Document name: Maintenance & Operational Procedures for the control of Legionella, water hygiene, ‘safe’ hot water, cold water, drinking water and non-drinking water. Document type



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2.15 Other Air Conditioning Units

2.15.1 Portable A/C Units.


From the date that this procedures document was accepted the Trust prohibits the use of such devices within any of the Trust properties. The Trust has prohibited the use of such devices on the grounds that HTM03:01 paragraph 5.28 states ‘units employing an internal water reservoir and wick to promote evaporative cooling must not be used in healthcare premises’. These units also require substantial frequent maintenance which is costly.

2.15.2 Split Units.


These units incorporate internal recirculation air filters and a drainage system to remove condensate form the cooling coil. The systems used around the Trust properties are not in continuous use (i.e. 24/7) and a review of the condition of these systems has found that the units only require an inspection and clean every 6 months by an external contractor.


2.16 Hydrotherapy Pools, Whirlpool Baths and Whirlpool Spas

2.16.1 General


Hydrotherapy pools, whirlpool baths and whirlpool spas provide conditions which may favour the growth of Legionella. Whirlpool spas are particularly vulnerable because of the recirculation of a relatively small volume of water; careful maintenance and chemical water treatment is needed in order to maintain water quality. A detailed log must be kept detailing the treatment method, filter cleaning and results of tests for pH, free residual halogen and other key parameters.

Whirlpool baths employ a single fill for each user, and do not present the same level of risk as spas, provided that the guidance recommended for hot and cold water systems is followed.


2.16.2 Guidance


Hydrotherapy pools and spa pools should be operated to the guidance given in the following publications published by the HSE and HPA:

  • ‘Legionnaires’ Disease: Controlling the risks associated with using spa baths’ [HSE Information Sheet]

  1. ‘Swimming Pool Water – Treatment and quality standards for pools and spas' [PWTAG]

  2. 'Management of Spa Pools – controlling the risk of infection' [HPA]

Copies of these publications should be held in the Estates Department, and used as the primary source of guidance for the management of such pools.

All information on condition, cleanliness, servicing and monitoring to be recorded in a pool log book. Non-compliance or incidents to be identified to the Authorised Person [Water] immediately, and the incident report record form completed.



2.17 Other Risk Systems


Further monitoring requirements for other risk systems should be based on the table section 3.4.
Internal ornamental fountains and features are not permitted within Trust properties. External ornamental fountains and features are the responsibility of building managers / unit managers to monitor and maintain them so as they do not present any hazard to health.
The Authorised Person [Water] must be informed of the existence of all external ornamental fountains and features for inclusion on the ‘Legionellosis Risk – Other Risk Systems Register’.

2.18 Renal Dialysis Unit

The water treatment plant is maintained under contract, reviewed annually by Estates maintenance.


Contractor’s service reports are held on file by the Estates Officer.
Disinfection of each plant is carried out in accordance with the PPM system.
Brine tank salt level and water filters [primary, charcoal, final] are checked accordance with the PPM system.

2.19 Drinking and Non Drinking Water Systems

2.19.1 Drinking Water Systems.


Domestic hot and cold water systems are considered drinkable. The design of storage systems, pipework, valve arrangements and other fittings used on the system shall be such that they do not allow the contamination of the drinking water systems which could encourage microbial multiplication. These systems shall be configured in accordance with:

  • Water Supply (Water Fittings) Regulations 1999;

  • BS EN 806 & BS8558.

  • Water Fittings & Materials Directory.

All pipework carrying fluids which are non-drinking will be labelled according to British Standard. This action will assist in avoiding possible cross connections between installations conveying drinking and non-drinking water or water from private supplies.


Lead free materials for formation of capillary joints of domestic water systems must be used.
Vending machines, ice machines, cold water dispensers and high pressure jet hoses must all be fed from a drinking water supply with suitable back flow prevention device installed.
Treatment system used on drinking systems must not cause a breach of the requirements of the Water Supply (Water Quality) Regulations 2000.
Wet fire protection systems i.e. hoses, sprinklers, wet risers must be isolated from any drinking water supply by a method which is permissible by the Water Supply (Water Fittings) Regulations 1999. These supplies when feed from a drinking supply are very rarely used, stagnation occurs and conditions prevail which encourage microbial multiplication.

2.19.2 Non Drinking Water Systems.


Rain water, surface runoff water, private water supplies, drainage of foul water, emergency use water tanks (currently there are no such tanks in use across the Trust) are classed as non-drinking water supplies and as such a potential source of pathogenic contamination. All non-drinking water systems should be colour coded or labelled as such.
Emergency use water tanks to be kept isolated from other water systems (drinking and non-drinking), by a suitable means which prevents back flow and microbial contamination. They should be treated regularly using Chlorine tablets to maintain water quality and checked with TVC samples periodically.

2.20 Water Conditioning


A temperature control regime is the method of water treatment used by South West Yorkshire Partnership NHS Foundation Trust as advocated in HTM04:01.

Should an alternative water treatment system regime be sought the onus shall be on the Trust to establish the efficacy of the system in its control of Legionella for each site, this shall be in the form of a trail. The trail will want to establish:



  • The control level;

  • The ability to achieve the control level;

  • The assurance that the control level will be maintained.




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