MANAGEMENT CONTROL POLICY:LEGIONELLA
UWE
_______________________________________________________________________________________________________________________________
MANAGEMENT CONTROL POLICY
FOR THE MINIMISATION OF RISK
FROM LEGIONELLOSIS
AND LEGIONNAIRES’ DISEASE
THIS DOCUMENT UAS BEEN FORMALLY APPROVED
BY THE UNIVERSITY OF WEST OF ENGLAND
AS PART OF THE HEALTH AND SAFETY MANAGEMENT PLAN
DATE
NAME
POSTION
Mr Phillip Kearns
Estates Operations Manager / Responsible Person
SIGANATURE
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POLICY INDEX
Section
Sub
Section
1
Content
Page
Nos
1.1
1.2
Document Control
Amendment Status
Distribution record
2.1
2.2
2.3
2.4
2.5
Policy Definitions and Responsibilities
Policy Statement
Scope of policy
Applicable Legislation
Responsibilities
Management Flowchart
3.1
3.2
3.3
3.4
3.5
3.6
Legionella Risk Management Plan
Legionella Risk Assessment
System Design
Control Methods
Legionellosis Maintenance Tasks
Control Parameters and Interpretation of Results
Control Documentation for Physical,Analytical and Microbiological Test Data
2
3
4
Legionella Outbreak Action Plan
5
5.1
5.2
5.3
5.4
Appendices - Technical
Legionella Management and Control tasks
Technical Test Data Record Sheets
Closing/Opening of Building / Area Documents
Out of Specification Water Quality
6.1
6.2
Appendices - Documentary
Policy Receipt Document
Responsibilities Notification
7.1
Appendices - Estate
Estate Schedule
6
7
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SECTION 1 – DOCUMENT CONTROL
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1. AMENDMENT STATUS
Amendment Detail
Issue
Date
Doc
Draft 1 for approval by N Cooper
Sept 07
Doc
Doc
Draft 2 N Cooper Modifications
Draft 3
31.10.07
04.08.09
Doc
Draft 4 review and update
Doc
Issued – Modified 20 August 2012
Page
Ref
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1.2
Distribution record
This Policy Document has a controlled circulation and should not be copied without the permission of
the Responsible Person.
The following hold authorised copies:
COPY No.
AUTHORISED COPY HOLDER
Each copy issued is to be signed and this is to be recorded as per the documentation contained in
appendix 6.1
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SECTION 2
POLICY DEFINTIONS AND RESPONSIBILITIES
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2. POLICY STATEMENT
It is the University of West of England Management (hereafter referred to as UWE) Policy to manage
the operation and maintenance of its Domestic and Process Water in line with current best practice,
complying with all current and relevant guidelines and legislation relating to the management and
control of Legionellosis including Legionnaires’ Disease.
Measures to be taken to attain this objective include:

The appropriate selection, design, installation and maintenance of plant.

The appointment and suitable training of “Responsible Person” competent to:

o
Liaise with all other organisations that supply UWE with services
pertaining to either; Legionellosis Management and Control and/or
Management & Control of Hot Water, whether accommodation, facilities
management, water treatment, consultancy etc.
o
Identify and assess the risk of Legionellosis resulting from work activities to
include breakdowns and abnormal situations.
o
Develop, implement and maintain appropriate and suitable Management
Systems, Personnel Training Programmes and plant treatment procedures.
o
Develop and maintain adequate records in order to demonstrate
compliance with best practice and fulfil legal obligations.
o
Ensure compliance with this Policy.
The regular monitoring of all implemented Management Systems, Training
Programmes and treatment procedures, to establish and ensure their continuing
efficacy and legislation compliance.
The UWE Approved Working Systems, which are to be held within this Document, have been prepared
in consultation with competent persons on the interpretation and understanding and practical
application of guideline and legal requirements described in current relevant guidelines and legislation
relating to the management and control of Legionellosis including Legionnaires’ Disease.
Responsible Person:
Name: …………… Signature:……….…………………..Date: ……………
Duty Holder:
Name:
…………… Signature:……….…………………..Date: ……………
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2.2
Scope of Policy
UWE attaches the greatest importance to the health, safety and welfare of staff and visitors to the
site. In this regard UWE has in operation a Management Programme to minimise, as far as is
practicable, the risk from Legionella bacteria.
The following sections outline the approach to be adopted for the prevention of colonisation of water
systems by Legionella bacteria and details a design and maintenance schedule for water systems,
which may be subject to such, at the UWE sites.
UWE recognises and accepts its responsibility under the Health and Safety at Work Act.
This Policy applies to:
1.
All Cold Water Systems: Including Mains (boosted or otherwise) or tank fed supplies,
distribution systems and outlets.
2.
Domestic Showers: Including tank fed showers, Mains fed showers with direct electrical
heaters, emergency dowsing showers and eye wash stations.
3.
Domestic Hot Water Systems: Including all direct and indirect calorifiers (primary heating coil,
electric immersion heater or otherwise), cistern-type water heaters and instant water heaters
(plate heat exchanges, electric or otherwise).
4.
Ancillary Plant: Process and any other plant which is liable to encourage Legionella growth
and/or create an aerosol.
It is the Policy of UWE that:
a)
All new water systems shall be designed, installed and operated in such a way as to minimise,
avoid or prevent the risk of Legionellosis.
b)
All existing water and air systems shall be operated and maintained in such a way as to
minimise or control the risk of Legionellosis.
No new water systems shall be introduced and no changes shall be made to water systems unless they
have first been authorised by the Responsible Person.
Undertakings
UWE recognises its responsibility to implement in full, all requirements described in current relevant guidelines and
legislation relating to the management and control of Legionellosis including Legionnaires’ Disease, particularly, the
Health and Safety Commission's Approved Code of Practice – L8.
UWE will undertake to:

Appoint an UWE Responsible Person to enable the implementation of the
requirements of this Policy. The Responsible Person will in turn appoint in writing
Engineering Support Staff (Estates) for all the UWE sites:

Identify and assess sources of risk from all water and ventilation systems found within
all the buildings of the Estate

Maintain a “Written Scheme” for preventing, reducing or controlling the risk.
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

1 2.2.2
Implement and manage precautions.
Keep records of the precautions implemented of the premises within UWE control.
The Estate
For the purposes of this Policy, the Estate comprises all the buildings currently occupied, and
maintained by The UWE sites. (under a full maintenance lease or otherwise). For a current list of the
Estate, see Appendix 7 – UWE Estate.
Other sites/buildings may, from time-to-time, be included and incorporated within the scope of this
Policy.
The UWE Responsible Person shall notify all landlords of leased buildings of their requirements under
this Policy.
2.2.3
UWE SERVICE PROVIDERS
For the purposes of this Policy, the Service Providers are organisations that supply The UWE with
services pertaining to Legionellosis Management & Control, whether accommodation, and or Facilities
Management, Water Treatment, equipment, Consultancy, etc.
At the time of this Policy the main Service Providers for the site Legionella Programme are:
Pure Group:
-:
Legionella Consultancy services
Risk Assessment and Review
Auditing,
Training
Remedial Work following Risk Assessment
Programme Monitoring, Sampling, Reporting
Chlorine Dioxide Dosing Systems
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2.3
Applicable Legislation
UWE, in implementing this Policy, will use, as a general source of practical help, the documents listed
below:

HSE ACoP L8 – The Control of Legionella bacteria in water systems – Approved Code
of Practice & Guidance 2001.

Health and Safety at Work etc. Act 1974, Sections 2, 3 and 4 (HSW).

Control of Substances Hazardous to Health Regulations 2002, Regulation 6 (COSHH).

The Public Health (Infectious Diseases) Regulations 1988.

The Water Supply (Water fittings) Regulations 1999.

The Water Supply (Water Quality) Regulations 2000.


BS 6700:1997 - Specification for Design, installation, testing and maintenance of
services
supplying water for domestic use within buildings and their curtilages.

Food Act 1990.
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2.4
GENERAL RESPONSIBILITIES
2.4.1 EMPLOYERS DUTIES
UWE as employers, have a general duty under The Health and Safety at Work Act etc. 1974 to ensure
so far as is reasonably practicable, the health, safety and welfare of all their employees.
HSWA 2(1) requires employers to:

Provide and maintain plant and systems of work that are safe and free from health risks,

Make arrangements for ensuring safety and the avoidance of health risks in connection with
the use, handling, storage and transportation of articles and substances (HSWA 2(2)b),

Provide such information, instruction, training and supervision to ensure the health and
safety at work of their employees [HSWA 2(2)c],

Provide a safe working environment [HSWA 2(2)e],

Those in control of premises must ensure that they are safe and that any plan or substance
do not endanger health of all persons at work and the general public (HSWA 4).
Employees have a duty under Section 7 of the Health and Safety at Work Act etc. 1974 to take
reasonable care for their own health and safety and of that of others who may be affected by their
acts or omissions at work.
Towards this end, employees should use correctly all work items provided by their employers, in
accordance with their training and their instructions they receive to enable them to use the items
safely.
Employees' duties under Section 7 also include co-operating with their employer to enable the
employer to comply with statutory duties for health and safety.
Employers or those they appoint (e.g. under Regulation 6) to assist them with health and safety
matters therefore need to be informed without delay of any work situation which might present a
serious and imminent danger. The danger could be to the employee concerned or, if it results from
the employee's work, to others.
Employees should also notify any shortcomings in the health and safety arrangements, even when no
immediate danger exists, so that employers in pursuit of their duties under the HSWA Act and other
statutory provisions can take such remedial action as may be needed.
2.4.2 PERSONNEL TRAINING
In order to allow the associated persons to act as effectively and cost-effectively as possible, all
relevant and associated members of staff should be offered scheduled and appropriate training. In
addition, the Institute Responsible Person, with the assistance of others, will provide as necessary inhouse training for all managers so that the procedures adopted to cope with high hazard units on their
site is understood.
All the appropriate Institute members of staff shall receive “Refresher” training every two-years or
when there have been changes to the relevant legislation.
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The training should cover relevant topics such as:









General knowledge on the Management and Control of Legionellosis
Legal responsibilities.
UWE Policy on legionella.
COSHH.
Monitoring Tasks.
System design
Cleaning and disinfection operations
Inspection and auditing
Recording of test data
Staff with specific responsibilities for actions to control the “Risk” should be given additional training in
how to carry out those particular tasks. In addition, persons who deputise should receive equivalent
training to the person whose function they are covering. The training required will vary from
individual to individual according to their background and responsibilities.
Individual records should be kept for these staff, and staff should not be allowed to perform their
duties without supervision until their training is completed. Training records should be signed by the
Institute Responsible Person, except for the UWE Responsible Person themselves which should be
signed by the Duty Holder. The level of knowledge should be regularly assessed and should be
programmed and continuous rather than sporadic.
A Qualified-Persons Register shall be drawn-up and maintained by the Responsible Person.
2.4.3 SPECIFIC TRAINING
All those involved with the site Legionella Programme should undergo general Legionella Awareness
Training. This should be certificated. The Responsible Person should have an extended Awareness
Session to explain their roles and consequent responsibilities.
The named Responsible Person need also a more theoretical qualification. The Legionella City and
Guilds, or similar, is appropriate for this
.
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2.5
MANAGEMENT FLOWCHART
2.5.1
GENERAL

It is the responsibility of any person employed by UWE (in whatsoever capacity) to comply with
the requirements of this Policy. Advice on the requirements of the Policy can be obtained at
any time from the Responsible Person.

The person ultimately responsible for all matters relating to Legionellosis Management &
Control, within the scope of this Policy, is the Duty Holder.

However, the operational responsibility is delegated to UWE Responsible Person.

The UWE Responsible Person is he/she with delegated specific actions, tasks and
responsibilities under the Legionellosis Management & Control Programme.

The UWE Responsible Person and Engineering Support Staff (Estates) are to be made aware of
their responsibilities under this Policy, in writing.

All service providers involved in the Legionellosis Management & Control Programme will need
to demonstrate and provide evidence of training appropriate to their activities.

Where there is any change in the personnel listed in the UWE Responsible Person section of
this Policy, the new employee must be made aware, in writing, of the type and extent of their
responsibility in relation to the Institute’s Legionellosis Management & Control Programme
and receive appropriate training where necessary.
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2.5.2
MANAGEMENT STRUCTURE FOR THE CONTROL OF LEGIONELLA
The following flowchart defines the inter relationship between all parties responsible for the
implementation and control of legionella.
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DUTY HOLDER
Assistant Vice
Chancellor
John Rushforth
RESPONSIBLE PERSON
Estates Operations
Manager
Phillip Kearns
Depty Responsible Person
Mechanical Maintenance
Engineer
Nigel Cooper
Maintenance Term
Contractor
Mitie TFM
Water Treatment/Hygiene
Contractor
Mitie Water
Staff will be properly trained and competent to carry out the appropriate measures, and UWE shall
facilitate such training as is necessary. Maintenance staff who come into direct contact with potable
water or structures and pipes which store or convey potable water will be appropriately trained in the
principles of water supply hygiene.
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2.5.3 DUTY HOLDER SHALL

Have Overall Responsibility for all aspects of Legionellosis Management & Control within UWE
Estate.

Nominate, or cause to be nominated, in writing, a "Legionella and Risk Management Steering
Committee" whose duties will be to advise on and monitor the implementation and efficacy of
all Legionellosis Management & Control Programmes across all sites constituting the Estate.
The Committee should consist of the Estates and Contract Management with Health & Safety
Representation, and the appointed Legionellosis Management & Control Consultants and
should be chaired by the Duty Holder.

Appoint, in writing, the UWE Responsible Person (letters of appointment and acceptance are
included in Appendix 6.2).

Authorise the ratification of this Policy Document detailing the scope of Legionellosis
Management & Control within UWE.
2.5.4 RESPONSIBLE PERSON SHALL

Have Overall Responsibility for the Implementation of the Legionellosis Management &
Control Programmes, on their site.

Facilitate suitable and sufficient Risk Assessments to identify the Risk of Legionellosis on all
buildings under their control and review these assessments on, at least, a two-yearly basis or
when there have been major alterations to a system.

Have Overall Responsibility for provision of Auditing the Legionellosis Management & Control
Programmes across the Institute, and reporting all findings to the "Legionella Risk
Management Steering Committee".

Ensure notification for all 3rd parties who maintain water facilities to buildings and or areas
occupied by UWE, of their requirements under this Policy.

Ensure that all new buildings purchased and or leased by the UWE under a full maintenance
lease are subjected to the scope of this Policy prior to coming on-line.

Assess the training needs for training of staff involved in the Legionellosis Management &
Control Management Programme and select suitable training establishments to provide
approved Training Courses.

Ensure personal training records are kept up to date.

Carry out a Tender Process and select suitable Water Treatment/Hygiene Contractors and
Consultants for the provision of services pertaining to Legionellosis Management & Control for
buildings under their control.

Advise the Duty Holder, via an Annual Report of the status of the Legionellosis Management &
Control Programme across the UWE.
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2.5.5 LEGIONELLA RISK MANAGEMENT STEERING COMMITTEE SHALL

Ratify all appointments of positions of “Responsibility”.

Ratify this Policy including all other relevant Documentation, Works Specifications, PPM
Programmes, etc.

Conduct an annual review of this Policy and issue amendments as required by the review.

Consider the efficacy of all contractors commissioned on Legionellosis Management & Control
and Management related projects.

Monitor the efficacy of all training Programmes implemented for associated staff.


Maintain a uniform Legionellosis Management & Control Programme across the UWE
Estate


Provide a forum of discussion and sharing of information pertaining to Legionellosis
Management & Control across the UWE Estate.

Put in place arrangements for reporting an outbreak or suspected outbreak of Legionella.
Note: The Committee should meet at intervals necessary to reflect the work load in-hand, but at least
6-monthly.
2.5.6 UWE SERVICE PROVIDERS


Carry out remedial work as indicated by UWE following Legionella Risk Assessment and
further inspections.
Carry out specific monitoring, sampling and testing duties and supply of chlorine dioxide
as per contract and as outlined for the site Legionella Programme within this document
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SECTION 3 – LEGIONELLA RISK MANAGEMENT PLAN
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3.1
LEGIONELLA RISK ASSESSMENTS
A suitable and sufficient assessment, shall be carried out on all buildings which are owned and/or
occupied by UWE under a “full repairing lease”, in order to identify and assess the risk of Legionellosis
from work activities and water sources on the premises and organise any necessary precautionary
measures. The Risk Assessments shall be carried out by specialists who can demonstrate they are
competent and capable of carrying out this work. The specialists shall be registered with the Legionella
Control Association.
Systems which are susceptible to colonisation by Legionellae sp., and which incorporate means for
creating and disseminating water droplets, shall be identified, and the risk they present will be
assessed.
Risks shall be assessed not just for the routine operation of the system, but also in unusual
circumstances, breakdown, abnormal operation, and commissioning. The main objective of the Risk
Assessment shall be to institute management procedures to ensure that compliance is continuing and
not notional and to demonstrate that management has identified all the relevant factors, has
instituted corrective or preventive action, and is monitoring that the plans are being implemented. In
addition, the Risk Assessment shall identify:

The risk to health, i.e. whether the potential for harm to health from exposure is reasonably
foreseeable unless adequate precautionary measures are taken.

What measures for prevention, or adequate control to minimise the risk from exposure to
Legionella, should be taken.
The assessment shall include identification and evaluation of potential sources of risk and:

the particular means by which exposure to Legionella from hot water is to prevented; or

if prevention is not reasonably practicable, the particular means by which the risk from
exposure to Legionella from hot water is to be minimised.
Where the assessment demonstrates that there are no reasonably foreseeable risks or that risks are
insignificant and unlikely to increase, no further assessment or measures are necessary. However, the
assessment shall be reviewed bi-annually and any necessary changes implemented or where there is
reason to believe that the original assessment may no longer be valid. This may be because of, for
example:

changes to the plant or water or its use;

changes to the use of the building in which it is installed;

the availability of new information about risks or control measures;

the results of checks indicating that the control measures are no longer effective.
The Risk Assessment shall include the following areas of the systems:
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3.1.1
COLD WATER SERVICES
Storage

Location, access and physical condition and hygiene standard of all domestic Water Storage
Tanks

Design and configuration of all domestic Water Storage Tanks.

Capacity requirements and available storage capacities of all domestic Water Storage Tanks.

Temperature profiles of all domestic Water Storage Tanks.

Biological activities of all domestic Water Storage Tanks.

Water Supply Regulations parameter compliance of all domestic Water Storage Tanks.
Distribution

Location, access and physical condition of all domestic distribution pipe-work (where
accessible).

Design and configuration of all domestic distribution pipe-work.

Temperature profiles of all domestic distribution services and outlets.

Biological activities of all distribution services.

Presence of dead-legs and areas of low-flow within all the domestic distribution services.

Usage considerations of all domestic distribution services.
3.1.2
HOT WATER SERVICES
Hot Water Generation and Storage

Location, access and physical condition of all domestic Hot Water Generating Units.

Design and configuration of all domestic Hot Water Generating Units.

Temperature profiles of all domestic Hot Water Generating Units, to include; flow, return and
drain temperatures.

Capacity requirements and available storage capacities of all domestic Hot Water Generating
Units.

Presence of temperature stratification within domestic Water Storage Calorifiers.

Biological activities of all domestic distribution services.
Distribution

Physical condition of all domestic distribution pipe-work (where known / accessible).
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
Design, configuration and accessibility of all domestic distribution pipe-work.

Temperature profiles of all domestic distribution services and outlets.

Biological activities of all domestic distribution services.

Presence of dead-legs and areas of low-flow within all the domestic distribution services.

Usage considerations of all domestic distribution services.
3.1.3

Presence of space-heating within all domestic distribution pipe-work.

Condition, temperature profiles and operation status of all showerheads within all
domestic distribution services.

Presence of undesired lengths of blended water pipe-work within all domestic
distribution services.

Presence of undesired lengths of blended water pipe-work within all associated
distribution services.

Temperature profiles of associated "direct-fed" distribution services and all "blended"
outlets.
THERMOSTATIC MIXING VALVES (TMVs)

Condition of all TMVs fitted.

Temperature profiles of all water dispensed from TMVs.

Accessibility of all TMVs fitted.

Installation and operation status of all TMVs fitted.
3.1.4
MANAGEMENT, MAINTENANCE, MONITORING AND RECORD KEEPING

Presence of and adequacy of all implemented Monitoring and Maintenance Programmes in
place.

Presence of and adequacy of all implemented Record Keeping Programmes in place.

Presence of and adequacy of all implemented Auditing Programmes in place.
All areas listed above shall be measured and a risk rating given indicating the contribution of each area
to the overall Risk.
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3.1.5
CURRENT RISK ASSESSMENT STATUS
The Responsible Person shall ensure that Legionella Risk Assessments are carried out and will be
required to maintain a record of these. In addition, a “Current Risk Assessment Status” listing shall be
maintained for the site.
3.1.6
INTERIM REPORTS
For all buildings/areas assessed to be of Moderate Risk or higher, the Risk Assessor shall issue an
“Interim Problem Notification Form” indicating any necessary immediate corrective and remedial
actions that need to be carried out. In addition, the “Interim Problem Notification Form” shall indicate
the Short/Medium-term and Long-term corrective and remedial actions that need to be carried out.
3.1.7
PREPARATION OF AN ACTION PLAN
On completion of the Risk Assessments, the Responsible Person shall undertake the following:

Consider the Risk Assessments, Interim Problem Notification Form Reports and Consultancy
Memoranda pertaining to each building, and ensure the design, arrangement, implementation
and management of all necessary Remedial Works required to allow the systems to comply
with the current and relevant guidelines and legislation, and to ensure minimisation or control
of the prevailing risk.

Consider the Risk Assessments, Interim Problem Notification Form Reports and pertaining to
each building, and ensure the design, arrangement, implementation and management of all
Pre-Planned Maintenance Programmes required to allow the systems to comply with the
current and relevant guidelines and legislation, and to ensure minimisation or control of the
prevailing risk.
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3.2
SYSTEM/PLANT DESIGN, INSTALLATION AND MAINTENANCE
3.2.1
GENERAL DESIGN AND INSTALLATION CONSIDERATIONS

All water using equipment that can affect the water supply, the environment and the user shall
be monitored regularly and be subjected to the following regime:

All designs must be carried out and presented in accordance with all relevant and current
Guidelines, British Standards and “best-practices”.

The systems shall be carefully designed to eliminate or minimise aerosol production and
excessive water retention. They must also be designed to be readily drained and cleaned.

No materials used in construction shall include those that are known to harbour or provide
nutrient for bacteria. Any materials that come into contact with the water in a hot and cold
water installation shall comply with the requirements of the Water Supply (Water Fittings)
Regulations 1999. (The list of products and materials that have been assessed for compliance
with the Water Supply (Water Fittings) Regulations 1999 requirements are listed in the current
edition of Water Fittings and Materials Directory that is updated every six months. Further
information on the selection of materials can be found in BS6700 and BS6920.

The use of flexible braided rubber hoses shall be discouraged in the installation of facilities,
and only WRAS approved hoses will be allowed. Preference should be given to fixed pipe-work,
constructed from materials in use within the system.

The systems as identified by risk assessment shall be maintained in a clean and sound
condition and must be easily and safely accessible.

All systems shall be frequently used (at least weekly), or suitably flushed to simulate the
necessary usage frequency, in order to avoid stagnant water which will increase the potential
of bacterial growth and proliferation. The usage frequency shall be regularly monitored and
reported upon.

All plant and distribution pipe-work (where accessible) shall be clearly labelled.
3.2.2
COLD WATER STORAGE TANKS

Cold water storage tanks shall be constructed from non-deleterious materials which must be
WRc approved.

Cold water storage tanks shall be designed in accordance with BS6700 (glass-reinforced plastic
(GRP) tanks should comply with BS7491 Parts 1, 2 and 3), installed in appropriate and suitable
locations to allow easy and safe access to facilitate inspection and maintenance.

Sectional Cold Water Storage tanks shall be designed with external assembly flanges and selfdraining profiles, since this arrangement facilitates easy cleaning of internal surfaces.

Externally located Cold water storage tanks shall be suitably protected from environmental
conditions, particularly the local high ambient temperatures for all new buildings and, where
practicable, for existing installations. Ventilation shall be achieved by means of louvered doors
fitted with insect screens.

Cold water storage tanks shall be protected from the ingress of light, insects and birds.

Cold water storage tanks shall be sized and arranged so as to minimise retention time of stored
water (24hrs maximum), and therefore to increase the rate of stored water exchange.
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
Cold water storage tanks shall be subjected to a “need” test which requires the user to
question the presence of each unit and consider its removal if the services it supplies can be,
equally well, supplied by converting the systems to domestic Mains fed only.

Each unit shall be subjected to an annual “drop-test”, or metered equivalent, designed to
ascertain the capacity and demand requirements of each system, in order to ensure that
excessive volumes of water are not unnecessarily stored. Eliminating storage within a system
would also allow the negation of the necessary PPM Programme tasks and their replacement
with much less onerous, more infrequent and less costly tasks to be carried out.

All associated pipework and valves should be adequately insulated and clearly labelled to
identify their purpose.

Where Cold water storage tanks are linked “in parallel”, each feed to each tank shall be fitted
with a water meter in order to allow for confirmation of equal and uniform usage from all
tanks in the configuration.

Various arrangements of pumping systems are indicated in BS6700. Where booster pumps are
to be installed, a break cistern will be required between the mains supply pipe and the pumps.
This is required in order to comply with the Water Supply (Water Fittings) Regulations 1999
with regard to prevention of backflow. Control of the pump(s) should be fully automatic in
operation and controlled by pressure sensors. Where two or more pumps are installed, the
design flow should be achieved with one pump stationary (or out of service). Automatic
control should be provided to cyclically and sequentially control all pumps to ensure that each
is regularly brought into service.

Cold water storage tanks shall be maintained in good condition, clean from excessive
corrosion, sludge deposition, scale deposition.

Stored water shall be maintained at a temperature of ≤20oC or <2oC above the supply).

Where indicated and when it is deemed necessary and practicable, Cold Water Storage Tanks
shall be upgraded, refurbished, modified or replaced so that they may comply with current
Water Supply (Water Fittings) Regulations 1999. Following these works, each tank shall be
cleaned and disinfected in accordance with BS6700 and L8 prior to it being allowed back into
service.

Cold Water Storage Tanks shall be subjected to periodic monitoring to include:
Temperature monitoring.
General physical inspections.

Cold Water Storage Tanks shall be subjected to a clean and disinfection, when the results of
the monitoring indicate the need.
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3.2.3
HOT WATER CALORIFIERS

Calorifiers shall be installed in appropriate and suitable locations to allow easy and safe
access to facilitate inspection and maintenance.

Where more than one Calorifier or heating device is used, they shall be connected in
parallel, taking care to ensure that the flow can be balanced so that the water temperature
from all the Calorifiers exceeds 60°C at all times, except for short periods of high demand.

The combined storage capacity and heater output must be sufficient to ensure that the
outflow temperature, at continuous design flow (at least 20 minutes) from calorifiers or
other heaters, should not be less than 60°C. This applies to both circulating and noncirculating hot water systems.

The positioning of the control and high limit thermostats, cold feed and return water
connections must ensure that these temperatures are achieved.

Means should be taken to prevent warm water entering the cold-feed. A check valve shall
be provided in the cold feed, as close to the calorifier as practicable, to prevent such
circulation. However, the installation of such a check valve shall not be carried out in
systems that use the cold feed for expansion. In these cases, the installation of a U-bend or
S-bend in the cold-feed, sufficient distance from the connection to the calorifier, so that
water which is warm is not displaced (on heating up) beyond the bend and the vertical pipe
rise shall be carried out.

On new installations expansion vessels shall be located on the cold feed rather than on the
hot water side of the system. The length of pipework between the expansion vessel and
cold feed shall be as short as practicable, e.g. less than 1 meter. Expansion vessels shall be
subjected to a weekly flushing regime (if practicable). Ensure that the diaphragm (or bag) is
not damaged during the process. Risk Assessments should be carried out on vessels to
determine whether they pose a risk.

The practice of terminating the air vent over the Water Storage Tank shall be discouraged.
The vent should be arranged to discharge over a separate tun-dish arrangement, with visible
Type A air gap, sited at a level that takes account of the hydrostatic head of the system. The
calorifier or water heater should be provided with a suitable safety valve of appropriate size
and vacuum release arrangement.

Where water quality indicates the need, cathodic protection from galvanic action by means
of sacrificial anodes shall be provided.

Calorifiers should be fitted with a de-stratification pump, where necessary, in order to avoid
temperature stratification of the stored water.
Some semi-storage/high-efficiency
Calorifiers are supplied with an integral pump that circulates water in the Calorifier. Destratification pumps shall not be fitted to this type of unit.

A single circulating pump shall normally be installed in the return. If, for reasons of
reliability, two pumps are installed in parallel they shall be arranged to have individual nonreturn and service valves and be controlled such that each one is brought into operation
every seven days. It is also allowable to have a system utilising one pump ion line, with a
(disconnected) spare available for immediate replacement as required.

When Calorifiers are isolated from the system (for whatever reason), the associated
distribution system shall be subjected to DAILY flushing. However, this is only necessary
when the Calorifier isolated is the sole supply of HWS to that distribution system. Where
more than one Calorifier supplies the distribution services, the isolated calorifier shall be
drained down and allowed to remain drained whilst off line.
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
A suitably sized drain shall be connected to the base of each calorifier (where practicable).

Calorifiers shall be maintained at the following temperature profiles at all times:
Stored /Flow at ≥60.0oC.
Return /Outlets at ≥50oC.
In order to ensure that the temperatures required to achieve thermal disinfection (>60ºC for
the “Flow” and >50ºC for Outlets) are maintained, it is important to ensure that:
1.
2.
3.
Ideally, the Calorifiers should be allowed to operate continuously ensuring that the heat
source is available constantly. Where the Primary Heating Source is not set by a timer,
the heating source should be left ‘on’ at all times.
Where the Timers are fitted and operated and cannot be removed, it is important to
ensure that the units are allowed to operate at a temperature of (min) >60ºc for at least 1
hour from, when they come ‘on line’, before any water is drawn from them.
Where a building is to remain un-occupied, the calorifier should be emptied and
pasteurised before being allowed back ‘on-line’.

Calorifiers shall be subjected to regular check for “Flow” and “Return” temperature.

Cistern-type water heaters shall be maintained such that the cold tank part of the heater is kept clean
and at the correct temperature, and the hot tank part maintained at a temperature of >60.0 oC allowing
for distribution temperatures of >50.0oC. A screened vent and an insect/rodent overflow screen shall
be fitted to the tank part of the units.

Instant water heaters (less than 15 litres in volume), including combination boilers, usually store small
water volumes, and because of this they do not usually need to be operated within the temperature
profile and limits prescribed for larger systems (≥60 oC for the ‘flow’ and (≥50 oC for the ‘return’ and
‘outlet’) which are necessary for thermal disinfection. These units can, therefore, be operated at “safe”
temperatures of ≤41.0oC although they should be switched-on at all times to ensure and encourage
adequate use. Infrequent use of these units (less than twice-weekly) would increase the potential of
bacterial growth and proliferation (as would be the case in all infrequently used areas throughout the
system – both hot and cold), although particularly in this case because of the low temperatures where
operated.

Calorifiers shall be subjected to inspections for water quality, calorifier physical condition, temperature
and bacterial activity (when necessary).

Calorifiers shall be subjected to a regular blow-down and flush via the drain point where fitted.

Cleaning, flushing and pasteurisation shall be carried out in the event of major modifications or after a
period out of service, before Calorifier is returned to service. Pasteurisation shall also be carried out
when the stored water temperature falls below 45.0 oC for more than 1 hour before the Calorifier is
returned to service.
3.2.4
HOT WATER AND COLD WATER DISTRIBUTION SYSTEMS

The design and installation of the hot and cold water distribution system shall comply with the
Water Supply (Water Fittings) Regulations 1999 and BS6700.

The design of the pipework shall ensure that there is no possibility of a cross-connection
between installations conveying potable water and an installation containing non-potable
water or water supplied from a private source (untreated). There shall be no possibility of
backflow towards the source of supply from any tank, cistern or appliance, whether by back
siphonage or otherwise.

All cold distribution pipework, mains and tank down feeds shall be located, as far as is
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practicable, to minimise heat gains from their environment. Pipework shall not be routed
through hot ducts or run adjacent to heat sources, such as radiators.

All pipework shall be insulated, except for any exposed final connections to facilities, and
should be arranged to eliminate or minimise dead-legs.

As far as possible, the objective shall be to design the cold water systems to ensure that the
inlet, outlet and surface water temperatures of cold water storage tanks are not greater than
20°C or two degrees above that measured at the main water meter. At cold water draw-off
points, a temperature of 20°C or 2°C above the temperature measured in the source cold
water storage tanks shall be reached within one minute.

Stagnation shall be avoided. Hot and cold water services shall be sized to provide sufficient
flow at draw-off points. The aim shall be to promote turnover of water by means of; the
design of the distribution circuitry, adequate usage and avoidance of “disused” areas.

Separate, human, drinking water systems should normally be provided directly from the mains
without storage, with stored cold water (down service) being used solely for supplies to WCs,
wash hand basins, etc. The supply shall not be softened. Additionally, it shall be established
that the usage is sufficient to avoid deterioration in water quality, for example, that the inlet
water temperature does not exceed 20OC and that the outlet does not remain unused. Stored
Water at UWE is considered fit for potable use.

The water supply to vending equipment shall be taken from a potable supply up stream of a
regularly used outlet with the minimum of intervening pipe run i.e. less than 3 metres. The
supply shall not be softened. Additionally, it shall be established that the usage is sufficient to
avoid deterioration in water quality, for example, that the inlet water temperature does not
exceed 20OC and that the outlet does not remain unused.

Designated drinking water systems and outlets water temperatures shall be measured at
regular intervals. Temperatures must be aimed to be maintained within +/- 2oC from incoming
mains water temperature. Temperature monitoring must be supported with periodic
microbiological analysis for the presence of E.coli and/or presumptive coliforms (from
representative locations).

The equipment shall be positioned so that the warm air exhaust does not impinge directly on
taps or hoses supplying cold water.

The domestic hot water system shall not be used for heating purposes. This includes all
radiators, towel rails, heated bedpan racks etc, whatever the pipework configuration.

Central “common blending” systems shall not be used unless all showers are used on a regular
basis, since the length of distribution pipework containing water in the temperature range that
supports bacterial growth and proliferation would far exceed the maximum permissible
lengths mentioned above.

A representative number of outlets, both CWS and HWS, shall be measured at least once
annually and a representative number ("direct" fed Sentinel taps) shall be measured at
monthly intervals. Temperatures shall be measured after two minutes for the CWS and one
minute for the HWS at full flow and be maintained at <20oC and >50oC respectively.

Temperature monitoring shall be supported with regular microbiological sampling when
considered necessary.
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3.2.5

THERMOSTATIC MIXING VALVES
The temperature from sentinel outlets shall be measured on a monthly basis and maintained
at:
41oC for showers
41oC for basins

The pipe-work length from the TMV to the outlet shall be restricted to a maximum of two
metres.

All TMVs shall be fitted with strainers, (but only if a regular cleaning regime can be
guaranteed) isolation valves and non-return valves.

All TMVs shall be accessible (as far as reasonably practicable).

All TMVs fitted to showers shall be inspected and subjected to a fail-safe test on a six-monthly
basis (carried out as described in the manufacturer’s instructions).

All TMVs shall be subjected to a strip-down, cleaning and disinfection when necessary as
indicated by the results of the inspection programme.
3.2.6
INFREQUENTLY USED OUTLETS

Management staff shall have the responsibility of identifying all infrequently used outlets
within their area and subjecting these to a weekly flushing programme as described in Deadleg Flushing Pro-Forma, see Appendix 5.2. The completed forms shall be retained within the
log-book for the site.

Where infrequently used facilities are deemed to be no longer required, they should be
removed.

Where a building or sections of the system remain unused for long periods of time, the
following steps shall be undertaken as follows:

Flush all water facilities (including toilet and urinal cisterns) thoroughly on a weekly basis
whilst the building is not in use.

If the facilities within a building are to remain unused for a prolonged period (more than
one month), then the system shall be drained down (including all vessels) and cleaned and
disinfected (any calorifiers are to be pasteurised) prior to being allowed back ‘online’ N.B. For
the “Area Closure and Opening Process and Dead-leg Flushing Pro-Forma, see Appendix 5.3.
Consideration shall be given to isolating the unused sections from the system and possibly
removing pipe-work and fixtures completely to avoid "dead-legs".
In addition to the flushing regime described above, careful consideration should be given to the
usage requirements of the system and any required system changes made accordingly. If it is
deemed that the facilities are being used seasonally or remain unused for prolonged periods of
time, then the following should be considered where practical:

Re-engineer the system so that all CWS throughout the system are provided directly
off the MCWS supply. This action will enable the isolation and removal of any cold
water storage tanks

As part of the re-engineering of the CWS, it is also recommended that any water
storage calorifiers are isolated and removed from the system and replaced with the
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

required number of ‘mains’ fed instantaneous, point-of-use or multipoint water
heaters of less than 15 litres in volume.
The absence of water storage vessels will reduce the inherent risk of storing stagnant
water although it would not negate the need for flushing the remaining system.
Fire hose-reels which are supplied by the Domestic Mains, where the line supplying
the hose-reels is quite exclusive, distinct and separate from the line supplying
domestic
facilities, the fire line shall be fitted with a suitable RPZ valve. Where the fire and
domestic supplies share the same line, each hose-reel spur shall be fitted with a
double check valve. It is important, however, to ensure that the valves are fitted as
close to the
domestic line as possible in order to ensure that the dead-leg up-to
the valves is kept as small as possible.
Although the removal of fire hose-reels and their replacement with local fire
extinguishers is the ideal solution, this may not be readily practicable in some cases where the above alternatives may be suitable.
Where the installation of RPZ or double check valves is not practicable, each unit shall
be subjected to a Weekly flushing regime in order to minimise stagnation and the
potential for increased bacterial proliferation.
Regular checking of the hose-reels, for operational integrity, shall be maintained. This
task, however, shall be carried out with due care and attention – ensuring that the
creation of aerosols is maintained as practicably low as possible.

Plumbed eyewash units should be flushed weekly to reduce bacterial contamination
and to verify proper operation. The water in a self-contained (bottle) eyewash station
must be refilled, disposed, and maintained in accordance with manufacturer’s
instructions. Emergency showers should also be flushed weekly to clean the line and
verify proper operation.
3.2.7 SHOWERS

All showers (shower-heads and associated hoses) shall be maintained in a good and
clean condition and free from excessive scale and dirt deposition.

In all user areas, all showers, which have a hot and cold supply, shall be fed via TMVs
which shall be maintained and operated at 41oC.

Central “common blending” shower-block systems shall not be used and all pipe-work
length from the TMV to the shower-head shall be restricted to a maximum of two
metres.

Where “common blending” shower-block systems are already in place and showers
are not in regular use. Each system shall be fitted with a solenoid valve (at the furthest
point from the mixer valve), programmed to automatically purge water for a three
minute period each day.

All showers which have a hot and cold supply shall be subjected to regular
temperature monitoring. The temperature monitoring shall be supported with regular
microbiological testing.

All shower-heads shall be inspected on a quarterly basis and de-scaled, cleaned and
disinfected. The disinfection process shall include all associated hoses.

Where biological results indicate significant local bacterial contamination, the
contaminated shower shall be removed from use and chlorinated.
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3.3
PRIMARY METHODS OF CONTROL
3.3.1
PRIMARY METHOD OF BACTERIAL CONTROL - TEMPERATURE
This is achieved by keeping domestic cold water at temperatures of less than 20 oC and hot water at
temperatures, when supplied from water heaters of greater than 15 litres in volume, of more than
60oC and more than 50oC for the stored and distribution services respectively. In order to ensure
maximum efficiency of the Thermal Disinfection method, it is important to keep all systems clean and
well used at all times and at the correct temperatures.
The efficacy of the bacterial control methods shall be monitored by the implementation of a suitable
monitoring and reporting Programme which shall encompass all water systems across all sites.
During specific circumstances, when “Thermal Control” or Water Treatment is shown, by the various
PPM Programme Monitoring Tasks, to be failing, the water quality shall be maintained by ensuring the
shot-dosing of a suitable disinfecting agent, the levels of which must be maintained within the
recommended limits for achieving disinfection as specified within the current edition of BS6700:
Clause 3:1:10:1997 and L8 – The Control of Legionella bacteria in water systems – Approved Code of
Practice & Guidance 2001.
3.3.2 CONTINUOUS ONLINE DOSING OF WATER SYSTEMS – BOWER ASHTON
Where temperature control has been shown to be ineffective then an alternative method
based on the use of chlorine dioxide shall be implemented.

Disinfection of the water is carried out by the automatic dosing of chlorine dioxide into the
water. Continuous monitoring of chlorine dioxide levels is undertaken with the intent of
maintaining a minimum of 0.1mg/l as Chlorine Dioxide at the outlets.

In the event that this function is undertaken by contractor it will be expected that the
contractor will arrange for this monitoring to take place and will also undertake a call out
procedure to investigate low chlorine dioxide levels.

Routine maintenance and monitoring of the chlorine dioxide dosing system is to be
undertaken monthly.

Running through taps to ensure that chlorine dioxide is present is also to be undertaken at
sentinel outlets every month utilising site report sheet.
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3.4
LEGIONELLA MAINTENANACE TASK FREQUENCIES
As a minimum standard UWE have adopted the following tasks and frequency of tasks that are
required to comply with L8.
Task
Problem Notification
System Alterations
Frequency
Interim Problem Notification
AS REQUIRED
Plant/System Alterations and Modifications
Notification
AS REQUIRED
Temperature Monitoring
6 MONTHLY
General Inspections
6 MONTHLY
Biological Monitoring
6 MONTHLY
Clean and Disinfection
ANNUAL
Temperature Monitoring
MONTHLY
General Inspections
6 MONTHLY
Biological Monitoring
6 MONTHLY
Clean and Disinfection/Pasteurisation
AS REQUIRED
Temperature Monitoring
MONTHLY
General Inspections
MONTHLY
Biological Monitoring
MONTHLY
Clean and Disinfection
AS REQUIRED
Temperature Monitoring
QUARTERLY
General Inspections
QUARTERLY
Biological Monitoring
QUARTERLY
Shower Head Clean and Disinfection
QUARTERLY
Flushing
WEEKLY
Fault Notification
MONTHLY
Plant Service Visit
6 MONTHLY
Chemical Residual Testing
MONTHLY
Selected outlets
6 MONTHLY
Failing Systems
AS REQUIRED
Selected outlets
6 MONTHLY
Failing Systems
AS REQUIRED
Cold water storage tanks
Water Storage Calorifiers
Distribution Systems
(*Sentinel Outlets)
Showers & Mixer Valves
Dead-Leg/Areas of Low-Flow
Defect Log Completion
Chlorine Dioxide
Legionella Testing
TVCC Testing
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All Remedial Works and Pre-Planned Maintenance Work, whether carried-out by appointed
Contractors or by The UWE personnel, or otherwise, shall be carried out in accordance with the
following requirements and shall:

Comply with ACoP L8 – “The Control of Legionella bacteria in water systems – Approved Code
of Practice & Guidance 2001”.

Comply with Control of Substances Hazardous to Health Regulations 1999, Regulation 6
(COSHH).

Comply with all the legal requirements of this document.

Comply with this Policy and use the Reporting and Logging Programme employed on site.

Only those persons who have appropriate training and can demonstrate competency in
Legionellosis management to be allowed to work on UWE systems.

All measuring equipment and fixed sensors shall be adequately and validly calibrated and
accompanied by a current calibration certificate.

Appropriate temperature “correction factors” shall be applied to surface temperatures Refer
to BSRIA Application Guide AG 4/94 – Guide Legionellosis – temperature measurements for
hot and cold water services.

All biological analysis shall be carried out by a suitably UKAS accredited laboratory.
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3.5
CONTROL PARAMETERS AND INTERPRETATION OF RESULTS
3.5.1 TEMPERATURES:
COLD WATER TEMPERATURES

Mains Cold Water:

Boosted Cold Water:

Tanked Cold Water:

Sentinel Outlet Cold Water:
Maximum 20oC
*
*
Maximum 20oC
*
Maximum 20oC*
Maximum 20oC
or 20 C above supply temperature
HOT WATER TEMPERATURES






Storage Calorifier “Set” point:
Storage Calorifier “Flow”:
Storage Calorifier “Return”:
Storage Calorifier “Drain”:
Storage Calorifier “Cold-feed”:
Sentinel Outlet Hot Water:
Minimum 60oC
Minimum 60oC
Minimum 50oC
Minimum 50oC
Maximum 20oC
Minimum 50oC




Cistern-type Water Heater “Set” point:
Cistern-type Water Heater “Flow”:
Cistern-type Water Heater “Cold-feed”:
Sentinel Outlet Hot Water:
Minimum 60oC
Minimum 60oC
Maximum 20oC
Minimum 50oC




Instant Water Heater (>15 litres) “Set” point:
Instant Water Heater (>15litres) “Flow”:
Instant Water Heater (>15litres) “Cold-feed”:
Sentinel Outlet Hot Water:




Instant Water Heater (<15litres) “Set” point:
Instant Water Heater (<15litres) “Flow”:
Instant Water Heater (<15litres) “Cold-feed”:
Sentinel Outlet Hot Water:
Minimum 60oC
Minimum 60oC
Maximum 20oC
Minimum 50oC
Comfort
Comfort
Maximum 20oC
Comfort
BLENDED WATER TEMPERATURES


Maximum 41oC
Maximum 41oC
Showers:
Basins/Sinks:
3.5.2 MICROBIOLOGICAL ANALYSIS
PROCEDURE - WHEN AND HOW TO SAMPLE DOMESTIC WATER SYSTEMS?

In general biological sampling will only be carried out on an 6 monthly basis which will
be dependant on the failure of other control measures such as temperature and
usage. This will normally be notified as required by the Water Treatment contractor.
However a set of samples should be taken 6 monthly on a small number of outlets for
Legionella Pneumophilia testing., This is to establish the efficacy of the primary
control measure, and may be discontinued when an established pattern of negative
samples is established.
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
Sampling must be carried out in accordance with the relevant sample collection
protocols.

Sampling from tanks must be carried out as far from the inlet as possible.
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RESULTS INTERPRETATION – WHAT DO THE RESULTS MEAN – DOMESTIC
WATER SYSTEMS?
Legionella Pneumophilia



<102cfu/l
>102cfu/l - <103cfu/l
>103cfu/l - <104cfu/l
Border Line
Significant
Highly Significant
T.V.C.C. (at either 22oC or 37oC)



<102cfu/ml
>102cfu/ml - <103cfu/ml
>103cfu/ml
Insignificant
Border-Line
Significant
Escherichia coli and Pseudomonas aeruginosa


<1cfu/100ml
>1cfu/100ml
Insignificant
Significant
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3.5.3 RESULTS REPORTING – HOW AM I TOLD ABOUT THE RESULTS?
Sample Collected
Sample to laboratory within 24
hrs from collection under
conditions described in
appropriate protocol
Legionella Samples
Other Samples
“Presumptive”
Results reported to
Contractor within 10 working
days
“Final”
Results reported to
Contractor within 6 working
days
“Presumptive”
Results reported to RP within 1
working day – in writing
“Final”
Results reported to RP within 1
working day – in writing
Follow Actions described in
“Presumptive Positive”
If Results are Significant
or higher - follow
Actions described in
Section 13.4
Phone client and email
“Presumptive Negative”
If Results are Borderline, wait for final
results before action is
taken
Phone client and email
Wait for final results
before action is taken
“Final”
(email)
Results reported to
Contractor within 14 working
days
“Final”
Results reported to RP within 1
working day – in writing
Follow Actions described in
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3.5.4
ACTIONS AFTER ANALYSIS RESULTS – WHAT DO I DO NOW?
Sample
Insignificant
Border-Line
Significant
NO NEED FOR
SYSTEM TO BE PUT
OUT-OF-USE AT
THIS STAGE
NO NEED FOR
SYSTEM TO BE PUT
OUT-OF-USE AT
THIS STAGE
Maintain current
monitoring regime.
Do not re-sample.
Clean, descale and disinfect
outlet (whether tap or shower)
and flush outlet thoroughly (for
at least 2 minutes) and resample taking only a Pre-Flush
sample.
Insignificant
Border-Line
Significant
Highly-Significant
Highly-Significant
Do not re-sample.
Consider the
source of
contamination and
review Risk
Management
Programme.
Follow Processes above
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3.6
RECORD KEEPING
3.6.1 REQUIREMENTS
Add in info for Aqualog

All findings and results from each task shall be entered in the appropriate, Building specific,
Log-sheet in the UWE Reporting and Logging manuals.

All records shall be kept and maintained for at least five years.

All entries shall be dated and bear the signature of the person carrying out each task.

The Data Recording Format shall:

Identify the installation requiring attention and how it operates.

Record results of the initial commissioning (if available) and any re-commissioning so
that observations made during maintenance checks can be compared.

Define the maintenance task or observation required and the frequency.

Provide for the recording of maintenance observations and results and for
comments to be made in respect of any defect seen during the inspection. This
facility should exist for each item of plant individually and for overall system
observations.

Provide for, and make reference to, any separate observation sheet required to
record extensive or abnormal observations which cannot be noted on the routine
inspection sheets.

Facilitate cataloguing and cross-referencing to other Data Recording Formats for
plant/installations on the same Site (for example, the refrigeration plant, the chilled
water installation, the air conditioning plant and the heat source).

Provide dates and results of inspections, tests and all associated works and
procedures.

Provide dates for next scheduled inspection, test and associated works visits.
3.6.2 CURRENT REPORTING AND LOGGING FORMAT
The current Reporting and Logging Programme is enclosed, for reference in Appendix 5
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3.7
AUDITING
The UWE Responsible Person:

Have Overall Responsibility for Auditing the Legionellosis Management & Control
Programmes across UWE

Shall carry-out, a detailed audit to assess the compliance of the Legionellosis
Management & Control Programme implemented in buildings under their control
with ACoP L8 and in particular the status of the Risk Assessment Schedules, the
Management Structures and Control procedures.
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4.0
LEGIONELLA OUTBREAK ACTION PLAN

To allow for the management of any incident, an Outbreak Committee shall be formed whose
members shall be made aware of their responsibilities, and all shall have nominated deputies,
who must also be aware of their places in the outbreak team.

The Committee shall consist of:
Policy Holder
Responsible Person.
Engineering Technical Staff Representative
UWE Safety Advisor.
Legionella Consultant.
Occupational Health Doctor

For the purposes of this document, a “Limited Outbreak” will mean that one person on the
site, or with specific site connections, is known to have Legionellosis. An “Outbreak” will mean
that two or more persons on the site, or with specific site connections, are known to have
Legionellosis.

Notification of this type of infection will usually be received from an external agency such as
the local Environmental Health department or from local hospitals, clinics etc. It is the duty of
the Responsible Person to assemble the Outbreak Committee with all speed.

Where no more than one person is known to be infected (Limited Outbreak), no notification of
external bodies/organisations/departments shall be necessary.

Where two or more persons are known to be infected, from an identified source - over a sixmonth period, would constitute an “Outbreak”. This shall require the Responsible Person, via
the Outbreak Committee, to notify the Local Health Authority (Consultant in Communicable
Disease Control if one is appointed), the Health Protection Agency (ex PHLS) and the HSE
through the recognised route of notification (RIDDOR).

In addition to informing and summoning the above, the Responsible Person shall be
responsible for informing the “Duty Holder” of the prevailing situation.

All actions instructed by the Outbreak Committee and undertaken by whoever shall be entered
in the site “Legionella Incident Book”.

Once initial outbreak evidence is received, decisions will need to be taken as to isolation of
systems, plant etc. The situation of the infected person(s) may have some effect on this
action, but it is probable that all high risk equipment will be shut down and isolated.

It is important that no general remedial addition of disinfectants is used at this stage. A
sampling procedure must be established and carried out. The advice and/or assistance of the
Health Protection Agency may be sought by the Consultant at this stage. When sampling is
completed to the satisfaction of the HSE, a remedial disinfection programme will be initiated.
All actions shall be documented with all sampling and results of same recorded.

The outbreak incident will only be deemed to be over when so described by the HSE.

All personnel associated with the investigation of the incident shall be involved in a review of
all the actions taken in order to reduce the risk of a reoccurrence, and to assimilate any lessons
to be learnt.
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SECTION 5 – APPENDICES TECHNICAL
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SECTION 5.3 CLOSING/OPENING OF BUILDING/AREA
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LEGIONELLA MANAGEMENT AND CONTROL TASKS
System/Plant
HOT AND COLD WATER DISTRIBUTION SYSTEMS
Task Description:
AREA CLOSURE AND OPENING PROCEDURES
If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an
alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the
Site.
This Section to be completed prior to area closure
Area proposed closure:
Reason for proposed closure:
Period of
closure:
Date for proposed closure:
Date of
opening:
Is the whole of the area proposed
for closure?
Yes
No
If No,
specify:
Is area supplied from a stand-alone
system or from other?
Yes
No
If No,
specify:
Will the use of the area change
following re-opening:
Yes
No
If Yes,
specify:
Has area been isolated from its
domestic water supply?
Yes
No
If Yes,
date?
If area not isolated, is it on
“Flushing” Programme?
Yes
No
If Yes, start
date:
If No, what other measures have
been taken, if any?
This Section to be completed at least Three Days prior to area opening
i.
Water temperatures to be recorded 3 times in 24 hours and must reach the required limits each time.
ii.
TMVs and Shower-heads (including shower hoses where fitted) shall be cleaned and disinfected.
iii.
Where area is supplied by a stand-alone system, the Cold water storage tank(s) shall be cleaned and disinfected and the
calorifier(s) pasteurised.
iv.
Water samples shall be taken for microbiological analysis (T.V.C.C., Legionella spp., Pseudomonas spp. and E.coli).
v.
The whole system shall continue to be flushed on a daily basis until the building/area is re-occupied.
The area shall not be permitted to re-open if any of the measured parameters (temperature and biological contamination)
fall outside the recommended limits.
All required actions have been undertaken and the associated temperatures and sampling results found to be within the
recommended limits. The area is, therefore, permitted to re-open:
Responsible Person:
Signed: .............................................................
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SECTION 5.1
LEGIONELLA MANAGEMENT AND CONTROL TASKS
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LEGIONELLA MANAGEMENT AND CONTROL TASKS
System/Plant
HOT AND COLD WATER DISTRIBUTION SYSTEMS
Task Description:
DEAD-LEG AND INFREQUENTLY USED OUTLET FLUSHING
Frequency:
WEEKLY
Limits:
EXPECTED USAGE FREQUENCY:
MAXIMUM DEAD-LEG LENGTH:
DAILY
300MM
If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an
alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the
Site.
Systems or individual outlets that are not frequently used allow the development of stagnant water conditions, which
increase the potential of bacterial growth and proliferation, including Legionella. In order to remove any stagnation that may
have developed or to stop stagnation from occurring in the first place, it is important to introduce a "flushing" programme
where necessary.
The flushing programme must be designed so that it allows for the whole dead-leg to be removed. This is achieved by
ensuring that the flushing is carried out at the specified system or outlet and for an appropriate length of time. The length of
time of purging water from the system is important because it is vital to ensure that all the stagnant water has been expelled
from the pipe-work and at least until "circulating" or "fresh" water is drawn from the outlet (water at temperatures exhibited
throughout the rest of the system). The flushing programme should follow the procedure outlined below:









Identify areas/outlets to be flushed.
Ensure that the system/outlet can be flushed (for a minimum of 3 minutes) safely and in a tidy manner into an
appropriate drain if not plumbed for drainage.
Ensure that the purging of water from outlets does not create an unnecessary amount of aerosol at least no more
than would be created when outlet is operated normally.
Ensure that "splash-back" is minimised, where practicable, by placing a sponge or another material capable of
absorbing some of the force of the water against the surface of the appliance.
Purge the hot and the cold or the mixed water in turn for a minimum of 2 minutes or for a period of time
necessary to draw water from the outlet at temperatures exhibited throughout the rest of the system.
If a system or an area consisting of multiple outlets requires flushing, it is important to begin with the nearest
outlet to the main distribution pipe-work, working progressively away from the main distribution pipe-work.
Where showers need to be flushed, it is important to ensure that, where practicable, the shower-head is
removed in order to reduce the potential of aerosol production. Where the head is fixed, exposure to the
aerosol produced must be minimised. One method that can be employed in this situation is the use of a
transparent plastic bag, fixed around the shower- head, with one corner pierced to allow partial discharge of
water.
Consider whether the system/outlet can be removed negating further flushing.
Log all procedures and results.
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LEGIONELLA MANAGEMENT AND CONTROL TASKS
Task No:
LEG 01
Task:
COLD WATER STORAGE TANK TEMPERATURE MONITORING
Frequency:
AS SPECIFIED IN SECTION 3.4
Limits:
INCOMING MAINS TEMPERATURE:
STORED WATER TEMPERATURE: <20oC
<20oC
If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an
alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the
Site.
Task Description



Using a long probe, electronic and calibrated thermometer, measure and record the temperature of the body of
the stored water. Remember to measure and record temperature reading from as far away from the ball cock as
possible. Care must be taken as not to contaminate the stored water by the use of unclean temperature probes.
Operate ball valve and measure the temperature of the water after 2 mins.
Measure and record the ambient temperature near to where the tank is located.
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LEGIONELLA MANAGEMENT AND CONTROL TASKS
Task No:
LEG 02
COLD WATER STORAGE TANK GENERAL CONDITION AND
BIOLOGICAL ACTIVITY INSPECTION
Task:
Frequency:
AS SPECIFIED IN SECTION 3.4
Limits:
WATER SUPPLY (WATER FITTINGS) REGULATIONS 1999
COMPLIANT.
NO CORROSION.
NO SLUDGE DEPOSITION.
NO STAGNATION.
NO BIOLOGICAL CONTAMINATION (<100cfu/ml)
If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an
alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the
Site.
Task Description






















If insulation allows for inspection of the external condition of the tank walls, inspect for corrosion pitting and
leaks.
Visually inspect internal walls of tank for signs of scale deposition, corrosion and slime deposits.
Visually inspect tank and associated valves/pipework for leaks.
Visually inspect bottom of tank for sludge deposition and state amount:
1 = slight and 10 = heavy
Visually inspect internal walls of tank for corrosion and state amount:
1 = slight and 10 = heavy
Visually inspect for signs of stagnation such as water surface dirt, oil films, insects, smell, low input.
Visually inspect water surface for; dirt, oil films, insects and state amount:
1 = slight and 10 = heavy
Visually inspect for slimy deposits on the internal walls of tank and state the colour of substance and state
amount; 1 = slight and 10 = heavy
Visually inspect for algae growth indicated by either green or red plant like growth on water surface
Visually inspect the insulation for signs of wear and tear and areas where the insulation has been removed
Visually inspect that the lid is correctly fitted and that any bolts are securely tightened.
Visually inspect that all insect/rodent screens fitted are clear from debris so that water can flow easily.
Visually inspect that the ball valve opens and closes correctly.
Visually inspect all pipework for signs of corrosion and leaks, and check the condition of insulation fitted.
Visually inspect all valves for correct operation, signs of corrosion and leaks.
Visually inspect all booster pumps fitted for correct operation.
When instructed to do so, using a suitable sterile container, collect a water sample and submit for biological
analysis. The analysis should measure the presence of contamination by general bacteria (Total Viable Colony
Count – T.V.C.C.)
Indicate the date that the tank was last cleaned and disinfected and indicate whether it was disinfected as routine
or due to adverse conditions.
Carry out an Annual Drop-test or verify usage by meter.
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LEGIONELLA MANAGEMENT AND CONTROL TASKS
Task No:
LEG 03
Task:
TANK CLEANING
Frequency:
AS SPECIFIED IN SECTION 3.4
Limits:
MINIMUM LEVEL OF CL2 INITIALLY: 50ppm
MINIMUM LEVEL OF CL2 AFTER 1HR
30ppm
MAXIMUM LEVEL OF CL2 AT END
<1ppm
If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an
alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the
Site.
Task Description













The pH of the water shall be measured and must be between 5.5 and 9.0 before chlorinating solution is
introduced. If pH is found to be below 5.5 the system shall be drained, flushed and refilled to level of overflow
with fresh water.
The tank(s) shall be filled to the level of the overflow with fresh water and chlorinating agent to give a minimum
free chlorine concentration of 50ppm (50mg/l), and when full, allow to stand for 1 hour.
After 1 hour, measure free chlorine level, if free chlorine level is below 30ppm, repeat step ii.
The tank(s) shall be drained and then thoroughly flushed out with clean mains water until tests indicate that the
residual chlorine concentration is no greater than 0.5ppm (0.5mg/l), or that present in the mains water supply.
Where the volume exceeds 5000 litres, the disinfected water must be neutralised, using sodium thiosulphate,
before disposal. The neutralised waste MUST NOT be drained through the system.
Fix ball valve in close position.
Isolate Tank from system. Outlets should be sealed from inside tank.
Empty the Tank via drain-point or by using a submersible or barrel type pump, in the absence of a drain-point or
should draining from drain-point is impracticable.
Clean Tank and remove all deposits of scale, corrosion and sludge deposition using a combination of hand
scraping and brushing together with application of chemicals to dissolve or soften the scale (where necessary).
Vacuum out all loose debris and deposits.
When using high-pressure jet washers to clean the internal surfaces of the Tank, suitable PPE must be used,
including a positive pressure respirator. In this circumstance, the escape of aerosols must be restricted or,
certainly, minimised.
Where oil and grease contaminants on the tank surface are implicated, they shall be removed using suitable
degreasants. Where necessary (and practicable) the tank can be steam cleaned to remove grease contaminants.
Where “significant” or “highly-significant” levels of biological contamination is reported, the Tank shall be
disinfected (using the disinfection method below), before the cleaning process is commenced.
Record on appropriate log sheet
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LEGIONELLA MANAGEMENT AND CONTROL TASKS
Task No:
LEG 04
Task:
TANK DISINFECTION USING BIOCHEM B600/B400
Frequency:
AS SPECIFIED IN SECTION 3.4
Limits:
MINIMUM LEVEL OF CL2 INITIALLY: 50ppm
MINIMUM LEVEL OF CL2 AFTER 1HR
30ppm
MAXIMUM LEVEL OF CL2 AT END
<1ppm
T.V.C.C. LEVEL:
<100cfu/ml
If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an
alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the
Site.
Task Description







The pH of the water shall be measured and must be between 5.5 and 9.0 before chlorinating solution is
introduced. If pH is found to be below 5.5 the system shall be drained, flushed and refilled with fresh water to
level of overflow.
The tank(s) shall be filled to level of overflow with fresh water and chlorinating agent to give a minimum free
chlorine concentration of 50ppm (50mg/l), and when full, allow to stand for 1 hour.
After 1 hour, measure free chlorine level, if free chlorine level is below 30ppm, repeat step ii.
The tank(s) shall be drained and then thoroughly flushed out with clean mains water until tests indicate that the
residual chlorine concentration is no greater than 0.5ppm (0.5mg/l), or that present in the mains water supply.
Where the volume exceeds 5000 litres, the disinfected water must be neutralised, using Chemclense C400, before
disposal. The neutralised waste MUST NOT be drained through the system.
Using a suitable sterile container, collect a water sample and submit for biological analysis. The analysis should
measure the presence of contamination by general bacteria (Total Viable Colony Count – T.V.C.C.).
Record on appropriate log sheet.
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LEGIONELLA MANAGEMENT AND CONTROL TASKS
Task No:
LEG 05
CALORIFIER MANUAL TEMPERATURE
BIOLOGICAL ACTIVITY INSPECTION
Task:
Frequency:
AS SPECIFIED IN SECTION 3.4
Limits:
FLOW TEMPERATURE:
RETURN TEMPERATURE:
COLD FEED TEMPERATURE:
T.V.C.C. LEVEL:
MONITORING
AND
≥60oC
O
≥50 c
<20oC
<100cfu/ml
If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an
alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the
Site.
Task Description






Measure and record the “Set” temperature setting of the thermostat (if fitted and calibrated). Temperature to
exceed 60oC.
Measure and record the “Flow” temperature using a contact thermometer or calibrated gauge. Temperature to
be taken from “Flow” pipework as close to the Calorifier as possible. Temperature to exceed 60oC.
Measure and record the “Return“ temperature using a contact thermometer or calibrated gauge. Temperature
to be taken from “Return” pipework as close to the Calorifier as possible. Temperature to exceed 50oC.
When instructed to do so, isolate Cold Feed and open drain point into a bucket and collect approximately the first
litre of water discharged. Using a suitable sterile container, collect a water sample and submit for biological
analysis. The analysis should measure the presence of contamination by general bacteria (Total Viable Colony
Count – T.V.C.C.).
Discard this and collect a further 10 litres of water. Measure and record temperature. Temperature to exceed
60oC.
Measure and record the “Cold Feed“ temperature using a contact thermometer or calibrated gauge.
Temperature to be taken from “Cold Feed” pipework one metre from the Calorifier as possible. Temperature NOT
to exceed 20oC. Record on appropriate log sheet
N.B. 1: If contact probe is to be used for temperature monitoring through copper pipework, a 2oC temperature adjustment
must be added to the recorded temperature before reporting temperature on the Log-sheet and the use of the
contact probe noted with the result.
N.B. 2: The temperature measurements shall be carried out at different times during the day in order to allow indicative
temperature monitoring of the vessel during a typical daily usage profile.
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LEGIONELLA MANAGEMENT AND CONTROL TASKS
Task No:
LEG 06
Task:
CALORIFIER PASTEURISATION
Frequency:
AS SPECIFIED IN SECTION 3.4
Limits:
T.V.C.C. LEVEL:
<100cfu/ml
If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an
alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the
Site.
Task Description








Purge Calorifier via drain point and refill.
Isolate all valves on the incoming and outlet sides.
Ensure that the “blow” valve is capable of withstanding temperatures of up to 80oC.
Bring Calorifier to 70oC (if practicable) and allow to stand at this temperature for at least 1 hour.
Ensure that no water is drawn from the Calorifier whilst pasteurisation in progress.
Allow Calorifier to reach its normal operating temperature, 60oC, and return to service.
Using a suitable sterile container, collect a water sample and submit for biological analysis. The analysis should
measure the presence of contamination by general bacteria (Total Viable Colony Count – T.V.C.C.).
Record on appropriate log sheet
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LEGIONELLA MANAGEMENT AND CONTROL TASKS
Task No:
LEG 07
Task:
CALORIFIER GENERAL CONDITION INSPECTIONS
Frequency:
AS SPECIFIED IN SECTION 3.4
Limits:
WATER SUPPLY (FITTINGS) REGULATIONS 1999 COMPLIANT.
NO CORROSION.
NO SLUDGE DEPOSITION.
NO STAGNATION.
NO BIOLOGICAL CONTAMINATION (<100cfu/ml)
If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an
alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the
Site.
Task Description














Report on the operational status of Calorifier by checking the status of the associated isolation valves.
If the Calorifier is OFF, indicate the date it came Off-line.
Report on the status of Inlet Valve and Outlet Valve.
Report on the operational status of the circulation pump(s) and shunt pump(s).
Visually inspect Calorifier and associated valves for leaks.
Visually inspect all pipework for signs of corrosion and leaks, and visually inspect the condition of insulation fitted.
Visually inspect all valves for correct operation, signs of corrosion and leaks.
Visually inspect all pumps fitted for correct operation and leaks.
Measure and record the temperature setting of the thermostat (if fitted).
Open the cold feed valve and then open the drain point allowing enough water to flow through so that any water
discoloration is removed.
Visually inspect the insulation for signs of wear and tear and areas where the insulation has been removed.
When instructed to do so, isolate Cold Feed and open drain point into a bucket and collect approximately the first
litre of water discharged. Using a suitable sterile container, collect a water sample and submit for biological
analysis. The analysis should measure the presence of contamination by general bacteria (Total Viable Colony
Count – T.V.C.C.).
Visually inspect that any gauges fitted are operating correctly. Compare against calibrated instruments.
Indicate the date that the calorifier was last pasteurised and indicate whether it was disinfected as routine or due
to adverse conditions.
Indicate the date of the last insurance inspection (where applicable).
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LEGIONELLA MANAGEMENT AND CONTROL TASKS
Task No:
Task:
Frequency:
Limits:
LEG 10
COLD WATER TEMPERATURE MONITORING - DCWS & MAINS
SUPPLY OUTLETS
AS SPECIFIED IN SECTION 11.0
MAINS TEMPERATURE: <20oC within 1 minute
DCWS TEMPERATURE:
<20oC within 1 minute
If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an
alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the
Site.
Task Description

Using an electronic and calibrated thermometer with a suitable probe, measure and record the outlet
temperature of the incoming Mains (usually from the tank ball-valve – if one is present, or from the nearest
outlet. The measurements shall be carried out after allowing the water to run for 2 minutes, at full-flow. This
temperature shall not to exceed 20oC.

Measure and record the outlet temperature of each designated “Sentinel” outlet, from each branch and subbranch of the distribution system, indicating whether Mains or Tanked fed. The measurements shall be carried
out after allowing the water to run for 2 minutes, at full-flow. This temperature shall not exceed 20oC. Where the
temperature exceeds 20oC, the cold water temperature at the incoming Mains shall be measured an recorded
(see above).
N.B. 1: On each monitoring visit, the temperature of the source supply (Mains or Tank) shall be measured.

Visually inspect and record the colour, and flow-rate of the water from the outlets inspected. The water shall be
clear from any discolouration and must run freely without any restrictions.
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LEGIONELLA MANAGEMENT AND CONTROL TASKS
Task No:
LEG 11
Task:
HOT WATER TEMPERATURE MONITORING - DIRECT FED OUTLETS
Frequency:
AS SPECIFIED IN SECTION 3.4
MINIMUM TEMPERATURE AT FURTHEST OUTLET: >50oC within 1
minute
Limits:
If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an
alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the
Site.
Task Description

Measure and record the outlet temperature, of each designated “Sentinel” outlet, from each branch and subbranch of the distribution system, indicating the source calorifier. The measurements shall be carried out after
allowing the water to run for 1 minute, at full-flow. This temperature shall not be less than 50oC. Where the
temperature is not achieved, the hot water “Flow” from the corresponding source calorifier shall be measured
and recorded.
N.B. 2: On each monitoring visit, the temperature of the source supply (Calorifier etc.) must be measured. This must
include the "flow" and "return" temperatures of each Unit in the system

Visually inspect and record the colour, and flow-rate of the water from the outlets inspected. The water shall be
clear from any discolouration and must run freely without any restrictions.
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LEGIONELLA MANAGEMENT AND CONTROL TASKS
Task No:
LEG 12
Task:
HOT WATER TEMPERATURE MONITORING - BLENDED OUTLETS
Frequency:
AS SPECIFIED IN SECTION 3.4
FROM THE TMV
41oC for showers and basins/sinks
Limits:
TO THE TMV
>50oC HWS to the TMV
<20oC CWS to the TMV
If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an
alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the
Site.
Task Description
1.


41oC for showers and basins/sinks etc.

Where these temperatures are exceeded, the TMV shall be adjusted in order to allow the unit to operate within
the recommended temperature limits described above.
Using an electronic and calibrated thermometer with a suitable contact probe, measure and record the
temperature of the HWS and CWS supply pipes of each TMV. The temperature of the CWS shall not exceed 20 oC
and the temperature of the HWS shall not be less than 50oC. The measurements shall be carried out following
task 1. (i).

2.
SHOWERS
Measure and record the “Initial” and “Final” outlet temperature, of each shower and bath fitted with a
Thermostatic Mixing Valve (TMV or otherwise). The measurements shall be carried out immediately and after
allowing the water to run for 1 minute at full-flow respectively. The “Initial” and “Final” outlet temperature
measured shall not to exceed:




SINKS AND BASINS
Measure and record the “Initial” and “Final” outlet temperature, of the HOT water outlet of each sink, basin and
other non-full body immersion outlets fitted with a Thermostatic Mixing Valve (TMV or otherwise). The
measurements shall be carried out immediately and after allowing the water to run for 1 minute at full-flow
respectively. The “Initial” and “Final” outlet temperature measured shall not exceed 41oC.
Where these temperatures are exceeded, the TMV shall be adjusted in order to allow the unit to operate within
the recommended temperature limits described above.
Using an electronic and calibrated thermometer with a suitable contact probe, measure and record the
temperature of the HWS supply pipe ONLY of each TMV. The temperature of the HWS shall not be less than 50oC.
The measurements shall be carried out following task 2. (i).
Measure and record the COLD water outlets of each sink, basin and other non-full body immersion outlets fitted
with a Thermostatic Mixing Valve (TMV or otherwise). The measurements shall be carried out immediately and
after allowing the water to run for 2 minutes at full-flow respectively. The outlet temperature measured shall not
exceed 20oC.
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LEGIONELLA MANAGEMENT AND CONTROL TASKS
Task No:
LEG 13
SHOWER HEAD CLEANING AND DISINFECTION USING CHEMCLENSE
C202SH
Task:
Frequency:
3 MONTHLY
Limits:
AS DICTATED BY CALCIUM CARBONATE DEPOSITS – MIN 30
MINUTES FOR DISINFECTION
If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an
alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the
Site.
Task Description





Dismantle the shower assembly and inspect the internal surfaces for signs of scale, biofilm
and other deposits/particulates.
Clean & disinfect the showerhead by placing the head in a solution of Chemclense C202SH*
for a maximum of 30 minutes. Refer to Product Data Sheet PDC202SH for further detail.
After 30 minutes, remove the shower head and rinse with clean mains water until all traces
of chemical have been removed.
Reassemble the shower head and flush through with hot shower water.
Record the activity on the technical test data record sheet
NOTES:
a)
Chemclense C202SH is an acidic product and when being used, appropriate
Health & Safety precautions must be taken. These will include as a minimum,
chemical resistant gloves and goggles. Refer to Chemclense C202SH COSHH
data.
b)
Chemclense C202SH is to be used as two parts water to one part chemical.
Where scaling is severe, Chemclense C202SH may be used neat. The product
contains a colour change indicator which goes from yellow to blue/green as
the descaling power is exhausted.
c)
Chemclense C202SH has been formulated for all materials of construction.
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LEGIONELLA MANAGEMENT AND CONTROL TASKS
Task No:
Frequency:
LEG 14
THERMOSTATIC MIXING VALVE (TMV)
DISINFECTION USING BIOCHEM B400/B600
AS SPECIFIED IN SECTION 3.4
Limits:
MINIMUM 100mg/l as Chlorine FOR 20 MINS
Task:
CLEANING
AND
If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an
alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the
Site.
Task Description








Each TMV shall be removed from its location and replaced with a new or previously serviced TMV. The removed
TMV shall be taken to a suitably equipped work-shop for service.
At the work-shop, each TMV shall be dismantled and physically cleaned from all scale deposits and scale
deposition (using a suitable descaling solution where necessary).
Rinse in clean water, allow to drip-dry and store in a cool and dry place.
Immediately prior to re-installation (same day), all components shall be disinfected (this applies to all cleaned and
new components). All components shall be flushed with clean water and immersed in a Sodium hypochlorite
disinfectant solution (100 ppm) for 20 minutes minimum.
Remove components from disinfectant solution and rinse with clean water to remove presence of chlorine.
Reassemble, refit and test operation of valve, including fail-safe test.
Measure and record and adjust (if necessary) the “maximum” outlet temperature.
Record the date that TMV has been replaced.
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LEGIONELLA MANAGEMENT AND CONTROL TASKS
Task No:
LEG 15
AHU TRAP CLEANING AND DISINFECTION USING BIOCHEM
B400/600
Task:
Frequency:
AS SPECIFIED IN SECTION 3.4
Limits:
MINIMUM 100mg/l as Chlorine FOR 20 MINS
If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an
alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the
Site.
Task Description







Each trap shall be removed from its location and taken to a suitably equipped work-shop for service.
At the work-shop, each trap shall be dismantled and physically cleaned from all scale deposits and scale
deposition (using a suitable descaling solution where necessary).
Rinse in clean water, allow to drip-dry and store in a cool and dry place.
Immediately prior to re-installation (same day), all components shall be disinfected (this applies to all cleaned and
new components). All components shall be flushed with clean water and immersed in a Biochem B400/B600
disinfectant solution (100 ppm) for 20 minutes minimum.
Remove components from disinfectant solution and rinse with clean water to remove presence of chlorine.
Reassemble, refit and fill trap with clean water.
Record the date that the trap has been replaced.
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LEGIONELLA MANAGEMENT AND CONTROL TASKS
Task No:
LEG 16
AHU COMPONENTS INSPECTION, CLEANING AND DISINFECTION OF
PERMANENTLY OR INTERMITTENTLY WETTED SURFACES WITHIN
THE AIR HANDLING SYSTEM
Task:
Frequency:
AS SPECIFIED IN SECTION 3.4
Limits:
MINIMUM 100 mg/l as Chlorine for 3 minutes minimum (using
spray)
If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an
alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the
Site.
Task Description












Report on the operational status of the unit.
Visually inspect the condition of the external surfaces of the unit and comment.
Visually inspect (if possible) the condition of the internal surfaces of the unit and comment. If practicable, isolate
unit in order to allow for thorough internal inspection to be carried out.
Visually inspect the condition of all traps fitted and comment.
Visually inspect (if possible) the condition of the drip-trays of the unit and comment. If practicable, isolate unit in
order to allow for thorough internal inspection of the drip-trays to be carried out. Alternatively, remove driptrays from the system and inspect.
Visually inspect (if possible) the condition of the drip-tray drains of the unit and comment.
Visually inspect (if possible) the condition of the eliminators of the unit and comment.
Visually inspect (if possible) the condition of the filters fitted and comment.
Visually inspect (if possible) the condition of the humidifier components of the unit and comment.
Visually inspect (if possible) the condition of the Chiller battery fitted and comment.
Visually inspect (if possible) the condition of the Heater battery and comment.
Using clean cloth, wipe over the unit components to be disinfected. To disinfect, spray the components with a
chlorine donor solution of 100 ppm strength, using small hand spray. Allow to stand for 3 mins only. Spray with
fresh clean water. Dry area with clean and clean cloth.
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SECTION 5.2
TECHNICAL TEST DATA RECORD SHEETS
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SECTION 6
APPENDICES – DOCUMENTARY
SECTION 6.1
POLICY RECEIPT DOCUMENT
From:
………………………………………..……………….
Date:
…………………………………………………………
Copy No.:
…………………………………………………………
CONFIRMATION OF RECEIPT OF DOCUMENT
This is a written confirmation that I am in possession of an authorised copy of the UWE Policy – “Management Document
for the Management and Control of Legionellosis Including Legionnaires Disease”, the number of which is listed above.
In signing this receipt, I confirm that I will ensure the safe-keeping and integrity of this document. I also confirm that I
will not copy or issue, to a third party or otherwise, the whole document or any part of it, for whatsoever purpose,
without the written consent of the UWE Responsible Person.
Signature: ………………………………………..…….….
Name:
Date:
…………………………………………………………
…………………………………………………………..
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6.2
RESPONSIBILITIES NOTIFICATION
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To:
…………………………………………………………….
From:
………………………………………..………………..
Date:
…………………………………………………………
Re:
NOMINATION OF RESPONSIBILITY FOR THE MANAGEMENT & CONTROL OF LEGIONNAIRES’ DISEASE AND SAFE
HOT WATER MANAGEMENT
I nominate
as the “Responsible Person" for the Management & Control of Legionnaires ’ Disease for all the buildings
currently occupied, owned and maintained by the Institute (under a full maintenance lease or otherwise).
The responsibilities of this nominated position include:

Overall Responsibility for the Implementation of the Legionellosis Management & Control Programmes, across
UWE

Have Overall Responsibility for Auditing the Legionellosis Management & Control Programmes across UWE, and
reporting all findings to the "Legionella Risk Management Steering Committee".

Advise others on all matters relating to the Management & Control of Legionellosis Management and ensure
that they are informed of all changes, or proposed changes, in the legislation/recommendations relating to
Legionellosis which may affect UWE, in general, and the buildings under their control, specifically.

Where necessary, carry out a Tender Process and select suitable Water Treatment/Hygiene Contractors or
Consultants for the provision of services pertaining to Legionellosis Management & Control.

Assess the training needs for training of staff involved in the Legionellosis Management & Control and
Programme and liaise between suitable training establishments, Consultants to provide approved Training
Courses.

Ensure personal training records are kept up to date.
I accept this nominated position and I undertake to implement all specified requirements as described in the Institute’s
“POLICY FOR THE MANAGEMENT AND CONTROL OF LEGIONELLOSIS INCLUDING LEGIONNAIRES DISEASE AND THE
MANAGEMENT
Name:
Signature:
…………………………..……………..
Date:
…………………………………………
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SECTION 7
APPENDICES - ESTATE
.
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- PROCEDURE WHEN WATER QUALITY IS OUT OF SPECIFICATION
Dear all,
Due to an issue with the water quality within the site/building we need to take the following precautions

Do NOT drink cold water from any tap on site.

There is plenty of bottled water in stores to supply cold drinks.

The restaurant staff are aware of the problem and have taken suitable precautions to protect their
meals.

Hot drinks and boiled water are perfectly safe to drink.

There is no danger from washing hands or clothes in the site water.

The hostels are on our system so the water they are included in this notice.

A few houses are fed from this part of the site. They have been informed.

The nursery is also fed from here. They have also been informed and supplied with bottled water.
These are precautionary measures and we are assured that there is no risk to health if the precautions
above are followed.
We expect to have the problem repaired shortly and will then start flushing the water system and checking
the treatment levels.
Once the water is declared safe by analysis, we will inform you all.
Contact point
………
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