Page 1


Responsible Directorate:


Responsible Director:

Director of Public Health

Date Approved: Committee:

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Section 1. 2. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Page Policy Statement Introduction Associated policies and procedures Aims and Objectives Scope of Policy Accountabilities and responsibilities Risk Assessments Equality Impact Assessments Training needs Monitoring Policy Compliance References

3 3 3 3 4 4 5 5 6 6 6

Appendices A B C D E

Background and procedural notes Key Stakeholders consulted/involved in the development of the policy/procedure Equality Impact Assessment Tool Action required in the event of an outbreak of Legionnaires’ Disease Guidance note for flushing outlets

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7 16 17 18 20

Policy Statement NHS Kirklees will ensure that all water systems within premises operated by the organisation are managed in accordance with the relevant guidance to reduce the risk of infection and burns/scalds from the systems



This policy has been formulated to ensure that there are correct management of water services and water temperatures within NHS Kirklees premises. Current statutory legislation:          

Health and Safety at Work Act 1974. The Management of Health and Safety at Work Regulations 1992. Water Supply (Water Quality) Regulations 2000. Water Supply (Water Fittings) Regulations 1999 HSC Approved Code of Practice L8 Food Safety Act 1990 (incl Temperature Control Regulations 1995 and General Food Hygiene Regulations 1995) Public Health (Infectious Diseases) 1988 Control Of Substances Hazardous to Health (COSHH) Regulations 2002 BS 6700 BS 1710:1984

This legislation requires both management and staff to be aware of their individual and collective responsibilities, for the provision of safe hot and cold water supplies, storage and distribution systems in healthcare premises. A risk assessment should be carried out by a competent person, who is a member of the Legionella Control Association’s, Approved list of Contractors. Compliance with procedures by all staff is continuing and not notional. 2.

Associated policies & procedures

This policy should be read in accordance with the following Trust policies, procedures and guidance:      3.

Records Management Policy Incident Reporting Health and Safety Policy Maintenance Policy Legionella Guidance document for unused/infrequently used outlets See Appendix E Aims and objectives

The aim of this policy is to recommend a system of water management which when fully implemented, will ensure that all the water systems used in NHS Kirklees properties are maintained in a safe and reliable condition, along with a full record of modifications, alterations, tests and remedial actions. Page 3 of 22


Scope of the policy

This policy must be followed by all NHS Kirklees, Locala CIC and KIER/MITIE employees who are involved with the management or use of Water Systems It must be followed by all staff who works for NHS Kirklees including those on temporary or honorary contracts, bank staff and students. All contractors who undertake work on the NHS Kirklees properties must adhere to the relevant procedures within the policy Breaches of this policy may lead to disciplinary action being taken against the individual. Independent contractors are responsible for the development and management of their own procedural documents and for ensuring compliance with relevant legislation and best practice guidelines. Independent contractors are encouraged to seek advice and support as required. 5.

Accountabilities and Responsibilities

The Chief Executive is responsible for the Trust wide implementation of this policy. The Chief Executive has delegated the day to day responsibility for the management of Water Systems to the Director of Public Health. The overall responsibility for the maintenance and quality of Water Systems, as defined in HTM 04/01, is Control of Infection or Consultant Microbiologist. The Chief Executive has delegated the day to day responsibility for the Maintenance of Properties and Services to the Executive Director (Finance and Efficiency) The Executive Director (Finance and Efficiency) will appoint (on behalf of the Chief Executive) a Designated Officer who must have relevant experience to ensure all aspects of this policy are implemented, monitored and recorded by the various Service Providers. This person to be the Acting Director Health Property Management (HPM). All Facilities Management service providers will notify the PCT of their Nominated Person, Responsible Person and Competent persons as defined in HTM 04/01 Service providers commissioned by NHS Kirklees and NHS Kirklees service managers are responsible for the implementation of this policy and procedure within their respective sites. The infection prevention and control team must inform the FM service provider (KIER or MITIE) help desk and health protection management of any suspected breach of this policy and complete an incident report. All personnel involved in commissioning new buildings, major refurbishment, upgrades, department closures or re-commissioning which involves the introduction of new water services, disruption and cutting into water services must fully comply with this policy at all stages of the project/contract. All materials used in the construction of systems must comply with water supply (water fittings) Regulations 1999 – Regulation 4: Requirements for water fittings.

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6. Risk Assessments A risk assessment must be carried out to identify and assess the risk of legionellosis from water systems. The purpose of the assessment is to identify: -

risk to health, the potential for harm to health from exposure is reasonably foreseeable unless adequate precautionary measures are taken measures for prevention, or adequate control to minimise the risk from exposure to legionella, should be taken.

All modifications, alterations and new installations must comply with the Water Supply (Water Fittings) Regulations 1999. Given the need to ensure items are correctly installed all details should be forwarded to the Responsible Officer (RO) for comment prior to any work being carried out. The RO will check planned works for compliance with current regulation and for legionella risk. The legionella risk includes both risk posed to the system by alteration/modification and by any item installed. The Health and Safety Commissions Approved Code of Practice and Guidance document L8 requires there is a written scheme for controlling legionella in water systems. The type of work included in this will be the installation of:            

New basins/bath/showers Water storage tanks Shower boost pumps Domestic base exchange water softeners Dishwashers Washing machines Bed pan washers and macerators Jacuzzi/whirlpool baths Water features Dental equipment Mains fed water coolers Drinks machines

The above list is not exhaustive, all items plumbed into the mains cold water, domestic tank fed cold water or hot water supplies should be considered. The following must be considered given their potential to affect the risk assessment:  

The removal of basins/baths/showers Modification/changing of existing water services.

Users of water systems must ensure that unused or infrequently used outlets within departments are identified and measures are in place to flush these outlets as per the guidance document 7. Equality Impact Assessment All public bodies have a statutory duty under the Race Relation (Amendment) Act 2000 to “set out arrangements to assess and consult on how their policies and functions impact on race equality.” This obligation has been increased to include equality and human rights with regard to disability age and gender. The Trust aims to design and implement services, policies and measures that meet the Page 5 of 22

diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. In order to meet these requirements, a single equality impact assessment is used to assess all its policies/guidelines and practices. This policy was found to be compliant with this philosophy (see appendix C). 8. Training Needs Analysis All personnel involved in maintaining services, altering or monitoring the PCT’s water services must be trained in all the latest relevant updates:   

Department of Health, Health and Safety Executive or any other relevant bodies. Manufacturers/technical training

Records of this training must be maintained. In order to ensure that policies, guidelines and protocols are introduced and work effectively, there is a need to provide adequate training and instruction. It is the responsibility of commissioned providers to ensure training of their staff is undertaken and recorded. It is the responsibility of facility management service providers to ensure their staff and contractors receive adequate training 9. Monitoring Compliance with this policy The policy will be monitored as part of the NHS Kirklees Infection Control Committee 10. References Department of Health 2006 HTM 04-01 The Control of Legionnella, hygiene, “Safe“ hot water, cold water and drinking water systems Part A: Design, installation and testing. HMSO London Department of Health 2006 HTM 04-01 : The Control of Legionnella, hygiene, “Safe” hot water, cold water and drinking water systems. Part B : Operational Management HMSO London. Health and Safety at Work Act 1974 HMSO London The Water Supply (Water fittings) Regulations 1999 Statutory Instrument 1999 No 1148 HMSO London. Health and Safety Commission Approved code of practice, Legionnaires Disease: the control of legionnella bacteria in water systems (L8) 2000. Health and Safety Executive London The Control of Substances Hazardous to Health Regulations 2002. Statutory instrument 2002 No 2677 HMSO London. The Management of Health and Safety at Work Regulations 1992. Statutory Instrument 1992 No 2051 HMSO London The Water Supply (Water quality) Regulations 2000. Statutory Instrument 2000 No 3184 HMSO London Page 6 of 22

APPENDICES Appendix A Background and Procedural Notes BACKGROUND Source of the bacteria Legionella bacteria are ubiquitous, surviving and multiplying in water. They are widespread in natural fresh water including rivers, lakes, streams and ponds and may also found in wet soil. Airborne dispersal may occur when water droplets are created. There is a strong likelihood of very low concentration of the bacteria existing in all open water systems including those of building services. The risk is related to the number and types of legionella in the water at the point of use. Legionella have been shown to colonise certain types of water fitting, pipe work and material used in the construction of water systems. Water quality can deteriorate in mixing valves, particularly when utilisation is low, because the mixed water can then become stagnant at a temperature favored by pathogens such as legionella. The presence of sediment, sludge, scale and organic material provides a good nutrient source for legionella. Evidence suggests that the presence of iron oxide (rust) also favors the growth of the organisms. Commonly-encountered organisms in water systems such as algae, amoebae and other bacteria serve as an additional nutrient source for legionella bacteria. Algae slime provides a stable habitat for multiplication and survival. Whilst exposure to direct sunlight may inhibit the growth of legionella bacteria, it does stimulate growth of algae and the formation of slimes. Legionella bacteria have also been shown to proliferate rapidly in association with some water-borne amoebae stagnant water encourages colonisation. The risk of healthcare-associated legionellosis depends on a number of factors such as: 

The presence of legionella in sufficient numbers.

Conditions suitable for multiplication of the organisms, for example temperatures between 20˚C and 45˚C and stagnant water.

A source of nutrients, for example sludge, scale, rust, protozoa, algae and other organic matter.

A means of creating and disseminating reparable droplets, for example cooling towers, showers and most other water draw-offs that are capable of creating a spray or causing splashing.

The presence of people who may be exposed to contaminated aerosols, especially those who are vulnerable to legionella infection, for example those with compromised immune or respiratory systems, and transplant patients. Page 7 of 22

Route of Infection The principal route of infection is through inhalation of the bacteria into the lungs. The risk rises with increasing numbers of inhaled bacteria. Aspiration of contaminated drinking water into the airways has also been described as a mode of transmission of legionnaires’ disease. Facts around legionella bacteria: Water Temperatures 20-45˚C optimum laboratory temperature for growth 37˚C PH: 6.9 Conditions: Water Iron Darkness Stagnation Travel: 500m in Air + possibly up to 2-3 miles if all conditions are in place. It is uncommon to find proliferation of bacteria below 20˚C and legionella do not survive for long above 60˚C. Legionella remain dormant in cool water, only multiplying when the temperature reaches a suitable level. Legionella exists in natural water sources and silts; outbreaks are often associated with soil disturbances and have a seasonal pattern associated with mild weather conditions. Infection is considered to have been acquired by inhalation of stale water droplets carrying the bacteria. The organism multiplies in the lungs and may spread to all parts of the body. The following may be present : Muscle pain High fever Aching joints Double or blurred vision Tremors Mental confusion Dry racking cough The incubation time following exposure to an aerosol containing live colonies of legionella can be as little as three days or as long as twenty-one days in extreme cases. Factors which increase susceptibility: Increasing age, particularly above 50 years (Children are rarely infected). Page 8 of 22

Sex: Males are three times more likely to be infected than females. Existing respiratory disease, which makes the lungs more vulnerable to infection. Illnesses such as cancer, diabetes, kidney disease or alcoholism, which weaken the natural defenses. Smoking, particularly heavy cigarette smoking. Patients on renal dialysis or taking immune-suppressant drugs, which inhibit the body’s natural defenses against infection. PROCEDURAL NOTES There is a legal requirement to protect and preserve the safety of staff, patients and the public. The PCT and commissioned service providers will ensure procedures are in place to satisfy this legal requirement Documentation It is essential to have comprehensive operational manuals for all items of plant that include requirements for servicing, maintenance tasks and frequencies of inspection. This information should be filed safely with all commissioning data. Documentation should also be drawn up as part of the health and safety file for the building. Record-keeping Management should ensure that an accurate record of all assets relating to the hot and cold water distribution systems is set up and regularly maintained, with records of all maintenance, inspection and testing activities kept up-to-date and properly stored. Records should be kept for at least five years. Hot Water Services Domestic hot water systems have been shown to be one of the most common sources of legionella bacteria. It is for this reason that the storage temperature should be set to 60˚C and the minimum temperature of all return legs to the vessel or water heater should be 50˚C. Actions should be taken to prevent warm water entering the cold feed line which may lead to conditions conducive to colonisation by legionella. The risk of scalding is a particular problem in healthcare premises, therefore thermostatic mixing devices will be required for hot water outlets. A risk assessment will be necessary to establish the type of device to be installed. The Health and Safety Commission’s (2000) Approved Code of Practice L8 permits a period of one minute to achieve an equilibrium temperature of 50˚C. A minimum of 55˚C may be required for the operation of suitable mixing devices required to provide “safe” hot water at the upper limit of the recommended range. Hot water at 55˚C is required in many cases for reasons of food hygiene or decontamination requirements, for example in kitchens and sluice rooms. In a well Page 9 of 22

balanced hot water circulating system, with the circulation taken close to the draw-off point, achieving temperature should be instantaneous. Temperature testing Tests should be performed prior to bringing the system into use to confirm the appropriate temperatures are achieved. Flushing All hot water outlets should be assessed for usage and if under utilised or unused outlets flushed at least twice weekly (see appendix E) Showers Showers with fixed heads are preferred for the prevention of backflow. Shower heads which have a means of adjusting the flow of water will exacerbate stagnation problems. Showers usage should be assessed and if under utilised or unused these should be flushed at least twice weekly.(See appendix E) Flushing Prior to systems being used a thorough regimen of flushing before disinfection must be carried out. Disinfection Before undertaking chemical disinfection, Health Property Management and the Infection Prevention and Control Team should be consulted. When considering a contractor to carry out any work, companies who are members of the Legionella Control Association must be utilised. The COSHH Regulations require that a risk assessment is undertaken before any product is utilised. This must be undertaken prior to the use of any disinfectant. Cold Water Services The Health and Safety Commission’s (2000) Approved Code of Practice L8 permits a period of two minutes to achieve an equilibrium temperature below 20˚C. Achieving this minimum requirement would be indicative for an exceptionally under-utilised water system in an unoccupied building. During commissioning, therefore, it is essential to encourage draw-off to simulate normal usage. The control of water temperature in the cold water service will essentially rely on good insulation and water turnover. Cold water services should be sized to provide to sufficient flow and should be insulated and kept away from areas where they are prone to thermal gains. Stagnation must be avoided.

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Water storage should be designed to minimise the time in the cistern, and maximise turnover of water to avoid stagnation and deterioration of water quality. All cold water – distribution pipe work, mains and cistern down feeds should be located to minimise heat gains from the environment. Pipe work should not be routed through hot ducts or run adjacent to heat sources. The water supply (water quality) regulations permit cold water to be delivered at temperatures up to 25˚C, in normal circumstances the temperature will be below 20˚C Flushing All cold water outlets (including WC’s) should be assessed for usage and if under utilised or unused flushed at least twice weekly (see appendix E) Prevention of Contamination In all cold water installations it is important that adequate protection is provided to all supplies against backflow. Water use in healthcare premises where backflow is likely to be harmful to health includes dental spittoons and equipment, bed pad washer, bidets, water outlets in laboratories. Microbiological Sampling Situations where there are taste or odour problems, microbiological monitoring for Total Viable Counts (TVCs) is not considered to be necessary. If monitoring is performed for these purposes, the detection of low TVCs is not necessarily an indication of the absence of legionella, but an indication of the overall water quality. All microbiological monitoring should be by approved methods and carried out in a United Kingdom Accredited Service (UKAS) laboratory. Tests for temperature performance Frequency Monthly

Check †Sentinel outlets

Cold water The water temperature should equilibrate below 20˚C after draw-off for 2 minutes 1,2


Inlets to Sentinel Thermostatic Mixing Valves (TMVs)

Temperatures as above


Water leaving and returning to calorifier

Hot water The water temperature should equilibrate to at least 50˚C after draw-off for 1 minute 3 Temperatures as above

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Notes These measurements are applicable to non-mixed outlets only Measurements can be made by means of surface temperature probes Also can be monitored continuously by BMS



In-coming cold water at inlet to building – in the winter and in the summer Representative outlets‡

The water should be below 20˚C 2

The water temperature should equilibrate below 20˚C after draw-off for 2 minutes 1,2

Also can be continuously monitored by BMS The water temperature should equilibrate to at least 50˚C after draw-off for 1 minute 3

† Sentinel outlets are normally those that – on a hot water service – are the first and last outlets on a recirculation system. On cold water systems (or non-recirculating hot water systems), they are the closest and furthermost from the storage tank (or water heater). The choice of sentinel taps should also include other outlets that are considered to represent a particular risk, for example those installed in accommodation in which particularly susceptible patients are treated, others identified in the risk assessment and temperature mapping exercise as having the least satisfactory temperature performance. ‡ Representative outlets include conventional and mixed-temperature taps: all taps checked annually. The Water Supply (Water Quality) Regulations 2000, permits water undertakers to supply water to premises at temperatures up to 25˚C. The water temperature will be below this maximum value, typically below 10˚C in winter and 20˚C in summer. If, during prolonged periods of high environmental temperature, the water temperature exceeds 20˚C, the water undertaker should be asked to see whether remedial action could be undertaken. Within the cartilage of the premises, the aim should be to ensure that the temperature difference between the in-coming supply and most distal parts of the distribution system is below 2˚C. Summary checklist for hot and cold water services Service Task Hot water services Arrange for samples to be taken from hot water calorifiers/water heaters in order to note condition of drain ater Check temperatures in flow and return at calorifiers/water heaters Check water temperature after draw-off from outlets for 1 minute to ensure that 50˚C has been achieved in sentinel outlets Visually check internal surfaces of calorifiers/water heaters for scale and sludge Check representative taps for temperature as above on a rotational basis Manual check to confirm secondary hot water recirculation pumps are operating effectively Page 12 of 22

Frequency Annually

Monthly Monthly



Cold water services

Mixed-temperature outlets Showerheads Sporadically-used outlets

Check tank water temperature remote from in-coming ball valve and mains temperatures. Check temperature in sentinel outlets after draw-off for 2 minutes to establish that it is below 20˚C Visually inspect cold water storage tanks and carry out remedial work where necessary. Check representative taps for temperature, as above, on a rotational basis Check delivery temperature in accordance with DO8 Dismantle, clean and descale showerheads and hoses Flush through and purge to drain, or purge to drain immediately before use without release of aerosols

6 monthly



6-monthly Quarterly, or as necessary At least twice weekly (see appendix E)

1. For effective operation of hot water services, the minimum equilibrium temperature should be 55˚C and be achieved within seconds. 2. For thermostatic mixing devices, temperatures should be measured at the inlet. 3. For satisfactory operation of cold water services, the outlet temperature within one minute should be below 20˚C. 4. Temperatures should be continuously monitored by the BMS where fitted. 5. Risk assessment may indicate the need for frequent flushing of outlets. It is preferable that this forms part of the daily cleaning routine where appropriate. Alternatively, self-purging showers that discharge water to a drain prior to use and without the release of aerosols can be considered. Testing for legionella Legionella can exist within many systems at extremely low levels or below the threshold of accurate detection (100 cfu/L). Up to now, in the absence of evidence of healthcare associated infection, testing (which is complex and expensive) has not been considered necessary. Health property management in consultation with infection prevention and control will need to consider the level of risk before deciding that legionella testing is required. For example, testing may be required: 

when storage and distribution temperatures do not achieve those recommended under the temperature control regimen and systems are treated with a biocide regimen, a monthly frequency of testing for legionella is recommended. This may be reduced as confidence in the efficacy of the treatment regimen is established. Page 13 of 22

in systems where the control regimens are not consistently achieved, for example temperature (weekly checks are recommended until the system is brought under control).

when an outbreak is suspected or has been identified.

on hospital wards with at-risk patients – for example those who are immuno-compromised.

As a minimum, samples should be taken as follows: 

from the cold water storage and the furthermost outlet from the tank.

from the calorifier flow, or the closest tap to the calorifier, and the furthermost tap on the hot water service circulating system.

additional samples should be taken from the base of the calorifier where drain valves have been fitted.

additional random samples may also be considered appropriate where systems are known to be susceptible to colonisation.

The sampling method for legionella should be in accordance with ISO 11731:2004. A UKASaccredited laboratory that takes part in the Health Protection Agency water external quality assessment (EQA) scheme for the isolation of legionella from water should test samples. Action following legionella sampling in hot and cold water systems: Legionella bacteria (CFU/L) >100 but <1000

Action required If only one or two samples are positive, system should be resampled. If a similar count is found again, a review of the control measures and risk assessment should be carried out to identify any remedial action to be taken. Or:


If the majority of the samples are positive, the system may be colonised with legionella. Disinfection of the system should be considered, but an immediate review of control measures and risk assessment should be carried out to identify any other remedial action required. The system should be resampled and an immediate review of the control measures and risk assessment should be carried out to identify any remedial action, including possible disinfection of the system. Retesting should take place 48 hrs after disinfection and until a satisfactory level of control has been achieved. Unless advised by infection prevention and control this will be after two clear samples have been achieved.

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Disinfection Before undertaking chemical disinfection, health property management and the infection prevention and control team should be consulted. When considering a contractor to carry out the work, companies who are members of the legionella Control Association should be utilised. The COSHH Regulations require that a risk assessment is undertaken before any product is utilised. This must be undertaken prior to the use of any disinfectant.

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Appendix B - Key stakeholders consulted/involved in the development of the policy/procedure

Stakeholders name and designation Acting Director HPM Head of Capital HPM Deputy Director Infection Prevention and Control Hotel Services Manager HPM Contract Manager (KIER) Policy Developments Group Kirklees Infection Control Committee

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Key Participant Yes/No Yes Yes Yes

Feedback requested Yes/No Yes Yes Yes Yes Yes Yes Yes

Feedback accepted Yes/No


Appendix C - Equality Impact Assessment Tool To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. Insert Name of Policy / Procedure Management of Water Systems and Control of Legionella 1.


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


 Ethnic origins (including gypsies and travellers)


 Nationality


 Gender


 Culture


 Religion or belief


 Sexual orientation including lesbian, gay and bisexual people


 Age


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



Is there any evidence that some groups are affected differently?



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



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



If so can the impact be avoided?



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



Can we reduce the impact by taking different action?


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APPENDIX D ACTION IN THE EVENT OF AN OUTBREAK OF LEGIONNAIRES’ DISEASE 1. Legionnaire’s Disease is notifiable under the Health Protection Legislation (England) 2010 2. The Health Protection Agency defines an outbreak as two or more confirmed cases of legionellosis occurring in the same locality within a six-month period. Location is defined in terms of the geographical proximity of the cases, and requires a degree of judgment. It is the responsibility of the “proper officer” for the declaration of an outbreak. 3. The local authority has an established incident plan to investigate major outbreaks of infectious diseases such as legionellosis. These are activated by the proper officer, who evokes an outbreak control group; the primary purpose is to protect public health. This will normally be convened to manage the incident and will involve representatives of the agencies involved. The Health & Safety Executive (HSE) or the local Environmental Health Officer (EHO) may be involved in the investigation of outbreaks, the aim being to pursue compliance with health and safety legislation. 4. The Local Authority, Consultant in Communicable Disease Control (CCDC) or Environmental Health Officer (EHO) acting on the behalf of CCDC (often with the relevant officer from the enforcing authorities – either HSE or the local authority) will conduct a visit to the premises. 5. As part of the outbreak investigation, the enforcing authority may make the following requests and recommendations: a. to close down any processors that are capable of generating and disseminating air-borne water droplets and require shut down until sampling procedures and any remedial cleaning or other work has been done. Final clearance to restart the system may be required. b. to take water samples from the system before any emergency disinfection is undertaken. This will help identify the cause of illness. The investigating officers from the local authority will take samples, or require them to be taken. c. to provide staff records to discern whether there are any further undiagnosed cases of illness, and to help prepare case histories of the people affected. d. to cooperate fully in an investigation of any plant that may be involved in the cause of the outbreak. This may involve, for example (i)

tracing of all pipe work runs;


detailed scrutiny of all operational records;


statements from plant operatives and managers;

(iv) statements from water treatment contractors or consultants Any infringements of relevant legislation may be subject to a formal investigation by the appropriate enforcing authority.

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Emergency cleaning and disinfection of water system If a water system, other than a cooling system, is implicated in an outbreak of legionnaireâ&#x20AC;&#x2122;s disease, emergency treatment of that system should be carried out as soon as possible. COURSE OF ACTION IF AN OUTBREAK OF LEGIONNAIRES' DISEASE IS SUSPECTED Health Property Management must be informed of any suspected outbreak of Legionnaires Disease by a member of the infection prevention and control team/committee. If an outbreak is suspected, then an outbreak incident control group will be convened with representation from the Public Health Laboratory and the local Medical Officer for Environmental Health to search for the source of the causative organism. This search is a specialist task which involves epidemiological studies and taking water samples for analysis. The Health and Safety Executive may be involved in the investigation of outbreaks under the Health and Safety at Work Act 1974. Local Authority Environmental Health Officers may also be involved. Note; It is essential that the Engineers do not drain or disinfect the systems before samples have been taken. The Engineers role is an important one - guiding specialists to the various water systems within the building, and, in particular, to the points from which samples can be taken. Easy access to these sampling points is essential. An investigation would concentrate upon all potential sources of legionella infection including: i. ii. iii. iv. v. vi. vii.

the domestic hot and cold water system distribution; showers or spray washing equipment; drainage systems and taps; whirlpool baths or therapy pools; humidifiers in ventilation systems; cooling coils in air conditioning systems; fountains and sprinklers;

To assist in such investigations the engineers will need to be able to provide details of all associated equipment, its location, technical data, the operating, and maintenance and spares information on all the above installations. Engineers must assist by advising the investigating team the extent of servicing on the site and locating taps and sample points. Off-site information will also be required, eg any local excavation or earth moving works; alterations to water supply systems or drainage systems or any other factors which may have a bearing on the site. The outbreak incident control group is responsible for identifying the cause of infection and will advise on cleaning, disinfection, any modifications and long-term control measures required.

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Appendix E NHS KIRKLEES DEPARTMENTAL GUIDANCE – WATER MANAGEMENT AND CONTROL OF LEGIONELLA Water systems are a known potential source of legionella bacteria and all water systems must be managed appropriately The minimum precautions that must be taken include: 

Inform the respective Facilities Management Service Provider of any water outlets (taps, showers etc) not in use. These can be disconnected or removed.

Any equipment that stores water should be cleaned/drained/replaced in accordance with manufacturers’ instructions and infection prevention and control protocols.

Seek the advice of Health Property Management and infection prevention and control team before purchasing any equipment that uses water.

Outlets that are not used at least once a week and cannot be removed should have all sources of water "run off" for at least three minutes, twice weekly by the department and documented on the record sheet below. This includes outlets that have been taken out of use on a temporary basis. Reference to the National Standards for Cleanliness indicates that cleaning staff should run the taps on a sink as part of the daily cleaning process. This is deemed adequate for considering the outlet has been run.

The Facility Management Service Provider will arrange for the water in vacant building/departments, to be run off for two minutes twice weekly or drain the water systems.

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NHS KIRKLEES WATER MANAGEMENT INSTRUCTIONS Water Systems and the Prevention and Control of Legionella Guidance. The signatories below have been provided with a copy of the guidance identified above and understand that it is our responsibility to ensure appropriate dissemination and implementation within our areas of responsibility/management PREMISES



Please retain completed records for Audit/Inspection

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WATER DRAW OFF RECORD SHEET All little used or unused water outlets (i.e. hot and cold taps on showers, baths, bidets, sinks, basins, etc.) must be run for at least three minutes on a twice weekly basis. NB: Unused toilets must also be flushed. The drawing off of water must be recorded in the table below. Please retain completed records for audit/Inspection (5 years) Premises_______________________Ward/Dept_________________________ Location of outlet

Water run for 3 mins


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