Advice to Schools and Directorates on Compliance with
HSE ACoP L8 (Legionnaires Disease)
Section Contents
1.
2.
3.
4.
5.
6.
Basic Requirements
Draft Departmental Policy
Lines of Communication
Risk Assessment Guidelines
Flushing Example Log Sheet
Flushing Example Method Statement
Page 1 of 11
DRAFT VERSION
6TH OCTOBER 2009
Section 1.
BASIC REQUIREMENTS
Before starting to carry out a risk assessment to assess the level of hazard of the likelihood of
contamination of a water system with legionella bacteria you should read the “Approved Code of
Practice and Guidance – L8” for the control of legionella bacteria in water systems, published by
the HSE, and the University Policy for the control of legionnaires disease. These documents
outline the statutory requirements and give helpful guidance.
This is a summary of what is required;
Management Structure
Following the University Policy, the Head of School or Directorate is classed as the Duty Holder
and has to nominate a Responsible Person who in turn oversees and audits the work of the
Competent Person who actually does or organises the work. This is a formal document to be
kept up to date and signed by the persons named.
Competence and Training
The Responsible Person and the Competent Person need to have had sufficient training to enable
them to perform their roles. The Responsible Person must be of sufficient rank to have the
authority to commit resources and expenditure to carry out the work. Certificates of competence
and training should be kept with the management structure document.
Risk Assessment
A risk assessment of all equipment using water must be carried out to assess the level of hazard.
Risk assessments should be reviewed every 2 years or when changes occur. Other relevant
hazards should also be identified e.g. COSHH hazards.. These risk assessments must be
recorded.
Control Measures
Once the hazards have been identified the actions taken to control legionella bacteria need to be
defined in writing i.e. prepare a written scheme. It may also be appropriate to prepare schematic
drawings of water systems.
Implementation of Control Measures
Control measures tend to be monitoring and routine inspections such as periodically sanitising
equipment and weekly monitoring of temperatures etc. The routine monitoring results should be
interpreted by a competent person and any remedial actions, where necessary, carried out
promptly.
Monitoring records are to be kept.
Remedial Actions
Remedial actions can be one-off actions to remove a particular hazard. E.g. removing a dead leg
in a water system or adjustments to sanitising temperatures etc. They can also be generated by
ongoing monitoring and maintenance work. Again records of these actions are to be maintained.
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DRAFT VERSION
6TH OCTOBER 2009
Audits
Audits of the documentation must be carried out at regular intervals to ensure that the control
measures are being maintained. The frequency of audits is at the discretion of the Responsible
Persons but I would suggest quarterly or half yearly periods at least.
Reviews
It is suggested that reviews of the whole of the measures to control legionnaires disease are
carried out every two years.
Record keeping
Records of all the above actions are to be maintained.
All records should be signed and dated by those people performing the tasks assigned to them.
Generally records are to be retained for five years.
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DRAFT VERSION
6TH OCTOBER 2009
Section 2.
1.
2.
3.
4.
5.
DEPARTMENTAL LEGIONELLA POLICY
Introduction
Roles and Responsibilities
Flushing of low use outlets
Non domestic uses of water
Review and Auditing
1) Introduction
This purpose of this policy is to define a framework that maintains the various domestic water
systems within <department name> under safe microbiological conditions and in accordance with
the requirements of ACoP L8, Legionnaires Disease, HSC January 2001.
The policy also relates to non domestic uses of water. In these cases the responsibility lies with
the Head of School or Directorate (Duty Holder) to assess the risk in all departments and
implement a managed scheme of precautions.
The policy follows on from the University and Estates Legionella Policies and should be read in
conjunction with those documents to fully understand the control strategy.
2) Roles and Responsibilities
Estates Department



To design, maintain and monitor water temperatures of domestic hot and cold water
systems in accordance with the requirements of ACoP L8 and University and Estates
Policies and Procedures.
To audit the department’s management systems and to provide expert assistance as
required.
To provide appropriate advice to department personnel.
Head of School or Directorate





To be responsible for managing the scheme for flushing of low use domestic outlets (3.
below).
To ensure that adequate records are kept.
To implement recommendations made by Estates should the risk be deemed to have
increased.
To manage the risk from non domestic water using equipment in the department that
presents a forseeable risk (see section 4)
Where appropriate, to employ the services of a suitable consultant to assist with Risk
Assessment, training and management of the control scheme.
3) Flushing of Low Use Outlets
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DRAFT VERSION
6TH OCTOBER 2009
It is an established fact that low usage of water systems greatly increases the risk of growth of
Legionella bacteria. Accordingly there is a requirement to periodically flush parts of the domestic
water system not in regular use.
It is the responsibility of the department to identify and manage the list of low use outlets. This
includes flushing the low use outlets on a weekly basis and maintaining a suitable records system.
4) Non Domestic Uses of Water
Any non domestic water using system or equipment must be managed to minimise the risk of an
outbreak of legionellosis associated with that system. This may include, but is not limited to,
lathes, cutting equipment, experimental apparatus and tanks, tidal tanks, dental chairs, salad
misters and water features.
To adequately manage the risk it requires a policy, responsible person and deputy, risk
assessment, written control scheme and keeping of records.
5) Review and Auditing
Section 1. Records of flushing of low use outlets and non domestic uses of water will be
maintained by the Responsible Person and reviewed every quarter by the Head of
Department (or nominated deputy). Records must be kept for 5 years.
Section 2. These records will be audited by the OSHEU a minimum of once every 12 months.
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DRAFT VERSION
6TH OCTOBER 2009
Section 3.
LINES OF COMMUNICATION
POLICY REGARDING ACOP L8, LEGIONNAIRES DISEASE
LINES OF COMMUNICATION – <department name>
CARDIFF UNIVERSITY
Address:
<department address>
Postcode:
The person with overall responsibility under the Health & Safety At Work etc. Act (HSW Act) for all safety
matters within the premises (Legionnaires’ Disease: The Control of Legionella Bacteria in Water Systems).
Duty Holder
Name:
<Head of School or Directorate>
Title:
Telephone Number:
E-mail Address:
Fax Number:
Sign and date:
Head of Department
With responsibility for implementing findings of legionellosis Risk
Assessment and written control scheme. Responsible Person
Name:
<Head of Department>
Title:
Telephone Number:
E-mail Address:
Fax Number:
Sign and date:
Page 6 of 11
DRAFT VERSION
6TH OCTOBER 2009
Principal Contact Person:
1st Recipient of information
For implementing findings of legionellosis Risk Assessment and
written control scheme. Deputy Responsible Person
<Chief Technician/Safety Officer>
Name:
Title:
Telephone Number:
E-mail Address:
Fax Number:
Sign and date:
1st Deputy Contact:
The person with delegated responsibility for implementation of the
written control scheme. Deputy Responsible or Competent Person
Name:
<Technician>
Title:
Telephone Number:
E-mail Address
Fax Number
Sign and date:
Building or Site Competent
Persons
Page 7 of 11
DRAFT VERSION
6TH OCTOBER 2009
Section 4.
RISK ASSESSMENT GUIDELINES
The risk assessments must address the following as a minimum:
1) There must be a detailed list of nominated authorities with names, job title and contact
information to include: duty holder (Head of School or Directorate), statutory nominated
responsible person, deputy nominated responsible/competent person, those who have
duties to control, outside contracted services and others related to water
hygiene/maintenance. The risk assessment must consider division of responsibilities.
2) Define the scope/exclusions of the Risk Assessment
3) The risk assessment is to consider the risk factors in the causal chain.
4) The risk assessment is to consider the potential of the system to become contaminated with
Legionella. Water source and quality airborne contamination potential. For most systems it
should be assumed that the system will become contaminated with Legionella, but there will
be specific factors that may increase that likelihood.
5) The risk assessment is to consider the potential for Legionella multiplication and hazards: Water temperature that promotes growth
 WRAS unapproved items were possible
 Inappropriate fittings
 Contravention of the Water Supply (Water Fittings) Regulations 1999
 Sources of nutrients and other organic contaminants
 Stagnation/dead legs/dead ends
 Control measures and their appropriateness and effectiveness
a. Chemical water treatment
b. Temperature control
c. Disinfection and cleaning regimes
d. Flushing of little used outlets
6) The risk assessment is to consider potential hazards for the release of aerosols:  Spray, splash and bubbles escaping through water surface
 Normal and abnormal use
 Engineering control measures such as drift eliminators, enclosures etc.
7) The risk assessment is to consider potential hazards for exposure of people to aerosols:  Location of equipment
 Numbers of people likely to be exposed
 Likely susceptibility of exposed population
8) The risk assessment will include references to sources of information e.g. on site
assistance by site familiar personnel.
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DRAFT VERSION
6TH OCTOBER 2009
9) The risk assessment will include a detailed description of the system(s) being assessed
including existing monitoring and water treatment provisions where applicable.
10) The risk assessment will include a comprehensive asset detail of plant and distribution
services, and include:  Condition
 Water temperature
 Compliance with current guidelines
 Areas of low or intermittent use
11) The risk assessment must identify risk factors and prioritise appropriate remedial action
according to severity
12) The risk assessment must include review records of monitoring data including those taken
as part of the assessment process: 


Temperature records of every outlet and vessel
Microbiological analysis if appropriate
Photographs (to be taken of as visual defects i.e. dead ends, dead legs, and incorrectly
fitted items. Also of all applicable plant i.e. calorifiers, cisterns, instant water heaters etc)
13) The risk assessment must include schematic system diagrams including showing areas of
concern i.e. areas out of use, in CAD electronic format (Autocad LT 2006) with a key or
legend as well as reference to as-installed drawings for new installations and their storage.
14) The risk assessment will include recommendations for the written scheme.
15) The risk assessment will identify other H&S issues such as COSHH., manual handling,
access etc and refer to safety data sheets for existing chemicals in use on the system(s).
16) The risk assessment must record training records and identify the need for refresher
courses or those that require training. This includes the details of the assessor.
17) The level of risk must be demonstrated clearly and explained in an uncomplicated manner
in order to understand the calculations or method used.
18) A bibliography is required.
Page 9 of 11
DRAFT VERSION
6TH OCTOBER 2009
Section 5.
FLUSHING EXAMPLE LOG SHEET
CARDIFF UNIVERSITY
Estates
Division
Legionellosis Management & Control Log-Books
School - Area / Section Outlet Flushing
Data Sheet [ Flushing required weekly. More frequently in clinical areas ]
Section 6.
School
Responsible
Person
Building
Section 7.
Date:
Room No.:
Type of
outlet:
Comments
Flushers
Signature
School RP
Signature
Action by School Responsible Person:
Completed Pro Forma to be forwarded to Departmental Responsible Person and filed in Department Log
Book
Page No.
Page 10 of 11
DRAFT VERSION
6TH OCTOBER 2009
Section 8.
FLUSHING EXAMPLE METHOD STATEMENT
LOW USE OUTLET FLUSHING - METHOD STATEMENT
Operative
1. Identify the location that requires flushing from the log sheet.
2. Determine how long outlet flushing is required from the log sheet.
3. Determine the type of outlets at the location. This will normally be hot and cold taps and
(sometimes) a shower.
Flushing
Whilst flushing take the following steps to minimise the risk of inhalation of water droplets:

If there are taps and a shower at the location always flush the taps first

When running taps minimise spray and water droplets by not running the taps too fast.
When flushing a shower take some or all of the following precautions, as appropriate, to minimise the
risk of inhalation of water droplets:
o
Close the cubicle door or curtain whilst the shower is running.
o
Remove the shower head from its holder and place it in a bucket at low level.
o
Remove the shower head and run the water straight from the hose.
o
Place a bucket directly under the shower head and run the outlet.
o
Place a shower curtain over the shower head and allow the water to run into the base of
the shower
I have received information regarding the procedure detailed above and understand the need to
adhere to it all times:
Name (Staff Member):
Dated:
Signed (Staff Member):
Dated:
Signed (Manager):
Dated:
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DRAFT VERSION
6TH OCTOBER 2009