Legionella Risk Assessment - Our Lady of Lourdes Catholic ...€¦ · Risk Assessment Ratings LR -...

Client Name: St Augustine's Catholic Primary and Nursery School Site Name: St Augustine's Catholic Primary and Nursery School Assessment Date: 18/08/2017

Assessor Name: Callum Kennedy Date: 21/08/2017

Page: 1 / 145

Legionella Risk Assessment St Augustine’s Catholic Primary & Nursery

School

Park Avenue

Mapperley Road

Nottingham

NG3 4JS

Assessment completed by: Callum Kennedy, Acquiesce

Environmental Compliance Limited

Assessment completion date: 21st August 2017

Assessment review date: 21st August 2019



Page: 2 / 145

Executive Summary

Site Description

St Augustine’s Catholic Primary School & Nursery School, is an educational facility based in Nottingham. The

two-storey building is mainly brick built and the original building was constructed in 1910. The mains school

was built in 1970 and the Nursery in 2012. Exposure potential for legionella is limited to those within the

building and there are no evaporative coolers on site. The school is open during all term times, so there is

potential for periods of extended or significantly reduced use or non-use in the summer time and at Christmas.

There are approximately 350 pupils using the school and 40-50 staff ranging over all age ranges and an equal

gender split.

The Systems

The domestic hot & cold system on site comprise of a mains fed cold water service which rises in the gas meter

cupboard and feeds all cold outlets in the building. It also feeds a cold water storage tank located in the tank

room on the roof space. This is turn feeds 2 primary coil heated calorifiers located in the basement boiler room.

This feeds domestic hot water to hot water outlets in the building as confirmed in the asset register and on the

schematic drawing. The mains also feeds 3 heating boilers which feed low temperature hot water to all

radiators in the building and also a number of electric point of use/low volume water heaters. The locations of

these are confirmed in the survey and on the schematic drawing.

The Management

At the time of the assessment, the duty holder & responsible person have been identified and the names are

confirmed in the management survey area of the assessment. Monitoring is currently carried out by a service

provider, Second Element and records appear to be up to date.



Page: 3 / 145

Assessment Information

Client Name: St Augustine's Catholic Primary and Nursery School

Park Avenue

Mapperley Road

Nottingham

Nottinghamshire

NG3 4JS

Client Contact: Christopher Bligh

Client Phone: 0115 9156995

Client Fax: NA

Client Mobile: 07860838390

Client Email: [email protected]

Site Name: St Augustine's Catholic Primary and Nursery School

Park Avenue

Mapperley Road

Nottingham

Nottinghamshire

NG3 4JS

Site Contact: Christopher Bligh

Site Phone: 0115 9156995

Site Fax: NA

Site Mobile: 07860838390

Site Email: [email protected]

Assessor: Acquiesce Environmental Compliance

257 Alvechurch Road

West Heath

Birmingham

B31 3PX

Assessor Name: Callum Kennedy

Assessor Phone: 0121 608 3272

Assessor Fax: NA

Assessor Mobile: 07875522338

Assessor Email: [email protected]

Signature: CKennedy

Date: 21/8/17

Risk assessment review date: 21/08/2019



Page: 4 / 145

Risk Assessment Scope

Acquiesce Environmental Compliance Ltd was commissioned by St Augustine's Catholic Primary and Nursery

School to carry out a risk assessment in accordance with the requirements of ACOP L8 Legionnaires Disease the

control of legionella bacteria in water systems. All the domestic water and heating systems found within the

building are included within this assessment

Additional Comments

This Risk Assessment should be reviewed regularly (at least every 2 years) and particularly if there are

reasonable grounds to believe that it may no longer be valid (ACOP L8 Para 27). It is advisable to conduct an

annual review of all monitoring programmes control schemes lines of communication and record keeping in

order to ensure that best practices are being maintained. Regular risk assessment reviews and the adoption of

effective procedures to prevent or control the risk will enable the Statutory Duty Holder to demonstrate that all

pertinent factors have been properly considered. (ACOP L8 Para 29)



Page: 5 / 145

Risk Assessment Responsibilities

The responsibility for implementing and completing the corrective measures remains with the Statutory Duty

Holder or nominated Responsible Person. We would recommend that you read the HSE ACoP L8: 2013

Legionnaires' disease. The control of legionella bacteria in water systems.

This can be down loaded from http://www.hse.gov.uk/pubns/priced/l8.pdf

Technical guidance is available in HSG274 Parts 1 to 3, please see further guidance section.

Failing to action the findings of a risk assessment may result in Legionella bacteria proliferating in the water

systems inspected. Legionella is potentially fatal.

The use of L8MS-Risk software does not negate the responsibility of the service provider to ensure the Risk

Assessor is competent to undertake legionellosis risk assessments. It is imperative that all operatives using

L8MS-Risk are suitable trained. To include:

Use of the software

Principals of risk assessment.

A sound knowledge of legionella legislation, water system design and control practices.

Those appointing a service provider must also ensure that the competence of the service provider is assessed, a

guide can be found in BS8580:2010 Water quality - Risk assessments for Legionella control - Code of practice.

Risk Assessment Ratings

LR - Legionella Risk Ratings

LR - Legionella Risk Rating has been used to prioritise corrective actions relating directly to legionella control.

Our assessment is based on the residual risk with the current design & control systems in place. Failure of the

current control system could easily result in the water system reverting to a far higher risk rating - the water

systems inherent risk.

Level 0 HAZARD (Legionellosis) x LIKELIHOOD (Very Low) = RISK (Minimal)

No additional action required.

Level 1 HAZARD (Legionellosis) x LIKELIHOOD (Low) = RISK (Slight risk under abnormal operating conditions)

Take actions when other more significant risks have been completed.

Level 2 HAZARD (Legionellosis) x LIKELIHOOD (Possible) = RISK (Possible risk with existing operating conditions)

Take actions when operationally practicable, time periods often programmed to fit with shutdowns or planned maintenance.

Level 3 HAZARD (Legionellosis) x LIKELIHOOD (Present) = RISK (Probable risk with existing operating conditions)

Take actions as soon as possible, time periods are typically a few months maximum.

Level 4 HAZARD (Legionellosis) x LIKELIHOOD (High) = RISK (Imminent risk of harm or loss)

Take immediate action to reduce the risk, this may include taking systems off line.

http://www.hse.gov.uk/pubns/priced/l8.pdf



Page: 6 / 145

GR - General Risk Ratings

GR - General Risk Rating has been used to prioritise corrective actions relating to general safety concerns, such

as working at heights, or scalding risks pointed out under our duty of care.

Level 0 No additional action required.

Level 1 Take actions when other more significant risks have been completed.

Level 2 Take actions when operationally practicable.

Level 3 Take actions as soon as possible.

Level 4 Take immediate action to reduce risk.

We as a service provider are unable to define exact time scales for corrective action as this is dependent on any

other risks within your organisation and the budget available for corrective actions. A programme of

implementation should be devised.



Page: 7 / 145

Key Individuals & Allocation of Responsibilities

Key Individuals:

Function Name Company Name Phone No. Email

Statutory duty holder details.

Caroline Caille St Augustine’s Primary & Nursery School

0115 915 6995 [email protected]

Responsible person details.

Christopher Bligh St Augustine’s Primary & Nursery School


Deputy to the responsible person.

Tracey Moore St Augustine’s Primary & Nursery School


Water hygiene contractor.

Unknown Second Element 01673 844 024 [email protected]

Risk assessor. Callum Kennedy AEC LTD 0121 608 3272 [email protected]

C & D contractor. Unknown Second Element 01673 844 024 [email protected]

Allocation Of Responsibilities:

Management tasks

Local authority for notification of evaporative cooling systems. Not Applicable

Conducting a legionellosis risk assessment / assessment reviews. AEC LTD

Provision of system schematics. AEC LTD

Remedial or corrective actions identified. Second Element/AEC LTD

Production of the written scheme. Second Element

Provision of method statements for works carried out. Second Element

Completion of COSHH assessments. Second Element

Provision of safety data sheets. Second Element

Setting up a program of works. Second Element

Definition of control parameters, measurement methods and sample locations.

Second Element

Provision of operating manuals. Unknown

Provision of emergency start-up and shut-down procedures. Unknown

Provision of a description of normal and safe operation. Unknown

Defining actions in the event of positive legionella result / outbreak. Second Element

Providing / assessing training and identifying staff competence. Second Element

Provision of a suitable record system. Second Element

Maintaining the record system. Second Element



Page: 8 / 145

Hot & Cold Tasks

Flushing of little used outlets. St Augustines Primary & Nursery School

Standby plant switching. St Augustines Primary & Nursery School

Checking temperatures in flow and return at calorifiers. Second Element

Checking hot and cold water temperatures at sentinel taps. Second Element

Shower head cleaning and disinfection. Second Element

Any defined routine sampling. Second Element

Storage cistern inspection. Second Element

Storage calorifier inspection. Second Element

Softener service. Not Applicable

Cleaning and disinfection services. Second Element

Mechanical maintenance services. G.K Plumbing

Water treatment services. Second Element



Page: 9 / 145

System ID

System Number: 01 (MCWS 1)

Description:

Direct mains fed water

Location: The mains water stop valve is located in the gas meter room of the main building

Describe Access: There are no access limitations relating to the location of the mains water stop valve.

System Served: The mains water system supplies all cold water outlets within the building and also the cold water storage tank. It also feeds the LTHW heating system

System Number: 02 (CWDS)

Description:

Cold water down service (stored)

Location: The domestic cold water tank is located in the tank room on the roof

Describe Access: Ladders are required to enable access to the tank room

System Served: The cold water storage tank feeds the calorifiers only

System Number: 03 (HWS)

Description:

Hot water service (stored)

Location: The calorifiers are located in the basement boiler room

Describe Access: There are no access limitations in relation to the hot water calorifiers

System Served: The calorifiers serve domestic hot water to outlets as confirmed in the asset register and on the schematic drawing

System Number: 04 (LTHW 1)

Description:

Heating / closed system

Location: The low temperature hot water boilers are located in the basement boiler room

Describe Access: There are no access limitations in relation to the low temperature hot water boilers

System Served: The low temperature hot water boilers feed heating water to all radiators in the building except the nursery block



Page: 10 / 145

System Number: 05 (EWH 1)

Description:

Electric Water Heater (EWH) <15 litres

Location: The electric water heater is located in the reception classroom

Describe Access: There is no access limitations in relation to the electric water heater

System Served: The electric water heater serves the reception classroom sink


Description:


Location: The electric water heater is located in the Year 1 boys toilets


System Served: The electric water heater serves hot outlets in the Year 1 boys & girls toilets


Description:


Location: The electric water heater is located in the Year 2 classroom area


System Served: The electric water heater serves hot water to the Year 2 classroom sink


Description:


Location: The electric water heater is located in the classroom near the 1st floor meeting room


System Served: The electric water heater serves hot water to the sink in the room which it is located in



Page: 11 / 145


Description:


Location: The electric water heater is located in Year 6 classroom


System Served: The electric water heater serves hot water to the Year 6 sink & Year 5 sink

System Number: 10 (WH 1)

Description:

Water Heater >15 litres Low Volume (WH)

Location: The water heater is located in the nursery roof space

Describe Access: Ladders are required for access to the roof space

System Served: The water heater serves hot water to the nursery entrance toilets and classroom sink


Description:


Location: The electric water heater is located in the nursery roof space


System Served: The electric water heater serves the nursery kitchenette sink

System Number: 12 (WH 2)

Description:

Water Heater >15 litres Low Volume (WH)



System Served: The water heater serves hot water to the water area and disabled toilet in the nursery block



Page: 12 / 145

System Number: 13 (MCWS 2)

Description:

Direct mains fed water

Location: The mains water stop valve for the nursery block is located in the nursery plant room

Describe Access: There are no access limitations relating to the location of the mains water stop valve.

System Served: The mains water system supplies domestic cold water to all cold outlets in the nursery block and the 3 water heaters in the roof space. It also feeds the LTHW heating system

System Number: 14 (LTHW 2)

Description:

Heating / closed system

Location: The low temperature hot water boiler is located in the nursery block plant room

Describe Access: There is no access limitations in relation to the low temperature hot water boiler

System Served: The low temperature hot water boilers feed heating water to all radiators in the nursery block

System Number: 15 (Management)

Description:

Management

Location: The previous legionella risk assessment and monitoring data is accessed via request to the site manager

Describe Access: Access to the previous legionella risk assessment and monitoring data is via the site manager

System Served: Legionella control for the whole school



Page: 13 / 145

Assessment Findings

Direct mains services (MCWS) - The mains water stop valve is located in the gas

meter room of the main building

System ID: 01

Survey Ref: MCWS 1


Serving: The mains water system supplies all cold water outlets within the building and also the cold water storage tank. It also feeds the LTHW heating system

Risk Ratings 4 3 2 1 0

Number of items that require attention - Legionella risks 0 0 2 0 9

Number of items that require attention - General risks 0 1 0 0 10

Questions not answered / Total number of questions 0 / 11

Question LR GR

6, Is distribution pipework insulated and likely to operate below 20°C? 2 0

Answer: No - Insulation is unsatisfactory.

Recommendation: Distribution pipework should be insulated to relevant British standards to reduce heat

gain.

Question LR GR

9, Is the direct mains system free from dead ends? 2 0

Answer: Dead ends present on site – See asset register for details.

Recommendation: The dead ends identified on schematics should be removed.

Question LR GR

8, Is the main protected against back flow (Wash down hoses, bib taps, Fire hoses Quick fill etc)?

0 3

Answer: Inadequate backflow protection for dishwashers, washing machines and hydro boilers

Recommendation: All dishwashers and washing machines need to have a double check valve fitted to

protect against back flow. All hydro boilers require a single check valve to be fitted



Page: 14 / 145

Cold Water Down Services (CWDS) - The domestic cold water tank is located in the

tank room on the roof

System ID: 02

Survey Ref: CWDS


Serving: The cold water storage tank feeds the calorifiers only





Question LR GR

8, Are all distribution valves labelled 1 1

Answer: No valves are labelled.

Recommendation: All valves need to be labelled so that they can be readily identified.

Question LR GR


Answer: Although insulated the distribution temperatures were found to be above the recommended 20°C,

possibly due to the current high ambient temperature during the summer months and reduced usage due to

summer holiday period

Recommendation: Ensure all distribution pipework is sufficiently insulated



Page: 15 / 145

Tank (Cistern) - The domestic cold water tank is located in the tank room on the

roof

System ID: 02

Survey Ref: CWST







Question LR GR

12, Internal condition of the tank? 2 0

Answer: The stored water is clear, with no surface scum and only light debris to the base, however there is

some pin hole staining on the walls of the tank

Recommendation: The tank should be cleaned & disinfected in line with Acop L8 recommendations

Question LR GR

18, Tank fitted with drain valve? 1 1

Answer: No drain valve fitted.

Recommendation: A suitable drain valve should be fitted to facilitate complete draining of the cistern. This

needs to be carried out without creating a dead leg area that may result in bacterial build up.

Question LR GR

26, Are the valves and tank labelled? 1 1

Answer: Valves and cistern are not labelled.

Recommendation: The cistern and main valves need to be labelled with an asset number to allow it to be

clearly identified.

Question LR GR

9, What is the stored water temperature in the tank? 1 0

Answer: Cistern temperature (>20°C) 21.4°C.

Recommendation: The increase in stored temperature compared to inlet temperature is most likely

attributed to the assessment taking place when turnover of the tank is significantly less than during term

time. Ensure the tank turns over its capacity during tank time. This can be measured by means of a drop test.



Page: 16 / 145

Calorifier (Water Heater) - The hot water calorifier is located in the basement

boiler room

System ID: 03

Survey Ref: CAL 1

Location: The hot water calorifier is located in the basement boiler room

Serving: The calorifier serves domestic hot water to outlets as confirmed in the asset register and on the schematic drawing





Question LR GR

6, Can the water heater be internally inspected? 2 0

Answer: No inspection hatch has been fitted.

Recommendation: As an inspection hatch has not been fitted, any debris in the water at the base of the

calorifier should be purged to a suitable drain on an annual basis.

Question LR GR

7, Are there details on the internal condition of water heater? 2 0

Answer: No - There has been no regular access to inspect the internal condition of the water heater.

Recommendation: Annual draining of the water heater and checking for debris in the base of the vessel is

needed as debris will harbour bacteria, the water heater should then be cleaned if considered necessary.

Question LR GR

13, Is the water heater causing the feed temperature to rise significantly? 2 0

Answer: Yes - Significant increase.

Recommendation: A check valve should be fitted to the inlet pipe to minimise water tracking back up the

supply pipe.

Question LR GR

10, Is the water heater linked or is stagnation likely? 1 0

Answer: The water heater is linked in parallel (2 heaters in total).

Recommendation: Ensure water flow and temperatures are maintained through all water heaters.



Page: 17 / 145

Question LR GR

17, Are Temperature Gauges/Thermometer pockets fitted to the Flow, Return and base of the water heater?

0 1

Answer: Yes - Gauges fitted and working to the heater and flow pipes. A gauge fitted to the return pipe

would help with ease of monitoring

Recommendation: Fit a temperature gauge to the return pipe on next plant shutdown



Page: 18 / 145


boiler room

System ID: 03

Survey Ref: CAL 2







Question LR GR





Question LR GR





Question LR GR




supply pipe.

Question LR GR






Page: 19 / 145

Question LR GR

15, Is the outlet temperature of the water heater satisfactory? 1 0

Answer: Temperature 54°C

Recommendation: The thermostat setting should be adjusted as the water heater is operating below target

temperatures.

Question LR GR


0 1






Page: 20 / 145

Hot Water Down Services (HWDS) - The calorifiers are located in the basement

boiler room

System ID: 03

Survey Ref: HWDS


Serving: The calorifiers serve domestic hot water to outlets as confirmed in the asset register and on the schematic drawing





Question LR GR

4, Is distribution pipework insulated? 3 0

Answer: Insulation present in plant rooms only.

Recommendation: Distribution pipework needs to be insulated to reduce heat loss and maintain the

required temperatures.

Question LR GR

10, Are all distribution valves labelled? 1 1

Answer: No valves labelled

Recommendation: All isolating valves should be labelled so that they can be readily identified.



Page: 21 / 145

Closed or Sealed systems - The low temperature hot water boilers are located in

the basement boiler room

System ID: 04

Survey Ref: LTHW 1


Serving: The low temperature hot water boilers feed heating water to all radiators in the building except the nursery block





Question LR GR

2, Are system conditions being tested? 0 2

Answer: No

Recommendation: Consider a regular water treatment check on inhibitor levels and corrosion control.



Page: 22 / 145

Hot Water Down Services (HWS) - The electric water heater is located in the

reception classroom

System ID: 05

Survey Ref: EWH 1


Serving: The electric water heater serves the reception classroom sink





Question LR GR


Answer: No



Question LR GR






Page: 23 / 145

Local water heater <15ltr (POU) - The electric water heater is located in the

reception classroom

System ID: 05

Survey Ref: EWH 1







Question LR GR

8, Is there a suitably sized and correctly installed expansion vessel? 2 0

Answer: Water in the expansion vessel is unlikely to turnover.

Recommendation: The expansion vessel should be replaced with an inlet / outlet type that ensures water

turnover.

Question LR GR


Answer: Temperature >60°C

Recommendation:

Question LR GR

13, Is the water heater labelled? 0 1

Answer: No

Recommendation: The water heater should be labelled with an asset number so that it can be clearly

identified.



Page: 24 / 145

Hot Water Down Services (HWS) - The electric water heater is located in the Year 1

boys toilets

System ID: 06

Survey Ref: EWH 2

Location: The electric water heater is located in the Year 1 boys’ toilets

Serving: The electric water heater serves hot outlets in the Year 1 boys & girls toilets





Question LR GR


Answer: No



Question LR GR






Page: 25 / 145

Local water heater <15ltr (POU) - The electric water heater is located in the Year 1

boys toilets

System ID: 06

Survey Ref: EWH 2

Location: The electric water heater is located in the Year 1 boys’ toilets






Question LR GR




turnover.



Page: 26 / 145


classroom area

System ID: 07

Survey Ref: EWH 3


Serving: The electric water heater serves hot water to the Year 2 classroom sink





Question LR GR

3, Do all parts of the distribution system (including returns) operate above 50°C? 3 0

Answer: No

Recommendation: Investigate the failure of the flow temperature

Question LR GR


Answer: No



Question LR GR






Page: 27 / 145


classroom area

System ID: 07

Survey Ref: EWH 3







Question LR GR




turnover.

Question LR GR


Answer: Switched off at time of survey.

Recommendation: The heater should be repaired or replaced.

Question LR GR

4, Is the heater working and in regular use? 1 0

Answer: Not working or off

Recommendation: Repair or replace the water heater.

Question LR GR


Answer: No


identified.



Page: 28 / 145


classroom near the 1st floor meeting room

System ID: 08

Survey Ref: EWH 4


Serving: The elctric water heater serves hot water to the sink in the room which it is located in





Question LR GR


Answer: No



Question LR GR






Page: 29 / 145

Hot Water Down Services (HWS) - The electric water heater is located in Year 6

classroom

System ID: 09

Survey Ref: EWH 5


Serving: The electric water heater serves hot water to the Year 6 sink & Year 5 sink





Question LR GR


Answer: No



Question LR GR


Answer: No


Question LR GR






Page: 30 / 145

Local water heater <15ltr (POU) - The electric water heater is located in Year 6

classroom

System ID: 09

Survey Ref: EWH 5







Question LR GR




turnover.

Question LR GR



Recommendation: The thermostat setting should be adjusted as the water heater is operating at an

incorrect temperature.



Page: 31 / 145

Calorifier (Water Heater) - The water heater is located in the nursery roof space

System ID: 10

Survey Ref: WH 1


Serving: The water heater serves hot water to the nursery entrance toilets and classroom sink





Question LR GR



Recommendation: As the water heater has no internal access but can be easily removed, it should be

chemically cleaned and loose scale removed. In some cases replacement is a better option.

Question LR GR



Recommendation: Introduce an annual internal water heater inspection and maintenance program.

Question LR GR

8, Is the water heater fitted with a drain valve in the base of the unit? 2 0

Answer: No

Recommendation: A suitable drain valve should be fitted to facilitate complete drainage and flushing of the

water heater.

Question LR GR

23, If the water heater is direct mains fed (>15 ltrs), is the supply fitted with a check valve & expansion vessel?

2 0

Answer: Yes although there is no way of draining expanded water from the vessel

Recommendation: Either for an inlet/outlet type expansion vessel to the heater, or fit a drain and isolation

valve to expansion vessel pipework to enable regular flushing.

Question LR GR


1 1

Answer: No temperature gauges are fitted.

Recommendation: It may improve ease of monitoring to fit a temperature gauge on the outlet pipe.



Page: 32 / 145

Question LR GR

21, Is the water heater and associated plant labelled? 1 1

Answer: No

Recommendation: The water heater and main valves should be labelled so that they can be readily

identified.

Question LR GR

19, Does the water heater have isolating valves? 0 1

Answer: Inlet isolating valve only.

Recommendation: Consider installing an outlet valve next time the plant is shutdown.



Page: 33 / 145

Hot Water Down Services (HWS) - The water heater is located in the nursery roof

space

System ID: 10

Survey Ref: WH 1







Question LR GR


Answer: No



Question LR GR






Page: 34 / 145


nursery roof space

System ID: 11

Survey Ref: EWH 6


Serving: The electric water heater serves the nursery kitchenette sink





Question LR GR


Answer: No



Question LR GR


Answer: No


Question LR GR






Page: 35 / 145

Local water heater <15ltr (POU) - The electric water heater is located in the nursery

roof space

System ID: 11

Survey Ref: EWH 6







Question LR GR


Answer: Water in the expansion vessel is unlikely to turnover as it has been fitted facing downwards

Recommendation: Re position the expansion vessel so it is on a vertical plane facing upwards. A drain and

isolation valve should also be fitted to enable regular flushing of the vessel, or fit an inlet/outlet type

Question LR GR





Question LR GR

12, Is the supply pipe to water heater fitted with a valve? 0 1

Answer: No

Recommendation: When operationally convenient an inlet valve should be fitted.(15mm)

Question LR GR


Answer: No

Recommendation: The water heater should be labelled for ease of identification



Page: 36 / 145


System ID: 12

Survey Ref: WH 2


Serving: The water heater serves hot water to the water area and disabled toilet in the nursery block





Question LR GR





Question LR GR




Question LR GR


Answer: No


water heater.

Question LR GR


2 0






Page: 37 / 145

Question LR GR


1 1



Question LR GR


Answer: No


identified.

Question LR GR






Page: 38 / 145


space

System ID: 12

Survey Ref: WH 2







Question LR GR


Answer: No



Question LR GR






Page: 39 / 145

Direct mains services (MCWS) - The mains water stop valve for the nursery block is

located in the nursery plant room

System ID: 13

Survey Ref: MCWS 2


Serving: The mains water system supplies domestic cold water to all cold outlets in the nursery block and the 3 water heaters in the roof space. It also feeds the LTHW heating system





Question LR GR

5, Are showers and spray taps in regular use, heads clean and free from scale and slime? 3 0

Answer: No - Use is unknown / low.

Recommendation: Remove the showers that are not used or if this is not possible add them to the flushing

regime.

Question LR GR


2 2

Answer: Closed system quick fill loops are still in place.

Recommendation: A double check valve suitable for fluid categories up to 3, Fluid which represents a slight

health hazard because of substances of low toxicity, should be fitted to the ~~.

Question LR GR




gain.

Question LR GR

7, Are all items in regular use (Wash down hoses, Emergency showers etc)? 2 0

Answer: No – See asset register for details.

Recommendation: Any outlets that are infrequently used (see asset register) should be included in the

weekly flushing regime.



Page: 40 / 145

Question LR GR

10, Have drinking water identification labels been used? 0 1

Answer: No - all outlets unlabelled.

Recommendation: Defined drinking water outlets need to be labelled so that they can be readily identified.



Page: 41 / 145

Closed or Sealed systems - The low temperature hot water boiler is located in the

nursery block plant room

System ID: 14

Survey Ref: LTHW 2


Serving: The low temperature hot water boilers feed heating water to all radiators in the nursery block





Question LR GR


Answer: No


Question LR GR

3, Does the system have a suitable method of dosing chemicals? 0 2

Answer: No

Recommendation: Install a suitably sized dosing pump.

Question LR GR

4, Have quick-fill links been removed? 0 2

Answer: No

Recommendation: Disconnect the pipe and isolate within 3 to 5 pipe diameters to avoid creating a dead leg.



Page: 42 / 145

Management - The previous legionella risk assessment and monitoring data is

accessed via request to the site manager

System ID: 15

Survey Ref: Management


Serving: Legionella control for the whole school





Question LR GR

19, Is there evidence of non-conformity control? 4 0

Answer: No

Recommendation: Each non-conformity requiring corrective action should be logged and the status of that

fault indicated so corrective action can be tracked and signed off for each particular fault identified.

Question LR GR

5, Is the responsible person competent or do they have access to competent help? 3 0

Answer: The responsible person has limited experience of legionella control.

Recommendation: The responsible person should obtain certificated training in Legionella management

such as QCF Level 3 Award in Legionella control for Responsible persons.

Question LR GR

20, Has staff competence been assessed or training planned? 3 0

Answer: No - Managers have limited experience in legionella control and are not considered competent.

Recommendation: Consider assessed legionella training for managers so there is evidence of their abilities.

Question LR GR

12, Do records show consultation with employees including information on the risks and controls?

2 0

Answer: No

Recommendation: Give employees an opportunity to comment on the assessment and control measures by

publicising that a legionella risk assessment has been performed. (ACoP L8:2013 Para 44)



Page: 43 / 145

Question LR GR

18, Is there evidence of service provider review meetings? 2 0

Answer: No documented review meeting notes seen.

Recommendation: Ensure the outcome of review meetings with your service provider are recorded.

Question LR GR

13, Are monitoring and inspection records complete and available for at least 5 years? 1 0

Answer: Monitoring has not been carried out for a full 5 year term

Recommendation: Ensure monitoring and inspection records are available for at least 5 years

Question LR GR

14, Is there a visit log for actions taken and dates? 1 0

Answer: No visit log found.

Recommendation: A visit log should be maintained in the record system detailing visits by service providers

and others with allocated tasks.



Page: 44 / 145

Surveys Report



System ID: 01

Survey Ref: MCWS 1







Question LR GR

1, Are materials WRc compliant? 0 0

Answer: Yes - Mainly Copper

Question LR GR

2, Is access reasonable for inspection of pipes? 0 0

Answer: Yes

Question LR GR

3, Location of incoming mains isolation? 0 0

Answer: The mains water stop valve is located in the gas meter room of the main building

Question LR GR

4, Are unnecessary aerosols produced (eg spray taps on TMV outlets)? 0 0

Answer: No spray taps fitted.

Question LR GR


Answer: No mains showers



Page: 45 / 145

Question LR GR




gain.

Question LR GR


Answer: Yes

Question LR GR


0 3

Answer: Inadequate backflow protection for dishwashers, washing machines and hydro boilers

Recommendation: All dishwashers and washing machines need to have a double check valve fitted to

protect against back flow. All hydro boilers require a single check valve to be fitted

Question LR GR


Answer: Dead ends present on site – See asset register for details.

Recommendation: The dead ends identified on schematics should be removed.

Question LR GR


Answer: Yes - Drinking outlets identified.

Question LR GR

11, Are there any drinking water outlets in unsatisfactory locations (toilets or workshops)? 0 0

Answer: None identified during survey



Page: 46 / 145



System ID: 02

Survey Ref: CWDS







Question LR GR


Answer: Yes

Guidance: Materials such as natural rubber, hemp, linseed oil-based jointing compounds and fibre washers

should not be used in domestic water systems. Materials and fittings acceptable for use in water systems are

listed in the directory published by the Water Research Centre. (ACoP L8 Para 152)

Question LR GR


Answer: Yes

Guidance: The pipework should be easy to inspect so that the thermal insulation can be checked to see that

it is in position and has remained undisturbed. (ACoP L8 Para 152c)

Question LR GR


Answer: Although insulated the distribution temperatures were found to be above the recommended 20°C,

possibly due to the current high ambient temperature during the summer months and reduced usage due to

summer holiday period

Question LR GR

4, Are unnecessary aerosols produced (eg spray taps on TMVs)? 0 0

Answer: No

Question LR GR


Answer: No showers.



Page: 47 / 145

Question LR GR

6, Is the CWDS free from dead ends? 0 0

Answer: None identified at time of survey.

Guidance: Hot and cold water systems should be designed and constructed so that they:

(b) aid safe operation - for example, without deadlegs, or if this is not possible, with the length of deadlegs

limited and non-essential standby plant disconnected or removed. (ACoP L8 Para 74)

Question LR GR

7, Are all items fed by the CWDS in regular use (Wash down hoses, Emergency showers etc)?

0 0

Answer: Yes

Guidance: The risk from legionella growing in peripheral parts of the domestic water system such as

deadlegs off the recirculating hot water system may be minimised by regular use of these outlets. When

outlets are not in regular use, weekly flushing of these devices for several minutes can significantly reduce

the number of legionella discharged from the outlet. (ACoP L8 Para 165)

Question LR GR

8, Are all distribution valves labelled 1 1

Answer: No valves are labelled.

Guidance: Stop valves, servicing valves and drain taps should be labelled so that the parts of the system

which they control can be determined for maintenance purposes. (WRAS G4.10)

Recommendation: All valves need to be labelled so that they can be readily identified.



Page: 48 / 145


roof

System ID: 02

Survey Ref: CWST







Question LR GR

1, Is safe access provided to inspect or clean the tank? 0 0

Answer: Yes - Ladders required.

Question LR GR

2, Construction of the tank? 0 0

Answer: One piece GRP

Question LR GR

3, Size or capacity of the tank? 0 0

Answer: 1.3 x 1.2 x 0.6m (approx 1022 litres)

Question LR GR

4, Is access restricted above the tank? 0 0

Answer: Access above the cistern is good.

Question LR GR

5, Describe the external structural condition of the tank? 0 0

Answer: In good condition

Question LR GR

6, Is the tank redundant, stagnant or over-sized? 0 0

Answer: No - Water turnover estimated at less than 24 hours during term time



Page: 49 / 145

Question LR GR

7, Is the tank linked to another? 0 0

Answer: No

Question LR GR

8, What is supply water temperature at tank inlet? 0 0

Answer: Temperature 18.8°C.

Question LR GR

9, What is the stored water temperature in the tank? 1 0

Answer: Cistern temperature (>20°C) 21.4°C.

Recommendation: The increase in stored temperature compared to inlet temperature is most likely

attributed to the assessment taking place when turnover of the tank is significantly less than during term

time. Ensure the tank turns over its capacity during tank time. This can be measured by means of a drop test.

Question LR GR

10, Is ambient temperature above 30°C? 0 0

Answer: No

Question LR GR

11, Microbiological sample taken as part of the survey? 0 0

Answer: No sample taken as part of the survey.

Question LR GR

12, Internal condition of the tank? 2 0

Answer: The stored water is clear, with no surface scum and only light debris to the base, however there is

some pin hole staining on the walls of the tank

Recommendation: The tank should be cleaned & disinfected in line with Acop L8 recommendations

Question LR GR

13, Material of inlet and outlet pipes? 0 0

Answer: Copper

Question LR GR

14, Are there isolating valves on the tank inlet and outlets? 0 0

Answer: Yes - Valves fitted to inlet and all outlets.



Page: 50 / 145

Question LR GR

15, Is a screened overflow pipe fitted? 0 0

Answer: Yes - Overflow screen fitted.

Question LR GR

16, Is a screened warning overflow pipe fitted? 0 0

Answer: Yes - Screen fitted on the warning overflow.

Question LR GR

17, Are potentially stagnant return pipes such as expansion pipes diverted? 0 0

Answer: No potentially stagnant pipes return to the cistern.

Question LR GR

18, Tank fitted with drain valve? 1 1

Answer: No drain valve fitted.

Recommendation: A suitable drain valve should be fitted to facilitate complete draining of the cistern. This

needs to be carried out without creating a dead leg area that may result in bacterial build up.

Question LR GR

19, Is the lid rigid, fixed and close fitting? 0 0

Answer: Yes - Section GRP

Question LR GR

20, Is the Lid fitted with screened vent? 0 0

Answer: Yes a screened vent is in place.

Question LR GR

21, Is the tank lid fitted with a close fitting inspection hatch? 0 0

Answer: Yes - Close fitting hatch installed.

Question LR GR

22, Is inlet pipework opposite to outlet pipework? 0 0

Answer: Yes - Inlet and outlet are at opposite ends.

Question LR GR

23, Is the tank and local pipework insulated sufficiently to prevent heat gain or loss? 0 0

Answer: Yes - Cistern and local pipes insulated.



Page: 51 / 145

Question LR GR

24, Is the tank and local area free from dead ends (Including internal components)? 0 0

Answer: Yes

Question LR GR

25, Are there any secondary make ups to the tank? 0 0

Answer: No additional potentially stagnant supplies present.

Question LR GR

26, Are the valves and tank labelled? 1 1

Answer: Valves and cistern are not labelled.

Recommendation: The cistern and main valves need to be labelled with an asset number to allow it to be

clearly identified.

Question LR GR

27, Are back flow arrangements adequate? 0 0

Answer: Not applicable



Page: 52 / 145


boiler room

System ID: 03

Survey Ref: CAL 1







Question LR GR

1, Water heater type and heating method? 0 0

Answer: Unvented indirect LPHW primary coil with immersion heater back up.

Question LR GR

2, Water heater orientation and material? 0 0

Answer: Horizontal copper vessel.

Question LR GR

3, Is safe access provided to the area around the water heater? 0 0

Answer: Yes the water heater has good access.

Question LR GR

4, Is the water heater required? 0 0

Answer: Yes - The water heater serves an appropriate number of outlets.

Question LR GR

5, Size of vessel (capacity)? 0 0

Answer: 2.1m x 0.8m Diameter (Approx 1050 litres)

Question LR GR







Page: 53 / 145

Question LR GR





Question LR GR


Answer: Yes - but not tested for operation.

Question LR GR

9, Describe the external condition of the water heater? 0 0


Question LR GR




Question LR GR

11, Is the water heater & local pipes sufficiently well insulated? 0 0

Answer: Yes - The water heater is well insulated.

Question LR GR

12, Are there any dead ends, long gauge feeds or dead legs associated with the heater? 0 0

Answer: No concerns identified.

Question LR GR




supply pipe.

Question LR GR

14, Will temperatures reach target throughout the vessel for at least 1 hour daily? 0 0

Answer: Yes - Stratification unlikely.



Page: 54 / 145

Question LR GR


Answer: Temperature 60°C +/-2°C

Question LR GR

16, Is the hot water return temperature from principle loops satisfactory? 0 0

Answer: Yes. Temperature 52°C measured by surface methods.

Question LR GR


0 1




Question LR GR


Answer: Copper

Question LR GR


Answer: Yes.

Question LR GR

20, Is stand by plant such as secondary return circulating pumps alternated weekly to prevent dead legs?

0 0

Answer: The hot water system is fitted with a single circulating pump.

Question LR GR


Answer: Yes

Question LR GR

22, Microbiological sample taken as part of survey? 0 0

Answer: No sample was taken as part of the assessment survey.

Question LR GR


0 0

Answer: The water heater is not direct mains fed



Page: 55 / 145

Question LR GR

24, Is the water heater fitted with a suitable temperature / pressure safety release valve? 0 0

Answer: NA- Not required.



Page: 56 / 145


boiler room

System ID: 03

Survey Ref: CAL 2







Question LR GR


Answer: Unvented indirect LPHW primary coil with immersion heater back up.

Question LR GR


Answer: Horizontal copper vessel.

Question LR GR


Answer: Yes the water heater has good access.

Question LR GR



Question LR GR


Answer: 2.1m x 0.8m Diameter (Approx 1050 litres)

Question LR GR







Page: 57 / 145

Question LR GR





Question LR GR


Answer: Yes - but not tested for operation.

Question LR GR



Question LR GR




Question LR GR


Answer: Yes - The water heater is well insulated.

Question LR GR



Question LR GR




supply pipe.

Question LR GR


Answer: Yes - Stratification unlikely.



Page: 58 / 145

Question LR GR



Recommendation: The thermostat setting should be adjusted as the water heater is operating below target

temperatures.

Question LR GR


Answer: Yes. Temperature 52°C measured by surface methods.

Question LR GR


0 1




Question LR GR


Answer: Copper

Question LR GR


Answer: Yes.

Question LR GR


0 0

Answer: The hot water system is fitted with a single circulating pump.

Question LR GR


Answer: Yes

Question LR GR





Page: 59 / 145

Question LR GR


0 0

Answer: The water heater is not direct mains fed

Question LR GR


Answer: NA- Not required.



Page: 60 / 145


boiler room

System ID: 03

Survey Ref: HWDS







Question LR GR



Question LR GR

2, Is access possible for inspection of pipes? 0 0

Answer: Yes

Question LR GR


Answer: Yes

Question LR GR


Answer: Insulation present in plant rooms only.



Question LR GR

5, Is the HWS free from dead ends? 0 0

Answer: None identified at time of survey

Question LR GR

6, Are unnecessary aerosols produced (such as spray taps)? 0 0

Answer: No spray taps



Page: 61 / 145

Question LR GR

7, Are trace heating techniques working? (used to maintain the temperature of single pipe systems)

0 0

Answer: Not fitted.

Question LR GR

8, Are TMVs considered necessary and operating correctly? 0 0

Answer: TMVs are considered necessary and are operating correctly.

Question LR GR

9, Are all items fed by the HWS in regular use (Wash down hoses, Emergency showers etc)? 0 0

Answer: Yes

Question LR GR






Page: 62 / 145



System ID: 04

Survey Ref: LTHW 1







Question LR GR

1, Does the majority of the system operate outside 20 - 50°C? 0 0

Answer: Yes

Question LR GR


Answer: No


Question LR GR


Answer: Dosing pump

Question LR GR


Answer: None found.



Page: 63 / 145


reception classroom

System ID: 05

Survey Ref: EWH 1







Question LR GR


Answer: Yes




Question LR GR


Answer: Yes



Question LR GR


Answer: Yes

Question LR GR


Answer: No





Page: 64 / 145

Question LR GR






Question LR GR



Question LR GR


0 0

Answer: Not fitted.

Question LR GR



Question LR GR


Answer: Yes





Question LR GR








Page: 65 / 145


reception classroom

System ID: 05

Survey Ref: EWH 1







Question LR GR

1, Is safe access provided to inspect water heater? 0 0

Answer: Yes

Question LR GR

2, Make of water heater? 0 0

Answer: Heatrae water heater

Question LR GR

3, Stored water volume in litres? 0 0

Answer: 15 litres

Question LR GR



Question LR GR

5, Water heater temperature preset or variable? 0 0

Answer: Variable

Question LR GR

6, Is the water heater feeding suitable local outlets? 0 0

Answer: Feeds directly to local outlet.



Page: 66 / 145

Question LR GR

7, Can expanded water be accommodated without hot water entering any supply pipe to which a cold water draw-off is connected?

0 0

Answer: Yes

Question LR GR




turnover.

Question LR GR



Question LR GR

10, Are materials local to the water heater WRc compliant 0 0

Answer: Copper




Question LR GR

11, Is the water heater and local area free from dead ends? 0 0

Answer: Yes

Question LR GR


Answer: Yes

Question LR GR


Answer: No


identified.



Page: 67 / 145


boys toilets

System ID: 06

Survey Ref: EWH 2







Question LR GR


Answer: Yes




Question LR GR


Answer: Yes



Question LR GR


Answer: Yes

Question LR GR


Answer: No





Page: 68 / 145

Question LR GR






Question LR GR



Question LR GR


0 0

Answer: Not fitted.

Question LR GR



Question LR GR


Answer: Yes





Question LR GR








Page: 69 / 145


boys toilets

System ID: 06

Survey Ref: EWH 2







Question LR GR


Answer: Yes

Question LR GR


Answer: Zip water heater

Question LR GR


Answer: 15 litres

Question LR GR



Question LR GR


Answer: Variable

Question LR GR


Answer: Feeds directly to local outlets



Page: 70 / 145

Question LR GR


0 0

Answer: Yes

Question LR GR




turnover.

Question LR GR



Question LR GR


Answer: Copper




Question LR GR


Answer: Yes

Question LR GR


Answer: Yes

Question LR GR


Answer: Yes



Page: 71 / 145


classroom area

System ID: 07

Survey Ref: EWH 3







Question LR GR


Answer: Yes




Question LR GR


Answer: Yes



Question LR GR


Answer: No


Question LR GR


Answer: No



Question LR GR






Page: 72 / 145



Question LR GR



Question LR GR


0 0

Answer: Not fitted.

Question LR GR



Question LR GR


Answer: Yes





Question LR GR








Page: 73 / 145


classroom area

System ID: 07

Survey Ref: EWH 3







Question LR GR


Answer: Yes

Question LR GR


Answer: Hyco water heater

Question LR GR


Answer: 15 litres

Question LR GR


Answer: Not working or off

Recommendation: Repair or replace the water heater.

Question LR GR


Answer: Variable

Question LR GR


Answer: Feeds directly to local outlet



Page: 74 / 145

Question LR GR


0 0

Answer: Yes

Question LR GR




turnover.

Question LR GR


Answer: Switched off at time of survey.

Recommendation: The heater should be repaired or replaced.

Question LR GR


Answer: Copper




Question LR GR


Answer: Yes

Question LR GR


Answer: Yes

Question LR GR


Answer: No


identified.



Page: 75 / 145



System ID: 08

Survey Ref: EWH 4







Question LR GR


Answer: Yes




Question LR GR


Answer: Yes



Question LR GR


Answer: Yes

Question LR GR


Answer: No





Page: 76 / 145

Question LR GR






Question LR GR



Question LR GR


0 0

Answer: Not fitted.

Question LR GR



Question LR GR


Answer: Yes





Question LR GR








Page: 77 / 145



System ID: 08

Survey Ref: EWH 4


Serving: The electric water heater serves hot water to the sink in the room which it is located in





Question LR GR


Answer: Yes

Question LR GR


Answer: Ariston water heater

Question LR GR


Answer: 15 litres

Question LR GR



Question LR GR


Answer: Variable

Question LR GR





Page: 78 / 145

Question LR GR


0 0

Answer: Yes

Question LR GR


Answer: No expansion vessel fitted on the POU water heater.

Question LR GR



Question LR GR


Answer: Copper




Question LR GR


Answer: Yes

Question LR GR


Answer: Yes

Question LR GR


Answer: Yes



Page: 79 / 145


classroom

System ID: 09

Survey Ref: EWH 5







Question LR GR


Answer: Yes




Question LR GR


Answer: Yes



Question LR GR


Answer: No


Question LR GR


Answer: No





Page: 80 / 145

Question LR GR






Question LR GR



Question LR GR


0 0

Answer: Not fitted.

Question LR GR



Question LR GR


Answer: Yes





Question LR GR








Page: 81 / 145


classroom

System ID: 09

Survey Ref: EWH 5







Question LR GR


Answer: Yes

Question LR GR



Question LR GR


Answer: 15 litres

Question LR GR



Question LR GR


Answer: Variable

Question LR GR


Answer: Feeds directly to local outlets



Page: 82 / 145

Question LR GR


0 0

Answer: Yes

Question LR GR




turnover.

Question LR GR





Question LR GR


Answer: Copper




Question LR GR


Answer: Yes

Question LR GR


Answer: Yes

Question LR GR


Answer: Yes



Page: 83 / 145


System ID: 10

Survey Ref: WH 1







Question LR GR


Answer: Un-vented, single immersion heated cylinder.

Question LR GR


Answer: Horizontal stainless steel vessel.

Question LR GR


Answer: Yes - Access is via a long ladder but possible.

Question LR GR



Question LR GR


Answer: 50 litres heater

Question LR GR







Page: 84 / 145

Question LR GR




Question LR GR


Answer: No


water heater.

Question LR GR



Question LR GR


Answer: No - Stand alone unit.

Question LR GR


Answer: Yes - The water heater and local pipes are well insulated.

Question LR GR



Question LR GR


Answer: Temperature <20°C

Question LR GR


Answer: Yes - The whole water heater is hot.

Question LR GR


Answer: Temperature 50°C +/-2°C



Page: 85 / 145

Question LR GR


Answer: No recirculation pipe fitted to the HWS.

Question LR GR


1 1



Question LR GR


Answer: Copper

Question LR GR




Question LR GR


0 0

Answer: The hot water system is not circulated..

Question LR GR


Answer: No


identified.

Question LR GR





Page: 86 / 145

Question LR GR


2 0




Question LR GR


Answer: Yes



Page: 87 / 145


space

System ID: 10

Survey Ref: WH 1







Question LR GR


Answer: Yes




Question LR GR


Answer: Yes



Question LR GR


Answer: Yes

Question LR GR


Answer: No





Page: 88 / 145

Question LR GR






Question LR GR



Question LR GR


0 0

Answer: Not fitted.

Question LR GR



Question LR GR


Answer: Yes





Question LR GR








Page: 89 / 145


nursery roof space

System ID: 11

Survey Ref: EWH 6







Question LR GR


Answer: Yes




Question LR GR


Answer: Yes



Question LR GR


Answer: No


Question LR GR


Answer: No





Page: 90 / 145

Question LR GR






Question LR GR



Question LR GR


0 0

Answer: Not fitted.

Question LR GR



Question LR GR


Answer: Yes





Question LR GR








Page: 91 / 145


roof space

System ID: 11

Survey Ref: EWH 6







Question LR GR



Question LR GR



Question LR GR


Answer: 15 litres

Question LR GR



Question LR GR


Answer: Variable

Question LR GR





Page: 92 / 145

Question LR GR


0 0

Answer: Yes

Question LR GR


Answer: Water in the expansion vessel is unlikely to turnover as it has been fitted facing downwards

Recommendation: Re position the expansion vessel so it is on a vertcal plane facing upwards. A drain and

isolation valve should also be fitted to enable fregular flushing of the vessel, or fit an inlet/outlet type

Question LR GR





Question LR GR


Answer: Copper




Question LR GR


Answer: Yes

Question LR GR


Answer: No

Recommendation: When operationally convenient an inlet valve should be fitted.(15mm)

Question LR GR


Answer: No



Page: 93 / 145


System ID: 12

Survey Ref: WH 2







Question LR GR


Answer: Un-vented, single immersion heated cylinder.

Question LR GR


Answer: Horizontal stainless steel vessel.

Question LR GR



Question LR GR



Question LR GR


Answer: 50 litres heater

Question LR GR







Page: 94 / 145

Question LR GR




Question LR GR


Answer: No


water heater.

Question LR GR



Question LR GR


Answer: No - Stand alone unit.

Question LR GR


Answer: Yes - The water heater and local pipes are well insulated.

Question LR GR



Question LR GR


Answer: Temperature <20°C

Question LR GR


Answer: Yes - The whole water heater is hot.

Question LR GR





Page: 95 / 145

Question LR GR


Answer: No recirculation pipe fitted to the HWS.

Question LR GR


1 1



Question LR GR


Answer: Copper

Question LR GR




Question LR GR


0 0

Answer: The hot water system is not circulated..

Question LR GR


Answer: No


identified.

Question LR GR



Question LR GR


2 0






Page: 96 / 145

Question LR GR


Answer: Yes



Page: 97 / 145


space

System ID: 12

Survey Ref: WH 2







Question LR GR


Answer: Yes




Question LR GR


Answer: Yes



Question LR GR


Answer: Yes

Question LR GR


Answer: No





Page: 98 / 145

Question LR GR






Question LR GR



Question LR GR


0 0

Answer: Not fitted.

Question LR GR



Question LR GR


Answer: Yes





Question LR GR








Page: 99 / 145



System ID: 13

Survey Ref: MCWS 2







Question LR GR



Question LR GR


Answer: Yes

Question LR GR

3, Location of incoming mains isolation? 0 0

Answer: Plant room of nursery block

Question LR GR

4, Are unnecessary aerosols produced (eg spray taps on TMV outlets)? 0 0

Answer: No spray taps fitted.

Question LR GR


Answer: No - Use is unknown / low.

Recommendation: Remove the showers that are not used or if this is not possible add them to the flushing

regime.



Page: 100 / 145

Question LR GR




gain.

Question LR GR


Answer: No – See asset register for details.

Recommendation: Any outlets that are infrequently used (see asset register) should be included in the

weekly flushing regime.

Question LR GR


2 2

Answer: Closed system quick fill loops are still in place.

Recommendation: A double check valve suitable for fluid categories up to 3, Fluid which represents a slight

health hazard because of substances of low toxicity, should be fitted to the ~~.

Question LR GR


Answer: Yes

Question LR GR


Answer: No - all outlets unlabelled.

Recommendation: Defined drinking water outlets need to be labelled so that they can be readily identified.

Question LR GR

11, Are there any drinking water outlets in unsatisfactory locations (toilets or workshops)? 0 0

Answer: None identified during survey



Page: 101 / 145



System ID: 14

Survey Ref: LTHW 2







Question LR GR

1, Does the majority of the system operate outside 20 - 50°C? 0 0

Answer: Yes

Question LR GR


Answer: No


Question LR GR


Answer: No

Recommendation: Install a suitably sized dosing pump.

Question LR GR


Answer: No

Recommendation: Disconnect the pipe and isolate within 3 to 5 pipe diameters to avoid creating a dead leg.



Page: 102 / 145



System ID: 15








Question LR GR

1, Has the statutory duty holder been defined in writing? 0 0

Answer: Yes - Named within allocation of responsibilities section of this assessment.

Question LR GR

2, Has a competent person or persons (Responsible person) been appointed in writing? 0 0

Answer: Yes - Named within allocation of responsibilities section of this assessment.

Question LR GR

3, Has an authorised deputy been appointed to enable cover during holidays or out of hours?

0 0

Answer: Yes - Named within this assessment.

Question LR GR

4, Has a suitable and sufficient risk assessment of the water systems been undertaken? 0 0

Answer: This management survey forms part of a detailed risk assessment. A previous legionella risk

assessment has been conducted and is available for inspection.

Question LR GR

5, Is the responsible person competent or do they have access to competent help? 3 0

Answer: The responsible person has limited experience of legionella control.

Recommendation: The responsible person should obtain certificated training in Legionella management

such as QCF Level 3 Award in Legionella control for Responsible persons.



Page: 103 / 145

Question LR GR

6, Do records show clear and up to date lines of communication within the organisation? 0 0

Answer: Yes

Question LR GR

7, Do records show clear and up to date lines of communication with service providers? 0 0

Answer: Yes - Clearly defined routes of communication are documented.

Question LR GR

8, Is the allocation of tasks comprehensive? 0 0

Answer: Yes

Question LR GR

9, Are service providers members of the LCA? 0 0

Answer: Yes

Question LR GR

10, Do service agreements confirm allocation of tasks? 0 0

Answer: Yes - The service agreement clearly sets out the allocation of tasks.

Question LR GR

11, Are emergency contact details provided for automated dosing or control equipment? 0 0

Answer: NA - There are no automated dosing or control systems.

Question LR GR

12, Do records show consultation with employees including information on the risks and controls?

2 0

Answer: No

Recommendation: Give employees an opportunity to comment on the assessment and control measures by

publicising that a legionella risk assessment has been performed. (ACoP L8:2013 Para 44)

Question LR GR

13, Are monitoring and inspection records complete and available for at least 5 years? 1 0

Answer: Monitoring has not been carried out for a full 5 year term

Recommendation: Ensure monitoring and inspection records are available for at least 5 years



Page: 104 / 145

Question LR GR

14, Is there a visit log for actions taken and dates? 1 0

Answer: No visit log found.

Recommendation: A visit log should be maintained in the record system detailing visits by service providers

and others with allocated tasks.

Question LR GR

15, Are schematic diagrams up to date and accurate? 0 0

Answer: Schematics are to be produced during this survey.

Question LR GR

16, Are general Health and Safety risk assessments available? 0 0

Answer: Not assessed as part of this survey.

Question LR GR

17, Are Material Safety Data Sheets available? 0 0

Answer: Not applicable.

Question LR GR

18, Is there evidence of service provider review meetings? 2 0

Answer: No documented review meeting notes seen.

Recommendation: Ensure the outcome of review meetings with your service provider are recorded.

Question LR GR

19, Is there evidence of non-conformity control? 4 0

Answer: No

Recommendation: Each non-conformity requiring corrective action should be logged and the status of that

fault indicated so corrective action can be tracked and signed off for each particular fault identified.

Question LR GR

20, Has staff competence been assessed or training planned? 3 0

Answer: No - Managers have limited experience in legionella control and are not considered competent.

Recommendation: Consider assessed legionella training for managers so there is evidence of their abilities.

Question LR GR

21, Has proof of service provider competence been provided? 0 0

Answer: Yes



Page: 105 / 145

Question LR GR

22, Is there a description of the correct and safe equipment operation, including precautions to be taken?

0 0

Answer: Yes - Control scheme provided as part of this risk assessment.

Question LR GR

23, Are there details on the treatment programme? 0 0

Answer: NA - There are no automated dosing or control systems.

Question LR GR

24, Are there details on test locations, frequencies, methods and control limits? 0 0

Answer: Yes - Control scheme provided as part of this risk assessment.

Question LR GR

25, Are there details on remedial measures to take if results exceed control limits? 0 0

Answer: Yes

Question LR GR

26, Are cleaning and disinfection method statements sufficient? 0 0

Answer: Yes

Question LR GR

27, Do site have an action plan for emergency conditions (Legionella positive / outbreak)? 0 0

Answer: Yes

Question LR GR

28, Is there a system to ensure assessments are reviewed regularly or due to change? 0 0

Answer: Yes

Question LR GR

29, Are water tanks being regularly and correctly inspected? 0 0

Answer: Yes

Question LR GR

30, Are water heaters being regularly and correctly inspected? 0 0

Answer: Yes



Page: 106 / 145

Question LR GR

31, If not opened is the water heater drain purged and sampled? 0 0

Answer: Yes

Question LR GR

32, Are water heater flow and return temperatures checked monthly? 0 0

Answer: Yes

Question LR GR

33, Are sentinel temperature monitoring locations correct and checked? 0 0

Answer: Yes – Locations are effective and regularly tested with records.

Question LR GR

34, Is a temperature profiling schedule (representative outlets) defined and in operation? 0 0

Answer: Yes – A rotational temperature monitoring plan is in place.

Question LR GR

35, Are local small volume heaters controlled and monitored? 0 0

Answer: Yes – Low volume heaters were found to be operating at 50°C or better and frequently used.

Question LR GR

36, Are TMVs listed and maintained as required? 0 0

Answer: Yes – TMVs are documented and maintained as required.

Question LR GR

37, Are infrequently used outlets listed and flushed? 0 0

Answer: Yes – Infrequently used outlets are documented and flushed as required.

Question LR GR

38, Are showers listed and cleaned and disinfected? 0 0

Answer: Yes – Showers are documented and cleaned as required.

Question LR GR

39, Are point of use filters used to provide a temporary control measure? 0 0

Answer: No – POU filters are not required.



Page: 107 / 145

Question LR GR

40, Do technical difficulties require the use of alternative (to temperature) methods for legionella control?

0 0

Answer: No alternative methods in use

Question LR GR

41, If alternative methods are used are they monitored to ensure effective control? 0 0

Answer: No alternative dosing is undertaken.

Question LR GR

42, Is microbiological sampling required (suitable locations and frequencies defined)? 0 0

Answer: Yes – Testing is carried out at the client’s request.



Page: 108 / 145

Record of Corrective Actions



System ID: 01

Survey Ref: MCWS 1



Q Recommendation LR GR

6 Distribution pipework should be insulated to relevant British standards to reduce heat gain.

2 0

Action By:

Complete Date:

Sign:

9 The dead ends identified on schematics should be removed.

2 0

Action By:

Complete Date:

Sign:

8 All dishwashers and washing machines need to have a double check valve fitted to protect against back flow. All hydro boilers require a single check valve to be fitted

0 3

Action By:

Complete Date:

Sign:



Page: 109 / 145



System ID: 02

Survey Ref: CWDS




8 All valves need to be labelled so that they can be readily identified.

1 1

Action By:

Complete Date:

Sign:

3 Ensure all distribution pipework is sufficiently insulated

1 0

Action By:

Complete Date:

Sign:



Page: 110 / 145


roof

System ID: 02

Survey Ref: CWST




12 The tank should be cleaned & disinfected in line with Acop L8 recommendations

2 0

Action By:

Complete Date:

Sign:

18 A suitable drain valve should be fitted to facilitate complete draining of the cistern. This needs to be carried out without creating a dead leg area that may result in bacterial build up.

1 1

Action By:

Complete Date:

Sign:

26 The cistern and main valves need to be labelled with an asset number to allow it to be clearly identified.

1 1

Action By:

Complete Date:

Sign:

9 The increase in stored temperature compared to inlet temperature is most likely attributed to the assessment taking place when turnover of the tank is significantly less than during term time. Ensure the tank turns over its capacity during tank time. This can be measured by means of a drop test.

1 0

Action By:

Complete Date:

Sign:



Page: 111 / 145


boiler room

System ID: 03

Survey Ref: CAL 1




6 As an inspection hatch has not been fitted, any debris in the water at the base of the calorifier should be purged to a suitable drain on an annual basis.

2 0

Action By:

Complete Date:

Sign:

7 Annual draining of the water heater and checking for debris in the base of the vessel is needed as debris will harbour bacteria, the water heater should then be cleaned if considered necessary.

2 0

Action By:

Complete Date:

Sign:

13 A check valve should be fitted to the inlet pipe to minimise water tracking back up the supply pipe.

2 0

Action By:

Complete Date:

Sign:

10 Ensure water flow and temperatures are maintained through all water heaters.

1 0

Action By:

Complete Date:

Sign:

17 Fit a temperature gauge to the return pipe on next plant shutdown

0 1

Action By:

Complete Date:

Sign:



Page: 112 / 145


boiler room

System ID: 03

Survey Ref: CAL 2




6 As an inspection hatch has not been fitted, any debris in the water at the base of the calorifier should be purged to a suitable drain on an annual basis.

2 0

Action By:

Complete Date:

Sign:

7 Annual draining of the water heater and checking for debris in the base of the vessel is needed as debris will harbour bacteria, the water heater should then be cleaned if considered necessary.

2 0

Action By:

Complete Date:

Sign:

13 A check valve should be fitted to the inlet pipe to minimise water tracking back up the supply pipe.

2 0

Action By:

Complete Date:

Sign:

10 Ensure water flow and temperatures are maintained through all water heaters.

1 0

Action By:

Complete Date:

Sign:

15 The thermostat setting should be adjusted as the water heater is operating below target temperatures.

1 0

Action By:

Complete Date:

Sign:

17 Fit a temperature gauge to the return pipe on next plant shutdown

0 1

Action By:

Complete Date:

Sign:



Page: 113 / 145


boiler room

System ID: 03

Survey Ref: HWDS




4 Distribution pipework needs to be insulated to reduce heat loss and maintain the required temperatures.

3 0

Action By:

Complete Date:

Sign:

10 All isolating valves should be labelled so that they can be readily identified.

1 1

Action By:

Complete Date:

Sign:



Page: 114 / 145



System ID: 04

Survey Ref: LTHW 1




2 Consider a regular water treatment check on inhibitor levels and corrosion control.

0 2

Action By:

Complete Date:

Sign:



Page: 115 / 145


reception classroom

System ID: 05

Survey Ref: EWH 1





3 0

Action By:

Complete Date:

Sign:


reception classroom

System ID: 05

Survey Ref: EWH 1




8 The expansion vessel should be replaced with an inlet / outlet type that ensures water turnover.

2 0

Action By:

Complete Date:

Sign:



Page: 116 / 145


boys toilets

System ID: 06

Survey Ref: EWH 2





3 0

Action By:

Complete Date:

Sign:


boys toilets

System ID: 06

Survey Ref: EWH 2





2 0

Action By:

Complete Date:

Sign:



Page: 117 / 145


classroom area

System ID: 07

Survey Ref: EWH 3




3 Investigate the failure of the flow temperature

3 0

Action By:

Complete Date:

Sign:


3 0

Action By:

Complete Date:

Sign:


classroom area

System ID: 07

Survey Ref: EWH 3





2 0

Action By:

Complete Date:

Sign:

9 The heater should be repaired or replaced.

2 0

Action By:

Complete Date:

Sign:



Page: 118 / 145



System ID: 08

Survey Ref: EWH 4





3 0

Action By:

Complete Date:

Sign:


1 1

Action By:

Complete Date:

Sign:


classroom

System ID: 09

Survey Ref: EWH 5





3 0

Action By:

Complete Date:

Sign:


2 0

Action By:

Complete Date:

Sign:



Page: 119 / 145


classroom

System ID: 09

Survey Ref: EWH 5





2 0

Action By:

Complete Date:

Sign:

9 The thermostat setting should be adjusted as the water heater is operating at an incorrect temperature.

2 0

Action By:

Complete Date:

Sign:


classroom

System ID: 09

Survey Ref: EWH 5





1 1

Action By:

Complete Date:

Sign:



Page: 120 / 145


space

System ID: 10

Survey Ref: WH 1





3 0

Action By:

Complete Date:

Sign:



Page: 121 / 145


System ID: 10

Survey Ref: WH 1




6 As the water heater has no internal access but can be easily removed, it should be chemically cleaned and loose scale removed. In some cases replacement is a better option.

2 0

Action By:

Complete Date:

Sign:

7 Introduce an annual internal water heater inspection and maintenance program.

2 0

Action By:

Complete Date:

Sign:

8 A suitable drain valve should be fitted to facilitate complete drainage and flushing of the water heater.

2 0

Action By:

Complete Date:

Sign:

23 Either for an inlet/outlet type expansion vessel to the heater, or fit a drain and isolation valve to expansion vessel pipework to enable regular flushing.

2 0

Action By:

Complete Date:

Sign:



Page: 122 / 145


nursery roof space

System ID: 11

Survey Ref: EWH 6





3 0

Action By:

Complete Date:

Sign:


2 0

Action By:

Complete Date:

Sign:


roof space

System ID: 11

Survey Ref: EWH 6




8 Re position the expansion vessel so it is on a vertical plane facing upwards. A drain and isolation valve should also be fitted to enable regular flushing of the vessel, or fit an inlet/outlet type

2 0

Action By:

Complete Date:

Sign:

9 The thermostat setting should be adjusted as the water heater is operating at an incorrect temperature.

2 0

Action By:

Complete Date:

Sign:



Page: 123 / 145


space

System ID: 12

Survey Ref: WH 2





3 0

Action By:

Complete Date:

Sign:


System ID: 12

Survey Ref: WH 2




6 As the water heater has no internal access but can be easily removed, it should be chemically cleaned and loose scale removed. In some cases replacement is a better option.

2 0

Action By:

Complete Date:

Sign:

7 Introduce an annual internal water heater inspection and maintenance program.

2 0

Action By:

Complete Date:

Sign:

8 A suitable drain valve should be fitted to facilitate complete drainage and flushing of the water heater.

2 0

Action By:

Complete Date:

Sign:

23 Either for an inlet/outlet type expansion vessel to the heater, or fit a drain and isolation valve to expansion vessel pipework to enable regular flushing.

2 0

Action By:

Complete Date:

Sign:



Page: 124 / 145



System ID: 13

Survey Ref: MCWS 2




5 Remove the showers that are not used or if this is not possible add them to the flushing regime.

3 0

Action By:

Complete Date:

Sign:

8 A double check valve suitable for fluid categories up to 3, Fluid which represents a slight health hazard because of substances of low toxicity, should be fitted to the ~~.

2 2

Action By:

Complete Date:

Sign:

6 Distribution pipework should be insulated to relevant British standards to reduce heat gain.

2 0

Action By:

Complete Date:

Sign:

7 Any outlets that are infrequently used (see asset register) should be included in the weekly flushing regime.

2 0

Action By:

Complete Date:

Sign:

10 Defined drinking water outlets need to be labelled so that they can be readily identified.

0 1

Action By:

Complete Date:

Sign:



Page: 125 / 145



System ID: 14

Survey Ref: LTHW 2




2 Consider a regular water treatment check on inhibitor levels and corrosion control.

0 2

Action By:

Complete Date:

Sign:

3 Install a suitably sized dosing pump.

0 2

Action By:

Complete Date:

Sign:

4 Disconnect the pipe and isolate within 3 to 5 pipe diameters to avoid creating a dead leg.

0 2

Action By:

Complete Date:

Sign:



Page: 126 / 145



System ID: 15





19 Each non-conformity requiring corrective action should be logged and the status of that fault indicated so corrective action can be tracked and signed off for each particular fault identified.

4 0

Action By:

Complete Date:

Sign:

5 The responsible person should obtain certificated training in Legionella management such as QCF Level 3 Award in Legionella control for Responsible persons.

3 0

Action By:

Complete Date:

Sign:

20 Consider assessed legionella training for managers so there is evidence of their abilities.

3 0

Action By:

Complete Date:

Sign:

12 Give employees an opportunity to comment on the assessment and control measures by publicising that a legionella risk assessment has been performed. (ACoP L8:2013 Para 44)

2 0

Action By:

Complete Date:

Sign:

18 Ensure the outcome of review meetings with your service provider are recorded.

2 0

Action By:

Complete Date:

Sign:

13 Ensure monitoring and inspection records are available for at least 5 years

1 0

Action By:

Complete Date:

Sign:



Page: 127 / 145

14 A visit log should be maintained in the record system detailing visits by service providers and others with allocated tasks.

1 0

Action By:

Complete Date:

Sign:

System ID Floor / Location Dead Leg

Little Used

Mains Stored Cold

Stored Hot

Mixed TMV



Page: 128 / 145

Asset Register

1 Ground - Boys Toilets: 1 x WC

3, 3 Ground - Boys Toilets: 2 x WHB TMV Controlled Sentinel Outlet 22.0 52.0 38.0

Nearest Hot Sentinel Outlet

1 Ground - Boys Toilets: 1 x Urinal

1 Ground - Year 5: 1 x Sink 20.0

1 Ground - Ladies Toilets: 2 x WC

3, 3 Ground - Ladies Toilets: 2 x WHB TMV Controlled Outlet 20.0 53.0 44.0

3, 3 Ground - Switch Room: 1 x Sink 18.0 55.0

1 Ground - Main Kitchen: 1 x Bib Tap

1 Ground - Main Kitchen: 1 x Dead End 1

1 Ground - Main Kitchen: 1 x Steam Oven

3, 3 Ground - Main Kitchen: 4 x Sink 18.0 53.0

1 Ground - Main Kitchen: 1 x Dishwasher

3, 3 Ground - Main Kitchen: 1 x WHB TMV Controlled Outlet 18.0 53.0 43.0

1 Ground - Kitchen Toilet: 1 x WC

3, 3 Ground - Kitchen Toilet: 1 x WHB TMV Controlled Outlet 18.0 54.0 42.0

1 Ground - Reception Area Toilet: 1 x WC

3, 3 Ground - Reception Area Toilet: 1 x WHB TMV Controlled Outlet 18.0 54.0 41.0

3, 3 Ground - Infants Gents: 1 x WHB 42.0

1 Ground - Infants Gents: 1 x WC

1 Ground - Infants Gents: 2 x Urinal

3, 3 Ground - Infants Gents: 1 x WHB TMV Controlled Outlet 19.0 55.0 42.0

1 Ground - Infants Ladies: 1 x WC

3, 3 Ground - Infants Ladies: 2 x WHB TMV Controlled Outlet 18.0 53.0 42.0

1 Ground - S.E.N: 1 x Sink 19.0

3, 3 Ground - Rec Class Boys: 2 x WHB TMV Controlled Outlet 21.0 50.0 41.0


Little Used

Mains Stored Cold

Stored Hot

Mixed TMV



Page: 129 / 145

1 Ground - Rec Class Boys: 2 x WC

3, 3 Ground - Rec Class Girls: 1 x WHB TMV Controlled Sentinel Outlet 21.0 50.0 41.0

Nominated Furthest Hot Sentinel

1 Ground - Rec Class Girls: 1 x WC

5, 5 Ground - Rec Classroom: 1 x Sink TMV Controlled Outlet 20.0 68.0 41.0

6, 6 Ground - Year 1 Boys Toilets: 1 x WHB TMV Controlled Outlet 20.0 69.0 41.0

1 Ground - Year 1 Boys Toilets: 1 x Urinal

1 Ground - Year 1 Boys Toilets: 1 x WC

6, 6 Ground - Year 1 Girls Toilets: 1 x WHB TMV Controlled Outlet 20.0 69.0 41.0

1 Ground - Year 1 Girls Toilets: 2 x WC

7, 7 Ground - Year 2 Classroom: 1 x Sink TMV Controlled Outlet 19.0 72.0 43.0

8, 8 First - Classroom nr Meeting Room: 1 x Sink TMV Controlled Outlet 19.0 67.0 42.0

1 First - Year 3 & 4 Classroom: 1 x Sink 18.0

1 First - Staff Room: 1 x Washing Machine

3, 3 First - Staff Room: 1 x Sink Sentinel Outlet 18.0 53.0

Furthest Hot Sentinel

1 First - Staff Room: 1 x Hydro Boiler

3, 3 First - Female Staff Toilet: 1 x WHB TMV Controlled Outlet 19.0 53.0 40.0

1 First - Female Staff Toilet: 2 x WC

1.9 First - Year 5 Classroom: 1 x Sink TMV Controlled Outlet 20.0 34.0 34.0

1 First - Year 6 Classroom: 1 x Dead End 1

1.9 First - Year 6 Classroom: 1 x Sink TMV Controlled Outlet 20.0 34.0 34.0

1 First - Boys Toilets nr Year 5: 2 x WC

3, 3 First - Boys Toilets nr Year 5: 1 x WHB TMV Controlled Outlet 20.0 53.0 25.0

3, 3 First - Girls Toilets nr Year 5: 1 x WHB TMV Controlled Outlet 20.0 53.0 40.0

1 First - Girls Toilets nr Year 5: 1 x WHB TMV Controlled Outlet 20.0 53.0 41.0

10 WH 1, 13 MCWS 2 Ground - Nursery Block Entrance Toilets: 3 x WHB TMV Controlled Outlet 19.0 50.0 38.0


Little Used

Mains Stored Cold

Stored Hot

Mixed TMV



Page: 130 / 145

1 x TMV feeds 3 x WHB

13 MCWS 2 Ground - Nursery Block Entrance Toilets: 3 x WC

10 WH 1, 13 MCWS 2 Ground - Nursery Block Classroom Area: 1 x Sink TMV Controlled Outlet 18.0 50.0 41.0

11 EWH 6, 13 MCWS 2 Ground - Nursery Block Kitchenette: 1 x Sink 18.0 52.0

13 MCWS 2 Ground - Nursery Block Water Area: 1 x Washing Machine

12 WH 2, 13 MCWS 2 Ground - Nursery Block Water Area: 1 x Sink TMV Controlled Outlet 18.0 52.0 40.0

13 MCWS 2 Ground - Nursery Block Disabled Toilet: 1 x WC

13 MCWS 2 Ground - Nursery Block Disabled Toilet: 1 x Electric Shower 1

12 WH 2, 13 MCWS 2 Ground - Nursery Block Disabled Toilet: 1 x WHB TMV Controlled Outlet 18.0 52.0 39.0



Page: 131 / 145

Assessment Photos

Title: Quick Fill Links

Comments: LR: 0 GR: 2 Located in the nursery block plant room. The quick fill links should be removed when not in use.

Title: Water Heater 1

Comments: LR: 0 GR: 0 Located in the roof space of the nursery block



Page: 132 / 145

Title: Mains Incoming to Main Building

Comments: LR: 0 GR: 0 Located in the gas meter cupboard

Title: Cold Water Storage Tank - External

Comments: LR: 0 GR: 0 Located in the tank room on the roof of the main building



Page: 133 / 145

Title: Cold Water Storage Tank - Internal

Comments: LR: 2 GR: 0 As can be seen, there is some light debris to the base of the tank. The concern is the staining to the walls which

could provide a nutrient source for bacterial growth. It should be cleaned & disinfected in line with Acop L8

recommendations

Title: Cold Water Storage Tank - Internal

Comments: LR: 2 GR: 0 Different angle of interior condition of tank



Page: 134 / 145

Title: Calorifier 1 & 2

Comments: LR: 0 GR: 0 Located in the basement plant room of the main building

Title: Pitted fittings of hot pipework in basement plant room

Comments: LR: 2 GR: 0 This build up of 'pitting' is the direct result of the oxidation process. Oxygen degrades metals through an

electro-chemical process of internal oxidation. The result is that the metal gradually get converted to an oxide

(rust), becoming thinner and weaker in the process. As the pipe corrodes, the impurities are deposited into the

water lines, thus providing a habitat for bacteria colonies to become established in, and nutrients for their

metabolisms.



Page: 135 / 145

Title: Dead End

Comments: LR: 2 GR: 0 Located under the sinks in the main kitchen. Dead ends will hold stagnant water, in which it is possible and

environment for bacterial growth can be created. Dead ends should be cut right back to the supply pipe they

are fed from.

Title: Electric Water Heater 1

Comments: LR: 0 GR: 0 The electric water heater is located in the reception classroom



Page: 136 / 145


Comments: LR: 0 GR: 0 The electric water heater is located in the Year 1 boys toilets


Comments: LR: 0 GR: 0 The electric water heater is located in the Year 2 classroom area



Page: 137 / 145

Title: Filter

Comments: LR: 2 GR: 0 Located under the sink in the first floor staff room. Filters should be services in-line with manufacturers

recommendations


Comments: LR: 0 GR: 0 The electric water heater is located in the classroom near the 1st floor meeting room



Page: 138 / 145


Comments: LR: 2 GR: 0 The electric water heater is located in Year 6 classroom. The outlet temperature of 34c is too low. The

thermostat should be increased.

Title: Dead End

Comments: LR: 2 GR: 0 Located in the Year 6 classroom. This dead end should be removed to prevent stagnation of water which could

potentially spread into the system



Page: 139 / 145

Title: Infrequently used shower

Comments: LR: 3 GR: 0 Located in the disabled toilet of the nursery block. As can be seen, the evidence suggests that this shower is

infrequently, if ever used. It should either be completely removed with all pipework cut right back, or added to

the weekly flushing regime.


Comments: LR: 2 GR: 0 Located in the roof space of the nursery block. As can be seen, the expansion vessel is pointing downwards and

has been fitted incorrectly. Expansion vessels should be upright on a vertical plane. The expansion vessel

should be re-fitted on a vertical plane and either replaced with an inlet/outlet type vessel, or have an isolation

valve and drain valve fitted to enable flushing of potentially stagnant water every 6 months



Page: 140 / 145

Title: Water Heater 2

Comments: LR: 0 GR: 0 Located in the roof space of the nursery block

Title: Mains in to Nursery Block

Comments: LR: 0 GR: 0 Located in the nursery block plant room



Page: 141 / 145

Control Scheme

Infrequently Used Outlets

Weekly -

Infrequently used equipment within a water system (ie not used for a period equal to or greater than seven

days) should be included on the flushing regime. Flush the outlets until the temperature at the outlet stabilises

and is comparable to supply water and purge to drain. Regularly use the outlets to minimise the risk from

microbial growth in the peripheral parts of the water system, sustain and log this procedure once started. For

high risk populations, eg healthcare and care homes, more frequent flushing may be required as indicated by

the risk assessment.

Where possible -

Consideration should be given to removing infrequently used showers, taps and any associated equipment that

use water. If removed, any redundant supply pipework should be cut back as far as possible to a common

supply (eg to the recirculating pipework or the pipework supplying a more frequently used upstream fitting)

but preferably by removing the feeding ‘T’.

1 x infrequently used outlet(s) - located Ground Nursery Block Disabled Toilet Electric Shower

Sentinel Locations

Monthly

Non-Circulating hot water - take temperatures at sentinel points (nearest outlet, furthest outlet and long

branches to outlets) to confirm they are at a minimum of 50°C within one minute

Circulating hot water - take temperatures at return legs of principal loops (sentinel points) to confirm they are

at a minimum of 50°C. Temperature measurements may be taken on the surface of metallic pipework.

Quarterly - Circulating hot water - take temperatures at return legs of subordinate loops, temperature

measurements can be taken on the surface of pipes, but where this is not practicable, the temperature of

water from the last outlet on each loop may be measured and this should be greater than 50°C within one

minute of running. If the temperature rise is slow, it should be confirmed that the outlet is on a long leg and

not that the flow and return has failed in that local area.

2 x WHB TMV Controlled Sentinel Outlet - Located Ground Boys Toilets

1 x WHB TMV Controlled Sentinel Outlet - Located Ground Rec Class Girls

1 x Sink Sentinel Outlet - Located First Floor Staff Room

Showers

Quarterly - Dismantle, clean, descale and disinfect removable parts, heads, inserts and hoses where fitted.

1 x Electric Shower - Located Ground Nursery Block Disabled Toilet



Page: 142 / 145

TMV

Monthly - Check and record blended water temperature regularly in healthcare applications or where the duty

holder assesses a high scalding risk exists. The manufacturer is likely to recommend regular temperature checks

where increased risks are perceived such as where patients are unable to immediately respond to an increase

in water temperature by either shutting the water off or removing themselves from the contact with the water.

Annually - Risk assess whether the TMV fitting is required, and if not, remove it.

2 x WHB TMV Controlled Sentinel Outlet - Located Ground Boys Toilets

2 x WHB TMV Controlled Outlet - Located Ground Ladies Toilets

1 x WHB TMV Controlled Outlet - Located Ground Main Kitchen

1 x WHB TMV Controlled Outlet - Located Ground Kitchen Toilet

1 x WHB TMV Controlled Outlet - Located Ground Reception Area Toilet

1 x WHB TMV Controlled Outlet - Located Ground Infants Gents

2 x WHB TMV Controlled Outlet - Located Ground Infants Ladies

2 x WHB TMV Controlled Outlet - Located Ground Rec Class Boys

1 x WHB TMV Controlled Sentinel Outlet - Located Ground Rec Class Girls

1 x Sink TMV Controlled Outlet - Located Ground Rec Classroom

1 x WHB TMV Controlled Outlet - Located Ground Year 1 Boys Toilets

1 x WHB TMV Controlled Outlet - Located Ground Year 1 Girls Toilets

1 x Sink TMV Controlled Outlet - Located Ground Year 2 Classroom

1 x Sink TMV Controlled Outlet - Located First Classroom nr Meeting Room

1 x WHB TMV Controlled Outlet - Located First Female Staff Toilet

1 x Sink TMV Controlled Outlet - Located First Year 5 Classroom

1 x Sink TMV Controlled Outlet - Located First Year 6 Classroom

1 x WHB TMV Controlled Outlet - Located First Boys Toilets nr Year 5

1 x WHB TMV Controlled Outlet - Located First Girls Toilets nr Year 5

1 x WHB TMV Controlled Outlet - Located First Girls Toilets nr Year 5

3 x WHB TMV Controlled Outlet - Located Ground Nursery Block Entrance Toilets

1 x Sink TMV Controlled Outlet - Located Ground Nursery Block Classroom Area

1 x Sink TMV Controlled Outlet - Located Ground Nursery Block Water Area

1 x WHB TMV Controlled Outlet - Located Ground Nursery Block Disabled Toilet

Mains

Hot weather - Incoming water temperature should be well below 20°C for most, if not all of the year. In an

exceptionally hot summer, it may be necessary to review the risk assessment and take appropriate action to

mitigate the risk.

MCWS 1 - The mains water stop valve is located in the gas meter room of the main building

MCWS 2 - The mains water stop valve for the nursery block is located in the nursery plant room

Tank (Cistern)

Annually (Summer) - Monitor the temperature of stored cold water and inlet (float valve) temperature.

Annually - Visual inspection of the cold water storage tank to check the condition of the inside of the tank and

the water within it. The lid should be in good condition and fit closely. The insect screen on the water overflow

pipe should be intact and in good condition. The thermal insulation on the cold water storage tank should be in

good condition so that it protects it from extremes of temperature. The water surface should be clean and

shiny and the water should not contain any debris or contamination. The cold water storage tank should be

cleaned, disinfected and faults rectified, if considered necessary.

CWST - The domestic cold water tank is located in the tank room on the roof



Page: 143 / 145

Calorifier (Water heater)

Monthly - Check calorifier flow temperatures (thermostat settings should modulate as close to 60°C as

practicable without going below 60°C).

Annually - Inspect calorifier internally by removing the inspection hatch or using a boroscope and clean by

draining the vessel. The frequency of inspection and cleaning should be subject to the findings and increased or

decreased based on conditions recorded.

At least Annually - Where there is no inspection hatch, purge any debris in the base of the calorifier to a

suitable drain. Collect the initial flush from the base of hot water heaters to inspect clarity, quantity of debris,

and temperature.

CAL 1 - The hot water calorifier is located in the basement boiler room

CAL 2 - The hot water calorifier is located in the basement boiler room

WH 1 - The water heater is located in the nursery roof space

WH 2 - The water heater is located in the nursery roof space

Local water heater <15ltr (POU)

Six Monthly - Check water temperatures to confirm the heater operates at 50–60°C (55°C in healthcare

premises) or check the installation has a high turnover. Flush any expansion vessels

EWH 1 - The electric water heater is located in the reception classroom

EWH 2 - The electric water heater is located in the Year 1 boys toilets

EWH 3 - The electric water heater is located in the Year 2 classroom area

EWH 4 - The electric water heater is located in the classroom near the 1st floor meeting room

EWH 5 - The electric water heater is located in Year 6 classroom

EWH 6 - The electric water heater is located in the nursery roof space

Pou \ Combi Boiler

Annually - Inspect and repair if required

EWH 1 - The electric water heater is located in the reception classroom

EWH 2 - The electric water heater is located in the Year 1 boys toilets

EWH 3 - The electric water heater is located in the Year 2 classroom area

EWH 4 - The electric water heater is located in the classroom near the 1st floor meeting room

EWH 5 - The electric water heater is located in Year 6 classroom

EWH 6 - The electric water heater is located in the nursery roof space

Management

Annually - Inspect the record system for completeness.

Management - The previous legionella risk assessment and monitoring data is accessed via request to the site

manager

Dead Legs

ASAP -

The dead ends or capped ends identified below should be removed. When removed, any redundant supply

pipework should be cut back as far as possible to a common supply (e.g. to the recirculating pipework or the

pipework supplying a more frequently used upstream fitting) but preferably by removing the feeding ‘T’.

Weekly (or as defined by the risk assessment) -

Dead ends within a water system that can not be removed should be fitted with a flushing valve and included



Page: 144 / 145

on the flushing regime. Flush the outlets until the temperature at the outlet stabilises and is comparable to

supply water. This procedure must be repeated and logged once started.

1 x deadleg(s) - located Ground Main Kitchen Dead End

1 x deadleg(s) - located First Year 6 Classroom Dead End

Other Hot/Cold Outlets

Annually - All hot and cold water locations - take temperatures at a representative selection of other points

(intermediate outlets of single pipe systems and tertiary loops in circulating systems) to confirm HWS are at a

minimum of 50°C (55 °C in healthcare premises) and CWDS are below 20°C to create a temperature profile of

the whole system over a defined time period.

1 x Sink - Located Ground Year 5

1 x Sink - Located Ground Switch Room

1 x Bib Tap - Located Ground Main Kitchen

4 x Sink - Located Ground Main Kitchen

1 x WHB - Located Ground Infants Gents

1 x Sink - Located Ground S.E.N

1 x Sink - Located First Year 3 & 4 Classroom

1 x Sink - Located Ground Nursery Block Kitchenette



Page: 145 / 145

Drawings & Additional Information

EWH

4

CLASS ROOM

NR MEETING ROOM

TMV

EWH

3

YEAR 2

TMV TMV TMV TMV TMV

EWH

2

EWH

5

TMV TMV

EWH

1

RECEPTION

CLASS

ROOM

TMV

TMV TMV

CWS 1

YEAR 3 - 4

SINK

TMV TMV

STAFF ROOM

SINK

WM

HYDRO

WHB WHB

YEAR 1 GIRLS

TOILETS

2 x WC WHB

UR

WC WHB WHB

YEAR 1

BOYS TOILETS

CAL 1

CAL 2

WM

2 x WC

WHB WHB

UR

WC

YEAR 6

YEAR 5

BOYS NEAR

YEAR 5

SINK

SINK

SINK

RECEPTION

CLASS GIRLS

2 x WC

RECEPTION

CLASS BOYS

2 x WC SINK

S.E.N

INFANTS

LADIES

2 x UR

WC

INFANTS

GENTS

GAS METER

CUPBOARDS

WC

DEADLEG

BIB TAP

STEAM OVEN

DW

REC. AREA

TOILETS

4 x SINK SINK WC

UR

WCSINK

WHB

2 x WHB 2 x WC

ROOF TANK ROOM

GROUND FLOOR

FIRST FLOOR

LADIES

TOILETS

YEAR 5 BOYS

TOILETS

FEMALE

STAFF

ROOM

MAIN KITCHEN

WC

KITCHEN

TOILET

BASEMENT

*NH

LEGEND

CAL

EWH

TANK COLD WATER

MAINS WATER

HOT WATER

OPEN VALVE

PUMP

COLD WATER STORAGE TANK

CALORIFIER

WASH HAND BASIN

SINK

WASHING MACHINE

DISHWASHER

SHOWER

URINAL

WATER CLOSET

ELECTRIC WATER HEATER

WC

UR

SH

DW

WM

SK

WHB

TMV

*FH

GIRLS YEAR 6

SINK

SINK

TMV TMV

WHBWHB

TMV TMV

WHBWHB

TMV TMV

WHBWHB

TMV

WHB

TMV

2 x WHB

TMV

WHB

TMV

WHB

TMV

WHB

TMV

WHB

SWITCHROOM

TMV

WHB

TMV

WHB

THERMOSTATIC MIXER VALVE

2 x WC

DRAWING NUMBER: REV:

DATE: DRAWN BY: SCALE:

DRAWING TITLE:

257 Alvechurch Road, West Heath

Birmingham B31 3PX

Tel no. 0121 608 3272

ST AUGUSTINES CATHOLIC PRIMARY SCHOOL

DOMESTIC HOT + COLD WATER SYSTEM

16.08.2017 A-LINE NTS

ACQ053-01

-

WH

1

ENTRANCE

TOILETS

TMV TMV

SINK3 x WHB 3 x WC

TMV TMV

WM

TMV

WHB

ELEC

SHOWER

(I.V.O)

EWH

6

WH

2

SINK SINK

CLASSROOM KITCHENETTE

WATER

AREA

PLANT

ROOM

WC

LEGEND

CAL

EWH

TANK COLD WATER

MAINS WATER

HOT WATER

OPEN VALVE

PUMP

COLD WATER STORAGE TANK

CALORIFIER

WASH HAND BASIN

SINK

WASHING MACHINE

DISHWASHER

SHOWER

URINAL

WATER CLOSET

ELECTRIC WATER HEATER

WC

UR

SH

DW

WM

SK

WHB

TMV THERMOSTATIC MIXER VALVE

DRAWING NUMBER: REV:

DATE: DRAWN BY: SCALE:

DRAWING TITLE:

257 Alvechurch Road, West Heath

Birmingham B31 3PX

Tel no. 0121 608 3272

ST AUGUSTINES CATHOLIC PRIMARY SCHOOL

NURSERY AREA

DOMESTIC HOT + COLD WATER SYSTEM

16.08.17 A-LINE NTS@A4

ACQ053-02

-

Legionella Risk Assessment - Our Lady of Lourdes Catholic ...€¦ · Risk Assessment Ratings LR -...

Documents

Transcript of Legionella Risk Assessment - Our Lady of Lourdes Catholic ...€¦ · Risk Assessment Ratings LR -...