with the test equipment being
29
used and are they suitable?
Does testing equipment have suitable resolution to differentiate action levels in the
30
method statement?
Do reports/certificates indicate the individual sent to site used the correct equipment
18
and chemicals required by the method statement?
Is there evidence of a report or certificate of the work that accurately reproduces the
operative's site record?
Start and finish times for the disinfectant or thermal contact time.
18, 19
Observations/follow up actions.
& IB3
Disinfectant levels or temperature achieved at the start, during and at the end of the
contact time.
Test results are credible.

Verification and Quality Control?


- All required visits are done to schedule (missed visit control when part of an ongoing
contract).
- Required plant and equipment tasks are completed.
20
- Appropriate corrective actions are advised to the agreed contacts.
- Significant non-conformances are recorded and tracked to conclusion.
- A representative proportion of output must be monitored to ensure compliance with
the above.
D) What you need to tell your customer

The member should tell their customer that it is the responsibility of the duty
holder/responsible person to:
a. Maintain the water system, and the water in it, in a clean condition and to
facilitate inspection to determine if the system is clean or not.
b. Make the systems available for the agreed work, with safe access, and adequate
notice to ourselves to schedule and execute the agreed work.
22 c. Provide us with any information on known risks and safety requirements in the
areas we will be working, and advise of any known deadlegs, redundant pipework
and the location of schematic diagrams.
d. Ensure any preparatory work you are responsible for is completed prior to
commencing cleaning and disinfection work.
e. Ensure any necessary trade effluent discharge consent is in place for effluent
generated from the cleaning and disinfection process.
Check list 04 - Cleaning & Disinfection

For required actions see Non-Conformity tab

Observations/Comments service standard


Non-Con Observations/Comments on evidence
compliance
Ref (E.G. RAMS/Reports/Certificates).
(E.G. Procedures/Processes/Templates)
Non-Conformity tab

Non-Con
Ref
Check list 05 - Consultancy
Brief description of the work(s) being audited:
- Quote(s) & Dates
- Job/Works(s) Ref & Date:

Clause Question

A) What does the standard cover


What is the scope of service for Independent Consultancy - does this align with the
1
LCA registration?
B) Competence of staff
Does the system for assessing training and competence identify the job aspects of
5
the Surveyor, Designer, Planner, Technician, Reporter and Auditor?
Is there a suitable process for matching the complexity of the work with the
6
competence of the individual carrying out the work?
C) Service Delivery
Does the member have a suitable process to describe and manage -
7 Design, execution and management of the required independent consultancy work?
Agreeing the Scope of Work?
- The project objectives?
- The premises and/or buildings to be included in the scope?
- Identification of water systems to be included?
- The requirements regarding reporting, e.g., format/standard of schematic drawings
and asset registers, the components of the written scheme of control to be produced?
8 - Any management scheme to be produced, etc. and any sources of reference used?
- Specific site safety and/or other requirements, e.g., induction training, etc?
- Means of presentation of the final report, e.g., electronic format, hard copy, number
of copies, etc.?
- Any exclusions or limitations to the service?
- Verification by the LCA Member of the consultant’s competence to carry out the
specific project?

Planning for the works including consideration of resources required?


10b
(e.g. laboratory services, record sheets, additional personnel, camera, tools).
Consultancy output offering balanced advice that can help informed decisions to be
11 &
made and to consolidate or enhance performance in controlling risks?
12a
- Does the output from the consultancy work match the scope?
Consultancy output independence from the provision of other services?
(e.g., water treatment, cleaning and disinfection, remedial or maintenance services,
12b endorsement of products and services of other organisations)
This may be appropriate if part of the scope and referencing supporting evidence for
the recommendations made?
Does the consultancy output provide prioritised recommendations which, where
applicable, clearly relate back to codes of practice and guidance documents pertinent
12c
to the system and project in question and which state clearly the benefits of
undertaking the action?
Does the member have a suitable process to describe and manage - Checking that
13a the consultancy has been completed to the scope agreed?
QA function for a proportional sample of all independent consultancy work.
Check that appropriate recommendations have been made?
13b
QA function for a proportional sample of all independent consultancy work.
Check for recording and tracking to conclusion any significant non-conformances?
13c
(Where the LCA Member has an ongoing relationship with the client)
D) What you need to tell your customer

The member should tell their customer that it is the responsibility of the duty
holder/responsible person to:
14 a. Provide us with any pertinent historic information relevant to the project.
b. Clearly define the work, its objectives, and outcomes.
c. Agree the expectations regarding the level of detail in and the report format.
Check list 05 - Consultancy

For required actions see Non-Conformity tab

Observations/Comments service standard


Non-Con Observations/Comments on evidence
compliance
Ref (E.G. RAMS/Reports/Certificates).
(E.G. Procedures/Processes/Templates)
Non-Conformity tab

Non-Con
Ref
Check list 06 - Training as a serv
Brief description of the work(s) being audited:
- Quote(s) & Dates
- Job/Works(s) Ref & Date:

Clause Question

A) What does the standard cover


What is the scope of service for Training and does this align with the LCA
1
registration?
B) Competence of staff
Does the system for assessing training and competence identify the job aspects of
3
the Surveyor, Designer, Planner, Technician, Reporter and Auditor?
Does the member have a suitable process to describe and manage - Carrying out the
training?
- To have suitable knowledge and experience in the subject
4 - Methods to remain up to date with current practice
- Training/Skills to be able to present information in an appropriate format
- Training/Skills to be highly motivated and able to engage an audience
- Training/Skills to be a good communicator
C) Service Delivery
Does the member have a suitable process to describe and manage -
Detailing how the training need is established and the course content and objectives
6
are formally agreed to meet the identified need?
7 Communicate the content of the training course?
8a Selecting an appropriate venue for training?
8b Appropriate group sizes for training?

Appropriate presentation methods?


- Presentation
8c
- Practical elements
- Attendee participation

8d Marked assessments at the end of the programme?


Issuing a certificate?
- Detailing the level achieved (or attendance)
- Course title
8e
- Date of the course
- The name of the training organisation
- Accreditations or other relevant information
Reviewing and updating training course content regularly to ensure it remains
9
current?
Observation and assessment of delegates for practical or field based training?
9a I Ability to follow instructions?
10 9a ii Ability to work by themselves and carry out required tasks?
9a iii Ability to work safely in respect of their own safety and the safety of others?
9a iv Ability to account for their actions in a clear unambiguous written record?
Checking that the training has been completed to the scope agreed?
11a
QA function for a proportional sample of all training work.
Checking that training assessment has been completed to the scope agreed?
11b
QA function for a proportional sample of all training work.
D) What you need to tell your customer
The member should tell their customer: that it is the responsibility of the duty
holder/responsible person to:
a. Assess the:
• training needs of your staff,
12
• review staff training records and identify any further training requirements
• complete regular competence assessments for specific tasks

b. Determine if the content of any training offered meets your requirements.


Check list 06 - Training as a service

For required actions see Non-Conformity tab

Observations/Comments service standard


Non-Con Observations/Comments on evidence
compliance
Ref (E.G. RAMS/Reports/Certificates).
(E.G. Procedures/Processes/Templates)
Non-Conformity tab

Non-Con
Ref
Check list 07 - Legionella Monitoring S
Brief description of the work(s) being audited:
- Quote(s) & Dates
- Job/Works(s) Ref & Date:

Clause Question

A) What does the standard cover


What is the scope of service for Legionella sampling offered and does this align with
1
the LCA registration?
Is there a process that requires Legionella test method to be UKAS accredited (For
2
culture testing)?.
Is there a process to confirm analysis methods (Off-site analysis) do not ignore other
3 species or serogroups?
(i.e. not specifically targeted at Legionella pneumophila)
B) Competence of staff
Does the system for assessing training and competence identify the job aspects of
6(a-g)
the Surveyor, Designer, Planner, Technician, Reporter and Auditor?
Is there a suitable process for matching the complexity of the work with the
7
competence of the individual carrying out the work?
C) Service Delivery
Does the member have a suitable process to describe and manage -
Survey/Information Gathering?
- System schematic diagrams to reference location of sample points
9(a-d) - Existing risk assessment and written scheme
- Identification of sample points
- Previous sample results
Design of Sampling Programme
- The points to collect samples from and why they are chosen
- Frequency of sampling
- Sample matrix (type of water and system tested)
10(a-f)
- Limit of detection required and sample volume
- The analytical/evaluation techniques to be used
- Method statement including, The sampling procedure e.g. pre-flush or post-flush
with disinfection, The sample volume, The reporting format and communication routes
IB3 Are there documented processes to - Avoid the use of composite samples?
Does the member have a suitable process to cover and manage - Agreeing the
Scope of Work?
- Premises and/or buildings to be included
- Identification of the systems and sampling points
- Frequency of sampling*
- Sampling procedure*
11(a-J) - Limit of detection and reporting units*
- Sample volume*
- Laboratory analysis and/or onsite evaluation technique*
- Agreement over lines of communication and reporting
- Reporting format and delivery method
- Access arrangements and times
* These items should also include an explanation for the selection
Does the member have a suitable process to describe and manage - Carrying out the
Work (Prep)?
12(a-d) - Check method statement/work instruction is valid
- Check correct bottle type is available (volume, neutraliser, in date, etc.)
- Check that the correct PPE/RPE and other resources are available
Does the member have a suitable process to describe and manage - Carrying out the
Work (Task)?
- Carry out tasks in the method statement
13(a-e) - Undertake required sampling
- Carry out onsite evaluation where required
- Understand and report onsite evaluation results (where applicable)
- Prepare and submit samples to the laboratory where required
Does the member have a suitable process to describe and manage?
- Sample description
- Whether the sample was taken pre or post flush
17(a-e)
- Sample temperature at time of sampling
- Residual biocide at time of sampling
- Whether this is an initial or a repeat sample

Does the member have a suitable process to describe and manage - Sample
transport & delivered to the laboratory?
- Transport of samples
14 - Temperature of transport/storage
15 & - Sample labelling and documentation (Member identification, sampler, sample points,
16 sample time, sample matrix, analysis required)- in appropriate condition
- as soon as is practical from the point of sampling.
(Samples should begin analysis, ideally within 24 hours but certainly within 48 hours
from sampling).

Does the member have a suitable process to describe and manage - Laboratory
Result Reporting?
19(a-c) - Confirming the laboratory have a sample reception process
- Confirming the laboratory report Interim result
- Confirming the laboratory issue of a final certificate
Does the member have a suitable process to describe and manage - Reporting
Analytical Results to the Client?
23 As a minimum, recommendations must be based on the guidance in HSG274, HTM
04-01, HSG282 or
other national guidance as applicable.
Avoiding transcription errors?
- the original laboratory certificate forwarded. or
22
- robust procedures in place to ensure that it is correctly transcribed and all data
transferred from the original certificate is included.
Verification and Quality Control?
- All required visits are done to schedule (missed visit control)
- Appropriate recommendations have been made for results
- Required samples are completed and any missing results are followed up
24(a-g)
- The correct control limits are employed
&
- Results are understood and interpreted correctly
25
- Appropriate corrective actions are advised to the agreed contacts
- Significant non-conformances are recorded and tracked to conclusion
- A representative proportion of output must be monitored to ensure compliance with
the above.
D) What you need to tell your customer
The member should inform the client that it is the responsibility of the duty
holder/responsible person to:
a. Have a legionella risk assessment, written scheme of control and schematic
diagram in place which includes a programme of treatment, monitoring, and
inspection (and may include legionella sampling) and make this available to us.
b. Provide sufficient information to allow us to design an appropriate treatment
programme, including a legionella sampling plan if appropriate.
26
c. Make the systems available for the agreed work, with safe access, and adequate
notice to ourselves to schedule and execute the agreed work.
d. Provide us with any information on known risks and safety requirements in the
areas we will be working.
e. Ensure the control scheme tasks you are responsible for are completed and
recorded.
f. Participate in the agreed review process.
eck list 07 - Legionella Monitoring Services

For required actions see Non-Conformity tab

Observations/Comments service standard


Non-Con Observations/Comments on evidence
compliance
Ref (E.G. RAMS/Reports/Certificates).
(E.G. Procedures/Processes/Templates)
Non-Conformity tab

Non-Con
Ref
Check list 08 - Plant & Equipme
Brief description of the work(s) being audited:
- Quote(s) & Dates
- Job/Works(s) Ref & Date:

Clause Question

A) What does the standard cover


What is the scope of service for plant and equipment offered and does this align with
1
the LCA registration?
B) Competence of staff
Does the system for assessing training and competence identify the job aspects of
6(a-f)
the Surveyor, Designer, Planner, Technician, Reporter and Auditor?
Is there a suitable process for matching the complexity of the work with the
7 & competence of the individual carrying out the work?
13(a) Including ensuring the staff/sub-contractor has the appropriate assessed
competence/capability to carry out the task?
C) Service Delivery
Does the member have a suitable process to describe and manage -
Design/Selection of Equipment or Service?
- Systems are designed to reduce or eliminate Legionella risk where possible
- Systems are designed and installed to comply with relevant codes and guidance
and state clearly what these are
10(a-e) - Systems are designed to facilitate inspection and maintenance
- Systems are so designed and constructed so that they will be safe and without risks
to health
- The design considers all mechanical, operational, chemical and management
aspects of any existing or proposed control programmes which are relevant

Agreeing the Scope of Work?


- The project objectives
- The premises and/or buildings to be included
- The identification of the systems to be included or impacted
- The scope of supply
- Responsibility for waste disposal including any trade effluent or trade waste created
11(a-h)
by the work
- Information and instructions on safe use of the installation are to be supplied
- Access arrangements and timescales
- An agreement between both parties defining the scope of the supply and
referencing the agreed level of detail in, and format of, for example, drawings, asset
registers, operation and maintenance manuals etc.
12 Informing the client where Plumbing Notification Laws apply?
Informing the client where the works creates liquid waste?
12
(One off or ongoing).
13(bi),
Providing an appropriate method statement/work instruction?
13(bv)
Including calibrated monitoring and inspection equipment?
&
Job reporting system (record of the completed work)?
13(bvi)
14(c) Checking the method statement/work instruction is valid?
Is there evidence of working to the method statement and completing the appropriate
15
report?
Handover/Completion?
- Adequate information for the user about the risks and measures necessary to
ensure that the plant and equipment, and the water systems in which they are
installed, will be safe and without risks to health.
16(a-d)
- As applicable provision of drawings, asset registers, operation and maintenance
manuals etc.
- As applicable demonstration and instruction for the client.
- If required, sign off by the customer on completion of the project.

Verification and Quality Control?


- All required visits are done to schedule (missed visit control when part of an ongoing
contract).
17(a-d) - Required plant and equipment tasks are completed.
& 18 - Appropriate corrective actions are advised to the agreed contacts.
- Significant non-conformances are recorded and tracked to conclusion.
- A representative proportion of output must be monitored to ensure compliance with
the above.
D) What you need to tell your customer

The member should inform the client that it is the responsibility of the duty
holder/responsible person to:
a. Consider that any changes to the system may alter the Legionella risk and
therefore require a review of risk assessment, associated control scheme and
records. This may result in:
• a reassessment of the legionella risk
• an update of the written scheme of control
• a revised schematic diagram
• a revision of the record keeping system
19
b. Make appropriate notification under the requirements of the Plumbing Notification
Laws.
c. Ensure the necessary trade effluent discharge consent is in place for any effluent
generated from any equipment installed.
d. Ensure any preparatory work you are responsible for is completed prior to
commencing plant and equipment work.
e. Ensure any equipment is installed, commissioned, operated, and maintained
correctly.
Check list 08 - Plant & Equipment

For required actions see Non-Conformity tab

Observations/Comments service standard


Non-Con Observations/Comments on evidence
compliance
Ref (E.G. RAMS/Reports/Certificates).
(E.G. Procedures/Processes/Templates)
Non-Conformity tab

Non-Con
Ref

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