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Office of the Director of Estates

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To attend all Quarterly Water System Meetings; To act as deputy to the Operations Engineering Manager; To ensure all water system or other legionella risks

Office of the Director of Estates &

    Property Services

POLICY

    TITLE POLICY FOR MANAGEMENT AND CONTROL OF

     LEGIONELLA RISK

    REFERENCE HS 33

Author M D O’Connor

    Status Live

    Last Revised March 2008

    Review Date March 2009 or a Legislation or service change

Other documents to which HSE Document “Legionnaires’ disease. The

    reference should be made control of legionella bacteria in water systems”

    which are fundamental to Approved Code of Practice and Guidance. Code

    this policy L8

    Legionella Procedures

Statement of Intent

    ? The intention of this policy is to ensure the University meets its legal

    responsibilities to prevent the proliferation of Legionella in water systems within

    University properties. The policy and associated procedures also gives guidance

    on the need to carry out risk assessments, safe systems of work and steps to

    take in the event of a Legionella outbreak.

    On line as version 4

Policy for Management and control of legionella risk 1 of 10 Version 1

    CONTENTS

    POLICY AND PROCEDURE FOR LEGIONELLOSIS MANAGEMENT

POLICY FOR LEGIONELLOSIS MANAGEMENT Page no.

1.0 Statement of Intent 3

2.0 Policy Objectives 3

3.0 Introduction 3

4.0 University Responsibilities 4

5.0 Commercial Services Responsibilities 4

6.0 Students Union Responsibilities 5

7.0 Estates & Property Services Responsibilities 6

8.0 Arrangements for Implementation 9

Policy for Management and control of legionella risk 2 of 10 Version 1

     UNIVERSITY OF SALFORD

    ESTATES & PROPERTY SERVICES

    POLICY FOR MANAGEMENT AND CONTROL OF LEGIONELLA RISK

    1.0 STATEMENT OF INTENT

The University is committed to providing a working environment including water and

    engineering services provision which is safe and without risks to the health, safety

    and welfare of its employees, students, contractors and visitors.

Employees of the University, and contractors engaged to work on University

    premises and water systems, plant and equipment must work with the employer to

    safeguard their own health, safety and welfare and bring to the employer’s attention

    any situation they are aware of which could pose a risk to their health, safety or

    welfare or that of their colleagues, students or others.

    2.0 POLICY OBJECTIVES

To provide a safe and healthy environment for all persons who may come in contact

    with our water or other systems

    To manage water systems risks in accordance with HSE document L8 and other

    safety guidance information.

    To comply with the requirements of the Health and Safety at Work Act 1974, The

    Management of Health and Safety at Work Regulations 1999 and HSE document L8.

    To manage the risk of the proliferation of legionella bacteria, in water and other

    systems and so protect health.

    3.0 INTRODUCTION

Legionellosis is the term used for infections caused by Legionella pneumophila and

    other bacteria from the family Legionellaceae. Legionnairesdisease principally

    affects those who are susceptible due to age, illness, immuno-suppression, smoking

    etc and may be fatal. Legionella is widespread in natural sources of water.

The majority of the Salford University properties contain some kind of water storage

    system, plant and equipment which is susceptible to bacterial colonisation. Therefore

    measures need to be taken and procedures put in place to control proliferation of

    Legionella bacteria within the water systems in the buildings owned, managed or

    maintained by the University of Salford.

    The principles behind the University’s Policy are:

    ? To take all reasonable and practical precautions to manage and control

    legionella bacteria in water systems.

    ? To protect the people occupying and visiting their premises, as well as

    passers by, within the vicinity of the institution from this risk.

    ? To ensure that appropriately trained and technically competent and

    experienced staff are available and resourced to adequately manage water

    systems and associated legionella control.

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? To control legionella exposure by ensuring that appropriate risk assessments

    and safe working practices are identified and followed by all Contractors and

    Sub-Contractors.

    ? Estates employees and Contractors commissioned to work on University

    Water Systems will be managed in accordance with this policy.

    ? Only competent Estates employees and contractors with specific expertise

    and competence will be allowed to design and work on University water

    systems, plant and equipment.

    ? To ensure the procedure for the control of Legionella bacteria in water

    systems, plant and equipment within the University of Salford properties shall

    be in accordance the Approved Code of Practice HSE document L8.

    4.0 UNIVERSITY RESPONSIBILITIES

Specific responsibilities for implementing this policy are identified below:

4.1 The Registrar

    ? Provide premises which are safe and without risk to building users;

    ? Appoint competent staff to undertake specific roles and responsibilities;

    ? Ensure adequate arrangements exist to manage the risks from water systems

4.2 Occupational Health and Safety Service - Director of Safety

    Services (OHSS)

    ? Provide advice in respect of the management and control of legionella

    ? To audit and review compliance with legislation and specifically HSE

    document L8 on water systems.

    ? To take a lead University role in a legionella outbreak situation

    ? Ensure the availability of a competent Health and Safety Officer.

4.3 Occupational Health and Safety Service Health and Safety

    Officer ? To provide safety advice on construction and Estates matters.

    ? To provide advice on water system safety legislative compliance.

    ? To give guidance on water systems training.

    ? To carry out such management system checks as instructed by the Director

    of OHSS.

4.4 University Purchasing Manager

    ? Where equipment is to be purchased that will require connection to the

    University’s water supply then Estates must be consulted prior to purchase to

    establish if any Legionella risk exists.

    ? Where advised of a potential risk of Legionella, to ensure any identified

    precautions are notified to the client and will be actioned prior to the

    equipment being installed.

    ? All correspondence to be sent to the responsible person in Estates,

    Commercial Services or the Students Union as appropriate.

Policy for Management and control of legionella risk 4 of 10 Version 1

    5.0 COMMERCIAL SERVICES (CS) RESPONSIBILITIES

5.1 Director of Commercial Services

    ? To execute the responsibilities of the ‘DUTY HOLDER’ (as defined in HSE

    document L8) on behalf of the University of Salford within the Commercial

    Services undertaking.

    ? To ensure a ‘RESPONSIBLE PERSON’ is appointed.

    ? To ensure a Policy and procedures on legionella control and management is

    in place and complied with.

    ? To ensure compliance with HSE document L8, other legislation and guidance

    in respect of all properties managed.

    ? To ensure adequate maintenance systems and competent resources are

    provided to ensure compliance can be achieved.

    ? To ensure all leased or wholly externally managed CS properties have

    adequate provisions identified in such leases, contracts, agreements or

    otherwise to ensure legionella risk is adequately and safely managed.

    ? To ensure an annual water system audit takes place, systems monitoring and

    review.

    ? To ensure communication and coordination is maintained between all parties

    who work on water systems, plant and equipment this includes Estates staff,

    consultant advisors and contractors when identified.

    ? To specifically ensure void properties or vacant rooms have a reliable and

    safe system of legionella control before reoccupation takes place. ? To ensure all catering equipment operated complies with all legionella risk

    reduction measures especially steaming and misting equipment. ? To obtain consent and keep the Executive Director of Estates fully briefed and

    informed of any water system adjustments or equipment installations on any

    Estates managed properties.

    ? To take a lead Commercial Services role in a legionella outbreak situation.

    ? To report any concerns or breaches relating to this policy to the Director of

    Occupational Health and Safety Services

    ? To specifically ensure the swimming pool and whirlpool, being high risk

    assets, have reliable and safe systems of legionella reduction management.

    6.0 STUDENTS UNION RESPONSIBILITIES

6.1 Students Union Chief Executive

    ? To execute the responsibilities of the ‘DUTY HOLDER’ (as defined in HSE

    document L8) on behalf of the University of Salford Students Union within the

    Students Union’s undertaking.

    ? To ensure a ‘RESPONSIBLE PERSON’ is appointed.

    ? To ensure a Policy and procedures on legionella is in place and complied with. ? To ensure compliance with HSE document L8, other legislation and guidance

    in respect of all properties managed.

    ? To ensure adequate maintenance systems and competent resources are

    provided to ensure compliance can be achieved.

    ? To ensure any leased or wholly externally managed properties have adequate

    provisions identified in such leases, contracts, agreements or otherwise to

    ensure legionella risk is adequately and safely managed.

    ? To ensure an annual water system audit takes place, systems monitoring and

    review.

    ? To ensure communication and coordination is maintained between all parties

    who work on water systems, plant and equipment this includes Estates staff,

    consultant advisors and contractors when identified.

    Policy for Management and control of legionella risk 5 of 10 Version 1

? To specifically ensure void properties or vacant rooms have a reliable and

    safe system of legionella reduction management before reoccupation takes

    place.

    ? To ensure all catering or other equipment operated complies with all

    legionella risk reduction measures especially steaming and misting equipment.

    ? To obtain consent and keep the Executive Director of Estates fully briefed and

    informed of any water system adjustments or equipment installations on any

    Estates managed properties.

    ? To take a lead Students Union role in a legionella outbreak situation.

    ? To report any concerns or breaches relating to this policy to the Director of

    Occupational Health and Safety Services

    7.0 ESTATES REPSONSIBILITIES

7.1 Executive Director of Estates

    ? Ensure provision and maintenance of buildings, which comply with Building

    Regulations, current Health and Safety legislation, relevant British Standards.

    ? To execute the responsibilities of the ‘DUTY HOLDER’ (as defined in HSE

    document L8) on behalf of the University of Salford within the Estates and

    Property Services undertaking.

    ? To ensure a ‘RESPONSIBLE PERSON’ is appointed.

    ? To ensure a Policy on legionella management is in place and complied with.

    ? To ensure adequate resources and competent staff manage water systems.

    ? To ensure an annual water system audit, systems monitoring and review

    takes place.

    ? To ensure communication and coordination is maintained between all parties

    who work on water systems, plant and equipment this includes Estates

    employed staff, consultant advisors and contractors when identified by key

    staff.

    ? Is not responsible for Commercial Services Accommodation, catering

    services or Student Union managed water system

    ? Will not be responsible for the legionella management of any equipment

    purchased by any other faculty, school or division that is connected to the

    University water system. Prior to making any connections to University

    Systems formal approval must be obtained from Estates and Property

    Services.

    ? To take a lead Estates role in a legionella outbreak situation.

7.2 Deputy Director of Estates

    ? Has been delegated the day to day responsibilities of the ‘DUTY HOLDER’

    (as defined in HSE document L8) on behalf of the University of Salford within

    the Estates and Property Services undertaking.

    ? To carry out the function of the Duty Holder as listed in section 5.4 but

    ensuring to keep the Executive Director of Estates fully briefed and informed.

    ? To ensure all leased properties have adequate provisions identified in such

    leases or otherwise to ensure legionella risk is adequately and safely

    managed.

7.3 Assistant Director- Operational Services

    ? To undertake the role of ‘RESPONSIBLE PERSON’ as defined in HSC

    document L8.

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    ? To ensure the legionellosis Policy is complied with and circulated for action. ? To be responsible for the identification and assessment of the risk programme

    for the prevention of the proliferation of Legionella bacteria in University water

    and other systems.

    ? To ensure University employed staff and budget holders are made aware of

    their responsibilities in relation to water systems design and maintenance.

    ? To ensure safe working procedures are in place taking advice as necessary

    so compliance can be maintained. To carry out regular monitoring and

    checking of water system procedures.

    ? To chair quarterly water systems meetings and arrange annual audits by the

    appointed external consultant.

    ? To agree a training programme in consultation with OHSS and request

    attendance.

    ? To appoint the Operations Engineer as a deputy.

    ? To report any significant safety breaches to the Duty Holder.

     7.4 Operations Engineering Manager

    ? To act as day to day operational senior manager on water systems, plant and

    equipment and for legionella reduction. ? To ensure all water system maintenance and alterations comply with HSE

    document L8 and other appropriate legislation. ? To ensure all water system maintenance and alterations comply with this

    policy and the associated procedures.

    ? To inspect and monitor the water and PPM management system on a

    monthly or a more regular basis if the need should arise. ? Report to the Responsible Person any significant breaches immediately which

    need to be urgently rectified safely.

    ? To proactively resolve minor water system or legionella issues if competent to

    do so.

    ? To oversee and report on the Operational Services water management

    system and attend the Quarterly Water System Management Meetings. ? To ensure appropriate records are maintained and updated including

    requests for line diagram updating from the appropriate person. ? To ensure appropriate persons are competent tested and trained to work on

    water systems.

    ? To report any resourcing issues to the Responsible person which are required

    so that legal compliance can be maintained. ? To act is deputy Responsible Person

    7.5 Building and Mechanical Manager

    ? To act as duty infrastructure manager for day to day maintenance on all water

    systems and other sources of legionella. ? To ensure all water system maintenance and alterations comply with HSE

    document L8 and other appropriate legislation. ? To ensure all water system maintenance and alterations comply with this

    policy and the associated procedures.

    ? To ensure all building water system risk assessments are carried out and are

    up to date.

    ? To ensure all appropriate persons are competent and are adequately trained

    for water and other systems work.

    ? That appropriate persons are aware of legionella reduction and personal risk

    in carry out such work.

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? To ensure the Estates Water System Planned Preventative Maintenance

    (PPM) is carried out in a timely and effective manner and to report any

    resource issues.

    ? To ensure appropriate records are maintained and updated including

    requests for line diagram updating from the appropriate person. ? To be responsible for updating the PPM system as found necessary.

    ? To oversee all Accommodation site works.

    ? To attend all Quarterly Water System Meetings

    ? To act as deputy to the Operations Engineering Manager

    ? To ensure all water system or other legionella risks are acted on in a timely

    manner and reported if significant to the Responsible Person. ? To examine weekly pasteurisation temperature readings and act on such

    results in a safe manner.

    7.6 Mechanical Chargehand

    ? To act on all water system or other legionella reduction works as instructed. ? To work strictly in accordance with this policy and the associated procedures

    within this document noting all legionella reduction measures and controls. ? To act as deputy to the Building and Mechanical Manager.

    ? To maintain records.

    ? To advise on any known risks.

    7.7 Estates Accommodation Supervisor

    ? To act on all water system or other legionella reduction works as instructed. ? To carry out and record regular temperature checks.

    ? To work strictly in accordance with the procedures within this document

    noting all legionella reduction measures and controls. ? To maintain records.

    ? To advise on any known potential risks.

    7.8 CAFM and Planned Preventative Systems Manager

    ? To identify and update timely the CAFM database with water system, plant

    and equipment.

    ? To identify from building files new PPM requirements and schedule according

    to risk assessment measures.

    ? To report any breaches or resource implications in relation to legionella risk

    reduction to the Responsible person.

    ? To attend Quarterly Water System meetings.

    7.9 Energy Manager

    ? To ensure pasteurisation of calorifiers is carried out in accordance with HSC

    document L8

    ? That the Building Management System (BMS) is used for monitoring

    temperature readings and any unsatisfactory results are brought to the

    attention of the Responsible Person.

    ? That all records from the pasteurisation temperature monitoring are filed in a

    timely manner on the University computer network shard drive.

    ? That the (BMS) is tested and checked on regular intervals to ensure reliability.

    ? To attend all Quarterly Water System Meetings

    ? To appoint a deputy to upkeep the pasteurisation records.

    7.10 Assistant Director- Developments

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? To ensure all project works are subject to risk assessment by appointed

    consultants or in-house designers in accordance with policy. ? Such risk assessments will consider the impact of the whole premises in

    terms of legionella reduction measures.

    ? To ensure water system design guidelines are in place at all times and

    compliant with HSC document L8 and these are circulated to all necessary

    parties and complied with.

    ? To ensure in- house design employees and consultants are competent to

    design and approve water systems works.

    ? Ensure that water and other systems are inspected, tested, chlorinated and

    certificated before being put in use.

    ? To update and circulate timely Estates water system and other information

    and file records including chlorination certificates centrally with the Operations

    section.

    ? To keep the water systems infrastructure manager informed on significant

    water system changes.

    ? To pass on all building file information so systems can be maintained to

    manage and reduce legionella risk.

    ? To ensure appropriate Development section staff attend quarterly water

    system meetings.

    ? To carry out timely amendments of water system line diagrams. To file such

    records centrally on the shared drive of the University computer network. ? To appoint an appropriate Deputy

    ? To ensure personal and staff training is identified and attended.

    7.11 Development/ Project Managers and Officers

    ? Prepare a written project specific Safety Plan and risk assessment for water

    services work taking in to account whole premises impact and ensure

    satisfactory implementation and commissioning.

    ? Ensure consultants and contractors engaged to carry out water systems work

    are competence tested to do the work safely

    ? Where the manager or project officer has a perceived lack of design or other

    expertise then further advice and assistance to be sought from line

    management.

    ? Any observed design errors or concerns involving water systems, plant or

    equipment on any part of the works to be carried out should be brought to the

    attention of line management.

    ? To ensure communication and consultation is effectively carried out and all

    records are filed centrally.

    7.12 Directors of other Faculties, Schools and Support Divisions

    ? To notify and take advice from Estates & Property Services prior to any

    equipment being purchased, leased or rented that will require connection to

    the University’s water infrastructure.

    ? To act on any advice given by Estates and Property Services regarding

    Legionella bacteria control.

Policy for Management and control of legionella risk 9 of 10 Version 1

7.13 Legionella Consultant

    ? To provide expert advice to the University on water systems and legionella

    reduction measures as requested.

    ? To carry out an annual audit and any monitoring or other works as requested. ? To carry out system risk assessments with in-house staff assistance as

    requested.

    ? To be advisor to the Duty Holder and Responsible Person.

7.14 Trades Staff

    ? To carry out all work safely and as instructed.

    ? To report any concerns to line management relating to water systems or

    legionella risk.

    ? To attend all training and act on such training proactively.

8.0 ARRANGEMENTS FOR IMPLEMENTATION

    ? The practical arrangements for implementing this policy are to be provided in

    the procedure documents that are to be developed by each Faculty, School or

    Support Division relevant to their specific responsibilities to manage

    Legionella within their undertaking.

Policy for Management and control of legionella risk 10 of 10 Version 1

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