Legionella Control Management Plan

Sandy Lane Nursery and Forest School

“Nurturing curiosity and inspiring imagination”

DOCUMENT STATUS

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Risk and Resilience Team

Legionella Control Management Plan

WARRINGTON BOROUGH COUNCIL

ASSISTANT CHIEF EXECUTIVES

PARTNERSHIPS AND PERFORMANCE

RISK AND RESILIENCE TEAM

POBOX 13

4TH FLOOR QUATTRO/NEW TOWN HOUSE COMPLEX

BUTTERMARKET ST

WARRINGTON

WA1 1JN

December 2012

3

Contents Page Page Number

Note

This Legionella Control Management Plan may be adapted by Directorates and Schools if appropriate add to this information to complement specific guidance, standard operating procedures and systems of work relevant to the control of Legionella in their activities.

1. Legionella Control Management Plan

Legionella Control Plan For

(Insert name of premises)

Sandy Lane Nursery and Forest School

Revision No.

(Insert number)

3

Annual Review Due

(Insert date)

May 2015

Legionella Logbook filed at

(Insert details of where the logbook is located)

Sandy Lane Nursery and Forest School Front Office (maintenance officer’s filing cabinet)

Legionella Survey and Risk Assessment filed at

(Insert details of where the Survey/risk assessment is located)

Sandy Lane Nursery and Forest School (maintenance officer’s filing cabinet (corridor entrance))

Management of the Risk of Legionella

Each identified level within the management structure will be trained to an appropriate level

Arrangements for Controlling the Risk from Legionella Infection

Arrangements

Every two years, Building Services,in combination with the Estates Department, will arrange a formal risk assessment for ALL identified premises, where Warrington Borough Council (WBC) has a statutory responsibility for the control of water borne bacteria (Legionella). In premises where WBC is the tenantand employs staff, this responsibility MAY fall to the landlord; Estates & Valuation has responsibility to monitor these lease arrangements. Assistant Directors/Premise Managers must confirm these arrangements in premises they use.

Where risk assessments are required, a specialist contractor accredited by the Legionella Control Association will be engaged by Building Services to undertake Legionella risk assessments. This two-yearly risk assessment is the basis of the corporate management strategy and is currently (2011/2012) funded centrally via the Building Maintenance Programme (BMP).

The specialist approved contractor will provide via the risk assessment a written scheme of monitoring (referred to in this guide as “management controls”), identify and prioritise any remedial works and offer guidance on emergency shut down procedures, to ensure that, as far as reasonably practicable, the risk from Legionella is controlled within a premise.

Weekly flushing

Where weekly flushing of rarely used outlets is identified in your premise a record of flushing should be maintained on site. Options to remove such outlets should be explored e.g. removal of fire hose reels and bib taps and dead legs(subject to the availability of funding, Building Services can commission contractors to carry out such removal work if requested to do so).

However if these rarely used outlets remain, it is the responsibility to manage and record flushing. The Premise Manager to ensure that operative training is provided for the “Appointed Person” to enable them to complete the flushing regime for the premise.

The Appointed Person to work under the direction of the Premise Manager, this will involve the monitoring / flushing to complement the contractors control measures and they must ensure that all records are maintained for the audit trail.

• Weekly flushing of rarely used outletsis required at this site

Record Keeping

The Premise Manager/Deputy must ensurethat appropriate records are kept and retainedthroughout the period for which they remain current and for at least five years after.

The Premise Manager should ensure that all precautions continue to be undertaken and that adequateinformation is available including a record of the assessment, precautionarymeasures and treatments should be kept. All records should be signed by the responsible person performing the various tasksassigned to them.

The control of Legionella is achieved by the application of a consistent system of preventative measures. In the event of an outbreak (the cause may be due to a breakdown in those control measures or the management system monitoring them). In the event of an outbreak it would be essential to prove all efforts had been made to prevent the outbreak, this would only be successfully achieved by producing a fully documented record of all control measures undertaken in that premise. Details of the management plan, risk assessments, monitoring, remedial work, adjustments or improvements carried out must be recorded, available and current.

Defects

WBC’s contract with the specialist approved water hygiene contractor will, if requested, rectify minor, easily resolved defects, eg, adjusting thermostats at the time of the water hygiene risk assessment or monthlyinspection. The contractor will bring all defects to the attention of the Premise Manager/Deputy Manager or appointed person immediately after inspection and place the written inspection report in the on-site Legionella logbook, this information will also be provided to Building Services.

Following the water hygiene risk assessment, the specialist approved contractor may recommend management controls and may also recommend any remedial works required to eliminate or reduce a risk within the water system (e.g. removal of redundant pipe work).

Remedial Works

1. The Building Services Team is to be made aware of the need for remedial works via regular remedial reports from the approved contractor. However, these reports are compiled and issued weekly, up to a month in arrears, but are subject to being costed which may take a period of time from the initial visit.It is therefore essential that Premise Managers read, understand and act upon all Legionella reports upon their immediate issue and receipt.
2. Premise Managers, supported by their Assistant Director, must decide whether to take immediate action in response to identified remedial works which may include, for example, commissioning remedial work via Building Services.
3. Premise Managers must consider the benefit of the remedial works in reducing the hazard and consequent management controls.

Important Note:

• Some remedial works can routinely be substituted by management controls.
• Even when remedial works are carried out, management controls will still be required.

Emergency Procedures (Premise Specific)

If defects are identified via monthly monitoring, the Premise Manager should assess the urgency of the issue based on their own training and the specialist approved water hygiene contractor’s recommendation. If it is deemed a high-risk, the Premise Manager should immediately consult with the Assistant Director.

If a system is considered high risk or infected, it is essential to have documented emergency procedures for isolating the suspect systems. This will involve managing the controlled isolation/shut down/disinfection to prevent any aerosol. Effective communication to the relevant building staff, throughout WBC management structure is vital and also the control of information to the media.

It is important to note that simply ‘turning the system off’ may result in an uncontrolled release of an infected aerosol. A documented, competent shut down procedure is necessary for each water system; guidance on safe and effective isolation of a system can be sought from the specialist water hygiene contractor.

Situations may also develop via local enquiries by Environmental Health officers investigating a suspected outbreak.

If an outbreak is suspected, these are usually investigated by an Outbreak Control Team whose purpose is to protect public health and prevent further infection, the Health and Safety Executive (HSE) or the local Environmental Health department may also be involved in investigating compliance with health and safety legislation.

In the event of an outbreak contact the Development and Public Protection Services

Tel: 01925 442645 Fax 01925 442564

Advice should also be sought from the specialist contractor and Assistant Director. The Risk and Resilience Team Health Safety (tel 442174) should also be informed.

Training

Premise Managers/Deputies and appointed persons who carry out the control measures andstrategies for Legionella should be suitably informed, instructed and trained, ensuring that tasks undertaken are performed in a safe and technically competent manner. Training must impart a detailed understanding of Legionella, how to manage the water system, how to keep records and how to resolve identified hazards.

Levels of training must be reviewed by Assistant Directors (ideally with links to the PRD process) as part of the annual management review and should ensure competency, with refresher training undertaken every three years, all records of all initial andrefresher training must berecorded and maintained. Training is an essentialelement of competence; it is not the only factor and should be viewed as a product of sufficient training, experience, knowledge and other personalqualities which are needed to undertake a job safely. Competence is dependenton the needs of the situation and the nature of the risks involved.

Water hygiene training is undertaken at St Werburgh’s Development Centrethose undertaking / completing the course would be considered competent to undertake the roles relating to Legionella management

When a competent system of controls is implemented in a premise, training at a level sufficient to enable any named individual to perform their tasks must be provided to the following people, arranged and funded by the relevant Assistant Director:

• A named Premise Manager (and Deputy) with the delegated responsibility of managing the water system(s) on the premises;
• The appointed person who will carry out the identified checks (if required).

Details of training are available from St Werburgh’s Development Centre on 01925 458100, information is also available on the intranet under People and Improvement, click on Employment, learning and skills and then click on Personal Development Centre.

Annual Review

The Assistant Director should review arrangements with the Premise Managers/Appointed Persons for managing Legionella on an annual basis.

The review should aim to confirm that documented procedures are being implemented on the ground and that contractors are performing as required. Importance should be attached to reviewing and comparing the service premise list with the Corporate Premises List, maintained by Estates & Valuation (E&V) to capture changes to premises, water systems or usage which should have been identified during the year.

Note: A full Legionella re-assessment is required when

1. The building system has changed.
2. The building use has significant change.
3. When information about risk or controls are updated.
4. When regular monitoring indicates a breakdown of control measures

Escalation

It is important to escalate to your line manager any issues that you are concerned about regarding the control of Legionella. Should your line manager / Head teacher is not be available in a timely manner, then ensure the matter is reported to your Assistant Director.

YOU MUST TAKE ACTION IF THERE IS A PROBLEM

Further information, advice and guidance

Detailed guidance can be found on the intranet in the Risk and Resilience Health and Safety section;

Health Safety & Welfare Guidance

Standard Operating Plan SOP01 The Control of Water Borne Bacteria, particularly Legionella in Civic Buildings

Standard Operating Plan SOP02 The Control of Water Borne Bacteria, particularly Legionella in Schools

Control of Legionella bacteria in water systems (L8) HSE

Advice can also be obtained from:

Specialist Legionella Contractor (as per the Water Hygiene Monitoring log book)

Manchester Working Specialist Services Group; Tel 0161 277 6345; Fax 0161 277 6364

Building Services

Mechanical & Electrical Team Leader Tel: 01925 442567 or Maintenance Manager Tel: 01925 44506

Warrington Borough Council’s Risk and Resilience Team Health and Safety

Tel: 01925 442174, 442039 and 442169.

APPENDIX 1

TAP TURNERS

• Eg Taps, WCs, Showers, Specialist Baths, Unoccupied areas, etc
• Flush all rarely used hot and cold water outlets for at least 2 minutes to remove any stagnant water in the system. Use agreed flushing method to minimise any spray produced

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