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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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:

Procedural

Staff group to whom it applies:

All staff within the Trust

Distribution:

The whole of the Trust

How to access:

Intranet

Issue date:

December 2012

Version:

1.05

Next review:

October 2014 – Extended to December 2016 for full review by recently commissioned Water Safety Group


Developed by:

Chris Curry, Specialist Services Compliance Manager & Authorising Engineer [Water].


Director leads:

Alan Davis, Director of Human Resources & Work Force Development


Contact for advice:

Chris Curry, Specialist Services Compliance Manager


Contents


SECTION 1 - MANAGEMENT REVIEW 2

1.1Review 2

1.2 Sampling and Monitoring 2

* File section C – these are individual property files held in the Schematic/Drawing Office. 2

1.2.1 Water Temperature Checks 2

1.2.2 General Microbiological/Legionella Sampling in potable Hot/Cold Water Systems 5



1.3 Water Sampling (for drinking and non drinking water systems) 7

1.3.1 Sampling Containers 7

1.3.2 Sampling Procedure 8

1.3.3 Action Regime Table 9

1.3.4 Laboratory Competence 10

1.4 Records 11

1.4.1 Retention Period 11

1.4.2 Record Keeping Forms 11

1.4.3 Incident Report Form 11

11

1.4.4 Schematics 11



SECTION 2 – Design, Operation & Maintenance 13

2.1 Design Control 13

2.2 Water Supply [Water Fittings] Regulations 1999 14

2.3 BS8558:2011 & BS EN 806 (parts 1 to 5) 14

2.3.1 Approved Materials 15



2.4 External Contractors 16

2.5 Maintaining control of systems during construction and testing 16

2.6 Testing & Commissioning 16

2.7 Contaminated Aerosols 16

2.8 Other Health & Safety Issues 17

2.9 Operation of Premises 17

2.9.1 Occupation of New Premises 17

2.9.2 Procedure in the Event of Closure of Part or All of a Building 17

2.9.3 Procedure in the Event of Re-occupation of an Indefinitely Closed Area. 19



2.10 Emergency and Outbreak Actions 20

2.10.1 Guidelines for Investigating Single Hospital Cases of Legionnaires’ Disease 21



2.11 Operation of domestic water systems 22

2.12 Domestic Cold Water Systems 23

2.12.1 Cold Water Cisterns and Cold Feed Tanks 23

2.12.2 Connections to Outside Services 23

2.12.3 Connections to Inside Services 23

2.12.4 Pressurisation / Supply Pumps 24

2.12.5 Gravity Systems 24



2.13 Domestic Hot Water Systems 25

2.13.1 Hot Water Storage and Distribution Temperatures 25

2.13.2 DHW Generator Operation 25

2.13.3 Domestic Hot Water Circulation Pumps 26

2.13.4 Electric Water Heaters 26

2.14 Air Conditioning Plant 26

2.14.1 General 26

2.14.2 Draining Traps and Pipework 27

2.14.3 Humidifiers 28

2.14.4 Heater Batteries 28

2.14.5 Air Handling Plant Inspection 28



2.15 Other Air Conditioning Units 28

2.15.1 Portable A/C Units. 28

2.15.2 Split Units. 28

2.16 Hydrotherapy Pools, Whirlpool Baths and Whirlpool Spas 29

2.16.1 General 29

2.16.2 Guidance 29

2.17 Other Risk Systems 29

2.18 Renal Dialysis Unit 29

2.19 Drinking and Non Drinking Water Systems 30

2.19.1 Drinking Water Systems. 30

2.19.2 Non Drinking Water Systems. 30

2.20 Water Conditioning 31

2.21 Cleaning and Disinfection 32

SECTION 3: TECHNICAL PROCEDURES 34

3.1 Domestic Cold Water Systems 34

3.1.1 Tank Cleaning Procedure 34

3.1.3 Loss of Incoming Mains Cold Water Supply 38

3.2 Domestic Hot Water [DHW] 39

3.2.1 DHW Generator Flushing 39

3.2.2 DHW Generator Maintenance 39

3.2.3 De-stratification Checks 40

3.2.4 Domestic Hot Water Temperature Less Than 45oC 40

3.3 Outlet Management 42

3.3.1 Showers 42

3.3.2 Thermostatic Mixing Valves [TMVs] 42

3.3.3 Little Used Outlets* 42

* Outlets include the following types: showers, baths, wash hand basins, sinks, WCs, sluices, bidets, taps. 43

3.3.4 Flexible Pipe Installations 43

When completing an installation all fittings will be made with fixed tails direct to the outlet. Flexible tails for installations shall only be used when fixed tail installation is not possible on the following appliances: Hi – Lo bath / wash hand basins, washing machines and dishwashers. When flexible tails have been installed then a check valve shall also be fitted pre flexible tail. 43

3.3.5 Safe Purging of Stagnant Water 43

3.3.6 High Pressure Hoses 43

3.3.7 Anti-Ligature Taps 43

3.3.8 The Safe Operation of Mains Fed Chilled Drinking Water Units / Vending Machines / Ice Machines. 44

3.4 Maintenance Checks for Other Water Systems 45

3.4.1 Strainers 46

3.4.2 Cleaning Water Systems within Buildings 46

3.4.3 Minor Plumbing Alterations 46

3.4.4 Major Plumbing Alterations [including work done through Procure21] 47

3.4.4 Certification 47

3.4.5 Notifications 47

APPENDIX 1: LEGIONELLA RECORDS DOCUMENT MAP 49



APPENDIX 2: RECORD SHEETS 51

APPENDIX 3: SENTINEL OUTLET MONITORING POINTS 115

APPENDIX 4: NEW SYSTEM DESIGN CHECK LIST 129

APPENDIX 5: BIBLIOGRAPHY 132





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