2. Introduction
This policy sets out the aims and objectives of Waverley Borough Council (WBC) to control water quality within their housing properties. It is to be read in conjunction with the Water Hygiene Management Plan and Procedures document and the individual Written Schemes produced for each property following the completion of a Risk Assessment. The Water Hygiene Management Plan and Procedures document and the Written Schemes provide further information and site-specific detail of how this policy should be implemented.
The aim of this policy is to introduce a structured responsibility and reporting schedule for the Management and Control of Legionnaires’ disease, including Legionellosis and “Safe” water, in compliance with current guidelines, legislation and Water Supply Regulations.
This policy details WBC’s duties regarding the safety of its employees, tenants, occupants, leaseholders, visitors, neighbours, the general public and any others likely to be affected. This Policy and the associated Water Hygiene Management Plan and Procedures, documents require all parties to comply with.
WBC's property portfolio is varied and includes properties of various sizes and risks. This Policy covers all the properties identified below:
Social housing properties
- houses
- flats and flat blocks
- maisonettes
- bungalows
- bedsits
- housing units
- Senior Living Schemes
- community rooms.
3. About Legionella
Legionella bacteria are common and can be found naturally in environmental water sources such as rivers, ponds, lakes and reservoirs, usually in low numbers. They can colonise manufactured water systems and can be found in cooling tower systems, hot and cold water systems and other plant equipment which is used for stored water.
To reduce the possibility of creating conditions in which the risk from exposure to Legionella bacteria is increased, it is important to control the risk by introducing measures which:
- do not allow proliferation (multiplication) of the organisms in the water system
- reduce, so far as is reasonably practicable, exposure to water droplets and aerosols.
Legionella bacteria can survive within a wide variety of environmental conditions and water temperatures in the range 20°C to 45°C, seem to favour growth. The organisms do not multiply below 20°C but become dormant and will not survive above 60°C for longer than several minutes. They may, however, multiply only when water temperatures reach a suitable level.
Legionella bacteria also require a supply of nutrients to multiply. Sources can include, for example, commonly encountered organisms within the water system itself such as algae, moulds, yeasts, amoebae and other bacteria. The presence of sediment, sludge, scale and other material within the system, together with biofilms, is also thought to play an important role in harbouring and providing favourable conditions in which the Legionella bacteria may grow.
A biofilm is a thin layer of micro-organisms which may form slime on the surfaces in contact with water. Such biofilms, sludge and scale can protect Legionella bacteria from temperatures and concentrations of biocide that would otherwise kill or inhibit these organisms, if they were freely suspended in the water.
WBC recognises the risk from Legionella bacteria within the buildings controlled by them, and the requirement for employees and contractors to comply with this policy and the associated procedures in conjunction with all current legislation.
4. Policy statement for Legionella control
Water quality can represent a significant risk to health as highlighted by regular outbreaks of Legionnaires’ disease. The responsibility of WBC to achieve control within accepted parameters is formally recognised by this policy.
Legionnaires’ disease can prove fatal as confirmed by several preventable cases. WBC will seek to address preventable cases of Legionnaires’ disease across their building portfolio for the protection of staff, contractors, and visitors. The associated liability of such an outbreak, with any media attention exposure, attached to even a suspected outbreak, necessitates the need for clear, concise guidelines to be published. These guidelines must give recommendations to be taken to prevent Legionella bacterium multiplying within the buildings owned or managed by WBC.
WBC accepts their responsibilities to take every reasonable precaution necessary to protect the welfare of people occupying and visiting their properties, as well as those passing by their buildings. To ensure that the highest standards reasonably practicable are maintained, guidance relating to the prevention of Legionella, issued by authorities such as the Health & Safety Executive and the British Standards Institution, relating to the prevention of Legionella will be adopted where relevant.
The foundation to WBC’s approach to water quality control is:
- identify and assess sources of risk
- prepare a scheme for preventing, removing, reducing or controlling the risk, including actions to be taken in the event of loss of control
- implement, manage and monitor all precautions possible
- keep records of the provisions implemented
- appoint appropriate persons to be managerially responsible for the implementation of this Policy.
It is WBC’s policy that Water Research Advisory Scheme (WRAS), approved materials or their equivalents such as KIWA Watertec or NSF International are used on their water systems.
Risk assessments and record keeping are a statutory requirement for the control of Legionella. WBC will ensure this is implemented as identified within the Water Hygiene Management Plan and Procedures document.
All employees have a role in protecting health and safety for all and water quality is part of this. Such basic information will be provided to all employees, and specific training and instruction will be given to all those directly involved with water safety management, to ensure competency levels are suitably maintained.
This Policy will be reviewed every two years, or whenever there is a reason to believe that this policy is no longer fit for purpose.
5. Responsibilities
WBC as employers have a general duty under The Health and Safety at Work Act 1974 to ensure so far as is reasonably practicable, the health, safety and welfare of all their employees. Employees have a duty to take reasonable care for their own health and safety and of that of others who may be affected by their acts or omissions at work. It also requires the employee’s co-operation with their employer, to enable the employer to comply with their statutory duties for health and safety.
Management has the overall responsibility for the implementation of this Policy to ensure that safe, reliable water supply, storage and distribution systems are operated within WBC housing properties. In addition, management has a statutory duty to ensure that compliance with this Policy is continual and not assumed. WBC must be able to demonstrate it has identified all the relevant factors, has instituted corrective or preventive action, and is monitoring the implemented plans.
It is the responsibility of any person employed by WBC in whatsoever capacity to comply with the requirements of this Policy.
The main roles within the Water Hygiene management structure (Duty Holder – Deputy Responsible Person) are listed below, the details of those within the roles can be found within the contact details section of this document. All other personnel within the water hygiene management structure are identified within the Water Hygiene Management Plan and Procedures document.
Duty Holder
See Appendix 1
The Chief Executive is deemed to be the Duty Holder and has the overall responsibility for ensuring compliance with all statutory regulations and therefore this policy. To fulfil their responsibility, the Duty Holder will:
- ensure the implementation of WBC’s management plan and procedures at all levels within WBC and the provision of adequate resources to meet the requirements of the procedures
- appoint through delegated responsibility, a competent individual with sufficient authority and knowledge — referred to as the 'Site Responsible Person' — to oversee the day-to-day management of the water systems. This person should also provide regular reports on the system's status and the effectiveness of control measures
- assist with budgets for compliant design, maintenance, operation and monitoring of water systems.
Devolved Duty Holder
See Appendix 1
The Director of Housing is deemed to be one of the Devolved Duty Holders in which some of the Duty Holders responsibilities have been assigned to. This includes the following:
- appointing a competent Responsible Person
- ensuring that the Water Hygiene policy and management plan and procedures documents are implemented within Housing
- monitoring and reviewing the effectiveness of the Housing water hygiene & legionella policy and management plan and procedures documents
- ensuring Legionella management arrangements are addressed in the Housing health and safety plans
- ensuring that Legionella management controls are suitably addressed in budgets submitted for full Council approval.
Devolved Duty Holder
See Appendix 1
The Strategic Director is deemed to be one of the Devolved Duty Holders in which some of the Duty Holders responsibilities have been assigned to. This includes the following:
- ensuring that the Housing water hygiene & legionella policy and management plan and procedures documents are implemented within Housing
- monitoring and reviewing the effectiveness of the Housing Legionella policy and management plan and procedures documents
- ensuring Legionella management arrangements are addressed in the Housing health and safety plans
- ensuring that Legionella management controls are suitably addressed in budgets submitted for full approval.
Devolved Duty Holder
See Appendix 1
The Head of Housing is deemed to be one of the Devolved Duty Holders in which some of the Duty Holders responsibilities have been assigned to. This includes the following:
- managing the responsible person
- the implementation and adherence to the water hygiene & legionella policy management plan and procedures within their Team and reporting non-compliance to the Strategic Director and Corporate Health and Safety Group
- to provide an oversight of Health & Safety issues for the Housing portfolio to ensure that this management plan and procedures are robustly followed
- responsible for recruiting a competent Regulatory Compliance Manager to implement and monitor Housing’s Legionella Policy and management plan and procedures documents, and monthly performance reporting
- ensuring that adequate resources are in place to meet the requirements of this management plan
- ensuring that a regime for Legionella management within the Housing portfolio is undertaken and remedial works completed
- input into the management of specialist Legionella contractors, attending the contract meetings as necessary
- monitoring best practice and innovation to ensure that Legionella management arrangements remain current and up to date with developing technical standards
- ensure Construction (Design & Management) Regulations are adhered to and sufficient information on Legionella management is included within construction project Health & Safety files where necessary.
Responsible Person
See Appendix 1
The Regulatory Compliance Manager has the role of Responsible Person and as such is tasked with:
- confirming the DRP is overseeing and monitoring day-to-day Legionella management arrangements
- developing and maintaining Housing’s Legionella Policy and management plan and procedures documents
- monitoring effectiveness of Housing’s Legionella Policy and management plan and procedures documents
- periodic reporting of performance to the Duty Holder(s)
- advising the Duty Holders on Legionella management, any unfulfilled duties, outstanding actions, management arrangements and, where applicable, new mitigation measures that are required
- monitoring best practice and innovation in order to ensure that Legionella management remains current and up to date with developing technical standards
- ensure Construction and Design & Management Regulations are adhered to, and sufficient Legionella management information is included within construction project Health & Safety files where appropriate
- developing and maintaining water hygiene & legionella management regime
- tracking and reporting implementation of the legionella management regime and adherence to set arrangements
- reviewing and monitoring the competence and performance of contractors and Council staff engaged for the Legionella management regime
- developing, publishing and distributing Legionella & other water safety management guidance for residents
- assisting in periodic Legionella contractor compliance audits, in conjunction with service area managers.
Deputy Responsible Person
See Appendix 1
The Compliance Officer for Water Hygiene has the role of Deputy Responsible person and as such is tasked with:
- day-to-day management of Housing’s Legionella Policy and management plan and procedures documents
- ensuring delivery of the water hygiene & legionella management regime and arranging resultant remedial measures
- auditing activities undertaken by other parties
- deputising for the Regulatory Compliance Manager by undertaking duties as appropriate and upon delegation
- ensuring that a training matrix which identifies WBC water safety awareness training requirements is developed and maintained
- arranging training for WBC staff via an appointed contractor.
Competent Contractors
For the purposes of this Policy, the service providers are organisations that supply WBC with services pertaining to "Water Hygiene Management & Control", whether Facilities Management, Water Treatment or Consultancy, etc. At the time of this Policy the responsibilities contracted to service providers for the site Legionella Programme are:
Risk assessments and planned preventative maintenance
To be awarded.
Remedials and planned works
SMS Environmental Services Ltd
Water hygiene provider account manager
See Appendix 1
The majority of the routine and corrective tasks directly applied to the sites water systems for Legionella control are to be delivered by external water hygiene providers. The external water hygiene providers will be responsible for ensuring that the water treatment programme is carried out in line with WBC’s Policy and the associated Water Hygiene Management Plan and Procedures document. The external water hygiene providers must ensure all associated legislation and guidance is followed.
6. Training and competence
Training should be both general and specific. Legionella awareness and responsible person training should be undertaken to a recognised standard such as City & Guilds. More specific training against this policy and site-specific written schemes should also be undertaken.
Training should be commensurate with the roles and include all relevant departments and contractors and subject to regular reviews to ensure that personnel maintain high competency levels, and that this is resulting in the water management system being utilised effectively and to negate potential staff turnover.
Records of all training/training matrices should be kept, including those of service providers, for the term of the contract.
All service providers should be approved by the Legionella Control Association (LCA).
7. Dissemination and implementation
This policy document will be held on WBC’s SharePoint. Any changes to this document must be implemented only with the authority of the Regulatory Compliance Manager.
8. Consultation, approval, ratification and review
This document will be issued for formal consultation in draft form prior to issue. The following staff will be consulted:
- Marlowe Environmental Services – 3rd Party Consultant
- all relevant Internal Departments
- Management Board
- Customer Panel
- Repairs Contract.
The Duty Holder is to review, approve and ratify this policy.
This policy is to be reviewed every two years unless otherwise indicated by a change in national guidance or in the event of an outbreak, case, or suspected case of legionellosis arising from a water system under the control of WBC. The review will be completed by the Regulatory Compliance Manager.