EPOL01 Water Safety Policy

Page 1


Water Safety Policy

Version: V5

Ratified by: Finance and Investment Committee

Date ratified: 03/01/2024

Job Title of author: Head of Health, Safety and Compliance

Reviewed by Committee or Expert Group Property, Health and Safety Steering Group

Equality Impact Assessed by: Head of Health, Safety and Compliance

Related procedural documents

Health and Safety at Work Policy

Review date: 03/01/2026 (2 years from ratification or legislation change)

It is the responsibility of users to ensure that you are using the most up to date document template – i.e. obtained via the intranet

In developing/reviewing this policy Provide Community has had regard to the principles of the NHS Constitution.

Version Control Sheet

Version Date Author Status Comment V1 New

V2 August 2011 Health & Safety Resilience and Security Manager Amended Organisation Change

V3 September 2017 Assistant Director of Estates & Facilities Updated Previously Legionella Policy updated in view of Provide now being a landlord as well as a tenant

V4 April 2022 Assistant Director of Estates & Facilities Updated In line with Document review date

V5 Jan 2024 Head of Health, Safety and Compliance Updated New format, legislation

1. Introduction

Provide has responsibility under the Health and Safety at Work Act 1974 and the Control of Substances Hazardous to Health Regulations (COSHH) 2002 to take all reasonable precautions to prevent or control the harmful effects of contaminated water (i.e. Legionella and Pseudomonas aeruginosa) to patients, staff and other persons working at or using its premises.

Provide has a responsibility to ensure that all its premises and those leased to Provide by external landlords are safely managed with respect to the management of water. The purpose of this policy is to ensure that adequate and appropriate systems and procedures are in place to provide, manage and maintain water supplies and systems for patient and medical use at Provide in accordance with statutory requirements (ACOP l8 4th edition, 2013), HTM04 and Health and Safety Guidance HSG274

2. Purpose

This water safety policy will be implemented throughout all premises, or parts of premises, that Provide occupies (this accommodation can be serviced accommodation, where management of Legionella is provided by the Landlord, or accommodation where Provide have a responsibility to undertake the management of the water system), or for which Provide is the landlord.

The policy aims to provide a structured reporting schedule for the management of water supplies and control of Legionellosis including Legionnaires’ Disease and Pseudomonas aeruginosa in compliance with current guidelines (HTM’s and Model Engineering Specifications, the Approved Code of Practice (ACoP) L8, Guidance HSG 274 and other relevant legislation.

Legionnaire’s disease is a potentially fatal form of pneumonia which can affect anybody, but which principally affects those who are susceptible because of age, illness, immunosuppression, etc. It is caused by the bacterium ‘Legionella Pneumophila’ and related bacteria. Legionella bacteria can also cause less serious illnesses which are not fatal or permanently debilitating.

Pseudomonas aeruginosa is a Gram-negative bacterium, commonly found in wet or moist environments. It is commonly associated with disease in humans with the potential to cause infections in almost any organ or tissue, especially in patients compromised by underlying disease, age or immune deficiency. Its significance as a pathogen is exacerbated by its resistance to antibiotics, virulence factors and its ability to adapt to a wide range of environments.

Provide regards health and safety as matters of prime importance and as such, the Provide Board will ensure, so far as is reasonably practicable, that the safety of employees at work, patients and other persons are not adversely affected, by any of Provide’s operational activities.

Provide as an employer, so far as is reasonably practicable, will comply with its legal duties and responsibilities for the control of Legionellosis throughout the premises that it owns or operates services from.

Provide has a responsibility to check that all external landlords, have safe operating and control strategies for all water and ventilation systems and have fully implemented the recommendations of:

• Legionnaires Disease (2013): the control of Legionella bacteria in water systems ACOP and guidance of regulations 4th edition: HSE.

• Health Technical Memorandum 04-01: The Control of Legionella Hygiene, safe hot water, cold drinking water and drinking water systems (be it part A: Design, installation and testing or part B: Operating management for Healthcare Premises and addendums).

• Health and Safety Guidance HSG274

3. Definitions

Water Safety

Aspects of the chemical, physical and microbiological condition of water supplied for domestic purposes (including consumption) and process requirements which has the potential to cause harm to human health.

Water Safety Plan /Risk Assessments (RA)

All water and water systems in healthcare facilities should be risk-assessed according to their intended use and patient immune status considering any identified inherent hazards within the facility and the quality of the water supply to the systems being assessed. The assessment of risk should take account of the most vulnerable population likely to be exposed to each potential source.

Water Safety Group (WSG)

The WSG is a multidisciplinary group formed to oversee the commissioning, development, implementation and review of the WSP. The aim of the WSG is to ensure the safety of all water used by patients/ residents, staff and visitors, to minimise the risk of infection associated with waterborne pathogens. It provides a forum in which people with a range of competencies can be 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. The WSG should have clearly identified lines of accountability up to the duty holder.

Duty Holder (Water)

The owner/ operator of a publicly accessible water system is the ‘duty holder’ who must comply with legislation that requires proper management, maintenance and treatment of water systems in your premises. Group Chief Executive delegates to Executive Finance Director who discharges responsibility through the Director for Estates and Facilities to take day to day responsibility for controlling any identified risk from Legionella bacteria.

Responsible Person (Water)

The Responsible Person (Water), possessing adequate professional knowledge and appropriate training is appointed in writing by the management to devise and manage the necessary procedures to ensure that the quality of water in healthcare premises is maintained. The Responsible Person is required to liaise closely with other professionals in various disciplines. The Responsible Person is required to liaise

closely with other professionals in various disciplines. In addition, the Responsible Person possesses a thorough knowledge of the control of Legionella.

Deputy Responsible Person (Water)

The Deputy Responsible Person (Water), possessing adequate professional knowledge and appropriate training is appointed in writing by the management to devise and manage the necessary procedures to ensure that the quality of water in healthcare premises is maintained. The Deputy Responsible Person is required to liaise closely with other professionals in various disciplines and report to the Responsible Person on a monthly basis on information related to water compliance.

Authorising Engineer (Water)

A professionally registered, qualified and suitably experienced person who is independent of the organisation(s) in the capacity of advisor in respect of Water Safety.

Maintenance Technician

A maintenance technician is someone who has sufficient technical knowledge and the experience necessary to carry out maintenance and routine testing of the water, storage and distribution system. This role is provided by external contracted personnel for Provide.

Tradesperson

A tradesperson is someone who is appointed in writing by the Responsible Person to carry out, under the control of the maintenance technician work on the water, storage and distribution system.

Contractor

A contractor is the person or organisation designated by management to be responsible for the supply, installation, validation and verification of hot and cold-water services, and for the conduct of the installation checks and tests. In relation to the control of Legionella, it is essential to ensure that potential contractors have suitable qualifications (for example companies/individuals who are members of the Legionella Control Association.

Infection Prevention Team

The infection prevention team advise on the clinical aspects of this policy and are involved in the implementation of procedures for the control of legionella and pseudomonas aeruginosa in clinical areas. The infection prevention team are advised of the results of waters audits/tests by the Director of Estates & Facilities for Provide.

Serviced Accommodation – properties/locations Provide operate from where the management of the water systems/Legionella control is provided by the Landlord – A full list of these sites are included in Appendix 1

Provide Managed Properties – Properties/locations - Provide operate from where the management of the water system/legionella control is the responsibility of Provide – A full list of these sites are included in Appendix 1

4. Duties

Board

The Board has overall accountability for the activities of the organisation, which includes water safety. The Board will ensure that they receive appropriate assurance that the requirements of current water safety legislation and the objectives of

Department of Health water safety guidance are being met. The Board discharges the responsibility for water safety through the Group Chief Executive

Group Finance Chief (Duty Holder)

The Chief Finance Officer will, on behalf of the Board, be responsible for ensuring that current water legislation is complied with and where appropriate, Department of Health water safety guidance is implemented in all premises owned, occupied or under the control of Provide.

The Chief Finance Officer discharges the day-to-day operational responsibility for water safety for checking all premises occupied by Provide meet the required water legislation to the Assistant Director of Estates and Facilities.

These responsibilities will be delegated to the Assistant Director of Estates and Facilities who will be responsible for overseeing that all Provide managed buildings, external contractors and Landlords have safe operating and control strategies for all water and ventilation systems and have fully implemented the recommendations of:

Legionnaires Disease (2013): the control of Legionella bacteria in water systems ACOP and guidance of regulations 4th edition: HSE

Health Technical Memorandum 04-01: The Control of Legionella Hygiene, safe hot water, cold drinking water and drinking water systems (be it part A: Design, installation and testing or part B: Operating management for Healthcare Premises and addendums).

The Chief Financial Officer will ensure that appropriate Risk Assessments are carried out and where remedial works or actions are highlighted as required ensure these are undertaken in the time scales required by the law.

Responsible Person

The nominated Responsible Person will be responsible for overseeing that Provide have safe operating and control strategies for all water and ventilation systems, whether it be in Provide owned/managed buildings or leased properties. The will:

• Assist the Head of Infection Prevention with responsibilities for water safety matters.

• Ensure that all Landlords have in place a clearly defined water safety policy.

• Ensure that Provide monitors all relevant supporting water safety plans and procedures owned by all external contractors responsible and accountable for the water safety of Provide buildings.

• Ensure co-operation between other employers where two or more share premises.

• Ensure through senior management and line management structures that full participation in staff awareness initiatives is maintained.

• Attend Water Safety Group meetings operated by external contractors (landlords & subcontractors)

• Report any exceptions directly to Duty Holder and the Head of Infection Prevention

• Report quarterly result of the monthly temperaturemonitoring of identified water outlets as part of the Estates and Facilities report to the Infection Prevention Group.

• Ensure that all work which has implications on water safety in new and existing buildings where Providehave services are carried out to a satisfactorytechnical standard and conforms to all prevailing statutory and mandatory water safety requirements.

• Ensure that all water installations and equipment are maintained and tested in accordance with the latest relevant legislation/standards, and that comprehensive records are kept. Records should be retained for at least five years.

• Ensure that appropriate Risk Assessment are carried out and where remedial works or actions are highlighted as required ensure these are undertaken in the time scales required by the law.

Estates Operation Manager and Compliance Manager

• Ensuring that all external contractors have safe operating and control strategies for all water and ventilation systems.

• Ensure that adequate operating and maintenance instructions exist, and adequate records are kept.

• Assist the Director of Estates & Facilities & Head of Infection Prevention with responsibilities for water safety matters.

Director of Infection Prevention and Control

The Director of Infection Prevention and Control (DIPC) is the person nominated by management to advise on the Infection Control Policy. The DIPC will be supported by the Head of Infection Prevention. The Director of Infection Prevention and Control is responsible for ensuring that water safety issues are highlighted at Board level.

Head of Infection Prevention

The Head of Infection Prevention will undertake to carry out all duties as delegated by the Director of Infection Prevention & Control. In addition, the Head of Infection Prevention will be responsible for:

• Allocating adequate management time and resources to ensure that the water safety risk is controlled at all times.

• Promoting the co-operation of all employees through clear senior management commitment, staff consultation and by the provision of awareness and training programmes.

• Monitoring this policy to ensure that objectives are being achieved. It will be reviewed, and if necessary, amended in light of legislative or organisational change.

• Monitoring performance and continually seeking improved performance in the control of the water safety risk.

• Working in close co-operation with all key parties to be able to effectively control risks arising from water systems.

• Ensuring appropriate action is taken in the event of an outbreak or suspected outbreak of Legionnaires disease.

• Assist the Director of Estate Facilities, Operations Manager & Compliance manager with responsibilities for water safety matters.

Deputy Responsible Person

The Deputy Responsible Person will undertake to carry out all duties as delegated by the Director of the Estates and Facilities Team and Estates Operations Manager.

• Complying with the relevant requirements of the Health and Safety Commission’s Approved Code of Practice and Guidance, “The control of Legionella bacteria in water systems” – L8 and SSG 274 and Health Technical Memorandum HTM 0401, “The control of Legionella, hygiene, ‘safe’ hot water, cold water and drinking water systems” as amended.

• Ensuring regular review of all systems identified as being at risk from bacteriological contamination and to prevent an outbreak.

• Implement, manage and monitor the bacteriological control measures and freely communicate findings to relevant stakeholders.

• Ensuring that when any new and refurbished systems are designed, installed and commissioned that they are in line with current good practice guidance to eliminate or adequately control the risk of bacteriological contamination.

• Maintaining records of the Legionella control measures implemented for all premises owned or occupied by Provide.

• Sharing any suitable information in relation to any third-party audits and assessments and work programmes in relation to bacteriological management and control.

• Ensuring those persons appointed to carry out the control measures and strategies are suitably qualified, instructed and trained and their suitability assessed.

• Ensuring that Legionella Risk Assessments are carried out in a timely and professional manner. Documenting all remedial actions required by the LRAs and ensuring these actions are completed in a time scale to a professional standard required by law.

• Updating the LRA action plan on a monthly basis and submitting these documents to the Responsible person for signing off once all actions are completed or highlighting to the Responsible Person any issues preventing compliance.

• Ensuring all water related activities are reported on within the monthly compliance report submitted to the Director of Estates and Facilities (Responsible Person).

• Ensuring that all water related information related to the LRAs, LRA action plan, water sampling and monthly water temperature testing is filed centrally within the Estates Compliance section on the shared drive and in hard copy on site within a Waterlog Book.

Authorising Engineer (Water) [External Specialist]

As required, an Authorising Engineer (Water) will be commissioned by the Director of Facilities and Estates to provide specialist support as deemed appropriate.

The Authorising Engineer (Water) will be required to demonstrate competence in their particular field of expertise.

Competent Person (Water)

Installers and maintainers of water systems will be commissioned by Landlords (or their Agents) or Provide and must be able to demonstrate a sound knowledge and specific skills in the specialist service being provided. This may include the installation and/or maintenance of water systems equipment/services such as:

• Water storage tanks, vessels, calorifiers and connecting pipework above and below ground.

• Ancillaries such as pumps, valves, meters, heaters

• Sanitary appliances and associated taps, thermostatic mixing valves and other fitting

• Fire-fighting services

• Water treatment and filtration installations for domestic, industrial, clinical and process requirements.

The following services might be provided by competent persons, who should be able to demonstrate a full understanding of, and work to BS 8580 – Water Quality: risk assessment for Legionella control – Code of Practice:

• Risk assessment and recording of system layout, condition and compliance.

• Installation, maintenance and decommissioning and removal.

• Commissioning, cleaning and disinfection of systems prior to being taken into use following installation or maintenance.

Landlords

In respect of this policy, in both instances where Provide are landlords and also tenants, they / we are responsible for:

• Appointing a Responsible Person for water as required under the Health and Safety Commission’s Approved Code of Practice & Guidance. “The control of Legionella Bacteria in water systems” – L8.

• Preparing and complying with its operational policy and related procedures, taking account of the requirements of Provide’s policy and procedures.

• Complying with the relevant requirements of The Health and Safety Commission’s Approved Code of Practice and Guidance, “The control of Legionella bacteria in water systems” – L8 and HSG 274 and Health Technical Memorandum HTM 0401, “The control of Legionella, hygiene. ‘safe’ hot water, cold water and drinking water systems” as amended.

• Ensuring regular review of all systems identified as being at risk from bacteriological contamination and identify, record and risk assess such systems. Where Provide occupy properties where water management is provided as part of an FM services, ensure that records are held on site, and landlords chased for any remedial actions. When negotiating new space for Provide services, copies of Water Management Plans should be requested prior to contract/lease signing.

• Ensuring that schemes are prepared to eliminate or adequately control the risk of Legionella contamination and to prevent an outbreak.

• Implement, manage and monitor the bacteriological control measures and freely communicate findings to relevant stakeholders.

• Undertaking the control measures in accordance with the stipulated frequencies and durations.

• Maintaining records of the Legionella control measures implemented for all premises.

• Compiling and maintaining detailed and accurate records in respect of all maintenance, repair and other matters relating to water safety.

• The appropriate maintenance of the facilities.

• Competently carrying out necessary repairs and remedial works.

• Ensuring that when any new and refurbished systems are designed, installed and commissioned that they are in line with current good practice guidance to eliminate or adequately control the risk of bacteriological management and control.

• Ensuring those persons appointed to carry out the control measures and strategies are suitably qualified, instructed and trained and their suitability assessed; and

• Co-operating with Provide Board and its representatives in maintaining a safe environment for patients, visitors and staff and complying with this policy and all relevant water safety legislation and applicable guidance.

Local Management

Matrons, Registered Care Managers, Assistant Directors, and Service Mangers/Leads are responsible for:

• Monitoring water safety within their respective workplaces and helping to ensure that contraventions of precautions do not take place.

• Ensuring that this document and relevant water safety instructions are brought to the attention of staff through local induction and on-going staff briefings.

• Ensuring that nominated staff attend training and briefing sessions.

• Notifying the Director of Estates & Facilities and Head of Infection Prevention of any proposals for ‘change of use’ within their area that may have an impact on water safety.

• Ensuring staff at all levels understand the need to report all water fittings that are taken out of regular use. To inform the Facilities and Estates department when areas are vacant for more than 5 working days. This will allow the Estates department to take action in respect to the required legionella precautions.

• Ensuring that all water fittings that are not in regular use are part of a documented flushing regime including who is responsible for flushing the fitting.

Water Safety Group (WSG)

The Water Safety Group will form part of the Property, Health & Safety Steering Group, where WSP’s will be monitored and reviewed.

The following is a list of tasks undertaken by the Group:

• To ensure effective ownership of water quality management for all uses.

• To review the risk assessments.

• To ensure the WSP is kept under review.

• To ensure all tasks indicated by the RA Action Plans have been allocated and accepted.

• To ensure new builds, refurbishments, modifications and equipment are designed, installed, commissioned and maintained to the require standards.

5. Consultation and Communication

This policy will be ratified by the Property, Health and Safety Group and the Estates and Facilities Team. Once ratified the policy will be uploaded onto the Provide Platform under MyCompliance

6. Monitoring

Provide will monitor the operation of this policy in order to:

• Measure its effectiveness

• Comply with Provides’ legal obligations

• Highlight practical issues and seek solution

7. Operational Assessment: Legionella

A suitable and sufficient risk assessment is maintained to identify and assess the risk of exposure to Legionella bacteria from work activities and water systems on the premises and any necessary precautionary measures. The assessment is carried out by or on behalf of:

• The employer, where the risk from their undertaking is to their employees or to other.

• The person who is in control of premises or systems in connection with work where the risk is present from systems in the building (e.g. where a building is let to tenants, but the landlord retains responsibility for its maintenance).

The risk assessment will assess sources of risk. This includes checking whether conditions are present which will encourage bacteria to multiply. A number of factors are required to create a risk of acquiring Legionellosis, including but not limited to:

• The presence of Legionellosis bacteria.

• Conditions suitable for multiplication of the organism e.g. suitable temperature (degrees centigrade)

• A means of creating and disseminating breathable droplets e.g. the aerosol generated by a cooling tower or shower.

• The presence (and numbers) of people who may be exposed, especially in premises where occupants are particularly vulnerable, such as patients in hospitals and residents in care.

As part of the risk assessment process in complex systems or premises, a site survey of all the water systems is carried out and includes an asset register of all associated plant, pumps, strainers and other relevant items. This includes an up-to-date schematic drawing/diagram showing the layout of the plant or system, including parts temporarily out of use.

Where a risk of bacterial contamination is established, work shall be carried out immediately to decontaminate the system by the specialist contractor who shall provide evidence of decontamination by means of certification.

Where the assessment demonstrates that there is no reasonably foreseeable risk or that risks are insignificant and unlikely to increase, no further assessment or measures are necessary. However, should the situation change, the assessment needs to be reviewed and any necessary changes implemented.

Any moderate or high risk that is deemed impossible or impractical to manage by the Operations Manager and/or Compliance Manager must be escalated to the Director of Estates and Facilities team & Head of Infection Control. This must be reported to the Property, Health and Safety Group and added to the risk register were appropriate.

The assessment is reviewed regularly, and whenever there is a reason that the original assessment is no longer valid.

Provide is required to consult employees on the identified risks of exposure to Legionellosis bacteria (deemed a significant risk) if identified in their work areas whilst measures are undertaken to control the risk. The employees should be given an opportunity to comment on the assessment and control measures to the Estates and Facilities Team.

8. Prevention

Where the assessment shows that there is a reasonably foreseeable risk, the use of water systems, parts of water systems or systems of work that lead to exposure has to be avoided so far as is reasonably practicable.

Where this is not reasonably practicable, there is a written scheme for controlling the risk from exposure which is implemented and properly managed. The scheme specifies measures to be taken to ensure that it remains effective. The scheme includes:

• An up-to-date plan showing layout of the plant or system, including parts temporarily out of use (a schematic plan would suffice).

• A description of the correct and safe operation of the system.

• The precautions to be taken.

• Checks to be carried out to ensure efficacy of scheme and the frequency of such check.

• Remedial action to be taken in the event that the scheme is shown not to be effective.

• For Legionellosis bacteria to develop there must be a number of connected circumstances to exist. To break the connection and reduce the risk of Legionellosis, strict procedures for the management of the water supply are essential. Simple precautions, listed below, form the basis for the control of Legionellosis bacteria growth in Provide premises:

• All taps and outlets and associated pipe work which are not needed due to disuse or underuse shall be removed as far back to the main pipework runs as is possible to avoid any dead legs remaining in situ with the risk of the content of any water.

• Hot water from calorifiers shall be maintained at or above 60 degrees centigrade and water in the circulation pipework and return to the calorifiers will not fall below 55 degrees centigrade.

• Pipe work carrying blended water shall be kept under a maximum length of 2 metres.

• Dead legs and spurs from the main hot water circulation system shall be kept as reasonably short as possible.

• Water stagnation shall be avoided, and systems flushed on a regular basis in accordance with HTM04 or more regularly as required.

• Regular planned preventative maintenance shall be carried out on all systems.

• Storage tanks and cisterns shall be kept clean and sealed from extraneous, matter and maintained at the temperature at and/or below 20 degrees centigrade.

• Where maintenance involves the draining of water systems, disinfection and cleaning of the system shall take place before the system is returned to operation.

• Where systems are known to be of uncertain quality or where consistent problems have been identified, additional water treatment measures may be necessary.

• Where areas are closed for more than 5 working days, the Responsible Person (Water) should be notified, and weekly flushing shall be maintained by the Estates and Facilities Team until the area re-opens or the system is drained and or isolated as far back to the main pipework runs as is possible to avoid any dead legs remaining in situ with the risk of the content of any water.

Provide will check that all further proactive measures to ensure a greater level of control by periodically sampling water and testing for general bacterial numbers (viable count), in those outlets that have been identified as high risk, have been undertaken by the Landlords (Contractors). This may require routine sampling by specialist appointed contractors who will establish levels of any variant forms of bacteria and required action to be taken.

9. Action in the Event of a Suspected Outbreak or Incident

Provide should be notified of an incident where an abnormal water count has been confirmed by their landlords or 3rd Party Contactors.

For action refer to Appendix 2

Provide will then disseminate this information accordingly to all necessary staff (See Appendix 4 – Communication Flow Chart.

Provide will also aid our landlords with any actions necessary, where reasonably practicable.

Where necessary, an incident team will be convened if there are two or more confirmed or presumptive cases of there is evidence or recent respiratory illness among others at the same location.

A multi-agency group shall meet to co-ordinate an investigation of the problem and progress any necessary action.

In England and Wales, Legionnaires’ disease is notifiable under the Health Protection (Notification) Regulations 2010. Under these regulations, registered medical practitioners must report cases of Legionnaires’ disease to the Proper Officer. These regulations also require human diagnostic laboratories to notify PHE of cases of Legionnaires’ disease identified by laboratory testing.

The Health and Safety Executive may be involved in the investigation of an outbreak.

10.References

Legionnaires’ disease. The control of legionella bacterial in water systems Approved Code of Practice and guidance, Health and Safety Executive 2013 (as amended) http://www.hse.gov.uk/pubns/books/18.htm

Legionnaires’ disease, Technical guidance, HSG274 pars 1, 2, & 3, Health and Safety Executive 2014 (as amended) http://www.hse.gov.uk/pubns/books/hsq274.htm

Health Technical Memoranda (HTM) 04-01 (including addendum) 2013, Department of Health https://www.gov.uk/govenment/publications/addendum-to-guidance-forhealthcareproviders-on-managing-pseudomonas-published

11.Statutory Requirements

It is the responsibility of the occupiers, owners of premises, general managers and Executive Finance Director to ensure that their premises and activities carried out within them comply with all statutes. The following, whilst not exhaustive are the main statutory requirements:

• Health & Safety at Work (1974)

• HSE Legionnaires disease: The control of Legionella Bacteria in water systems AcoP18

• Management of Health and Safety at Work Regulations 1999

• Public Health (Infectious Diseases) Regulations 1988

• Water Supply (Water Quality) Regulations 2016

• Food Safety Act 1990

• Water Supply (Water Fittings) Regulations 1999

• Workplace (Health, Safety and Welfare) Regulations 1992

• Provision and Use of Work Equipment Regulations 1998

• Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013

• Personal Protective Equipment at Work Regulations 1992

• Control of Substances hazardous to Health (COSHH) Regulations 2002

• HSE EH40/2005 Workplace exposure limits

• Pressure Systems Safety Regulations 200

• Manual Handling Operation Regulations 1992

• British Standards (BS E 806 & BS 1710 :1984)

Appendix: 1

Water System Management by

Landlord

Braintree Community Hospital

Brentwood Community Hospital

Broomfield Hospital

Burnham Clinic

Halstead Hospital

Moulsham Lodge

Orsett Hospital

Phoenix House

Phoenix Hospital

Poundbury, Dorset

Springfield Green Clinic

St Peters Hospital

Tekhnicon House

Witham Health Centre

Wren House

Chelmer Clinic

Coggeshall Road

React Worksop

React Doncaster

React Congleton

React Scarborough

React Richmond

List as of November 2023

Water System Management by Provide

900 The Crescent

Crouch Vale Medical Centre

Fern Lodge

Cypress Gardens

The Ridgeway

Kestrel House + CliniCabin

The Stow

Southgate House

Stapleford House

Brigg React

Buxton React

Livewell Manor Street

Wren House

Appendix: 2

To ensure that we remain compliant and stay within the “Best Practice” guidelines in accordance to L8 ACOP Provide Estates have adopted the below strategy for L8 water management across our owned/managed property portfolio.

Each Property Contains the Below Records & Continued Management Plan

We have a Legionella Risk Assessment for each building carried out by a professional body that includes written scheme, building schematics and remedial action plan. This is reviewed every 2 years by the Competent.

Person/Responsible Person to ensure the risk has not increased and the RA is still fit for purpose and suitable for continued use, if any small alterations are made these are updated on the RA by the CP/RP and signed for, if any major alterations have been made to the system a renewal may be required, Including new/updated schematics with new outlets or pipe runs this will be run past the RP as the authoriser for all works associated under L8.

We have a full remedial action plan from the RA that highlights the risks associated with L8 in that property is stored in the on-site water safety folder. For each remedial action once completed the Responsible Person signs with acknowledgment that the action has been completed along with proof of completion of the identified works and includes the Works Order or signed Engineers Job Report this allows us to demonstrate the works identified was carried out and completed to a compliant standard by professional and allows us to demonstrate a fully auditable trail if required.

We carry out monthly temperature checks on all outlets across the estate to monitor temperature range, this way we ensure that if any temperatures are out of the normal parameters we can immediately see and therefore proactively control this before it reaches failure stages and records to prove compliance held locally on-site and our shared drive.

We conduct quarterly samples on those outlets that have been identified as High Risk in the RA, to actively monitor Legionella & TVC activity within the property’s water system as part of our management plan, our samples are taken and the analysis is conducted by a UKAS Accredited Lab, the samples certificates are assessed by the RP/CP then stored on-site in the water safety folder or the necessary action taken to Clean, Descale, Chlorinate, Flush and Re-sample for results to be back within 24 hours if we have a sample failure. Outlets in those areas identified as Low Risk are sampled if and when temperature testing parameters are not met. As per HTM o4 part B recommendations

We carry out quarterly descales of all shower heads & hoses as part of our active management plan; we also retain certificates of chlorination on-site in water safety folder to prove compliance for auditable purposes.

We carry out weekly flushing of all little used outlets including eyewash stations etc. if applicable to ensure that we prevent any stagnation, therefore this ensures that bacteria does not have a chance to develop these outlets are flushed for a minimum of 2 mins depending on run of pipework it may be longer.

We carry out Cold Water Storage cisterns inspections as and when required we work to 12 monthly minimum inspections and monthly temp check with quick visual as a

proactive measure then clean and disinfect as per results of inspection all records are then checked & verified then stored in the on-site water safety folder.

We carry out annual Calorifier & Expansion Vessels inspections and flushing of drain off valves on a monthly basis, monthly temperature checks for Flow and Returns is also carried out. All records and evidence are kept in the on-site water safety folder.

We ensure that all installation’s both existing and future are WRAS approved products and ensure that all dead legs are removed and prevented in installs, the Responsible Person is involved with all stages of water related projects and this is included the project specification to ensure continued compliance.

We instruct a specialist water treatment company to undertake annual TMV servicing and we ensure that they replace filters; strainers etc. to prevent build-up of any bacteria in the tap heads, tap body and associated pipework, service records are kept on-site in the water safety folder as part of our continual maintenance regime and auditable trails.

We also ensure that check valves are installed to prevent backflow contamination to mains water supply on all outside taps and the required valves are also installed internally to associated appliances.

Records are to be retained for at least 5 years.

In the event of a Positive Legionella Sample Result we will implement the following Process – please see attached process chart

https://www.england.nhs.uk/wpcontent/uploads/2021/05/DH_HTM_0401_PART_B_acc.pdf - Page 56

https://www.england.nhs.uk/wpcontent/uploads/2021/05/DH_HTM_0401_PART_B_acc.pdf - page 58

Appendix: 3 Communication flow process

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 1: ‘Screening’

Name of project/policy/strategy (hereafter referred to as “initiative”):

Water Safety Policy

Provide a brief summary (bullet points) of the aims of the initiative and main activities:

To ensure that the water used across all Provide areas and locations is adequately monitored for fitness of use.

Project/Policy Manager: Head of Health, Safety and Compliance Date: Nov 23

This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community – i.e. on the grounds of race (incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equality neutral” (i.e. have no effect either positive or negative). In the case of gender, consider whether men and women are affected differently.

Q1. Who will benefit from this initiative? Is there likely to be a positive impact on specific groups/communities (whether or not they are the intended beneficiaries), and if so, how? Or is it clear at this stage that it will be equality “neutral”? i.e. will have no particular effect on any group.

All service users and staff

Q2. Is there likely to be an adverse impact on one or more minority/under-represented or community groups as a result of this initiative? If so, who may be affected and why? Or is it clear at this stage that it will be equality “neutral”?

No impact

Q3. Is the impact of the initiative – whether positive or negative - significant enough to warrant a more detailed assessment (Stage 2 – see guidance)? If not, will there be monitoring and review to assess the impact over a period time? Briefly (bullet points) give reasons for your answer and any steps you are taking to address particular issues, including any consultation with staff or external groups/agencies.

No impact

Guidelines: Things to consider

Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.

The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.

Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.

Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan.

Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?

It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.

It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 2:

(To be used where the ‘screening phase has identified a substantial problem/concern)

This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.

Q1. What data/information is there on the target beneficiary groups/communities? Are any of these groups under- or over-represented? Do they have access to the same resources? What are your sources of data and are there any gaps?

N/A

Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations? If yes, how? Which are the main groups it will have an impact on?

N/A

Q3. Will the initiative have an adverse impact on any particular group or community/community relations? If yes, in what way? Will the impact be different for different groups – e.g. men and women?

N/A

Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative? Summarise (bullet points) any important issues arising from the consultation.

N/A

Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact? Are there specific factors which need to be taken into account?

N/A

Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required.

N/A

Guidelines: Things to consider

An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised.

It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations, and could form a specific part of the initiative.

The consultation process should form a meaningful part of the initiative as it develops, and help inform any future action.

If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.

Further information:

Useful Websites www.equalityhumanrights.com Website for new Equality agency www.employers-forum.co.uk – Employers forum on disability www.efa.org.uk – Employers forum on age

© MDA 2007 EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage One: ‘Screening’

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