The management of hot and cold water systems for legionella bacteria policy and procedures

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Draft OCT 2014


Kenny Allen

Consultation with EB

Consultation with SPC

Consultation with JCC

Final Approval by EB

Final Approval by SPC

Approval by University Court

Publication on Web Site

(a)Purpose 2

(b)Scope 3

(c)Principles 4

(d)Procedure 6

(e)Accountabilities 28

(f)Policy Links 31

(g)Review & Monitoring 33

(h)Implementation 39

(i)Maintenance Checks for Other Water Systems 41

(j)Checklist for New Water System Designs 42

(k)Record Keeping Forms 44



The policy of the Glasgow Caledonian University [hereinafter referred to as “the organisation”] is to provide and maintain safe and healthy working conditions, equipment and systems of work for all staff and visitors, and to provide such resources, information, training and supervision as needed for this purpose. The organisation aims to do all that is reasonably practicable to manage the Control of Legionella Bacteria and to follow the steps laid out in the procedures. This will be judged on the basis of the balance of risk, cost and difficulty. The HSE’s Approved Code of Practice and Guidance Document [L8] – “Legionnaires’ disease: the control of Legionella bacteria in water systems” is taken as the primary source of guidance on matters relating to legionellosis risk management. Where highly vulnerable persons may be present, such as healthcare premises, Health Technical Memorandum (HTM) 04, The control of Legionella, hygiene, “safe” hot water, cold water and drinking water systems is the primary reference document. HTM 04 Parts A & B; and Scottish Hospital Technical Note 2 Domestic hot and cold water systems for Scottish Healthcare Premises can provide a useful indication of best practice.

The policy of the organisation is to meet the requirements of the relevant guidance, and to comply with these procedures so far as is reasonably practicable.

The management, control and prevention of Legionella Bacteria will be a continual commitment by the organisation involving regular management and progress meetings, and a risk assessment programme. Re-assessments will also fulfil many of the monitoring, inspection and record keeping requirements, including programme implementation, and system condition.

The Facilities Department, Estates Manager has been appointed by the organisation as the Responsible Person [Legionella].

This policy is formally accepted by the organisation. The organisation will do all that is reasonably practicable to comply with its requirements, and will make the necessary resources available.


All staff members that can affect the Management of Hot and Cold Water Systems for Legionella Bacteria shall conduct their tasks in accordance with this guidance; report any defects, suspicions or concerns regarding the design, condition, operation or performance of water systems that might increase the risk of Legionella Bacteria proliferation; keep relevant records; and attend the Management of Hot and Cold Water Systems for Legionella Bacteria awareness/training sessions.

Where any staff has a concerns regarding the hot and cold water systems they should be reported to their Line Manager and reported to the Facilities Department Help Desk on 0141 331 3999.


c.1Management Audit

An annual Management, Control and Prevention of Legionella Bacteria audit is undertaken in order to ascertain the effectiveness of the broad management arrangements. The methodology for audit may vary from year-to-year in order to ensure a fresh outlook on each occasion. The audit report includes recommendations for improvement and forms part of the legionellosis risk management system. A quarterly audit of site log books is also undertaken.

c.2Risk Screening

Prior to the conduct of on-site risk assessments, a risk screen will be performed in order to prioritise the water systems for detailed risk assessment, in order that the potentially highest risk systems are surveyed first.

c.3Risk assessment

The organisation undertakes and reviews the Management, Control and Prevention of Legionella Bacteria risk assessment under the following circumstances:-

  • On a regular basis, frequency dependent on risk –

Water system/AHU Risk

Frequency of Risk Assessment




Every 2 years


Every 3 years


Risk screen every 3 years

  • Reassessment takes place whenever there is reason to believe the latest risk assessment may no longer be valid e.g. due to a change of building use;

  • Desk based risk review of risk assessments is also undertaken on a regular basis;

At the time of each risk assessment, schematics of hot and cold water systems are checked to show that they are up to date and the existence of water connections to outside services is checked.

The organisation ensures that risk assessment:-

  • Is undertaken employing competent help;

  • Identifies and evaluates potential sources of risk;

  • Encompasses all buildings and all water systems.

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