Water Safety PlanWater Safety Management Group Standard Agenda 1. Apologies For Absence 2. Minutes...

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Water Safety Plan for

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1.0 Executive Summary

The Trust has a statutory requirement to control the risk of outbreaks of Legionellosis in the workplace. An outbreak of the disease could result in prosecution under the Health and Safety at Work etc Act 1974 (H&SWA), The Management of Health and Safety at Work Regulations 1999 and the Control of Substances Hazardous to Health Regulations 2002 (COSHH). The Trust has a statutory requirement to ensure all domestic water installations meet with the conditions laid down by the Water Regulations Advisory Scheme. Failure to comply could result in prosecution under the Water Supply (Water Fittings) Regulations 1999. The Trust has a requirement to control the risk of scalding in the workplace. A scalding incident could result in prosecution under the Health and Safety at Work etc Act 1974 (H&SWA). The Trust has a requirement to provide water of a quality commensurate with the demands of the application. Failure to comply could result in an increase of injurious risk to the end user.

Under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and its associated Code of Practice on the prevention and control of infections and the Care Quality Commission (Registration) Regulations 2009, the Trust has a duty to assess and manage the risk of, and prevent, detect and control the spread of, infections, including those that are health care associated.

The purpose of this Water Safety Plan is to provide a practical framework for ensuring compliance with all relevant guidance

2.0 Policy/Lines of Communication

Name Contact details

Fiona Edwards – Chief Executive Tel: 01372 216137 Email: [email protected]

Professor Jonathan Warren – Director of Nursing Tel:01372 216137 Email: [email protected]

Lorna Payne – Chief Operating Officer Tel: 01372 216137 Email: [email protected]

Evonne Harding – Director of Risk & Safety Tel: 01372 216137 Email: [email protected]

Roman Trotsyuk –Technical Services Manager Tel: 07557 076847 Email: [email protected]

Dr Jane Tinkler – Authorising Engineer Tel: 07770 604666 Email: [email protected]

Gregg Hayman– General Manager (Bouygues) Tel: 07799 343553 Email: [email protected]

Kevin Palmer – Service Manager (Bouygues) Tel: 07766 998092 Email: [email protected]

Contact Details

3.0 Water Safety Group

The Water Safety Group (WSG) is a multidisciplinary group formed to oversee the Water Safety Plan (WSP) and ensure the safety of all water. People with a range of competencies can be brought together to share responsibility. It will typically comprise those who are familiar with water systems and equipment, those who understand which factors increase the risk of infection from pathogens and those who have knowledge of the particular vulnerabilities of the at risk population in the Trust buildings.

The water safety group will:

Determine particular vulnerabilities of the at risk population

Review risk assessments

Review WSP

Agree and Review remedial measure and actions with agreed deadlines

Ensure monitoring procedures in place

Ensure new builds and refurbishments are designed, installed and commissioned to the required standards

Oversee training requirements

Oversee any water treatment controls required

Ensure surveillance of clinical and environmental monitoring

Water Safety Management Group

Terms of Reference

1. Purpose

To ensure the safety of all water used by patients/residents, staff and visitors and to minimise the risk of infection associated with waterborne pathogens

To oversee the implementation and management of all Trust policies and procedures in relation to Water Safety.

To monitor performance of Water Safety Management

To review and address issues of non-compliance to current or future anticipated standards, regulations and legislation, and to escalate where necessary in line with the Trust’s Risk Management Strategy.

To provide assurance, performance and exception reporting to the appropriate higher authority, including the Trust Board.

2. Membership & Attendance

Assistant Director of Estates and Facilities (Chair)

Health and safety Lead (Deputy Chair)

Infection Control Lead

Compliance Manager

Maintenance provider

Procurement Manager

Authorising Engineer (Water)

3. Frequency of Meetings

Bi-Monthly or more frequent if required

4. Reporting

Reports monthly to health and safety committee

5. Quorum

The meeting will be quorate if Chair or Deputy present plus 3 more members

Water Safety Management Group

Standard Agenda

1. Apologies For Absence

2. Minutes from the Previous Meeting agreed?

3. Matters Arising from previous meeting

4. Water Safety Plan review

a. Any changes to management structure

b. Any changes to ‘at risk’ population and locations

c. Any changes to written scheme

5. Risk assessment review/Remedial action update

6. Monitoring records/remedial action update

7. L8 Guard latest results

8. Audit Results (not discussed above)

9. Surveillance of clinical and environmental monitoring

10. New Builds/Refurbishments/Modifications

11. Training

12. Any other business

4.0 BACKGROUND and HIGH RISK GROUPS

4.1 Legionnaires’ Disease

The disease first appeared in a recognisable form as a result of an outbreak in America during 1976. Retrospective studies of unexplained illnesses have shown that similar outbreaks have been occurring for as long as records have existed.

The disease is not a major cause of illness when set against the usual pneumonias that it closely resembles. Studies by the Health Protection Agency (HPA) and the Communicable Disease Surveillance Centre (CDSC), indicate that it causes about 200 cases a year severe enough to require hospital treatment. Of these about 43% will have been acquired abroad and will only have shown symptoms on the victims return to this country. The fatality rate is low about 10% but many more will suffer some form of permanent damage to their health

Ideal conditions for growth

Temperature: 20-45C (optimum=37C)

pH: 6 to 9

Conditions: Water

Iron

Darkness

Stagnation

Travel: 500m in Air +Possibly up to 2-3 miles if all conditions are in place

Legionnaires’ Disease is a potentially fatal respiratory infection caused by inhaling droplets of water contaminated by the bacteria. There is no evidence that the disease is transmitted by ingestion or directly from person to person. The organism is widely distributed in nature and is commonly found in soil and surface waters. It thrives at temperatures between 20 - 45°C. The organism may commonly be found in the hot water systems of large buildings such as hospitals, hotels and offices, usually without any significant risk to staff or patients. Outbreaks have originated from air-conditioning systems, particularly their associated cooling towers, hot water systems and showers have also been recognised as sources of infection.

The Incubation Period

May range from 2-10 days, but is usually 3-6 days. Males are more likely to be affected than females. Previously healthy people may develop Legionnaires’ Disease; however individuals particularly at risk include those who smoke, have chronic respiratory disease and are immunocompromised. Symptoms include high fever, chills, headache and muscle pain. A dry cough develops and most patients have difficulty in breathing. Some patients develop diarrhoea or vomiting and others become confused or delirious. Legionnaires’ Disease may not always be severe and mild cases may go unrecognised.

Tests to confirm its presence may take a further five to ten days.

4.2 Pseudomonas aeruginosa

Pseudomonas aeruginosa is a Gram-negative bacterium, commonly found in wet or moist

environments. It is commonly associated with disease in humans with the potential to

cause infections in almost any organ or tissue, especially in patients compromised by

underlying disease, age or immune deficiency Its significance as a pathogen is exacerbated

by its resistance to antibiotics, virulence factors and its ability to adapt to a wide range of

environments.

Pseudomonas aeruginosa thrives in relatively nutrient-poor environments at a range of

different temperatures and can become one of the species in biofilms where a slime layer

binds a mixed bacterial population to surfaces. Although most bacteria will remain fixed

within the biofilm, some will become detached resulting in free-floating (planktonic) forms

that can cause contamination of the water layer above the biofilm.

Biofilms will be present on the plumbing materials in the water system but in most cases, Pseudomonas aeruginosa will be concentrated within 2 metres of the point of water delivery at the outlet, i.e. after the water has left the circulation system.

During cleaning, there is a risk of contaminating tap outlets with microorganisms, if the same cloth is used to clean the bowl of the hand basin before the tap. These bacteria may be of patient origin, so it is possible that bacteria, including antibiotic resistant organisms, could seed the outlet, become resident in any biofilm and have the potential to be transmitted to other patients.

Although this policy focuses on Pseudomonas aeruginosa, other opportunistic pathogens may behave in a similar manner but appear less frequently as clinical problems. Sampling could also identify pathogens such as Stenotrophomonas and Burkholderia or other opportunistic pathogens if clinical surveillance suggests investigation is needed.

The need to consider the risk associated with pseudomonas aeruginosa is principally

dictated by the users groups within properties under the control of the Trust and those

classed as Augmented care

AUGMENTED CARE

Vulnerable patient groups who would be considered to be in augmented care

environments include;

a. Those patients who are severely immunosuppressed because of disease or treatment: this will include transplant patients and similar heavily immunosuppressed patients during high-risk periods in their therapy;

b. Those cared for in units where organ support is necessary, for example critical care (adult paediatric and neonatal), renal, respiratory (may include cystic fibrosis units) or other intensive care situations;

c. Those patients who have extensive breaches in their dermal integrity and require contact with water as part of their continuing care, such as in those units caring for burns.

Identification of patients of significant risk

The following units have been identified as those areas with patients of significant risk from Legionella bacteria

None

Signed: Date:

Position: Review Date:

The following units have been identified as those areas with patients of significant risk from waterborne P. aeruginosa contamination.

None

Signed: Date:

Position: Review Date:

5.0 Assessment of Risk 5.1 Legionella Bacteria The Trust will employ competent external contractors who are members of the Legionella Control Association, to carry out a risk assessment on its behalf. It will include all risk items such as:

Cold water storage tanks, sumps & cisterns

Hot water generators & calorifiers

Pumps, heat exchangers

Hot and cold water distribution systems

Evaporative condensers / wet cooling systems

Cooling towers, air conditioning units and air handling units

Any other water risk items e.g. dead-legs, fountains & stagnant water

Swimming pools, spas, birthing baths, hydrotherapy pools The legionella risk assessment will be carried out in accordance with BS8580:2010 Plant room and building pipe work schematics will form part of the risk assessment process. The risk assessment will create a register of asset which will form the foundation of the operational processes The risk assessment will produce a list of remedial actions and options that will created into a time limited action plan. Whenever there is reason to doubt the robustness of current controls or the current risk assessment is no longer valid, the building, processes & procedures will be re-assessed, for example:

a change to the water system or its use;

a change to the use of the building where the system is installed;

new information available about risks or control measures;

the results of checks indicating that control measures are no longer effective;

changes to key personnel;

a case of legionnaires’ disease/legionellosis associated with the system 5.2 Pseudomonas Aeruginosa Where it is determined by the Water Safety Group (WSG) that areas of augmented care are

present within a Trust property then the risk will be assessed in accordance with the HTM 04-01

Addendum

The assessment will consider;

Engineering Risk

Clinical Risk

Decontamination/cleaning procedures

The system will be reassessed whenever the WSG considers it no longer to be valid

5.3 Scalding Risk from Hot Water temperatures To prevent injury from scalding from any tap, shower or other hot water outlet, thermostatic mixing devices will be fitted to limit discharge temperatures. The need for the type of mixer and recommended output temperature will be in line with (the HGN 'Safe' hot water and surface temperatures: 1998- superseded by HTM 04-01 in respect to TMVs and outlets) – Table 2 in Part A of HTM 04-01. This will not, or may not apply to kitchen hot water boilers, dishwashers, theatre instrument washers and & laundry services, for example, where water temperatures need to be necessarily high; other control measures will apply in those circumstances. Whenever patients, residents and visitors have access, the maximum surface temperature of space heating devices and surface mounted pipe work within 2 meters of the floor, shall not exceed 43 degrees C. The Trust, in line with the requirements of HTM 04-01 Part A and the Health and Safety Executive guidance HSG274 Part 2 The Control of legionella Bacteria in Water Systems will assess the scalding risk in all operational areas, and wherever possible remove/refrain from using them.

The risk assessments are kept in:

Assessment type Location Signed/Date

6.0 Written Scheme 6.1 Cold water systems

Cold water storage tanks/cisterns (including integral water tanks on combination water heaters) will be inspected at least annually to determine the operation, condition, cleanliness and compliance to the Water Regulations and if necessary, cleaned and disinfected in accordance with BS:8558:2015 and PD855468:2015

Cold water storage temperatures will be maintained wherever possible at less than

20C (max 2C over meter temperatures) with 12 hour maximum storage capacity.

Cold water storage temperatures will be taken annually and include the inlet and stored temperature at the cistern outlet. The temperatures will be recorded during the summer months

Cold water distribution temperatures will be taken monthly at sentinel outlets

(maximum temperature 20C within two minutes of operation). Their location will be determined by the schematics created during the legionella risk assessment

Where two or more pumps are installed for cold water pressurising systems, the pumps will be switched automatically to minimise stagnation.

Expansion units will be installed on cold water lines, they will be vertical to prevent debris accumulation and as close to the point of application as reasonably practicable. Where practical they should be flushed monthly and bladders replaced if possible in accordance with manufacturers guidelines

6.2 Hot Water Systems

Domestic hot water storage temperatures will be maintained at a minimum of 60C

and readings taken at least monthly at flow (min 60C) and return (min 50C) positions

All stand-by hot water distribution circulation pumps will be removed and stored locally for emergency use.

For circulating systems domestic hot water distribution temperatures will be taken

monthly at sentinel outlets on the principle circuits (minimum temperature 55C after one minute). Their location will be determined by the schematics created during the legionella risk assessment

On a quarterly basis (using a rolling monthly rota) hot water distribution temperatures will be taken on returns (or the nearest outlet) on the subordinate

circuits (minimum temperature 55C after one minute). Their location will be determined by the schematics created during the legionella risk assessment

For non-circulating systems: domestic hot water distribution temperatures will be taken monthly at sentinel points (nearest outlet, furthest outlet and long branches

to outlets) (minimum temperature 55C after one minute).

Domestic hot water storage vessels will be inspected, and cleaned and thermally disinfected on an annual basis, where possible.

Off line units will be drained until required. They will be pasteurised prior to reinstatement.

Where anti-stratification pumps are fitted to domestic water calorifiers, they will operate for a period of hour a day at times of low water demand

Measures for the safe start up of all hot water generators are required

Water heaters must be inspected annually internally via hatch or boroscope camera. If not possible the unit must be flushed at least annually and the condition of the drain water noted.

Thermal disinfection is required if the temperatures falls below 50C Combination water heaters (with cold feed tanks above the hot water vessel) are not recommended.

If drains exist on expansion vessel they should be flushed regularly

6.3 Alternative Treatments

In accordance with HSG274 Part2, chlorine dioxide, chlorine or silver/copper ionisation can be used.

Where alternative treatment is used this will be as a secondary control system. Thermal control will, in accordance with HTM 04-01 and HSG274 Part 2 is the primary legionella control mechanism.

All systems employed will be maintained in accordance with the requirements of HSG274 Part 2 and HTM 04-01

Where chlorine dioxide is employed, the level of total oxidant (chlorine dioxide, chlorite and chlorate) will not exceed 0.5ppm

Chlorine dioxide will not be supplied to user groups identified as being susceptible. 6.4 Water Softeners

On a weekly basis the salt levels will be visually checked and topped up, if required. Undertake a hardness check to confirm operation of the softener.

The units will be serviced on an annual basis

Cleaning and disinfection of the water softener resin and brine tank will be undertaken annually

6.5 Showers

Infrequently used showers must be removed wherever possible.

All showers must be used at least twice weekly or flushed as part of the flushing programme.

Adjustable spray heads must not be used

Showerheads (including removable parts), inserts and hoses will be cleaned and descaled on a quarterly basis

6.6 Low use outlets

A low use outlet is any outlets used less than every 3 days, they can be found in areas of periodic occupation, vacated wards/room and rooms used for storage over their original purpose and typically medical areas no used as office space.

Areas where there has been a changing use should be reviewed if possible the service removed cutting back all redundant pipe work back to the parent main.

Where the outlet is deemed necessary to remain in place, this should be flushed hot and cold for a period of 3 minutes.

Where low use outlets are identified within augmented care setting, these are to be flushed daily for at least 1 minute.

The process of low use outlet flushing is to be controlled by the clinical users. More specifically they will risk assess their area weekly to establish any outlets deemed low use so that flushing can take place.

6.7 Point of use water heaters/Combination Water Heaters

Point of use water heaters will be used in instances where the use within an area would not be considered sufficient to warrant a standard hot water storage system or where the efficiency of an existing system is proved to be compromised.

The type of unit employed will be dictated by local requirements.

The output from Point of Use water heaters will be tested on a monthly basis to confirm they operate at 55-60°C.

The output from combination heaters will be tested on a monthly basis to confirm they operate at 55-60°C.

6.8 Air Handling Units

All wetted areas in the Trust air handling units will be cleaned and disinfected on 6-monthly basis, this will include humidifier chambers, cooling batteries and chambers and all associated drains and catch trays

6.9 Space Heating

Space heating fed from the domestic hot water system will not be used. This includes towel rails, heated bed-pan racks etc. All such identified equipment will be removed and alternative heating provided.

6.10 Hydrotherapy Pools, whirlpool baths and spas

For Hydrotherapy pools, whirlpool baths and spas careful maintenance and chemical treatment is essential to maintain water quality.

A log will be kept of the treatment, filter back wash and user rates

The pH, free residual halogen and other treatment parameters as recommended by the Hydrotherapy Association of Chartered Physiotherapists Standards for Good Practice. will be taken and recorded

Weekly microbiological tests will be taken and analysed in accordance with the Pool Water Treatment Advisory Group - Swimming pool water: treatment and quality standards for pools and spas

6.11 Portable Air Conditioning Units

Where potable air conditioning or room humidifiers are used, they must comply with the safety notice NHS ESN (96)06.

Units should not include a means to spray or atomised a water source into the air stream.

The use of portable units will only be considered in exceptional circumstances. 6.12 Water Features

Ornamental fountains will be installed outside only

The fountain must be contained within the confines of the pond/basin. This will be checked as part of the legionella risk assessment review.

The water treatment will be determined by a specialist contractor, they will establish appropriate operational limits and provide a working record on site

Exposure to high winds should be avoided as they can disperse spray beyond the immediate confines of the basin/pond. The apex of the water column/jet should not exceed the distance to the nearest edge of the basin/pond for the same reason. An overflow/outlet to a suitable drain should be provide for easy emptying and cleaning. Where possible, a permanently installed freshwater supply pipe with topping- up device should be provided. Their provision should be subject to a risk assessment and approval by the WSG, and appropriate action is required to minimise the risk. Any top-up supply from a wholesome water supply should be supplied via a backflow prevention device giving fluid category 5 protection-typically an air gap of Type AA or AB.

6.13 Vending Machines/Ice Machines/Drinking Water Machines

Vending and Ice making machine must be installed in accordance with the manufacturer’s instructions.

All units used on site must be WRAS approved

They must be installed in accordance with HTM 04-01 Part A and the Water Supply (Water Fittings) Regulations 1999.

Supply pipe work must be less than 3m

A double check valve should be installed onto the supply pipe work to prevent backflow.

The unit should be positioned on a section of pipe work up stream of a well-used outlet. The inlet pipe work must not feed across the hot exhaust vent.

The must be maintained in accordance with the manufacturer’s instructions

Any filters mounted on the inlet pipe work will be changed in accordance with the manufacturer’s instructions

Ice machines will not be installed in augmented areas.

6.14 Flexible hoses

The Trust will work to the guidance contained within EFA DH(2010)03

Flexible hoses will not be used

Solid copper connections will be used when flexible hoses are replaced.

New installations will utilise solid copper final connections 6.15 Point of Use (POU) Filters POU filters prevent the discharge of planktonic legionella from the tap and shower outlets.

They will be used, on the instruction of the infection control lead. as a temporary measure only until a permanent safe engineering solution is developed when undesirable conditions associated with legionella bacteria, pseudomonas aeruginosa or other bacterial challenge is identified

The POU filters will be used in accordance with the manufacturer’s instructions,

The service start date will be recorded on the unit, lifespan or end date will not be exceeded. The filters will be replaced at this time or when the flow becomes impeded.

6.16 Thermostatic Mixing Valves (TMVS) In accordance with HTM04-01 and HGG274 Part 2 the need for thermostatic mixing valves will be risk assessed The Trust will where possible remove/not use TMVs where end user safety can be assured Where TMV’s are used e.g. Patient areas, visitor's areas etc, these will be;

Fitted as close to the point of use and must not in any case be further than 2m away.

NHS Estates D08 specification should be used wherever a type 3 TMV is specified by the guidance – i.e. Bidet, Shower, Bath and washbasin for geriatric, paediatric, learning difficulty, mental health and any other patient considered at risk

Checked for operational performance, on each visit this will include o Set point attainment (100% flow) o Set point attainment (50% flow) o Cold water fail safe o Hot water supply temperature check o Cold water supply temperature check

APPLICATION MAXIMUM STABILISED TEMPERATURE °C

BASINS/SINKS 43

SHOWERS 43

BIDETS 40

GENERAL BATHING 46

ASSISTED BATHING 48

TMVs will be checked for temperature and fail safe on a six monthly basis

On an annual basis all filters/strainers associated with the TMVs will be removed, inspected, cleaned, descaled and disinfected

6.17 Lawn sprinklers and garden (or similar) hoses In certain conditions, lawn sprinklers may retain stagnant water in the pipework/hose supplying the sprinkler head: they may also produce an aerosol spray. The pipework may be installed underground or via a flexible hose over ground. Irrigation systems and hoses for these purposes should be supplied via backflow prevention devices giving fluid category 5 protection – typically an air gap type AA or AB, which requires a break tank and booster pump to provide adequate pressure to the irrigation nozzle or hose outlet. A risk assessment should be undertaken prior to use to minimise the risk by implementing suitable control measures. 6.18 Flowers and plants Consideration should be given to providing specific facilities for regularly disposing of wastewater and compost outside in-patient accommodation. This should not be provided in dirty utilities. 6.19 Blind ends If dead legs are identified, they should be removed where this is not reasonably practicable they should be minimised.

Monitoring regime

Service Action to take Frequency

Calorifiers 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

Annually, or as indicated by the rate of fouling

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

Annually, but may be increased as indicated by the risk assessment or result of inspection findings

Check calorifier flow temperatures (not below

60 °C)

Check calorifier return temperatures (not below 50 °C)

Monthly

Hot water

services

For non-circulating systems: take temperatures at sentinel points (nearest outlet, furthest outlet and long branches to outlets) to confirm they are at a minimum of 55 °C within one minute

Monthly

For circulating systems: take temperatures at return legs of principal loops (sentinel points) to confirm they are at a minimum of 55 °C Temperature measurements may be taken on the surface of metallic pipework

Monthly


Hot water services

For circulating systems: 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 55 °C. 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

Quarterly (ideally on a rolling monthly rota)

All HWS systems: take temperatures at a representative selection of other points (intermediate outlets of single pipe systems and tertiary loops in circulating systems) to confirm they are at a minimum of 55 °C to create a temperature profile of the whole system over a defined time period

Representative selection of other sentinel outlets considered on a rotational basis to ensure the whole system is reaching satisfactory temperatures for legionella control

POU water

heaters (no

greater than

15 litres)

Check water temperatures to confirm the heater operates at

55–60 °C or check the installation has a high turnover

Monthly–six monthly, or

as indicated by the risk assessment

Combination water heaters

Inspect the integral cold water header tanks as part of the cold water storage tank inspection regime, clean and disinfect as necessary. If evidence shows that the unit regularly overflows hot water into the integral cold water header tank, instigate a temperature monitoring regime to determine the frequency and take precautionary measures as determined by the findings of this monitoring regime

Annually


Combination water heaters

Check water temperatures at an outlet to confirm the heater operates at 55–60 °C

Monthly

Cold water tanks

Inspect cold water storage tanks and carry out remedial work where necessary

Annually

Check the tank water temperature remote from the ball valve and the incoming mains temperature. Record the maximum temperatures of the stored and supply water recorded by fixed maximum/minimum thermometers where fitted

Annually (Summer) or as indicated by the temperature profiling

Cold water services

Check temperatures at sentinel taps (typically those nearest to and furthest from the cold tank, but may also include other key locations on long branches to zones or floor levels). These outlets should be below 20 °C within two minutes of running the cold tap. To identify any local heat gain, which might not be apparent after one minute, observe the thermometer reading during flushing

Monthly

Take temperatures at a representative selection of other points to confirm they are below 20 °C to create a temperature profile of the whole system over a defined time period. Peak temperatures or any temperatures that are slow to fall should be an indicator of a localised problem

Representative selection of other sentinel outlets considered on a rotational basis to ensure the whole system is reaching satisfactory temperatures for legionella control

Check thermal insulation to ensure it is intact and consider weatherproofing where components are exposed to the outdoor environment

Annually


Showers and spray taps

Dismantle, clean and descale removable parts, heads, inserts and hoses where fitted

Quarterly or as indicated by the rate of fouling or other risk factors, eg areas with high risk patients

POU filters Record the service start date and lifespan or end date and replace filters as recommended by the manufacturer (0.2 µm membrane POU filters should be used primarily as a temporary control measure while a permanent safe engineering solution is developed, although long-term use of such filters may be needed in some healthcare situations)

According to manufacturer’s guidelines

Base exchange softeners

Visually check the salt levels and top up salt, if required. Undertake a hardness check to confirm operation of the softener

Weekly, but depends on the size of the vessel and the rate of salt consumption

Service and disinfect Annually, or according to manufacturer’s guidelines

Multiple use filters

Backwash and regenerate as specified by the manufacturer

According to manufacturer’s guidelines

Infrequently used outlets

Consideration should be given to removing

infrequently used showers, taps and any

associated equipment that uses 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’


Infrequently used outlets

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

Twice Weekly, or as indicated by the risk assessment

TMVs Risk assess whether the TMV fitting is required,

and if not, remove Where needed, inspect,

clean, descale and disinfect any strainers or

filters associated with TMVs

To maintain protection against scald risk, TMVs require regular routine maintenance carried out by competent persons in accordance with the manufacturer’s instructions. There is further information in paragraphs 2.152– 2.168

Annually or on a frequency defined by the risk assessment, taking account of any manufacturer’s recommendations

Expansion vessels

Where practical, flush through and purge to drain

Where removable, change bladders and diaphragms

Monthly–six monthly,

as indicated by the risk assessment

7.0 Records Monitoring results, treatments, analytical reports and remedial actions must be recorded, dated and signed. (If electronic then details of person who carried out the work). This records will provide a full history of tasks completed in line with the written scheme. All records will be kept for a minimum of 5 years Full method statements for tasks can be found in Appendix 1 of this Water Safety Plan

The monitoring records are kept in:

Record type Location Signed/Date

Low use flushing L8 Guard JT 27/6/18

8.0 Remedial Actions

In the event of non-compliance the following corrective measures can be adopted. All remedial measures/actions carried out must be recorded, dated and signed (If electronic then details of person who carried out the work).

COLD WATER SYSTEMS

High tank temperatures

May be a result of:

High Temperature Mains Supply o All outlets on site will be flushed on a weekly basis to maintain water flows

through the distribution system.

Overcapacity – storage should be no more than one days use. In the instance of this being exceeded

o The working volume of the tank must be reduced o Number of connected tanks be rationalised o A smaller tank be installed o The tank is bypassed onto mains if does not contravene Water Regulations

Warm ambient temperatures. In this instance o The tank and pipework can be insulated o The working volume of the tank must be reduced o Number of connected tanks be rationalised

Dirty Tanks

Tank can be visually dirty or microbiological contaminated. In this instance the tank is cleaned and chlorinated and the integrity of the tank checked. i.e. lid fitting well, overflow screened

High Distribution Temperatures

This may be a result of:

High Temperature Mains Supply – See above. This is most likely only to occur during the summer months (between July and September).

The elevated water temperature will be noted across all cold outlets on site. The sentinel point in the boiler room is close to the incoming main a therefore is the best point of reference.

In the instance it is noted that the incoming mains exceed 20°C the following will apply;

o All outlets on site will be flushed on a weekly basis to maintain water flows through the distribution system.

Cross Contamination via a thermostatic mixing valve (TMV) – localised high cold water temperature will potentially be a result of cross contamination of the cold water distribution system with hot water from failure of a thermostatic mixing valve. This will typically produce cold water temperatures significantly above 25°C especially at the source TMV.

o Suspect TMV’s will be removed and the non return valves cleaned. o Units will be replaced as required.

Low Use – This typically will be manifest as localised elevated cold water temperatures.

This will typically produce cold water temperatures in the 20-28°C.

The affected outlets should be flushed daily with temperatures monitored. Should this be found to have a positive effect on reducing cold water temperatures then the need for the outlet should be reviewed with it removed (along with all associated pipe work) . If this is not possible then it should be included in the flushing programme.

Legionella sampling should be carried out if the issue cannot be readily resolved.

HOT WATER SYSTEM

Poor Flow Temperature

If the hot water flow temperature is found below the temperature of 60°C,

this may be a result of:

Boiler Failure - On detection of low temperature, the boiler (or primary heat source i.e. gas supply) must be checked immediately. Thermostat Set Point/Operation - The thermostat should be checked for correct operation. Boiler Unable To Cope With Demand - This may be due to poor sizing or reduced efficiency due to scaling.

Following any corrective works, the system will be thermally disinfected this will require

Isolation of the calorifier. Heat up to at least 60°C and leave for one hour. Return the unit to service opening valve slowly to reduce the risk of sediment disturbance. Each Tap and appliance should be run sequentially for at least 5 minutes at the full

temperature, this should be measured

Failure to resolve the issue will require legionella sampling to be implemented until this has occurred

Poor Return Temperature

If the return temperature falls below 50°C, this may be a result of;

Recirculation pump failure – This will also create a poor hot water response at all hot water taps in the building.

The operation of the re-circulation pump should be checked 1. Is it powered up? 2. Is it spinning? 3. Are any valves shut?





Cross Contamination via a thermostatic mixing valve (TMV) – localised low hot water temperature will potentially be a result of cross contamination of the hot water distribution system with cold water from failure of a thermostatic mixing valve.

This can produce low return temperatures especially in conjunction with sporadic low hot water sentinel outlet temperatures

o Suspect TMVs will be removed and the non return valves cleaned. o Units will be replaced as required.





Low Hot Water Distribution Temperatures

This may be a result of:

Low Flow Temperature – See Above

Poor Return Temperatures – See Above

Cross Contamination via a thermostatic mixing valve (TMV)

– See Above.

Low Use – This typically will be manifest as localised low hot water temperatures.

The affected outlets should be flushed daily with temperatures monitored. Should this be found to have a positive effect on increasing hot water temperatures then the need for the outlet should be reviewed with it removed (along with all associated pipe work) . If this is not possible then it should be included in the flushing programme.

Legionella sampling should be carried out if the issue cannot be readily resolved.

Poor System Balance – This typically will be manifest as low hot water temperatures in an operational area

The local hot water flow and return pipe work should be monitored.

Rebalancing of the distribution system will be required by a specialist contractor.

Given there is typically a lead time between the identification of a balancing issue and its correction then legionella sampling should be implemented

Action in the event of a Legionnaires disease outbreak

1 Legionnaires' disease is not notifiable under public health legislation in England and Wales but, in Scotland, legionellosis (i.e. all diseases caused by legionella) is notifiable under the Public Health (Notification of Infectious Disease) (Scotland) Regulations 1988.

2 An outbreak is defined by the Public Health Laboratory Service (PHLS) as two or more confirmed cases of legionellosis occurring in the same locality within a six-month period. Location is defined in terms of the geographical proximity of the cases and requires a degree of judgement. It is the responsibility of the Proper Officer for the declaration of an outbreak. The Proper Officer is appointed by the local authority under public health legislation and is usually a Consultant in Communicable Disease Control (CCDC). In Scotland, it is the Consultant in Public Health Medicine (CPHM) employed by the Health Board and acting as Designated Medical Officer for the local authority.

3 Local authorities will have established incident plans to investigate major outbreaks of

infectious disease including legionellosis. These are activated by the Proper Officer who invokes an Outbreak Committee, whose primary purpose is to protect public health and prevent further infection. This will normally be set up to manage the incident and will involve representatives of all the agencies involved. HSE or the local authority EHO may be involved in the investigation of outbreaks, their aim being to pursue compliance with health and safety legislation.

4 The local authority, CCDC or EHO acting on their behalf (often with the relevant officer

from the enforcing authorities - either HSE or the local authority) may make a site visit.

5 As part of the outbreak investigation and control, the following requests and recommendations may be made by the enforcing authority.

(a) To shut down any processes which are capable of generating and disseminating airborne water droplets and keep them shut down until sampling procedures and any remedial cleaning or other work has been done. Final clearance to restart the system may be required.

(b) To take water samples (see paragraphs 124-13 1, Part 2) from the system before any emergency disinfection being undertaken. This will help the investigation of the cause of the illness. The investigating officers from the local authority/ies may take samples or require them to be taken.

(c) To provide staff health records to discern whether there are any further undiagnosed cases of illness, and to help prepare case histories of the people affected.

(d) To co-operate fully in an investigation of any plant that may be suspected of being involved in the cause of the outbreak. This may involve, for example:

(i) tracing of all pipework runs;

(ii) detailed scrutiny of all operational records;

(iii) statements from plant operatives and managers;

(iv) statements from water treatment contractors or consultants.

6 Any infringements of relevant legislation, may be subject to a formal investigation by the appropriate enforcing authority

9.0 Microbiological sampling

9.1 Legionella Bacteria Legionella sampling will normally be considered under the following circumstances:

In patient areas where populations are at an increased risk from legionellosis, i.e. those

with low immune systems, neutropenic patients. In these areas the sampling should be

undertaken on a quarterly basis and from the following locations:

Cold water storage tank (if applicable)

Flow and drain from the calorifier/PHE

Representative pure hot and cold outlets in the area.

Hot and cold outlets would be tested pre and post flush and levels of detection should go down to 100cfu/l

NONE CURRENTLY FOR THE TRUST

Where control parameters (i.e. temperature are no consistently achieved). Following

monthly temperature monitoring the results will be assessed and if there are three

months of consistent poor temperatures legionella sampling would commence. The

frequency should ideally be weekly or at least back to back samples until the control

temperatures are rectified. As the concern is systemic failure only post flush samples are

required. Again tanks, calorifiers and pure hot and cold water is too be tested dependent

on whether it is the hot or the cold or both which is out of specification. If it is a non-high

risk area the detection limits need only go down to 100cfu/l

When an outbreak is suspected or has been identified

The Water Safety Group will approve any areas which fall outside of the above definitions which will attract routine sampling. The sampling will be in accordance with BS 7592:2008 Sampling for legionella in water and related materials. The Water Safety Group will monitor trends and advise on any identified modifications to the sampling programme. 9.2 Pseudomonas Aeruginosa It will be the Policy of the Trust not to carry out routine sampling unless an area is identified as augmented care. NONE CURRENTLY FOR THE TRUST

Pre and Post -Not Detected

Legionella

Results Flow Chart

>100 <1000

Sample again in 3 months

> 1000

Remove outlet from service

Remediation

Retest at 3 days

Reinstate outlet

+ Ve

+Ve

-Ve

Re-sample

Re-sample

-Ve

+Ve

Satisfactory: No further action

required

Review all results

Remediation

Retest at 3 days

-Ve

10.0 Ward/Department/Area Closures Departmental Managers will inform the Engineering Department of the extent of the closure i.e. Ward/Department or Area containing water outlets i.e. bathrooms, sanitary areas, kitchens, etc. Closure less than 60 days If the closure is to be for less than 60 days arrangements will be made by the Departmental Manager to flush all WC cisterns and open all taps and showers for a period of three minutes on a twice-weekly cycle. (Showers to be run hot and cold). Records of flushing should be completed by diary entry or simple log book. Closure greater than 60 days If the closure is to be for more than 60 days the services will all be disconnected by the Engineering Department. If the hot water system is fed from secondary pipe work that feeds to other occupied areas it will remain connected and the hot taps only will be flushed for three minutes on a twice-weekly basis. Re-opening of Closed Areas. Prior to the procedure for re-opening closed areas the Service/Site Manager will advise the Engineering Department with respect to possible change of use for the area to be opened: i.e., type of patients, scalding risk, etc. to enable remedial works and funding to be identified. Closure was less than 60 days If the closure had been less than 60 days and twice-weekly flushing as described above had been carried out and recorded the area can be occupied immediately when re-opened Closure was greater than 60 days If the closure had been for more than 60 days, any disconnected pipe work should be reconnected for use. The system is then disinfected by the Engineering Department in accordance with HTM 04-01 and BS8558:2015 AND pd855468:2015 within seven days of the system being brought into use, unless hot and cold water temperatures are maintained and twice-weekly flushing is carried out. The disinfection will be that all tanks will be dosed with sodium hypochlorite solution to give a free chlorine residual of 50 + 10ppm in the water and allowed to stand for 1 hour with all outlets closed. Each outlet and tap is progressively opened away from the tank until the chlorine is detected. All taps are then closed and the pipes left charged for a further hour. The tap(s) furthest from the tank(s) will be measured for its free residual chlorine level. If it is less than 30ppm the chlorination will be repeated. If it is 30ppm or greater the system will be drained and flushed thoroughly with fresh water and re-filled. Should full chlorination prove difficult due to the nature of the working areas served by the distribution system consultation between the Engineering Department, Infection Control and appropriate independent consultants will take place to determine a suitable course of action. For hot water where appropriate and alternative thermal disinfection can be carried out by raising the temperature of the whole of the contents of the calorifier then circulating this water throughout the system for at least an hour. Each tap and appliance will be run sequentially for at least five minutes at the full temperature and measured. For a successful disinfection the

temperatures at the taps and appliances will not fall below 60C.

After disinfection microbiological tests for bacterial colony counts at 22C and 37C, Total Coliforms and Escherichia coli. Pseudomonas aeruginosa and legionella bacteria. The system will not be brought into service until the following parameters are achieved:

Parameter Level Allowed

TVC at 37C (cfu/ml) Less 100 fold increase over parent sample


Total Coliforms 0 cfu/100ml

Escherichia coli 0 cfu/100ml

Pseudomonas Aeruginosa <1 cfu/100ml

Legionella Bacteria <100cfu/l

11.0 New and modified hot and cold water systems Building and refurbishment projects which incorporate new pipe work will:

Be designed and installed to meet the requirements of the guidance contained within HTM04-01, HSG274 and the Water Supply (Water Fittings) Regulations 1999.

Be submitted to the Water Safety Group for consultation

Contractors must be suitably trained on water hygiene covering the risks of their working practices. This must include the prevention of cross contamination from tools and other components

In accordance with the Department of Health alert notice (DH (2010)3) wherever possible final connection to taps will be made in solid copper pipe work

Where it is deemed flexible hoses must be used due to the mode of operation of the device or type of installation, hose must be WRAS approved and of a non EPDM construction.

Hot and cold-water service systems will be commissioned and tested in accordance with BS 8558:2015, PD855468:2015 and HTM 04-01-Part A.

Be installed such that the requirements of the operational procedures are not compromised

Microbiological sampling must be carried out 2-3 days after the disinfection of the system, the samples should represent the system installed and incorporate sources samples for comparison. The analysis must include:

Parameter Level Allowed



Total Coliforms 0 cfu/100ml

Escherichia coli 0 cfu/100ml

Pseudomonas Aeruginosa <1 cfu/100ml

Legionella Bacteria <100cfu/l

Will be subject to a new legionella risk assessment (and pseudomonas if applicable)

At handover, the following will be provided to the Estates Department:

a) as-fitted/installed drawings/schematics. b) operating and maintenance instructions/manuals. c) certified records of pressure testing and disinfection. d) certified records of testing of control devices including pressure,

temperature and fail-safe. e) microbiological results

12.0. Training and Records of Training Those involved in the management and collection of data will be suitably trained to carry out their allotted tasks. Externally contractors will be required to provide company Legionella Controls Association certification and site representative competency Trust employees training records will be kept and reviewed annually and are kept.. _________________________________________________________________________

13.0. Audits/Reviews

The Water Safety Plan and its contents will be reviewed regularly.

Appendix 1

Method Statements

Water Safety PlanWater Safety Management Group Standard Agenda 1. Apologies For Absence 2. Minutes...

Documents

Transcript of Water Safety PlanWater Safety Management Group Standard Agenda 1. Apologies For Absence 2. Minutes...