Water Safety Management Retirement Living Courts Policy

1.  POLICY STATEMENT
2. PURPOSE AND SCOPRE OF THE POLICY
3. DUTIES
4. DEVELOPMENT PROCESS
5. EQUALITY IMPACT ASSESSMENT
6. DISSMEINATION AND IMPLEMENTATION ARRANGEMENTS
7. PROCESS FOR MONITORING COMPLIANCE AND EFFECTIVENESS
8. MANAGEMENT PLAN
9. REVIEW AND REVISION ARRAGEMENTS
10. REFERENCES 
11. APPENDICES

Wealden District Council [hereinafter referred to as the “Council”] has a duty of care to residents, visitors and staff to ensure a safe and appropriate residential environment.

The Council accepts its responsibility under the Health and Safety at Work etc. Act 1974 and the Control of Substances Hazardous to Health Regulation 2002 [as amended], to take all reasonable precautions to prevent, control and guard against the harmful effects of waterborne pathogens water to residents, visitors, staff and other persons working at or using its premises.

The Chief Executive carries ultimate responsibility for a safe and secure environment. Aspects of that responsibility have been assigned / delegated to other appointed individuals within the Council, these are defined under “Roles and Responsibility” section of this Policy document. 

The Chief Executive has appointed the Director of Community and Customer Services as the Designated Person.  Designated Person is responsible for ensuring overall operational control is in place.

The Designated Person has appointed the Property Services Manager as the Competent Responsible Person [Water].  This Policy is issued and maintained by Competent Responsible Person [Water] on behalf of the Council.

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

This Water Safety Plan [WSP] [Policy, Procedures, Log Books] applies to all Council employees [including those managed by a third party] and housing premises where they work, Council owned and occupied, including those properties which the Council may occupy under lease.

The management of water safety will be a continual commitment by the Council involving regular management and progress meetings, and a commitment to a risk assessment programme.

2.1    Purpose

This Policy shall ensure the following are in place to safeguard all residents, visitors, staff and assets in Council owned Retirement  Living Courts in order to prevent and reduce harm or loss;

• a. To set out a clear framework to protect all staff, residents and visitors by minimisation of the risks associated with waterborne pathogens;

  b. To identifying the correct practice for managing water risk systems so far as is reasonably practicable for staff to implement based upon nationally accepted guidance;

  c. To enable staff to understand their responsibilities in relation to this Policy document;

  d. To detail arrangements for ensuring this Policy is monitored and reviewed to reflect current legislation and guidance;

  e. To detail the process for version control to ensure persons who require it, have access to the most current version of the document. Ensuring arrangements are in place for archiving revised policies.

The WSP shall be supported with adequate resources and suitably qualified, trained and competent staff to ensure the successful implementation of the Policy, Procedures & Log Books in the Retirement Living Courts.

2.2 Scope

This Policy sets out the management approach to be adopted by the Council for providing, maintaining safe water systems and preventing infection from Council water systems within the Retirement Living Courts.

The Policy applies to all service users, visitors and staff associated with Council Retirement Living Courts and should be read and implemented whenever water related risk management advice is required in one of these buildings.

2.3     General needs properties

This Water Safety Policy, and associated Water Safety Plan documents, relates primarily to Wealden s Retirement Living Courts. Particular emphasis is being given to the court residents as they are classified as a vulnerable group under the relevant Health and safety guidance. This means the residents require a higher level of care than general needs residents and the systems should therefore be subject to closer monitoring.

As a local authority, Wealden has a duty to all its housing stock however, under Health and Safety guidance, general needs properties are classified as domestic properties and are recognised as a lower risk group. Measures are taken in respect of general need properties which includes; undertaking a compliancy checklist at void stage and providing the tenant with information and advice (such as flushing the toilet and running the taps and shower after being away for a long period of time), which complies with the relevant technical guidance.

The Water Hygiene Centre, a specialist water hygiene consultant, undertook a general needs risk screening exercise on behalf of Wealden on all general needs properties and identified no particular risks.

The Water Hygiene Centre, a specialist water hygiene consultant, undertook a general needs risk screening exercise on behalf of Wealden on all general needs properties and identified no particular risks.

3.1           Management Responsibility

Those persons with key management responsibilities are detailed below and their communication pathways and other relevant supporting staff are represented in below.

All relevant persons shall fully appreciate the actual and potential risks of water borne pathogens [including Legionella and the concept of risk management. Although compliance with the WSP tasks may be delegated to staff, or undertaken by contractors, accountability cannot be delegated.

Any person intending to fulfil any of the staff functions specified below should be able to prove that they possess sufficient skills, knowledge and experience to be able to perform safely the designated task(s).

3.1.1       Duty Holder

The Chief Executive is the statutory Duty Holder. The Duty Holder has overall accountability for Health & Safety within the Council, including all aspects of water safety and the quality of water supplies.

3.1.2       Designated Person [Water]

The Director of Community and Customer Services is the Designated Person [Water]. They are appointed in writing by the Duty Holder.

The Designated Person [Water] will provide the informed position to HMT level. They are responsible for the organisational arrangements [strategic leadership, direction and overview] which will ensure that compliance with standards is achieved [including proposed developments take account of impact on water safety]. Any management issues [including water system issues] have been reported to HMT having being resourced and solved. They won t have technical or operational duties, but, will be supported in the role by the Council management structure that delivers governance, assurance and compliance.

3.1.3       Senior Operations Manager

The Head of Housing is the Senior Operations Manager [SOM].  They are appointed in writing by the Designated Person [Water].

The SOM will be the informed link to the Designated Person [Water] at HMT level as such they shall:

a. Immediately inform the Designated Person [Water] if any suspected legionella outbreaks / incidents occurs. As well as taking an active role in any investigations;

b. Ensure this Policy is reviewed, ratified and implemented;

c. Ensure accountability and responsibility arrangements are in place and implemented.

3.1.4      Competent Responsible Person [Water]

The Property Services Manager is the Competent Responsible Person [Water]. They are appointed in writing by the Designated Person [Water].

To facilitate this role the Responsible Person [Water] will be required to liaise closely with other professionals in various disciplines, as such will be supported by the Senior Operational Manager, Deputy Responsible Person [Water], Authorised Persons [Water] and the Retained Independent Water Hygiene Consultant to ensure suitable provision to maintain the service.

The RP [Water] shall:

a. Be professionally and operationally responsible for water quality;

b. Establish budgets overall and single items limits;

c. Chair the Water Safety Group [WSG] meetings or delegate to Deputy Responsible Person;

d. Issue the WSP [Policy, Procedures, Log Books];

e. Monitor the implementation and efficacy of WSP [Policy, Procedures, Log Books];

f. Co-ordinate with the Retained Independent Water Hygiene Consultant for help, advice and in response to any investigation arising for non-compliant issues and for the ongoing development of the Estate;

g. Ensuring that all control schemes handed over are appropriately documented, commissioned and signed off in accordance with the WSP. Any issues arising with the control schemes will be reported by the SOM back to the Property Services Team for resolution;

h. Assist with annual management audits completed by the Retained Independent Water Hygiene Consultant;

i. Carry out the necessary actions defined in the procedures manual should an outbreak situation associated with waterborne pathogens be suspected or confirmed;

j. Attend management training as determined by training needs analysis, but at least every three years.

3.1.5       Deputy Responsible Person [Water]

The Property Services Team Leader is the Deputy Responsible Person [Water]. They will be appointed by the Designated Person [Water]. DRP [Water] will deputise in the absence of the Competent Responsible Person [Water] and will act on their behalf.

The DRP [Water] shall:

a. Provide the Competent Responsible Person [Water] with information on the status of service;

b. Be responsible for the development & implementation of the WSP [ensure compliant with ACoP L8 [including HSG274 Parts 1, 2 & 3];

c. Attend the Water Safety Group [WSG] meetings;

d. Chair the monthly Operational Water Group [OWG] meetings or delegate to Authorised Person [Water];

e. Inform the RP [Water], Retained Independent Water Hygiene Consultant and the Authorised Person [Water] of all positive water sample results and the associated action being taken to resolve them;

f. Co-ordinate with the Retained Independent Water Hygiene Consultant for help, advice and in response to any investigation arising for non-compliant issues and for the ongoing development of the Estate;

g. Assist with the review this WSP [Policy, Procedures, Log Book] and its ratification;

h. Assist with management audits and records audit;

i. Commission additional surveys [including pipework] in response to risk assessment recommendations, sampling issues [positive results] or other observed faults / conditions reported. The issue of orders / job tickets for remedial works [in response to the additional survey findings] to relevant consultant, approved contractor and / or maintenance supervisor;

j. Ensure the Council records management system is maintained, complete and operational. As well as ensuring drawings / plans / schematics are maintained, updated, produced of all the Council water systems / buildings where a change has occurred;

k. Manage refurbishment works [major or minor] in accordance with the WSP;

l. Ensure water risk assessments be completed for all projects before commencement and once the system is operational;

m. Inform WSG at the earliest possible opportunity where new premises or existing premises are to be altered or refurbished so water hygiene requirements can be assess in the planning stages;

n. Ensure all commissioning, handover records, O&M manuals, risk assessments including evidenced records are received on completion of a project;

o. Ensure that the design of new and refurbished water systems follows the latest regulations, standards, guidance and the WSP;

p. Review & maintain the Planned Preventative Maintenance [PPM] schedules to ensure they are correctly defined in the WSP;

q. Ensure that any non-complaint occurrences / issues reported from the APs [Water] in the periodic PPM tasks are actioned;

r. Issue Permits to Work and other appropriate documentation as required to Competent Persons and / or approved contractors. With approved contractors ensuring their competence has been checked;

s. Manage those Project Managers who are leading on refurbishment works [major or minor] or new development works to ensure they are completed in accordance with the WSP;

t. Be responsible for leading on the explanation to users on the function of risk systems and organise adequate information and training to support those systems;

u. Agree the risk minimisation scheme with the APs [Water];

v. Ensure that Incident reporting is completed in full for positive water sample results and failures in the management systems;

w. Investigate any reported defects, suspicions or concerns regarding the design, condition, operation or performance of water systems that might increase the risk of waterborne pathogen proliferation. These shall also be reported to the RP & AP [Water];

x. Inform the RP [Water], Retained Independent Water Hygiene Consultant and Authorised Person/s [Water] of all positive water sample results and the associated action being taken to resolve them;

y. Carry out the necessary actions should an outbreak situation associated with waterborne pathogens be suspected or confirmed;

z. Lead reporting incidents to the HSE and act as key liaison with the HSE during any visits;

aa. Liaise with 3rd parties external to the Council on assurance [see Landlord and 3rd Parties ]

bb. Routinely reviewing the training needs analysis, with suitable training being delivered where required.

cc. Attend management training as determined by training needs analysis, but at least every three years.

3.1.6       Authorised Person [Water]

The Contracts Officer is the Authorised Persons [Water]. They will be appointed by the Designated Person [Water].

The AP [Water] shall:

a. Attend the Water Safety Group [WSG] meetings & Chair the monthly Operational Water Group [OWG] meetings;

b. Review & identify changes needed to the WSP Policy, Procedures, Log Book];

c. Be responsible for the implementation of the WSP;

d. Assist with management audits and records audit;

e. Arrange and review water risk assessments of Council water systems / buildings as defined in this Policy;

f. Implement and action of agreed remedial works in line with the risk minimisation scheme;

g. Commissioning additional surveys [including pipework] in response to risk assessment recommendations, sampling issues [positive results] or other observed faults / conditions reported. The issue of orders / job tickets for remedial works [in response to the additional survey findings] to relevant consultant, approved contractor and / or maintenance supervisor. On completion of the work ensure drawings are updated, noted and dated;

h. Supervising refurbishment works [major or minor] outside the scope of Capital Projects in accordance with the WSP, including the monitoring of completed work by appointed contractors;

i. Issue all relevant PPM work orders to Competent Persons and then ensuring that all PPM works orders are completed on time, are recorded and filed in the Council s document management system. Ensuring the Council s document management system is maintained;

j. Ensure that any non-complaint occurrences / issues reported by the Competent Persons are actioned in a timely response by the CP and reported the DRP;

k. Ensuring that all planned and reactive sampling activities are carried out in accordance with the WSP and that results are reviewed, escalated to the DRP and actioned [where necessary in a timely and professional manner] in accordance with the WSP;

l. Ensure the external consultants & contractors are suitably qualified & competent [as defined in Competence ]. Evidence shall be held in the form of qualifications and membership to Legionella Control Association [LCA] & Water Safe Register;

m. Issuing Permits to Work and other appropriate documentation as required to Competent Persons;

n. Maintain the records system, quality of service and maintenance of system safety (integrity).

o. Liaising with the water undertaker and ensure that equipment that is permanently connected to the water supply is properly installed;

p. Be responsible for leading on the explanation to users on the function of risk systems and organise adequate information and training to support those systems;

q. Carry out the necessary action should an outbreak situation associated with waterborne pathogens be suspected or confirmed;

r. Attend management training as determined by training needs analysis, but at least every three years.

3.1.7       Retained Independent Water Hygiene Consultant

The Retained Independent Water Hygiene Consultant [Water] [hereinafter referred to as RI [Water] will remain independent of the Council and remain independent of providing remedial services.

The Retained Independent Water Hygiene Consultant shall:-

a. Advise & support on updates to the WSP [policy, procedures, log book], water sample results and non-compliant issues identified and what actions can be taken to resolve them;

b. Undertaken annual management audits;

c. Monitor performance through reviewing compliance ;

d. Assist with risk assessment reviews;

e. Attend the Water Safety Group [WSG] meetings;

f. Deliver training based on needs analysis.

3.1.8       Competent Person [Water]

The Council has a mixed environment with their own staff and external contractors. Both of which are used to execute the tasks required within the WSP.

External contractors are commissioned by the Council to provide monitoring and repairs services. These contractors are known as the External Competent persons [ECP]. The contractor s individual employees will not be appointed in writing by the Council, instead the AP [Water] will ensure the contracting company are members of the Legionella Control Association [LCA] and / or Water Safe Registered. Contractor s employees are required to hold plumbing qualifications. Evidence of membership and qualifications are required and shall be issued by the external contractors to AP [Water].

The ECP shall:

a. Attend monthly Operational Water Group [OWG] meetings;

b. Provide monthly compliances reports;

c. Inform the AP [Water] and DRP [Water] of non-compliant issues on the same day as they found/observed;

d. Provide the skilled installation and/or maintenance of water risk systems;

e. Conduct all of their water system related tasks in accordance with the WSP & PPM system, they shall complete all required records and return to the AP [Water];

f. Only use WRAS approved materials when working on water systems;

g. Employ their highest standard quality of work;

h. Maintain good hygiene practices with tools, equipment, components/accessories to be used on water systems thus preventing contamination of water systems and outlets;

i. Report any defects, suspicions or concerns regarding the design, condition, operation or performance of water systems that might increase the risk waterborne pathogen proliferation;

j. Ensure good personal hygiene [including clothing and foot ware] practices [reporting any recent communicable illness to AP [Water] before commencing any work on water systems;

k. Report any defects, suspicions or concerns regarding the design, condition, operation or performance of water systems that might increase the risk waterborne pathogen proliferation to RP [W];

l. Attend updated training at least every three years, or sooner if determined by the training needs analysis.

With ECPs a specification appertaining to new works will be produced which will include:-

a. A standard form within the contract documentation which define roles, responsibilities and procedures of parties concerned;

b. Submission of risk assessments and method statements with relation to compiled schedules;

3.1.9   Retirement Living Court Managers

3.1.10 Retirement Living Court Managers
Retirement Living Managers [RLM] are the managers of Retirement Living Courts, they have control over the use of water in their property. In order to fulfil their legal obligations.

The RLM shall:

a. Follow the guidance contained within the WSP;

b. Ensure that all water outlets are used at least weekly with adequate records kept of flushing;

c. Report any defects, suspicions or concerns regarding the design, condition, operation or performance of water systems that might increase the risk of waterborne pathogen proliferation.

3.1.10   Council Staff / Cleaning Contractors

All staff members that can affect water hygiene risk, as such they report any concerns, suspicions regarding the operation or performance of water systems that might increase the risk of waterborne pathogen proliferation i.e. little used outlets. Maybe required to attend training sessions [where necessary].

Employees may be consulted regarding the assessment and control measures according to their role. Each risk assessment/risk minimisation scheme report [at organisational level] shall include an Employee Summary for dissemination to unions/employees at the discretion of the Competent Responsible Person [Water].

3.2 Communication Pathways

4.1           Identification of need

To meet the requirements of ACoP L8 and HSG274, other associated guidance documents, this Policy and the associated WSP.

4.2           Consultation and Communication with Stakeholders

The organisation recognises that policies need to be developed in consultation and communication with a range of stakeholders:

• Competent Responsible Person [Water];
• Deputy Responsible Person [Water];
• Authorised Person [Water];
• Retained Independent Water Hygiene Consultant [Water].

5.1           Aim

The Council aims to ensure its policies promote equality both as a provider of services and as an employer. Please see APPENDIX 2 for Equality Impact Assessment.

6.1           Dissemination

This Policy document is available in a read-only format via the document store on the Council s i-Drive for staff to access. As the Policy is reviewed any updated copy of the Policy shall replace the existing Policy hosted on the Council i-Drive. Any changes to this document must be implemented only with the authority of the Competent Responsible Person [Water].

6.2   Implementation

Support and advice to assist in the implementation of this document is available from the:

• Competent Responsible Person [Water];
• Deputy Responsible Person [Water];
• Authorised Person [Water];
• Retained Independent Water Hygiene Consultant.

7.1           Monitoring Compliance

Arrangements in place for ensuring and monitoring compliance within this Policy and associated WSP are achieved through reviewing and auditing as defined in the table below:

7.2           Effectiveness

Effectiveness of compliance is detailed at the Water Safety Group meetings.  The WSP is based on external standards [see section 10 References].

8.1 Water Safety Plan [WSP]

The WSP [referred to by the HSE as the ‘Written Scheme’] for the Council is a defined suite of supporting  documents, which are designed to ensure Water Safety is being proactively managed within the council.  The WSP is made up of the following documents:

8.2            Water Safety Group [WSG]

To comply with the HSE L8 Approved Code of Practice, the Council has an established Water Safety Group [WSG] and Water Safety Plan [WSP].

The aim of the WSG is to ensure the safety of all water used by residents, staff and visitors, and to minimise the risk of infection associated with waterborne pathogens.

The WSG is multi-disciplinary group and is a forum in which people with a range of competencies through the Council are brought together to share responsibility and take collective ownership for ensuring it identifies water-related hazards, assesses risks, identifies and monitors control measures and develops incident protocols.

As such, membership to the WSG broadly includes those:

a. Who are familiar with all water systems and associated equipment in the building(s) and the factors that may increase risk of infection from Legionella and other waterborne pathogens (that is, the materials and components, the types of use and modes of exposure, together with the susceptibility to infection of those likely to be exposed);

b. Who have knowledge of the particular vulnerabilities of the at-risk population within the property;

c. Representatives from areas where water may be used where exposure to aerosols may take place.

The WSG undertakes:

a. The commissioning, development & implementation of the WSP.
b. The provision of advice on the remedial action required when water systems or outlets are found to be contaminated and the risk to susceptible residents is increased.
c. Decision making on the safety and integrity of the water systems and associated equipment that use water to which residents, staff and visitors could be exposed do not go ahead without being agreed by the WSG. This includes consultations relating to decisions on the procurement, design, installation and commissioning of water services, equipment and associated plant [includes seeking assurance should be sought from the manufacturer regarding safety for residents and service-users].

The Terms of Reference [ToR] for the WSG can be found in Appendix 3 of this Policy.  The ToR defines:

a. The purpose of the WSG;

b. Membership of the WSG;

c. Frequency of meetings, Quorate arrangements along with agenda;

d. Objective of the WSG;

e. Reporting arrangements.

The WSG has clearly identified lines of accountability / communication pathways [see 3.2 Communication Pathways] up to CMT. The roles and responsibilities of these members are defined within this Policy. Only members of the WSG shall attend meetings, unless they are unable to attend it is expected they will inform the Chairperson and detail a nominated deputy to attend the WSG in their place.

8.3 Operational Water Group [OWG]

This is a separate group to the WSG. The OWG meets on a monthly basis [or sooner if deemed necessary] with the objective of providing assurance of operational performance, monitoring for the Council risk systems along with completing the risk assessment review process and documenting this review. The OWG shall also ensure asset registers are accurate and kept up to date detailing all assets relating to hot and cold water systems.

The OWG is chaired by the Authorised Person and is attended by the DRP [Water], APs & ECPs. Formal minutes are taken. Reports on performance, risk minimisation action plans, sampling results and incidents are summarised and reported to the quarterly WSG meetings.

8.4 Water Safety Plan [WSP]

It is prepared by the RP [Water], DRP [Water], AP [Water] with input from the Retained Independent Water Hygiene Consultant.

The WSP is made up for several individual documents:

• Policy document;
  * Risk Assessments providing detail on the risk systems within Council properties which is then used to developed the operational procedures [see below];
  * Operational procedures [including routine maintenance, routine monitoring, emergency actions [outbreak, confirmed/suspected cases, and non-compliant occurrences] for all Council risk systems;
  * Log Books – documented record management system, the associated forms and check sheets to be used by ECP as part of the routine monitoring and inspections.

The WSP also details the control strategy for managing water risk systems along water sampling need with identified areas and locations for sampling water.

A risk system is classed as system or device that contains, holds or uses water where there is a reasonable foreseeable risk associated with that system.

8.5 Auditing

A programme of auditing the written scheme elements is defined in section 7 Monitoring Compliance & Effectiveness . This will inform the organisation s assurance framework.

Monitoring the performance of ECP should be completed by DRP [Water] & AP [Water]. The use of another contractor to monitor the performance of the ECP should be avoided as this could lead to a conflict of interest.

An annual water risk management audit is undertaken by the Retained Independent Water Hygiene Consultant with assistance from the RP [Water], DRP [Water] & AP [Water] 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 performance monitoring completed by the DRP [Water] and APs [Water] will require inspection of systems and their records to establish the degree of compliance of records present and accuracy of the records. These quarterly performance audit applies to all Council properties. The results of this quarterly performance audit will be reported at the WSG.

a. the required level of service is met;

b. all the required plant is being maintained;

c. system performance is being maintained (that is, by the implementation of microbial sampling and temperature/biocide-level- monitoring regimes);

d. maintenance is being carried out to the agreed standard;

e. correct replacement parts are being used;

f. the agreed spares stocks are being held on site;

g. records are being correctly maintained;

h. the agreed standards, number of staff, and number of visits are being achieved;

i. plant is being operated to achieve optimum energy usage;

j. health and safety requirements are being complied with;

k. only agreed subcontractors with the appropriate knowledge and competence are being employed;

l. the client and typical users of the building are satisfied;

m. invoices accurately reflect the work carried out, including materials expended;

n. breakdowns do not occur too often;

o. adequate consideration is being given to the potential environmental impact of contractors actions, for example disposal of lubricants, chemicals, worn parts etc. that cannot be recycled.

8.6 Risk Assessments & Drawings.

 8.6.1       Water Risk Assessments

The Competent Responsible Person [Water] will ensure that suitable and sufficient risk assessments are up to date and valid. The AP [Water] shall ensure risk assessments are commissioned when needed [see criteria below]. The risk assessment must be completed in accordance with:

• * ACOP L8 [fourth edition] 2013;
  * HSG274 [Parts 1, 2 & 3] [as applicable];
  * HTM04:01 [Parts A, B & C];
  * SHTM 04:01 [Parts A, B, E & G]
  * SHTM 04:02 [Parts A, B & C]
  * BS8580:2010.
  * HGN Safe Hot water and Surface Temperatures ;

The Council requires the risk assessment to be completed by a competent person, the DRP [Water] shall ensure the assessor is competent [this may include the need for formal interview with examples of risk assessment reports and projects they have been involved with] and independent of supplying any ongoing remedial work.
Accreditation to UKAS to ISO/ISE 17020:2012 and membership to the Legionella Control Association [LCA] is one means of ensuring competence.

 The risk assessor(s) shall be given access to competent assistance from the Council. This may be in the form of:

• a. engineering and building expertise;
  b. as-fitted drawings and schematic diagrams;
  c. clinical expertise;
  d. knowledge of building occupancy and use including vulnerability of residents;
  e. bespoke equipment plus policies, procedures and any protocols (for example cleaning of wash-hand basins and disposal of clinical effluent etc.).

 The risk assessment shall:

a. Encompass all buildings and all water systems;

b. Identify and evaluate potential sources of risk;

c. Include an assessment of occupant vulnerability;

d. Use an established risk scoring matrix;

e. Include an assessment of engineering, considering correct design [inherent risk and actual risk], installation, commissioning, maintenance, verification and effectiveness as a control measure;

f. Include a review of schematics of hot and cold water systems to check they are up to date and the existence of water connections to outside services is checked;

g. An assessment of underused outlets and flushing regimes;

h. Include information on Scalding risk;

i. The unnecessary use of non WRAS approved materials [i.e. Flexi hoses];

j. Review monitoring, sampling and testing records.

The assessment of risk is an ongoing process, and as such the AP [Water] should ensure the risk assessments are regularly reviewed and updated [see Appendix 5 – Risk Assessment Review Schedule and Risk Assessment Need Notification], specifically when:

a. a change to the water system or its use;

b. a change to the use of the building where the system is installed;

c. new information available about risks or control measures;

d. the results of checks indicating that control measures are no longer effective;

e. changes to key personnel;

f. a case of legionnaires disease/Legionellosis associated with the system.

The Council will support this risk assessment process by giving guidance on any specific clinical risks where it is deemed appropriate.

The DRP [Water] will communicate the latest risk assessment report and minimisation scheme actions at the WSG. The WSG will consider the overall recommendations in context of the Council Risk Register.

For those properties which are not owned by the Council but the Council occupies, the RP will request evidence from the Duty holder for that property that water safety risk is being proactively managed [see Appendix 5 Landlord / 3rd Party Evidence of Risk Assessment letters].

8.6.2 Drawings

As-fitted drawings shall identify all key components in the installation, i.e. water meters, cisterns, filters, calorifiers, water heaters, isolation valves.  These drawings should be kept up to date.  These drawings will help inform the risk assessment and are necessary to perform adequate temperature control checks and will be valuable for identifying potential problems with poor temperatures.

Schematic drawings are not formal technical drawings, they are intended to be easy to read without specialist training / experience.  They provide the reader with an idea of layout and position of components and connections.  These drawings should be kept up to date.  These drawings assist with the risk assessment process. 

8.7 Risk Minimisation Scheme

The risk assessment shall form the basis of a risk minimisation scheme describing the particular means by which the risk from exposure to waterborne pathogens is to be minimised so far as is reasonably practicable. The remedial actions within the associated risk minimisation schemes shall be reasonably practicable and prioritised on the basis of risk, cost and difficulty.  The risk minimisation scheme shall be reviewed at the monthly OPW and approved by the WSG.

8.8 Training & Competence

 8.8.1 Training

The WSG will review training needs analysis at each meeting and implement a training programme to ensure all those defined in the control strategy have received appropriate information, instruction and training to undertake their associated duties. Records of training and attendance of appropriate training shall be kept. Refresher training shall be given dependent on review of training needs analysis.

Competence of staff and contractors shall be assessed according to their role and duties. To ensure competence has been assessed it will viewed in context with the individuals experience, knowledge and background.

Where allocated tasks are being to others then supervisors / managers / operatives need to have received adequate training in respect to role, duties, water hygiene and control strategies.

To ensure the delivery of safe wholesome water at all outlets and preventing contamination [which may lead to health-associated infections] Council implement a water hygiene training scheme. The Council recognises that individuals are aware of their duty to protect the health of residents, staff and visitors and that they are responsible for ensuring that they inform their line manager if they come into contact with any disease that has the potential to cause harm.

Hygiene training will cover an appreciation of practices that can affect water hygiene, outlet cleanliness and resident safety. Those working on water systems [including outlets] will receive training in the need for good hygiene and how to prevent contamination of water supplies and outlets. Those responsible for housekeeping tasks such as outlet flushing and cleaning of outlets shall also be trained and competence assessed in respect to their role and how to prevent contamination of water supplies.

The water hygiene training should encompass the following elements:

• * Council governance arrangements in relation to water hygiene and safety;
  * Council WSP [policy, procedures, log book;
  * Waterborne pathogens and their consequences;
  * Council control strategies and how a water distribution systems, water outlets, components and any associated equipment can become contaminated;
  * Roles & responsibilities of individuals to prevent the contamination of the water distribution system and water outlets and assisting in ensuring control measures in place are effective;
  * How the safety of water can be maintained by good hygiene practices [personal hygiene along with dealing with clothing, footwear, cleaning equipment/materials, tools and storage when considering water hygiene];
  * When not to work with water intended for domestic purposes;
  * System design;
  * Components/accessories (taps, TMVs);
  * Disinfection and cleaning equipment/ materials;
  * How to store and handle pipes;

8.8.2 Competence

The Council can uses ECPs to undertake aspects of the operation, maintenance and control measures. While these ECPs have legal responsibilities, the ultimate responsibility for the safe operation rests with the Council Dutyholder.

Employing ECPs or consultants does not absolve the Council Dutyholder of responsibility for ensuring that control procedures are carried out to the standard required to prevent the proliferation of waterborne pathogens in the Council water systems.

Those who appoint ECPs [DRP [Water / APs [Water] / Asset Management Co-Ordinator] shall make reasonable enquiries to satisfy themselves of the competence of contractors in the area of work before they enter into contracts for the treatment, monitoring, and cleaning of the water systems, and other aspects of water treatment and control [see Appendix 6 Evidence of Contractors Competence letter].

The Council shall be satisfied that any ECPs employed are competent to carry out the required tasks and that the tasks are carried out to the required standards. The ECPs should inform the AP [Water] of any risks identified and how the system can be operated and maintained safely.

The Legionella Control Association s A Recommended Code of Conduct for Service Providers provides an illustration of the levels of service to be expected from service providers.

This Code of Conduct does not have legal status but may give guidance to those who appoint special contractors about the standards of service they should expect to receive from service providers who abide by the Code.

Only installers with the appropriate qualifications, regulatory knowledge and competence shall be used to install and maintain water installations. Water Safe register holds details from all seven Approved Contractors Schemes for businesses that have registered plumbing installers [authorised through the Water Supply (Water Fittings) Regulations 1999].

The Council recognises the benefits of using an Approved Contractor is they can carry out some work without the need to provide advanced notification to the water undertaker, and their work will be certified upon completion. A work completed cerificate issued by a Water Safe recognised plumber provides a defence for property owners who are challenged by a water undertaker enforcing the Water Supply (Water Fittings) Regulations 1999 or during legal proceedings.

8.9 Record Keeping

All records shall be readily available on site, in an appropriate format, for use by any member of the WSG or outside organisations. Electronic data management tools be utilised to facilitate the intelligent use of data for the WSG to easily monitor trends and analyse chemical and microbiological parameters.

Records should be kept for at least five years.

Comprehensive operational manuals for all items of plant that include requirements for servicing, maintenance tasks and frequencies of inspection should be readily available on site.
Any commissioning data should also be kept with these manuals.

Asset registers are established and should be designed to provide the following information:

• a. an inventory of plant and water- associated equipment;
  b. a basis for identifying plant details;
  c. a basis for recording the maintenance requirements;
  d. a basis for recording and accessing information associated with maintenance;
  e. a basis for accounting to establish depreciation and the provision needed for plant replacement;
  f. information for insurance purposes.

9.1           Process for Reviewing this Policy

The review date for this document will be annually, unless otherwise indicated by change in national guidance or as a result of the risk incident reporting system. Prior to being signed off at HMT it will be discussed and agreed at the Water Safety Group.

9.2           Version Control

This document has been revised from its previous format and is a later version. Details of version control can be found in Appendix 1.

9.3           Archiving

The Competent Responsible Person [Water] Council will be responsible for document control including the recording, storing and controlling of current procedural documents and archiving.

Health Technical Memorandum 04-01: The control of Legionella, hygiene, safe hot water, cold water and drinking water systems. Parts A, B & C: 2016 and Supplement 2015.

Health Technical Memorandum 03-01: Specialised ventilation for healthcare premises. Parts A and B: 2006

Approved Code of Practice, Legionnaires disease: the control of Legionella bacteria in water systems. [L8] 2013 4th Edition. HSG274 Parts 1, 2, 3.

The Health and Safety at Work etc. Act: 1974

Reporting of Incidents, Diseases and Dangerous Occurrences Regulations 2013

The Management of Health and Safety at Work Regulations: 1999

The Water Supply [Water Fittings] Regulations: 1999

The Water Supply [Water Quality] Regulations: 2010

The Control of Substances Hazardous to Health Regulations: 2002

The Building Regulations: 1992

BS7592 2022 Sampling legionella in water services

BS8680 2020 Water Safety Plans

BS8580-1 2019 Risk assessment for legionella and its associated standard BS8580-2 2022 Risk assessment for Pseudomonas

BS 8558:2015 – Installation, testing and maintenance of services supplying water for domestic use within buildings and their curtilages specification

BS EN 806. Parts 1 to 5. Specifications for installations inside buildings conveying water for human consumption.

Water Regulations Advisory Scheme [WRAS] Water Regulations Guide: 2004

Water Regulations Advisory Scheme [WRAS] Water Fittings and Materials Guide: 2005

Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013

Appendix 1 – Version Control Sheet

This sheet should provide a history of previous versions of the Policy and changes made.

Reviewed 22^nd August 2018 – no changes required

Reviewed 13th July 2020 updated to reflect corporate restructure and updating of training matrices

Reviewed 20th December 2023 by Water specialist consultant, British standard document references updated, terminology to Competent Responsible person updated, frequency of incident reporting review increased as recommended.

Appendix 2 – Equality Impact Assessment

Add Chart

Appendix 3 – WSG Terms of Reference

Water Safety Group Terms of Reference

 1.0       Purpose of Group

To provide assurance to HMT and CMT, that there are appropriate risk management infrastructure and controls in place to minimise the risk of harm and infection from water used by residents, staff and visitors associated with waterborne pathogens.

The WSG provides a forum for those individuals with delegated roles and responsibilities to take collective ownership for ensuring it identifies water-related hazards, assesses risks, identifies and monitors control measures and develops incident protocols.

The group shall also be responsible for ensuring it identifies microbiological hazards, assess risks, identifies and monitors control measures and develops incident protocols.

To provide clear guidance on how to maintain safe water within the Councils premises and the processes to be adopted and monitored.

2.0     Membership

The WSG will be chaired by the Competent Responsible Person or if delegated to, the Deputy Responsible Person, who has appropriate knowledge, competence and experience for the role as Chair. The RP [Water] has the management responsibility to ensure actions arising from the WSG are implemented within the Council. In their absence, Deputy Responsible Person [Water] will act as the Chair Person.

Membership of the Group will include:

Deputies for absent members will be permitted to attend the meeting.

Additional members may be invited as required such as Court Managers.

It is expected that members will attend at least 80% of scheduled meetings.

3.0     Frequency of Meetings

The WSG will routinely meet on a quarterly basis.

The WSG always act in an appropriate and timely manner in response to issues or incidents that have been reported. Where episodes of colonisation or infection of residents that could be related to the water system are referred by the Property Services team to the chair of the WSG for any additional action to be determined.

Individual responsibilities should not be restricted by the need to hold formal meetings.

4.0     Remit of WSG:

• * to work with and support the Property Services team;
  * to ensure effective ownership of water quality management for all uses;
  * to determine the particular vulnerabilities of the at-risk population;
  * to review the risk assessments;
  * to ensure the WSP is kept under review including risk assessments and other associated documentation;
  * to ensure all tasks indicated by the risk assessments have been allocated and accepted;
  * to ensure new builds, refurbishments, modifications and equipment are designed, installed, commissioned and maintained to the required water standards;
  * to ensure maintenance and monitoring procedures are in place and that records of all maintenance, inspection and testing activities are kept up to date and properly stored;
  * to ensure accurate records for all assets relating to hot and cold water distribution systems are set up and regularly maintained;
  * to review environmental monitoring data;
  * to agree and review remedial measures and actions, and ensure an action plan is in place, with agreed deadlines, to ensure any health risks pertaining to water quality and safety are addressed;
  * to determine best use of available resources;
  * to be responsible for training and communication on water-related issues;
  * to oversee water treatment with operational control monitoring and to provide an appropriate response to out- of-target parameters (that is, failure to dose or overdosing of the system);
  * to oversee adequate supervision, training and competency of all staff;
  * to ensure surveillance of environmental monitoring

5.0     Agenda Setting

A set agenda is issued for each WSG meeting.  This will be issued along with any amendments to the agenda and any supporting papers for the meeting 10 working days prior to the meeting by the chair/deputy chair

6.0     Quorum

The WSG will be considered quorate when over 50% of its core membership is present.

7.0     Reporting Arrangements

Detailed minutes of the group meetings are recorded, distributed promptly to the members of the WSG and retained on file to demonstrate good management, appropriate and timely actions and good governance.

8.0     Review Date

These terms of reference
will be reviewed and approved at the same time as this Policy by the Council to
ensure the WSG is delivering against its purpose and remit.

Appendix 4 – Training Needs Matrix and Programme

*RP = Role of Responsible Person – Management (1 day). *AP = Role of Authorised Person – Technical (1 day). *CP = Role of Competent Person [half day].

*Water Regs = WATERSAFE. *Awareness = Awareness / briefing training session (1 hr). *[T.B.S.] = To be scheduled

Appendix 5 – Contractors Competence

 Details of contractor‘s individual employee competency details held on file.