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PagePolicy on the control of Legionella, Pseudomonas and water hygiene, safe hot water, cold water

and drinking water - Version 9

2

1.0 INTRODUCTION .................................................................................................................................................. 3

2.0 PURPOSE AND SCOPE OF THE POLICY ........................................................................................... 4

2.1 PURPOSE ................................................................................................................................................................. 4 2.2 SCOPE ..................................................................................................................................................................... 4 2.3 DEFINITIONS ............................................................................................................................................................ 5

3.0 DUTIES .................................................................................................................................................................. 7

3.1 MANAGEMENT RESPONSIBILITY ................................................................................................................... 7 3.1.1 General ............................................................................................................................................... 7 3.1.2 Responsible Person [Water] ...................................................................................................... 7 3.1.3 Infection Control Officer [Water] .................................................................................................. 8 3.1.4 Independent Water Hygiene Consultant ..................................................................................... 9 3.1.5 Trust Senior Operational Manager ............................................................................................ 10 3.1.6 Authorised Person [Water] ...................................................................................................... 11 3.1.7 Competent Persons ................................................................................................................... 12 3.1.8 Building Managers / Departmental Managers ............................................................................. 13 3.1.9 Other Professional Persons ....................................................................................................... 14 3.1.9.1 Engineering Professionals and Design Professionals ............................................................... 14 3.1.9.2 All staff .................................................................................................................................... 14

4.0 DEVELOPMENT PROCESS ................................................................................................................ 15

4.1 IDENTIFICATION OF NEED ......................................................................................................................... 15 4.2 CONSULTATION AND COMMUNICATION WITH STAKEHOLDERS ................................................................ 15

5.0 EQUALITY IMPACT ASSESSMENT .................................................................................................... 16

5.1 AIM……………………………………………………………………………………………………………………………………………..16

6.0 DISSEMINATION AND IMPLEMENTATION ARRANGEMENTS ................................................... 17

6.1 DISSEMINATION .................................................................................................................................................... 17 6.2 IMPLEMENTATION ................................................................................................................................................. 17

7.0 PROCESS FOR MONITORING COMPLIANCE AND EFFECTIVENESS .................................... 18

7.1 MONITORING COMPLIANCE ...................................................................................................................... 18 7.1.1 External Standard Requirements ............................................................................................ 18

7.2 EFFECTIVENESS ................................................................................................................................................... 18

8.0 MANAGEMENT PLAN………………..……………………………………………………………….19

8.1 EMPLOYEE CONSULTATION ..................................................................................................................... 19 8.2 RISK MANAGEMENT AUDIT ...................................................................................................................... 19 8.3 PROPERTY RISK SCREENING .................................................................................................................. 19 8.4 RISK ASSESSMENT – LEGIONELLOSIS RISK ........................................................................................... 19 8.5 RISK ASSESSMENT – PSEUDOMONAS RISK ............................................................................................ 20 8.6 RISK MINIMISATION SCHEME .................................................................................................................... 20 8.7 WRITTEN PRO EDURES MANUAL .............................................................................................................. 21

9.0 REVIEW AND REVISION ARRANGEMENTS ................................................................................... 22

9.1 PROCESS FOR REVIEWING THIS POLICY ................................................................................................... 22 9.2 VERSION CONTROL .................................................................................................................................. 22 9.3 ARCHIVING ............................................................................................................................................................ 22

10.0 REFERENCES .............................................................................................................................................. 23

11.0 OTHER TRUST REFERENCE DOCUMENTS ............................................................................... 24

12.0 APPENDICES ................................................................................................................................................ 25

APPENDIX 1 – ORGANOGRAM ........................................................................................................................ 26

APPENDIX 2 – EQUALITY IMPACT ASSESSMENT TOOL ....................................................................... 27

APPENDIX 3 – CHECKLIST FOR THE REVIEW AND APPROVAL OF POLICY DOCUMENT ........... 28

APPENDIX 4 – VERSION CONTROL SHEET ................................................................................................. 30



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1.0 INTRODUCTION The policy of South West Yorkshire Partnership NHS Foundation Trust [hereinafter referred to as the “Trust”] is to provide and maintain safe and healthy working conditions, equipment and systems of work for all staff and visitors, and to provide such resources, information, training and supervision as needed for this purpose.

The Trust aims to do all that is reasonably practicable to manage the risk of legionellosis, pseudomonas and water hygiene, safe hot water, cold water and drinking water [hereinafter referred to as “water hygiene”] and to follow the steps laid out in this policy document and the associated written procedures manual. This will be judged on the basis of the balance of risk, cost and difficulty.

The HSE’s Approved Code of Practice and Guidance D cument [L8] – “Legionnaires’ disease: the control of Legionella bacteria in water systems” is taken as the primary source of guidance on matters relating to legionellosis risk management. Where highly vulnerable persons may be present, such as healthcare premises HTM.04:01 is the primary reference document. In lower risk situations, HTM.04:01 can also provide a useful indication of best practice.

The policy of the Trust is to meet the requirements of the relevant guidance, and to comply with these policy document and associated written procedures manual so far as is reasonably practicable. This policy document and associated written procedures manual applies to all Trust premises.

The management of legionellosis risk will be a continual commitment by the Trust involving regular management and progress eetings, and a commitment to a risk assessment programme.

This policy document is formally accepted by the Chief Executive. The Chief Executive will do all that is reasonably practicable to comply with its requirements, and will make the necessary resources available.

The Head of Estates & Facilities [West] has been appointed by the Chief Executive as the Responsible Person [Water].



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2.0 PURPOSE AND SCOPE OF THE POLICY 2.1 Purpose

The Trust is committed to reducing the risks associated with Legionellosis by providing arrangements to ensure effective practice, and training and audit required to ensure compliance. This policy document describes how the organisation will achieve this by;

a. Setting out a clear framework to protect all staff, patients and visitors by

minimisation of the risks associated with Legionella bacteria.

b. Identifying the correct practice for water hygiene risk minimisation and control for staff to implement based upon nationally accepted guidance.

c. Enabling staff to understand their responsibilities in relation to this policy

document and associated written procedures document.

d. Describing arrangements for ensuring this document is monitored and reviewed to reflect current legislation and guidance.

e. Describing the process for version control to ensure persons who require

it, have access to the most current version of the document.

f. Ensuring arrangements are in place for archiving revised policies. 2.2 Scope

The policy applies to all service users, visit rs and staff associated with the Trust and should be read in association with the written procedures manual and implemented whenever water hygiene risk management advice is required.

Although accepted and evidence based core principles for legionellosis risk management are clearly identified within both this policy document and separate written pro edures manual, it is inappropriate for the Trust to make a blanket statement in relation to these.

This policy document and associated written procedures manual cannot anticipate all eventualities, therefore professional judgement should be used to identify the appropriate course of action needed to protect those who are vulnerable and / or at risk.

The on-going risk management process will enable those involved, namely, Responsible Person [Water], Senior Operations Manager, Authorised Persons [Water], Competent Persons and the Infection Prevention Control Team to identify the level of vulnerability and risks posed to individuals; including service users, members of the public and staff members, thereby ensure appropriate action will be taken.



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2.3 Definitions

Aerosol A suspension in a gaseous medium of solid particles, liquid particles or solid and liquid particles having negligible falling velocity.

Air-conditioning A form of air treatment whereby temperature humidity and air cleanliness are all

controlled within limits determined by the requirements of the air-conditioned enclosure.

Bacteria (Singular bacterium) a microscopic, unicellular (or more rarely multicellular) organism.

Biocide A substance which kills micro-organisms.

Biofilm A community of bacteria and other micro-organisms, embedded in a protective layer

with entrained debris, attached to a surface.

Blow- down/bleed-off

Water discharged from the system to control the concentration of salts or other impurities in the circulating water; usually expressed as a percentage of recirculating water flow.

Calorifier An apparatus used for the transfer of heat to water in a vessel by indirect means, the source of heat being contained within a pipe or coil immersed in the water.

Chlorine An element used in disinfection.

Cold water service

Installation of plant, pipes and fitting in which cold water is stored, distributed and subsequently discharged.

Dead end/blind end

A length of pipe closed at one end through which no water passes.

Deadleg Pipes l a ing to a fitting through which water only passes when there is draw-off from the fitting.

Disinfection A process, which destroys or irreversibly inactivates microorganisms and reduces

their number to a non-hazardous level.

Distribution circuit

Pipework, w ich distributes water from hot or cold-water plant to one or more fittings/appliances.

Domestic water services

Hot and cold water intended for personal hygiene, culinary, drinking water or other domestic purposes.

Hot water service (HWS)

Installation of plant, pipes and fittings in which water is heated, distributed and subsequently discharged (not including cold water feed tank or cistern).

Legionnaires’ disease

A form of pneumonia caused by legionella bacteria.

Legionellae The genus legionella belongs to the family legionellae, which has over 40 species. These are ubiquitous in the environment and found in a wide spectrum of natural and artificial collections of water.

Legionella Type of aerobic bacterium, which is found predominantly in warm water

environments. (Singular of legionellae).

L. pneumophila One of the causative organisms of Legionnaires’ disease.

Legionellosis Any illness caused by exposure to legionella.

Pontiac fever A disease caused by species of legionella, an upper respiratory illness less severe than Legionnaires’ disease.

Micro-organism An organism of microscopic size including bacteria, fungi and viruses.



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Nutrient A food source for micro-organisms.

Pasteurisation Heat treatment to destroy micro-organism usually at high temperature.

Sero-group A sub-group of the main species.

Sentinel taps For a hot water services - the first and last taps on a recirculating system. For cold water systems (or non-recirculating hot water systems), the nearest and furthest taps from the storage tank. The choice of sentinel taps may also include other taps which are considered to represent a particular risk.

Sludge A general term for soft mud-like deposits found on heat transfer surfaces or other

important sections of a cooling system. Also found at the base of calorifiers and cold water storage tanks.

Shunt pump A circulation pump fitted to hot water service/plant to overcome the temperature

stratification of the stored water.

Stagnation The condition where water ceases to flow and is therefore liable to microbiological growth.

Thermal disinfection Thermostatic mixing valve

Heat treatment to disinfect a system.

Mixing valve in which the temperature at the outlet is pre-selected and controlled automatically by the valve.

Total viable counts (TVC)

The total number of culturable bacteria (per volume or area) in a given sample (does not include legionella).

Risk assessment

Identifying and assessing the risk f om legionellosis from work activities and water sources on remises and determining any necessary precautionary measures.



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3.0 DUTIES 3.1 Management Responsibility

The Chief Executive of the Trust has overall accountability for all aspects of water hygiene.

Those persons with key management responsibilities are detailed below and their lines of communication with respect to each and other relevant supporting staff are represented in Appendix 1.

3.1.1 General

All relevant persons shall fully appreciate the actual and potential risks associated with water hygiene and the concept of risk management Although compliance with the guidance may be delegated to staff, or undertaken by contract, accountability cannot be delegated.

3.1.2 Responsible Person [Water]

The Responsible Person [Water] will be required to liaise closely with other professionals in various disciplines. This individual’s role involves:

a. Approving and identifying any changes to this policy document and the

associated written procedures manual;

b. Ensuring sufficient resources available, so far as is responsibly practicable, for the continued management of water hygiene, including:

i. Training needs are fulfilled for those persons involved in the management of legionellosis risk;

ii. Risk assessments are completed and re-assessments are undertaken at least every two years (sooner if there is a change in the use, occupation or systems within a building);

iii. Remedial works are completed in line with risk minimisation schemes;

c. Co-ordinating with independent water hygiene consultant for continued

competent help;

d. Chair the routi e Water Hygiene Management Group meetings;

e. Carrying out the necessary actions should an outbreak of Legionnaires’ disease be suspected;

f. Attend appropriate awareness/training sessions, at least every three years.



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3.1.3 Infection Control Officer [Water] Within the Trust the Infection Control Officer [Water] role is deemed to be Senior Infection Prevention Practitioner who is supported by the Microbiologist from Mid Yorks NHS Trust.

Microbiological expertise is provided by the appointed Infection Control Officer [Water] and/or Independent water hygiene consultant.

The Infection Control Officer [Water] will head the Outbreak Control Team, as determined in HTM.04:01. Part B “Operational Management” Appendix 1.

The function of the Infection Control Officer [Water] is to:-

a. Take responsibility for the maintenance of water quality;

b. Advise on any review and updates to this policy document and the


c. Attend the routine Water Hygiene Management Group meetings;

d. Carry out the necessary action if an outbreak of Legionnaires ’ disease is suspected;

e. Advise on the location of “high risk” patient services and those areas

relating to medical devices i e. dental equipment;

f. Attend appropriate awareness/training sessions, at least every three years. The Infection Control Officer [Water] will also inform the Responsible Person [Water] if circumstances change within any ward/department that might affect legionellosis/water hygiene r sk.



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3.1.4 Independent Water Hygiene Consultant The independent water hygiene consultant acts as the independent competent help and shall provide advice and assistance to the Trust and the staff associated with legionellosis risk management.

The independent water hygiene consultant shall:

a. Attend the routine Water Hygiene Management Group meetings and

generate minutes;

b. Advice on risk assessment programme;

c. Undertake property risk screens;

d. Undertaken an annual management risk audit;

e. Periodically update this policy document and associated written procedures manual;

f. Deliver periodic training based on needs analysis;

g. Advise on sampling requirements and assist with the interpretation of any

results and actions required.

Policy on the control of Legionella, Pseudomonas and water hygiene, safe hot water, cold water and drinking water - Version 9

3.1.5 Trust Senior Operational Manager The Trust Senior Operational Managers will be appointed by Responsible Person [Water] to whom delegated responsibility may be given. They will act on behalf of the Responsible Person [Water] in their absence.

They facilitate the maintenance and development aspect of water hygiene within the Trust ensuring service quality and compliance. These individual’s role involves:

a. Advise and feedback back on any changes to the policy document and


b. Advise on continuing procedures and actions f r the prevention or control of legionellae;

c. Liaising with the water undertaker and ensure that equipment that is

permanently connected to the water supply is properly installed;

d. Monitor the implementation and efficacy of the procedures manual and the associated records;

e. Co-ordinating with independent water hygiene consultant for continued

competent help;

f. Assist with the completion of annual risk management audit;

g. Attend the routine Water Hygiene Man gement Group meetings;

h. Assisting with the necessary actions should an outbreak of Legionnaires’ disease be suspected;

i. Attend appropriate awareness/training sessions i.e. revisions to the policy

document and / or the written p rocedures manual, at least every three years.


3.1.6 Authorised Person [Water] The Authorised Persons [Water] will be appointed by the Responsible Person [Water].

The Authorised Persons [Water] will have responsibility for:

a. Implementation and actioning of the day to monitoring and maintenance of risk systems [the PPM system]. This will include the overseeing of any specially appointed contractors / service providers;

b. Managing the risk assessment and re-assessment programme for

properties;

c. Implementation and actioning of necessary remedial works in line with the risk minimisation scheme;

d. Shall ensure that only UKAS approved laboratories with Legionella testing

competence shall be used by the Authority and or any of the associated Competent Persons (including subcontractors);

e. Resolving operational issues as they occur and ensuring that Incident

Report forms are completed in full;

f. Maintenance of record keeping system;

g. Ensuring continued validation competent persons and contractor competence is checked;

h. Assist with the annual risk management audit and periodic record audits;

i. Attend the routine ater Hygiene Management Group meetings;

j. Assisting with the necessary actions should an outbreak of Legionnaires’

disease be suspected;

k. Attend appropriate awareness/training sessions i.e. revisions to the policy document and / or the written procedures manual, at least every three years.


3.1.7 Competent Persons The Trust has an estates team who under take monitoring and remedial works.

The Trust, from time to time, also appoints external contractors to assist with delivery of PPM tasks, monitoring tasks and remedial work tasks.

The estates team and external contractors are known as ‘competent persons’.

All Competent Persons shall:

a. Conduct all of their water system related tasks in accordance with:

I. this policy document;II. the associated written procedures ma al;

III. the requirements of the Planned Preventative Maintenance system.

b. Employ the highest standards of workmanship;

c. Complete all work in a workman like manner;

d. Only WRAS approved materials when working on water systems;

e. Report any defects, suspicions or concerns regarding the design, condition, operation or performance of water systems that might increase the risk of Legionella proliferation [i.e. blanked-off pipes that do not serve outlets] or little/un-used outlets are found they should be reported to their respective Authorised Person [Water];

f. Keep relevant records;

g. Attend appropriate awareness/training sessions i.e. revisions to the policy

document and / or the written procedures manual, at least every three years.

When the situation arises where the Trust requires the services of external contractor then the Authorised Person [Water] shall:

a. Issue a standard form within any contract documentation which define

roles, responsibilities and procedures of parties concerned;

b. Obtain a submission of method statements and risk assessments in relation to planned remedial works. This will include, but not limited to, procedures which involve Working at Height, Working in Confined Spaces, Electrical Safety at Work, and any other permit to work systems;

c. Undertaken a contract review to allow for agreed deviation from the initial

contract documents, these shall be mutually agreed and documented;

d. Must request and hold evidence of competency & training records for all external contractors prior to any proposed contract being issued / approved. The Trust defines competency as ‘approved contractor’ which requires the external contractor to be members of WRAS ‘Approved


Plumber Scheme’. Up to date evidence of competence of each member of staff who will working on the water systems being provided.

3.1.8 Building Managers / Departmental Managers

Building Managers / Departmental Managers are those persons who have control over the use of water in their buildings i.e. clinic / surgery.

These individuals hold the legal consequences of the operational aspects of water hygiene control within their buildings. In order to fulfil their legal obligations these individuals must follow the guidance contained within this policy document and the associated written procedures manual.

In particular they must ensure that:

a. All water outlets are used at least twice weekly and/or permanently

removed;

b. Any defects, suspicions or concerns regarding the design, condition, operation or performance of water systems that might increase the risk associated with water hygiene are reported to their respective Authorised Person [Water] for further investigation;

c. Attend water hygiene awareness/training sessions at least every three

years.


3.1.9 Other Professional Persons

3.1.9.1 Engineering Professionals and Design Professionals

All specialist professionals shall ensure: a. They follow the guidance laid down in this policy document, the

associated written procedures manual, the relevant primary reference publications upon which this is based;

b. They shall also ensure that they are up to date, by attending

relevant awareness and training sessions. Providing evidence to the Responsible Person [Water] of competence and training records;

c. The person commissioning external designers is responsible for

ensuring the design requirements of this document are met.

d. Provide evidence of membership to an appropriate trade association i.e. the Legionella Control Association [LCA], WRAS Approved Plumber Scheme.

e. They shall report any defects, suspicions or concerns regarding

the design, condition, operation or performance of water systems that might increase the risk associated with water hygiene.

f. Keep records of all actions taken with respect to water hygiene

[incl. legionella] control shall be ge rated and maintained. 3.1.9.2 All staff

All staff members that can effect on water hygiene as such shall conduct their tasks in accordance with this policy document and associated written procedures manual.

All staff should report any defects, suspicions or concerns with water system i.e. where blind ends [i.e. blanked-off pipes that do not serve outlets] or little/un-used outlets are found they should be reported to the Authorised Persons [Water].


4.0 DEVELOPMENT PROCESS 4.1 Identification of need

To meet the requirements of NHSLARMS [Department of Health, 2008] the existing policy format has been revised. Information within existing policies has been placed in separate sections of the revised policy and additional sections added.

This policy will be reviewed every two years.

The Trust acknowledges the need to have a formal policy document and associated written procedures manual to provide practical guidance for all within the Trust relating to water hygiene.

4.2 Consultation and Communication with Stakeholders

The organisation recognises that policies need to be developed in consultation and communication with a range of stakeholders:

Senior Infection Prevention Practitioner; Microbiologist from Mid Yorks NHS Trust; Independent water hygiene consultant; Senior Operations Manager [Water]; Authorised Person [Water]; Competent Persons.


5.0 EQUALITY IMPACT ASSESSMENT 5.1 Aim

The Trust aims to ensure its policies promote equality both as a provider of services and as an employer. Please see APPENDIX 2 for Equality Impact Assessments.


6.0 DISSEMINATION AND IMPLEMENTATION ARRANGEMENTS 6.1 Dissemination

This policy document is available in a read-only format via the document store on the Trust intranet and internet. Staff are informed of any changes to the document via the periodic Water Hygiene Risk Management review meetings. Any changes to this document must be implemented only with the authority of the Responsible Person [Water].

6.2 Implementation

Support and advice to assist in the implementation of this document is available from the following persons:

a. Senior Operations Manager;

b. Authorised Persons [Water].


7.0 PROCESS FOR MONITORING COMPLIANCE AND EFFECTIVENESS 7.1 Monitoring Compliance

Monitoring compliance for this policy is taken from the various legislation and guidance documents [see 7.1.1 External Standard Requirements].

7.1.1 External Standard Requirements

Health Technical Memorandum 04-01: The control of Legionella, hygiene, ‘safe’ hot water, cold water and drinking water systems. Parts A and B: 2006

Health Technical Memorandum 03-01: Specialised ventilation for healthcare premises. Parts A and B: 2006

Approved Code of Practice, Legionnaires’ disease: the control of Legionella bacteria in water systems. [L8]:2000

Water sources and potential Pseudo onas Aeruginosa contamination of taps and water systems – advice for augmented care units: 31/03/12

The Health and Safety at Work etc Act: 1974

The Management of health and Safety at Work Regulations: 1999

The Water Supply [Water Fittings] Regulations: 1999

The Water Supply [Water Quality] Regulations: 2000

The Control of Substances Hazardous to Health Regulations: 2002

The Building Regulations: 1992

BS EN 806. Parts 1 to 5. Specifications for installations inside buildings conveying water for human consumption.

BS 7592:2008 - Description: Sampling for Legionella bacteria in water systems. Code of practice

Water Regulations Advisory Scheme [WRAS] Water Regulations Guide: 2004

Water Regulations Advisory Scheme [WRAS] Water Fittings and Materials Directory

7.2 Effectiveness

Please refer to 8.2 Risk Management Audit.


8.0 MANAGEMENT PLAN 8.1 Employee Consultation

Employees shall be consulted regarding the assessment and control measures. This shall be via the Health and Safety TAG and Health & Safety sub groups as appropriate. Additionally each risk assessment/risk minimisation scheme report [at organisational level] shall include an Employee Summary for dissemination to unions/employees at the discretion of the Responsible Person [Water].

8.2 Risk Management Audit

An annual legionellosis risk management audit is undertaken in order to ascertain the effectiveness of the broad management arrangements. The methodology for audit may vary from year-to-year in order to ensure a fresh outlook on each occasion. The audit report includes recommendations for improvement and forms part of the legionellosis risk management system.

8.3 Property Risk Screening

Prior to the conduct of on-site risk assessments, a risk screen may be performed in order to prioritise the water systems for detailed risk assessment, in order that the potentially highest risk systems are surveyed first.

8.4 Risk Assessment – Legionellosis Risk

The Authorised Persons [Water] undertakes and reviews legionellosis risk assessment under the following circumstances:-

Small domestic properties, served by individual single pipe water systems, are

risk assessed by legionellosis risk screening, a desk based risk assessment exercise. The screen is undertaken every two years. Based on the findings, re resentative properties will be subject to on-site risk assessment;

Reassessment takes place whenever there is reason to believe the latest risk

assessment may no longer be valid e.g. due to a change of building use; The review of risk assessment shall be based on on-site re-assessment of risk on

an annual basis for premises with high vulnerability occupants and every two years for other premises. Desk based risk review of risk assessments is also undertaken on a quarterly basis.

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

The Authorised Persons [Water] shall ensure that:

a. Those persons / organisation employed to undertake risk assessments are

competent to do so and registered with the Legionella Control Association. This organisation must be independent and shall not be used to complete,


undertaken or deliver any remedial works arising from the risk assessment;

b. The risk assessment will be completed in accordance with BS8580:2010;

c. The risk assessment shall include:

I. Identifies and evaluates potential sources of risk;

II. Includes an assessment of occupant vulnerability;

III. Uses an established risk scoring matrix;

IV. Encompasses all buildings and all w t r systems.

8.5 Risk Assessment – Pseudomonas Risk

Guidance issued to all Trusts with particular focus on augmented care units / areas, advised pseudomonas risk assessments be completed for each unit / area. SWYPFT has reviewed the guidan e and concluded that the Trust has no augmented care units /areas. The Trust infection prevention and control team (IPCT) have, in compliance with the guidance, completed the required risk assessment and concluded that, although the Trust has no augmented care areas / units, existing practices are adequate and safe.

The IPCT includes the Director of Infection Prevention and Control (DIPC), Consultant Microbiologists, IPC nurses, Facilities staff, the Responsible Person for Water, Capital planning representatives and IPC Link workers.

The risk assessment involv d a review of the role and function of all units in Business Delivery Units (BDUs) throughout the organisation and confirms.

individual clinical risk assessments are in place for all immuno- suppressed

service users existing practices in all inpatient units are adequate and safe.

there is an appropriate existing policy and action plan, including risk management

of Pseudomonas aeruginosa, in place and being implemented to protect susceptible service users within the organisation.

Further recommendations include:

Cleaning practices are to be followed and these should be reviewed by Facilities to ensure all practices remain adequate.

The regular use of outlets will also help with water hygiene inc. legionellosis risk.

8.6 Risk minimisation scheme

The risk assessments shall form the basis of a Risk Minimisation Scheme describing the particular means by which the risk from exposure to Legionella bacteria is to be


minimised. The remedial actions within the Risk Minimisation Scheme shall be reasonably practicable and prioritised on the basis of risk, cost and difficulty.

8.7 Written Procedures Manual

The written procedures manual is distributed internally by the Senior Operations Manager, to those persons with responsibilities for legionellosis risk management.

The written procedures manual describes the particular means by which the risk from exposure to Legionella bacteria is to be controlled.


9.0 REVIEW AND REVISION ARRANGEMENTS

9.1 Process for Reviewing this Policy

The review date for this document will be every two years, unless otherwise indicated by change in national guidance or as a result of the risk incident reporting system.

9.2 Version Control

This document has been revised from its previous format and the current version number is details on the front of this policy document.

Refer to Appendix 3 for details of version changes.

9.3 Archiving

The Senior Operations Manager will be responsible for document control including the recording, storing and controlling of current procedural documents and archiving.

Record Retention Period

This policy and procedures document Throughout the period for which theyremain current and for at least twofurther years.

Risk assessments

Risk minimisation scheme and details of its implementation

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

At least five years


10.0 REFERENCES Health Technical Memorandum 04-01: The control of Legionella, hygiene, ‘safe’ hot water, cold water and drinking water systems. Parts A and B: 2006

Health Technical Memorandum 03-01: Specialised ventilation for healthcare premises. Parts A and B: 2006

Approved Code of Practice, Legionnaires’ disease: the control of legionella bacteria in water systems. [L8]:2000

Water sources and potential Pseudomonas Aeruginosa contamination of taps and water systems – advice for augmented care units: 31/03/12

The Health and Safety at Work etc Act: 1974

The Management of Health and Safety at Work Regulations: 1999

The Water Supply [Water Fittings] Regulations: 1999

The Water Supply [Water Quality] Regulations: 2000 The Control of Substances Hazardous to Health Regulations: 2002 (as amended)

The Building Regulations: 1992

BS EN 806. Parts 1 to 5. Specifications for installations inside buildings conveying water for human consumption.

BS 7592:2008 - Description: Sampling for Legionella bacteria in water systems. Code of practice

Water egulations Advisory Scheme [WRAS] Water Regulations Guide: 2004

Water Regulations Advisory Scheme [WRAS] Water Fittings and Materials Directory


11.1 OTHER TRUST REFERENCE DOCUMENTS

This document should be read in conjunction with the following Trust documents;

Estates & Facilities Department Emergency Operational Procedures. Infection Prevention and Control Policy Confidentiality Policy Health & Safety Policy Waste Management Policy COSHH Guidance Moving and Handling Policy Incident Management and Patient Safety Policy Occupational Health Policy Mandatory Training Policy Whistle Blowing Policy Maintenance & Operational Procedures for the control of Legionella,

water hygiene, ‘safe’ hot water, cold water, drinking water and non- drinking water.


12.0 APPENDICES

safe

APP

Infection Con[Wate

Senior InfectionPractitioner

Building / Ward /Managers

Trust S[Sout

Polie hot water, col

PENDIX 1 – Or

ntrol Officer er] n Prevention r [South]

/ Department [South]

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APPENDIX 2 – Equality Impact Assessment Tool To be completed and attached to any policy document when submitted to the Executive Management Team for consideration and approval. Yes/No Comments

1 Does the policy/guidance affect one group less or more favourably than another on the basis of:

Race NO

Ethnic origins (including gypsies and travellers)

NO

Nationality NO

Gender NO

Culture NO

Religion or belief NO

Sexual orientation including lesbian, gay and bisexual people

NO

Age NO

Disability - learning disabilities, physical disability, sensory impairment and mental health problems

NO

2 Is there any evidence that some groups are affected differently?

NO

3 If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

NO

4 Is the impact of the policy/guidance likely to be negative?

NO

5 If so can the impact be avoided? N/A

6 What alternatives are there to achieving the policy/guidance without the impact?

N/A

7 Can we reduce the impact by taking different action?

N/A

If you have identified a potential discriminatory impact of this policy, please refer it to the Director of Corporate Development or Head of Involvement and Inclusion together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact the Director of Corporate Development or Head of Involvement and Inclusion.



APPENDIX 3 – Checklist for the Review and Approval of Policy Document To be completed and attached to any policy document when submitted to EMT for consideration and approval.

Title of document being reviewed:

Yes/No/ Unsure

Comments

1 Title

Is the title clear and unambiguous?

Is it clear whether the document is a guideline, policy, protocol or standard?

2 Rationale

Are reasons for development of the document stated?

3 Development Process

Is the method described in brief?

Are people involved in the development identified?

Do you feel a reasonable attempt has been made to ensure relevant expertise has been used?

Is there evidence of consultation with stakeholders and users?

4 Content

Is the objective of the document clear?

Is the target population clear and unambiguous?

Are the intended outcomes described?

Are the statements clear and unambiguous?

5 Evidence Base

Is the type of evidence to support the document identified explicitly?

Are key references cited?

Are the references cited in full?

Are supporting documents referenced?

6 Approval

Does the document identify which



Title of document being reviewed:

Yes/No/ Unsure

Comments

committee/group will approve it?

If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document?

7 Dissemination and Implementation

Is there an outline/plan to identify how this will be done?

Does the plan include the necessary training/support to ensure compliance?

8 Document Control

Does the document identify where it will be held?

Have archiving arrangements for superseded documents been addressed?

9 Process to Monitor Complia ce and Effectiveness

Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document?

Is there a plan to review or audit ompliance with t e document?

10 Review Date

Is the review date identified?

Is the frequency of review identified? If so is it acceptable?

11 Overall Responsibility for the Document

Is it clear who will be responsible implementation and review of the document?

APPENDIX 4 – Version Control Sheet This sheet should provide a history of previous versions of the policy and changes made

Version Date Author Status Comment / changes

1 26/11/07 P.Gunn Draft N/A

2 01/10/08 P.Gunn Draft Facilities Dept. technical changes - various

3 19/10/08 P.Gunn Draft Trust standardisation

4 11/02/08 P.Gunn Draft Policy & Procedures document separation.

5 07/08/09 Daniel Pitcher Draft Update of policy document. Total revi ion of procedures manual.

6 22/10/09 Daniel Pitcher Draft Revision of policy document & procedures manual following consultation.

7 23/02/10 Daniel Pitcher Draft Annual revision of policy document & procedures manual following consultation.

8 16/05/11 Daniel Pitcher Draft Annual revision of policy document & procedures manual following consultation.

9 29/10/12 Daniel Pitcher Draft Revision of policy document & procedures manual following the merger with Barnsley PCT.

9 08/11/12 Daniel Pitcher Draft Edit to policy document following review of version 8.

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