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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Procedure:

NEW TMV INSTALLATION RECORD SHEET

Frequency:

As necessary

Acceptance date:

Oct’12

File Ref:

C – LEG12

Next review date:

Oct’14


Property:




Location:





Room No:




Docket No:




Description of TMV location:




TMV Manufacturer

and Type:




TMV Asset No.




Work carried:




Approved temperatures for TMVs settings based on activity / area where the TMV is required.

Note: All tactile taps/outlet where fitted, to achieve a 6 litres/minute [minimum] throughput, whilst in operation

Area/activity

Recommended

temperature (°C)

Staff bases, ward, consulting rooms, in-patient areas, out-patient areas and general areas to which staff and visitors may have access.

41

Paediatric baths

General baths

Assisted baths


40

43

46



Showers & Hair-wash facilities

41

Bidets

38

All sinks, kitchens, pantries, slop sinks

55

Staff-only access i.e. Offices

43







TEMPERATURE TEST:

  1. Set temperature: __________________ Deg. C.




  1. Flow temperature hot: __________________ Deg. C. (pipe temperature prior to mixer valve




  1. Flow temperature cold: __________________ Deg. C. (pipe temperature prior to mixer valve)

FAIL TEST:

Simulate a cold water supply failure by slowly turning off the cold supply.



  1. Valve closes down: Yes / No




  1. Time to shut off: _______________ seconds.

I, the undersigned, have completed the works outlined above:

Competent Person


Name:

Signature:


Date:

Authorised Person [Water]


Name:

Signature:

Date:

Additional docket numbers issued:




PPM:

TMV / SHOWER MAINTENANCE

PPM Ref:

C – LEG43

Frequency:

Every 6 months

For all TMV's carry out servicing using manufacturers service kit.


Inspect check valves & filters (clean or replace as necessary).
Re-instate and calibrate to correct temperatures detailed below:

Area/activity

Recommended

temperature (°C)

Staff bases, ward, consulting rooms, in-patient areas, out-patient areas and general areas to which staff and visitors may have access.

41

Paediatric baths

General baths

Assisted baths


40

43

46



Showers & Hair-wash facilities

41

Bidets

38

All sinks, kitchens, pantries, slop sinks

55

Staff-only access i.e. Offices

43

Thermostatic mixing control valves (hot supply to be 55OC or greater, cold supply to be less than 20 OC to teat mixing valve fail safe).


Procedure for fail safe:

  1. Run the hot tap and check the water temperature with a calibrated thermometer is at correct for the type outlet (according the table detailed above) (+ or - 1oC) with the control at hot.




  1. Shut off the cold supply to the valve and ensure that the discharge shuts off within 2/3 seconds.




  1. If a failure occurs:

    1. strip down,

    2. service,

    3. repair

    4. retest.




  1. Reinstate the supply.




  1. If fail safe does not work valves must be stripped & overhauled (parts replace as necessary).




  1. The valves must then be commissioned to D08 specification.


RECORD SHEET C – LEG43 MUST BE FILLED IN AND RETURNED TO THE AUTHORISED PERSON [WATER]





Procedure:

TMV / SHOWER MAINTENANCE

Frequency:

Every 6 months

Acceptance date:

31/03/10

File Ref:

C – LEG43 [page 1 of 2]

Next review date:

31/03/11


Property:




Location:





Docket No:




Thermometer Serial No.:




BIANNUAL TEST:

Check operation of mixer, set temperature (according to guide table below) and simulate fail test (see description below). Record the pipe temperature pre TMV, record the mixed outlet (hot & cold) and NON MIXED outlet (hot & cold) temperatures. Report any defects below.



Fail Test:

A simulated cold water fail test shall be carried out following the overhaul or calibration of each valve by SLOWLY turning off the cold water to the valve and observing the water flow stopping.

A simulated hot water fail test shall be carried out following the overhaul or calibration of each valve by SLOWLY turning off the hot water to the valve and observing the water flow stopping.


Approved temperatures for TMVs settings based on activity / area where the TMV is required.

Area/activity

Recommended

temperature (°C)

Staff bases, ward, consulting rooms, in-patient areas, out-patient areas and general areas to which staff and visitors may have access.

41

Paediatric baths

General baths

Assisted baths


40

43

46



Showers & Hair-wash facilities

41

Bidets

38

All sinks, kitchens, pantries, slop sinks

55

Staff-only access i.e. Offices

43

*Where difficulty is experienced setting TMV temperature then a variation of +/- 1OC is acceptable.


Continued overleaf....



Procedure:

TMV / SHOWER MAINTENANCE

File Ref:

C – LEG43 [page 2 of 2]


Ward / Dept.


Room No.

Test done

(tick)

Outlet data



TOC OK?

Fail Test

OK


Initial & Date

6 M

Ann

WHB/Sink/ Bath/Shower etc.

TMV fitted (tick)

TMV Asset No.

Valve Type

Pre TMV TOC

Hot TOC

Cold TOC




Yes

No






































































































































































































































































































































































































































































Comments:

I, the undersigned, have completed the works outlined above:

Tradesperson


Name:

Signature:


Date:

Authorised Person [Water]


Name:

Signature:





Additional Docket Numbers Issued:




*** PLEASE PHOTOCOPY THIS FORM AS NECESSARY TO ACCOMMODATE ALL TMVs FOUND ON THE WARD / DEPARTMENT ***


PPM:

TMV / SHOWER MAINTENANCE

PPM Ref:

C – LEG47

Frequency:

Annually

For all TMV's carry out servicing using manufacturers service kit.


Inspect, check, strip and overhaul all valves & filters (clean or replace as necessary).
Re-instate and calibrate to correct temperatures detailed below:

Area/activity

Recommended

temperature (°C)

Staff bases, ward, consulting rooms, in-patient areas, out-patient areas and general areas to which staff and visitors may have access.

41

Paediatric baths

General baths

Assisted baths


40

43

46



Showers & Hair-wash facilities

41

Bidets

38

All sinks, kitchens, pantries, slop sinks

55

Staff-only access i.e. Offices

43

Thermostatic mixing control valves (hot supply to be 55oC or greater, cold supply to be less than 20 OC to teat mixing valve fail safe).


Procedure for fail safe:

  1. Run the hot tap and check the water temperature with a calibrated thermometer is at correct for the type outlet (according the table detailed above) (+ or - 1oC) with the control at hot.




  1. Shut off the cold supply to the valve and ensure that the discharge shuts off within 2/3 seconds.




  1. If a failure occurs:

    1. strip down,

    2. service,

    3. repair

    4. retest.




  1. Reinstate the supply.




  1. If fail safe does not work valves must be stripped & overhauled again (parts replace as necessary).




  1. The valves must then be commissioned to D08 specification.


RECORD SHEET C – LEG47 MUST BE FILLED IN AND RETURNED TO THE AUTHORISED PERSON [WATER]





Procedure:

TMV / SHOWER MAINTENANCE

Frequency:

Annual

Acceptance date:

31/03/10

File Ref:

C – LEG47 [page 1 of 2]

Next review date:

31/03/11


Property:




Location:





Docket No:




Thermometer Serial No.:




ANNUAL TEST:

Check operation of mixer, set temperature (according to guide table below) and simulate fail test (see description below). Record the pipe temperature pre TMV, record the mixed outlet (hot & cold) and NON MIXED outlet (hot & cold) temperatures. Report any defects below.

Strip down and overhaul. Fit new seals and parts as required. Reset temperature (according to guide table below) and simulate fail test (see description below). Record mixed outlet and NON MIXED outlet temperatures. Report any defects below.


Fail Test:

A simulated cold water fail test shall be carried out following the overhaul or calibration of each valve by SLOWLY turning off the cold water to the valve and observing the water flow stopping.

A simulated hot water fail test shall be carried out following the overhaul or calibration of each valve by SLOWLY turning off the hot water to the valve and observing the water flow stopping.


Approved temperatures for TMVs settings based on activity / area where the TMV is required.

Area/activity

Recommended

temperature (°C)

Staff bases, ward, consulting rooms, in-patient areas, out-patient areas and general areas to which staff and visitors may have access.

41

Paediatric baths

General baths

Assisted baths


40

43

46



Showers & Hair-wash facilities

41

Bidets

38

All sinks, kitchens, pantries, slop sinks

55

Staff-only access i.e. Offices

43

*Where difficulty is experienced setting TMV temperature then a variation of +/- 1OC is acceptable.


Continued overleaf....

Procedure:

TMV / SHOWER MAINTENANCE

File Ref:

C – LEG47 [page 2 of 2]

Ward / Dept.

Room No.

Test done

(tick)

Outlet data



TOC OK?

Fail Test

OK

Initial & Date

6 M

Ann

WHB/Sink/ Bath/Shower etc.

TMV fitted (tick)

TMV Asset No.

Valve Type

Pre

TMVTOC

Hot TOC

Cold TOC




Yes

No






































































































































































































































































































































































































































































Comments:

I, the undersigned, have completed the works outlined above:

Competent Person


Name:

Signature:


Date:

Authorised Person [Water]


Name:

Signature:





Additional Docket Numbers Issued:




*** PLEASE PHOTOCOPY THIS FORM AS NECESSARY TO ACCOMMODATE ALL TMVs FOUND ON THE WARD / DEPARTMENT ***

PPM:

NON CRITICAL SERVICES VENTILATION SUPPLY PLANT CLEANING AND INSPECTION

PPM Ref:

C – LEG06

Frequency:

Every 6 months

Complete an inspection of each AHU as detailed below and complete record form C – LEG06.
General check on overall condition of unit. Repair/renovate as required.

Check all thermal and acoustic linings.

Examine for any undue noise, vibration, lack of performance, etc. and report findings.

Check flexible connections, examine security of retaining bands, replace damaged sections if necessary.

Check security brackets and associated supports.

Check tension, alignment and condition of fan drive belts; re-tension / renew (as a complete set) as required.

Check condition of motor/drive casings and motor vent grilles and clean as required.

Check electrical connections.

Check safety guards are secure.
All procedures must comply with the Health and Safety at Work etc Act and COSHH regulations;


  1. Notify all persons working in those areas served by the plant to be disinfected;

  2. Switch off all ventilation systems containing devices to be disinfected;

  3. Close the plant isolating dampers;

  4. Open and remove the inspection covers/access doors on both sides of the devices;

  5. Spray all internal surfaces of the humidifier section or cooler battery/cooling coil with a 5 ppm chlorine solution until all surfaces are thoroughly wetted, also flood drip trays and drainage system with the same solution and allow to stand for a minimum of two hours;

  6. Spray all internal surfaces of the humidifier and cooler battery/cooling coil with sufficient clean water to remove all traces of the chlorine solution from the device, its drip trays and drainage system;

  7. Restore the plant to normal operation;

  8. If any suspicion arises as to the possible contamination of the system then the microbiologist should be requested to take swab tests from all drain trays and cooler battery/cooling coil tubes and fins;

As an alternative to steps (f) and (g) detailed above, the surfaces may be steam cleaned;


RECORD SHEET C – LEG06 MUST BE FILLED IN AND RETURNED TO THE AUTHORISED PERSON [WATER]






Procedure:

NON CRITICAL SERVICES VENTILATION SUPPLY PLANT CLEANING AND INSPECTION RECORD SHEET

Frequency:

Every 6 months

Acceptance date:

Oct’12

File Ref:

LEG06 [page 1 of 2]

Next review date:

Oct’14

Building:




Location:




System ID:




Docket No:




Item

Work description

Y

N

1

Inform departments concerned that plant is to be shut down.







2

Is the plant room secure (locked)







3

Is the ventilation plant running upon entering the plant room?







4

Is the ventilation plant adequate labelled with a unique reference / asset / plant No.







5

Is the ventilation plant safely accessible for inspection and maintenance?







6

Is the overall exterior condition of the ventilation plant in a good condition?

If ‘NO’ detail reasons…









7

Are the principle ducts of the ventilation plant lagged?







8

Are any pipework leading to the ventilation plant adequately lagged?







9

Is the position of the air intake for the ventilation plant clear of any dirty, debris, build up of rubbish and unobstructed?







10

Is the position of the air intake for the ventilation plant at least 10 meters away from any extract or foul air from other sources i.e. gas scavenging outlets?







11

Do internal lights work? (Replace faulty bulbs once isolated). Report other faults.







12

Electrically isolate power supplies to the plant and make safe and lock off.







13

Do motorised dampers close on plant shut down?







14

Remove access panels to all areas to be cleaned including batteries.







15

With inspection plates open, using a torch, are the fins of heating and chilling batteries are clear and free of lint, dust & debris?







16

Having completed a visually inspect all heating & chilling batteries is there any sign of damage and leakage, including all local control valves etc?

If possible rectify the fault, otherwise report to Authorised Person [Water] for further attention.









17

Vacuum out all ducts of the ventilation plant, heating and chilling batteries including the areas around them?







18

Are the internal drainage drip trays stainless steel?







19

Are the internal drainage drip trays fully accessible or capable of being removed for cleaning?







20

Are the internal drainage drip trays below chillers and/or humidifiers clear of any corrosion of water i.e. there is no ponding of water?







21

Are the duct work drainage drip trays clear and free flowing? (clear if required).







22

Spray chiller batteries and surrounding ductwork, drain areas and any other low points in the local ductwork with hypochlorite solution at 5ppm dilution.

Ensure that both sides of the batteries are treated.









23

If a humidifier is present is it in operation?







24

Remove all glass traps, clean with a ‘bottle brush’, fill trap with clean water and then refit unit.

Ensure there is an air break of at least 15mm between the trap and tundish.









25

Visually inspect and check mechanical drive to the plant including pulley belts, pulley tensions (where fitted) and bearings. Adjust and lubricate as required.







26

Are manometers oil levels acceptable (fill with oil if required)







27

Are all guards in a good condition and secure?

Refix guards where necessary.









28

Is the condition of associated control valves and pipework in good order?

If ‘NO’ detail reasons…











Procedure:

NON CRITICAL SERVICES VENTILATION SUPPLY PLANT CLEANING AND INSPECTION RECORD SHEET

Frequency:

Every 6 months

Acceptance date:

Oct’12

File Ref:

LEG06 [page 2 of 2]

Next review date:

Oct’14

Item

Work Description

Y

N

29

Are all filters in place and in good condition (i.e. not need replacing).

Where filters may need replace then report to Authorised Person [Water] for actioning.









30

Are the main filters correctly fitted with no air-bypass.







31

Are all pre-filters correctly fitted with no air-bypass.







32

Refit all access panels and check seals are intact.







33

Remove locks and then restart plant, inspect the plant for any odd noises, leakage from any pipework, valve gear.







34

Did the ventilation plant restart satisfactorily?







35

Record pre-filter differential pressure in comments box below.







36

Record main filter differential pressure in comments box below.







37

Record manometers readings in comments box below.




38

Did the automatic change over operate satisfactorily?




39

Have you cleaned down plant and wipe up all spills caused by your work.







40

Have you cleared away any debris and redundant materials from the plant room.







41

Enter any comments or any faults and defects along with any actions you have taken in the area below and complete the box below.

Sign and return this document to the Authorised Person [Water].









Observations & additional comments.
Pre Filter Diff:
Main Filter Diff:
Manometer:


I, the undersigned, have completed the works outlined above:

Competent Person


Name:

Signature:


Date:

Authorised Person [Water]


Name:

Signature:

Date:

Additional docket numbers issued:





PPM:

Split Unit Clean & Inspection

PPM Ref:

C – LEG10

Frequency:

Quarterly


SPLIT UNIT INSPECTION AND CLEANING IS UNDER TAKEN BY A

SPECIALIST CONTRACTOR.
CONTRACTOR TO ISSUE THEIR COMPLETE JOB SHEET FOR EACH UNIT

AND THESE MUST BE FILED IN C – LEG10.





PPM:

WATER SOFTENER CHECKS

PPM Ref:

C – LEG24

Frequency:

Every 6 months



WATER SOFTENER INSPECTION AND CLEANING IS UNDER TAKEN BY A

SPECIALIST CONTRACTOR.


CONTRACTOR TO ISSUE THEIR COMPLETE JOB SHEET FOR EACH UNIT

AND THESE MUST BE FILED IN C – LEG24






Procedure:

MODIFICATION AND WORK RECORD SHEET TO RECTIFY DEFECTS FOUND [EITHER FROM THE LEGIONELLOSIS RISK ASSESSMENT OR AS FOUND / OCCUR]

Frequency:

As necessary

Acceptance date:

Oct’12

File Ref:

N/A

Next review date:

Oct’14


Property:




Location:





System ID:




Docket No:




A description of the condition experienced:



Proposed solution / recommendation:


Target date for completion:




Who’s Authorised for completing:





Nature of work carried out:

I, the undersigned, have completed the works outlined above:

Competent Person


Name:

Signature:


Date:

Authorised Person [Water]


Name:

Signature:

Date:

Additional docket numbers issued:







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