Water Hygiene Policy
INTRODUCTION
1.1 1.2 1.3 Legionellosis is a collective term for diseases caused by legionella bacteria including the most serious Legionnaires’ disease, as well as the similar but less serious conditions of Pontiac fever and Lochgoilhead fever.
Legionnaires’ disease is a potentially fatal form of pneumonia and everyone is susceptible to infection. The risk increases with age, but some people are at higher risk, e.g. people over 45, smokers and heavy drinkers, people suffering from chronic respiratory or kidney disease, diabetes, lung and heart disease or anyone with an impaired immune system.
Legionnaires’ disease is normally contracted by inhaling small droplets of water (aerosols), suspended in the air, containing the bacteria.
Therefore, it is important that WCCHA control the risks by introducing measures which reduce and/or control the risk of legionella growth and proliferation of legionella bacteria and other organisms in the water systems and reduce, so far as is reasonably practicable, exposure to water droplets and aerosol in non-domestic and domestic stock as required. This will reduce the possibility of creating conditions in which the risk from exposure to legionella bacteria is increased.
2. SCOPE OF THE POLICY
2.1 2.2 WCCHA must establish a policy which meets the requirements of the Health and Safety at Work Act 1974 and the Management of Health and Safety at Work Regulations 1999 (the Management Regulations). In addition to this, the policy must provide assurance that measures are in place to demonstrate compliance with the Control of Substances Hazardous to Health Regulations 2002 (as amended) and to identify, manage and/or mitigate risks associated with hot and cold water systems and any other systems that may cause exposure to legionella bacteria. The L8 approved code of practice, “Legionnaires’ disease. The control of legionella bacteria in water system”, is available to duty holders to provide practical guidance on how to comply with their legal duties in relation to legionella.
WCCHA must also ensure compliance with water hygiene legislation is formally reported at Senior Management Team (SMT) and Board level, including the details of any non-compliance and planned corrective actions.
2.3 2.4 This policy applies to all companies employed or contracted to WCCHA and therefore it is relevant to all WCCHA employees, tenants, contractors and other persons or other stakeholders who may work on, occupy, visit, or use its premises, or who may be affected by its activities or services.
It should be used by all to ensure they understand the obligations placed upon WCCHA to maintain a safe environment for customers and employees within the homes of each customer, and within all communal areas of buildings and ‘other’ properties owned and managed.
3. RESPONSIBILITY
3.1 Key Roles and Responsibilities
3.1.1 In order to ensure that this Water Hygiene Policy, and the supporting Water Hygiene Procedure are adhered to, WCCHA will appoint suitably competent personnel to act as the ‘Responsible Person’ on behalf of WCCHA to oversee the implementation and review of these documents.
3.1.2 Although the organisation has an appointed a ‘Responsible Person’, WCCHA will be ultimately responsible for ensuring compliance with current legislation and to ensure that the organisation fulfils its duties and responsibilities as outlined in this policy document and the supporting Water Hygiene Procedure.
3.1.3 Appointed Duty Holder – WCCHA Directors will fulfil the role of the appointed ‘Duty Holder’ on behalf of WCCHA in order to ensure the appropriate management of the risks associated with Water Hygiene.
As a result, WCCHA Directors will hold responsibility for the implementation of this document, and supporting procedure, as well as ensuring compliance is achieved and maintained.
3.1.4 Acting Responsible Persons – WCCHA Directors shall ensure that there are suitable arrangements in place for the implementation of the Water Hygiene Procedure, as well as overseeing the delivery of the agreed survey inspection programmes and the prioritisation and implementation of any works arising from the surveys.
3.1.5 WCCHA Board will have overall governance responsibility for ensuring the Water Hygiene Policy is fully implemented to ensure full compliance with the regulatory standards, legislation and approved codes of practice. As such the Board will formally approve this policy and review it periodically. The first review will be undertaken 18 months after the approval of this new policy, and then every two years thereafter (or sooner if there is a change in regulation, legislation or codes of practice).
3.1.6 The Board will receive regular updates on the implementation of the
Water Hygiene Policy and compliance performance along with notification of any non-compliance issue which is identified. This is so they have assurance that the policy is operating effectively in practice.
3.1.7 The SMT will receive reports in respect of water Hygiene performance and ensure compliance is being achieved. They will also be notified of any non-compliance issue identified.
3.1.8 The housing teams will provide key support in gaining access into properties where access is proving difficult and use standards methods to do so. They will also facilitate the legal process to gain access as necessary.
3.2 Competent Persons
3.2.1 WCCHA will ensure that the appointed person or representative (Legionella) is appropriately competent; holding a recognised qualification in legionella control through the completion of a certified training course designed to meet the training needs of a ‘duty holder’ or ‘responsible person’ for legionella control.
3.2.2 Training includes courses by BOHS (British Occupational Hygiene Society) such as P901 – Management and control of building hot and cold water services, City and Guilds, CIBSE, or HABC around the requirements of ACoP L8 – ‘Legionnaires’ disease: The control of legionella bacteria in water systems’.
3.2.3 WCCHA will ensure that only suitably competent consultants and contractors, registered members of the Legionella Control Association (LCA) or equivalent, are procured and appointed to undertake risk assessments, prepare written schemes of control and undertake works in respect of water hygiene and legionella control.
3.2.4 Appointed representatives will check the relevant qualifications of employees working for these contractors to ensure that all persons are appropriately qualified for the work that they are carrying out.
These checks will be undertaken on an annual basis and evidenced appropriately.
4. POLICY
4.1 Obligations
4.1.1 The Control of Substances Hazardous to Health Regulations 2002 (as amended) (COSHH), the Management of Health and Safety at Work Regulations 1999 and the Health and Safety at Work Act 1974 place a duty, as an employer or person in control of a premises (e.g. a landlord), to take suitable precautions to prevent or control the risk of exposure to legionella.
4.1.2 WCCHA as the ‘Duty Holder’ as defined by ACOP 8 is responsible for Health and Safety and must take the right precautions to reduce the risks of exposure to Legionella, including understanding how the organisation will:
• Identify and assess sources of risk
• Manage any risks
• Prevent or control any risks
• Keep and maintain the correct records
4.1.3 WCCHA must ensure there is a risk assessment undertaken for all hot and cold water systems, cooling plant and any other systems that can produce water droplets to establish any potential risks and implement measures to either eliminate or control identified risks.
4.1.4 WCCHA as the ‘Duty Holder’ responsible for control of legionella and water hygiene safety must appoint a competent/responsible person to take managerial responsibility for legionella control – risk assessment, production of a written scheme and implementation of that scheme to prevent or control the risks. A competent person is someone with sufficient authority, competence, necessary skills, knowledge of the system and experience. WCCHA will ensure that properties are risk assessed by a competent person for potential to cause exposure to legionella.
4.1.5 In addition, the ‘Duty Holder’ will appoint an authorised deputy responsible person who will provide cover to the responsible person in their absence. The deputy responsible person should be trained, instructed, and informed to the same level as the responsible person, and they should assist in the frequent monitoring of the control scheme(s).
4.2 Statement of Intent
4.2.1 WCCHA acknowledges and accepts its responsibilities with regard to water hygiene safety and preventing exposure to legionella.
4.2.2 4.2.3 4.2.4 4.2.5 4.2.6 4.2.7 4.2.8 4.2.9 WCCHA will hold accurate records against each property it owns or manages setting out the requirements for water hygiene risk assessments and safety checks.
WCCHA will periodically review risk assessments (every 2 years) in case anything changes in the system. Where a system is identified as more likely to undergo change and is therefore a higher risk, the risk assessment will be reviewed on a more frequent basis, dependent on the determined level of risk. WCCHA will ensure that a ‘written scheme of control’ is developed and fully implemented for all properties risk assessed as requiring controls to adequately manage the risk of legionella exposure. The schemes will be assessed by WCCHA competent person as high, medium or low risk.
WCCHA will ensure that a risk assessed approach for water hygiene safety is adopted as part of the void standard, when carrying out works on void properties prior to re-let. These checks will be applicable on all void properties prior to commencing works which may affect the hot and cold water systems and that any identified risk control measures are fully implemented where identified.
WCCHA will ensure that a sample audit is undertaken of a minimum of 5% of all written schemes of control by an independent third party consultant to ensure that all control actions are being fully and robustly implemented by the competent person.
WCCHA will ensure audits are undertaken annually, by an independent competent person, to all systems identified as a high risk (e.g. older persons’ schemes) to ensure that all control actions are being fully and robustly implemented.
WCCHA will ensure that only suitably competent consultants, surveyors, risk assessors and engineers undertake works for the organisation in respect of water hygiene safety.
WCCHA will make written schemes of control in communal areas of buildings available to inform occupants on how the risk of exposure to legionella bacteria is being managed and controlled.
WCCHA will have a robust process in place to gain access to properties where tenant vulnerability issues are known or identified whilst ensuring the organisation can gain timely access to any property in order to be compliant with this policy and safeguard the wellbeing of the tenant.
4.2.10 WCCHA will establish and maintain a plan of all continuous improvement activity undertaken with regards to water hygiene safety.
4.2.11 WCCHA will liaise with property owners/landlords of accommodation we lease or manage on their behalf to ensure that evidence of compliance is available or that relevant checks can be undertaken.
4.3 Compliance Risk Assessment/Inspection Programmes
4.3.1 Risk assessment – WCCHA will establish and maintain a risk assessment for water hygiene safety operations. This risk assessment will set out the organisations’ key water hygiene risks together with appropriate mitigations.
4.3.2 CDM – to comply with the requirements of the Construction, Design and Management Regulations 2015 (CDM) a Construction Phase Plan will be completed for all void works, component replacement works and refurbishment projects where applicable.
4.3.3 Legionella risk assessments – WCCHA will carry out a programme of legionella risk assessments and risk assessment reviews to properties containing any water system that could present a risk of exposure to legionella. These risk assessments will be reviewed at least every two years, or after any works have been completed to the installation.
4.3.4 Communal blocks and ‘other’ properties – all communal blocks and ‘other’ properties will be subject an initial visit to establish whether a legionella risk assessment is required. Where a risk assessment is not required then WCCHA will record this as such on their records, including the date of the initial visit. Where a legionella risk assessment is required WCCHA will ensure this communal block or ‘other’ property is included in the programme.
4.3.5 Domestic properties – WCCHA will undertake an annual programme of sample surveys, based on design, size, age and type of water supply, in 5% of the general needs units on a rolling programme, whereby all properties will be eventually assessed over time.
4.3.6 Supported Living Stock – As a property owner or manager, Progress has a duty to identify and assess the risk of Legionella in properties within its control where it has responsibility for the water system, and if necessary, manage that risk through a written scheme that can be monitored, and keep records of any precautions taken. As per the relevant legislative requirements governing the control of Legionella, which are contained within the L8 Approved Code of Practice (3rd Edition) and underpinned by section 3(2) of the Health & Safety at Work Act, and the Control of Substances Hazardous to Health
Regulations 2002, Progress will take all reasonable steps to reduce the risk of Legionella to those who could be affected. In supported living and extra care blocks Progress will carry out risk assessments as far as it is reasonable to do so. Properties will therefore be assessed using a risk based approach where those which are deemed to be the highest risk will be subject to regular water temperature testing.
4.3.7 Void properties – Properties left unoccupied will have frequent flushing or systems drained to comply with the Water Hygiene Procedure. Properties remaining unoccupied for more than no more than 120 days shall have their hot and cold water installations drained down. Before occupation, these premises are to have their water systems disinfected and flushed.
4.3.8 WCCHA will carry out a programme of maintenance visits by competent persons to all properties that have a written scheme of control in place.
These programmes will ensure that all maintenance and testing set out in the written scheme of control is fully completed at the times and intervals stated. The results of these visits will be recorded electronically.
4.3.9 WCCHA will appoint an independent competent person to complete a programme of compliance audits to 5% of written schemes of control to ensure that all control actions are being fully and robustly implemented. In addition all schemes identified as high risk will receive an annual audit.
4.4 Compliance Follow up Work
4.4.1 WCCHA will ensure there is a robust process in place for the management of any follow-up works required following the completion of a legionella risk assessment or where identified by the competent person when undertaking required maintenance activities.
4.4.2 WCCHA will ensure that there is a robust process in place to collate and record details of all remedial works and water testing completed against individual installations.
4.5 Record Keeping
4.5.1 WCCHA will establish and maintain a core asset register of all properties that have a written scheme of control for water hygiene in place. This register will also hold data against each property asset of the legionella risk assessment carried out.
4.5.2 Inspection and re-inspection dates, along with LRA and monitoring records will also be held electronically.
4.5.3 WCCHA will establish and maintain accurate records of all written schemes of control and any associated remedial works and water testing as per the organisation’s Data Retention Policy.
4.5.4 WCCHA will maintain log books for all relevant sites as required to record the details of the results from the ongoing monitoring and inspection, where required.
4.5.5 WCCHA will hold and maintain accurate records on the qualifications of all consultants, surveyors, risk assessors and engineers undertaking water hygiene works for the organisation.
4.5.6 WCCHA will ensure robust processes and controls are in place to provide and maintain appropriate levels of security for all water hygiene safety related data.
5. REGULATORY STANDARDS, LEGISLATION, AND APPROVED CODES OF PRACTICE
5.1 5.2 5.3 Regulatory Standards – the application of this policy will ensure compliance with the regulatory framework and consumer standards (Home Standard) for social housing in England, which was introduced by the Regulator of Social Housing (RSH).
Legislation – the principle legislation applicable to this policy is the Health and Safety at Work Act 1974, the Management of Health and Safety at Work
Regulations 1999 (the Management Regulations) and the Control of Substances Hazardous to Health Regulations 2002 (as amended) (COSHH).
WCCHA has a legal obligation under COSHH to prevent or control exposure to biological agents. Being harmful to human health, legionella falls within the scope of these regulations.
Codes of Practice – the principle approved codes of practice applicable to this policy are:
• ACoP L8 – ‘Legionnaires’ disease: The control of legionella bacteria in water systems’ (4th edition 2013).
• HSG274 – Legionnaires’ disease: Technical guidance Part 1: The control of legionella bacteria in evaporating cooling systems (2013).
• HSG274 – Legionnaires’ disease: Technical guidance Part 2: The control of legionella bacteria in hot and cold water systems (2014).
• HSG274 – Legionnaires’ disease: Technical guidance Part 3: The control of legionella bacteria in other risk systems (2013).
• INDG458 – Legionnaires’ disease: A guide for duty-holders Leaflet (HSE Books 2012).
5.4 Sanctions – WCCHA acknowledges and accepts its responsibilities in accordance with the regulatory standards, legislation and codes of practice and that failure to discharge these responsibilities properly could lead to a range of sanctions including prosecution by the Health & Safety Executive under the Health & Safety at Work Act 1974, prosecution under the Control of Substances Hazardous Regulations to Health (COSHH), prosecution under the Corporate Manslaughter and Corporate Homicide Act 2007, and via a serious detriment judgement from the Regulator of Social Housing.
5.5 Tenants – WCCHA will use the legal remedies available within the terms of the tenancy agreement, lease or licence should any tenant refuse access to carry out essential safety checks, maintenance and safety related repair works.
5.6 Additional Legislation – This Water Hygiene Policy also operates in the context of the following legislation:
5.6.1 The Workplace (Health Safety & Welfare) Regulations 1992
5.6.2 Construction, Design and Management Regulations 2015
5.6.3 Housing Act 2004
5.6.4 Landlord and Tenant Act 1985
5.7 5.6.5 5.6.6 Homes (fitness for Human Habitation) Act 2018
Housing Health and Safety Rating System (HHSRS) 2006
5.6.7 Data Protection Act 2018
5.6.8 RIDDOR 2013
This policy also links to the following WCCHA Policies:
5.7.1 Health and Safety Policy
5.7.2 Data Archival, Retention and Disposal Policy
6. IMPLEMENTATION
6.1 Training
6.1.1 WCCHA will ensure that all operatives working for, or on behalf of the organisation have the relevant training required for their role. This will be managed via periodic assessments of training needs and resulting programmes of internal and/or external training.
6.2 Performance Reporting
6.2.1 Robust key performance indicator (KPI) measures will be established and maintained to ensure WCCHA is able to report on performance in relation to water hygiene / legionella safety.
6.2.2 KPI measures will be produced and provided at SMT level on a monthly basis and at Board level on a quarterly basis. As a minimum these KPI measures will include reporting on:
Data – the total number of:
• Properties – split by communal blocks and ‘other’ properties
• Properties on the LRA programme
• Properties not on the LRA programme
• Properties with a valid ‘in date’ LRA. This is the level of compliance expressed as a number and a %
• Properties where the LGSR/certification has expired and is ‘out of date’. This is the level of non-compliance expressed as a number and a %
• Properties which are due to be inspected and tested within the next 30 days. This is the early warning system.
Narrative – an explanation of the:
• Current position
• Corrective action required
• Anticipated impact of corrective action
• WCCHA with completion of follow-up works
6.3 Non-Compliance/Escalation Process
6.3.1 Any non-compliance issue identified at an operational level will be formally reported to SMT in the first instance.
6.3.2 The SMT will ensure the Board are made aware of any non-compliance issue so they can consider the implications and take action as appropriate.
6.3.3 In cases of a serious non-compliance issue the SMT and Board will consider whether it is necessary to disclose the issue to the Regulator of Social Housing in the spirit of co-regulation as part of the Regulatory Framework.
7. CONSULTATION
7.1 A series of consultation meetings have taken place when reviewing this policy, including a policy principles session with WCCHA Board.
8. REVIEW
8.1 Ordinarily this policy will be reviewed following WCCHA standard three yearly timeframe. However, an initial review timeframe of eighteen months is being adopted to ensure that any changes required, following the implementation of new systems and processes, can be captured at the earliest opportunity.
9. EQUALITY IMPACT ASSESSMENT
9.1 An EIA is currently being drafted alongside this policy review.