WATER SAFETY POLICY. Version Water Policy V2. Date to be reviewed June 2019 To by reviewed by Strategic Water Safety Group

Transcription

1 East Cheshire NHS Trust WATER SAFETY POLICY Version 2.0 File ref Water Policy V2 Date approved draftcomments[1] June 2016 Date to be reviewed June 2019 To by reviewed by Strategic Water Safety Group Water Safety Policy June 2016 Page 1

2 Water Quality Control and Potable Water Policy. Executive Summary: It is the policy of East Cheshire NHS Trust (the Trust0 to provide and maintain a safe and healthy environment for all staff, patients and visitors. The Trust aims to implement this policy to manage Water Quality and Potable Water and to follow the steps laid out in the following Policy. Supersedes: Policy for the Control of Legionella and Potable Water Description of Reference to Health & SC Act 2008 Amendment(s): Responsibilities amended to align with new job titles Addresses update to align with department re-locations Updated reference guidance documents Task Schedules consolidated (Appendix 6) Minor amendments to some job titles and flowchart This policy will impact on: This policy will be applicable to all departments within the Trust. Financial Implications: No financial implication identified with the amendment of this Policy Policy Area: All areas within the Document ECT ECNHST Reference: Version Number: Version 2 Effective Date: June 2016 Issued By: Review Date: June 2019 Author: (Full Job title ) Consultation: Estates Officer Statutory Impact Assessment Compliance Date: APPROVAL RECORD Committees / Group Estates Water Group SWSG N/A Date June 2016 June 2016 Approval Committee Received for information: Infection Control & Risk Management June 2016 Group Head of Estates (Responsible Person) June 2016 Director of Finance (Designated Person) Infection Control Team Ward and Department Managers Head of Facilities - Soft FM June 2016 June 2016 June 2016 June 2016 Water Safety Policy June 2016 Page 2

3 TABLE OF CONTENTS 1.0 General Policy Statement Primary Objectives Organisational Responsibilities Roles & Responsibilities Delegated Responsibilities Management of Water Temperature Records and Record Drawings Training Requirements Management of Low Usage Water Outlets Risk Assessments Risk Minimisation Programme Performance Audit Policy Review 9 Appendices Appendix 1 Terms of Reference 10 Appendix 2 ECNHST Flow Chart for the Management of Legionella 13 Appendix 3 Assurance Reporting Route 14 Appendix 4 Monthly Tasks carried out by Estates/Contractor 15 Appendix 5 Quarterly Tasks carried out by Estates/Contractor 15 Appendix 6 Six Monthly tasks carried out by Estates/Contractor 15 Appendix 7 Annual Tasks carried out by Nominated Contractor 15 Water Safety Policy June 2016 Page 2

4 1.0 Scope of the policy 1.1 The East Cheshire NHS Trust (the Trust) recognises its duties under health & safety legislation and guidance for the management of water quality and the control of legionella. The Trust also recognises its duties as a registered healthcare provider under the Health and Social Care Act Regulations regarding the safety and suitability of premises (Reg. 15(1) Premises & equipment, and Reg. 17 Good Governance). 1.2 The Trust is committed to the effective & safe management of water systems & legionella on all its premises and to the management of the risks arising in water systems to its employees (& others) in all of their workplaces. 1.3 The prime objective of this policy is to ensure the proper care and maintenance of the Trust s water supply services in the interests of patients, the Trust s workforce and other persons entering the Trust s premises. 1.4 Water is to be maintained in a safe condition and be managed in such a manner that very hot water does not injure people, specifically those at highest risk with medical, mental or ageing disabilities. High risk areas will be clearly identified and knowledge of these areas, together with the necessary safeguards will be provided to local managers. 1.5 This policy includes the control of legionella which can cause a pneumonia which can be fatal. The bacterium is widespread in natural fresh water and there are various sources of the organism and routes of transmission to humans. The principal route of infection is through inhalation of the bacteria into the lungs. The disease may affect healthy people but there is a much higher risk of infection for many categories of patients. 1.6 This document and the procedures outlined, require the cooperation of all employees, all staff, building users and contractors who also have responsibilities to ensure a safe and healthy working environment is maintained at all times. Management and staff are to do all that is reasonably practicable to achieve compliance in the management of water quality & the control of legionella 2.0 Legislation and guidance 2.1 Section 2 of the HSCA 2008 Regulations 2014 sets fundamental standards for the provision of services by Trusts. These require that the provision of premises and equipment must be safe, clean, and secure. 2.2 Regulation 15(1)2 (premises and equipment) requires that users of premises are protected against the risks associated with unsafe or unsuitable premises by means of adequate maintenance and proper operation of the premises. 2.3 Regulation 17 (Good Governance) requires that the quality and safety of the services provided are assessed and monitored in order to: (1) Improve the quality and safety of the services, and; (2) Mitigate the risks relating to the health, safety and welfare of service users and others. 2.4 The outcome expected is that people are in safe, accessible surroundings that are being adequately maintained and that comply with any legal requirements relating to the premises. 2.5 The following legislation and guidance specifically applies in respect of the management of water services on trust premises: Health and Safety at Work etc., Act 1974, Sections 2, 3 and 4 (HSWA) Control of Substances Hazardous to Health Regulations, (COSHH) Regulation 6, Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (HSCA 2008 Regulations 2014) 3

5 The Management of Health and Safety at Work Regulations Legionnaires Disease-the control of Legionella bacteria in water systems, Approved Code of Practice and Guidance (known as L8) Health Guidance Note Safe hot water and surface Temperatures Health Technical Memorandum Parts A & B, & Addendum The Control of Legionella, hygiene, Safe hot water, cold water and drinking water systems. Health Technical Memorandum Part A and Part B Heating and Ventilation Systems. 2.6 The Health and Safety Commission s publication - Legionnaires disease, the control of legionella bacteria in water systems, Approved Code of Practice (L8) & HSG 274 (3 Parts) provides a framework and guidance for the Trust to achieve this relative to the hazards imposed 2.7 Additional legislation and guidance applying to the management of water are set out in Appendix Roles and Responsibilities Statutory duty holder The Chief Executive is the statutory duty holder for and the management of water systems and the control of legionella The statutory duty holder is to ensure that suitable arrangements are in place for the safe management of water including the control of legionella. The duty holder is to appoint in writing: An Authorised Engineer (Water Safety & Quality); A Designated/ Responsible Person (Water systems); A Deputy Responsible Person (Water systems); An Infection Control Officer or Consultant Microbiologist (Water Quality) The statutory duty holder is to ensure that the management of water systems on Trust premises is undertaken in accordance with this policy. Executive Designated Person The Director of Finance is the Executive Designated Person in respect of the management of water systems in Trust premises The Designated Person will make arrangements for the safe management of water systems and for the control of Legionella The Designated Person is also the appointed Responsible Person for the management of water systems in Trust premises. 3.2 Responsible Person The Head of Estates is the appointed Responsible Person for the management of water systems in Trust premises The Responsible Person (Water) will support the Designated Person in the implementation of this policy. 3.3 Deputy Responsible Person The Deputy Responsible Person (Water) is the Estates Operations Manager responsible for the day-to- day management of the hot and cold water services including the formulation of specific operational procedures to ensure the overall integrity of domestic

6 water systems and equipment He/she is responsible for the appointment and coordination of the Authorised Engineer (Water Safety & Quality) who will review water management services He/she will ensure that Legionella Risk Assessments are undertaken in order to identify areas of risk. These Risk Assessment reports will be held centrally within the Estates Department office He/she, with support from Infection Control, will develop a prioritised programme for water quality and control of legionella risk minimisation. Consideration will be given to cost, risk and difficulty. 3.4 Infection Control Officer The Infection Control Officer shall be nominated by the Director of Nursing Quality & Performance to provide advice on infection control policy in respect of water In the event of an outbreak of Legionnaire s Disease (Legionellosis) or other waterborne infections, the Infection Control Officer will lead the Infection Control Team in managing the outbreak in accordance with IC Outbreak and Significant Incident Policy. 3.5 Health & Safety Manager The Health & Safety Manager is to advise on Health and safety issues related to water quality and the implementation of this policy. 3.6 Soft F.M The Soft Facilities Management team shall be responsible for the following activities ensuring that all the appropriate activities are monitored and logged. Monitoring and Assurance Cleaning methods Flushing Descaling Infection Control Housekeeping 3.7 Ward Managers/ Department Manager The input of managers and site managers is key in the effective management of water quality & legionella control for the areas within their control Managers and site managers are responsible for: Ensuring that the programme flushing of low use outlets is undertaken and that records of flushing are returned to the estates department; The reporting of defects to the Estates Department. All works of modification or alterations to hot and cold water systems comply with the building regulations and relevant guidance. Contractors have the necessary experience, qualifications and training prior to commencing work on hot and cold water systems. Contractors are required to undertake all works in accordance with East Cheshire NHS Trust site rules. Management of water temperature Cold water services The Trust aims to keep the temperature of water in service mains below 20 C. In order to control heat gain in cold water services all cold water pipe work and storage

7 tanks are to be insulated It is noted that the legal maximum temperature of water supplied by the Statutory Undertaker (Water Company) is 25 C The temperature of the mains water supply is to be measured twice a year to check that the supplied water is less than 20 C. 3.9 Hot water services The Trust aims to keep the temperature of water stored in calorifiers, point of use water heaters and hot water storage cylinders at least 60 C; The Trust aims maintain a minimum return temperature of 50 C in circulated hot water Where the temperature of water stored in calorifiers falls below 45 C (or if they are taken out of service) they will be: Drained and refilled twice to flush out any sediment and contaminated water; then, Heated to at least 70 C and held at that temperature for a minimum of one hour, before returning to service by slowly opening the outlet valves (to reduce any turbulence in the downstream pipe-work from disturbing any sediment debris) All staff, visitor, inpatient and outpatients washing facilities will generally be provided with TMV3 Type 3 thermostatic mixing valves at the point of use which comply with NHS Estates Model Engineering Specification DO8 and are set to reduce the temperature down to a safe level of: Bath.43 C Assisted Bath..46 C Showers and Hair- washing..41 C Wash hand basin..41 C In staff only areas, wash hand basins may be fitted with a mechanical mixing valve, or tap, with maximum temperature stop. All taps shall comply with BS 5779 (materials used fabricating the tap, its dimensions, design, construction and testing of nonthermostatic, non-compensating spray mixing taps) All other hot water facilities (i.e. in kitchens) will be provided with warning notices advising the user of very hot water above the outlets. 4.0 Records and record drawings 4.1 The safe management of water systems requires the management and retention of records and record drawings including records of: Drawings of domestic water pipe-work systems and air handling units; Operation and maintenance manuals of domestic water plant and equipment; Hot and cold water outlets (baths, shower, basins, etc); Tanks, cisterns, or any other water appliance which may present a Legionella hazard; Air handling units (AHU s); Water tank cleaning, water service treatment regime; Hot and cold water tap outlet temperatures; Thermostatic mixing valves, stating location & asset number (baths, showers, hot & cold water taps, bib taps, and cold water chillers); All water outlets without thermostatic mixing valves.

8 5.2 The Responsible Person (Water systems) will determine the numbers of higher risks points in the water systems and develop a prioritised work programme to remove or mitigate these risks. 6. Training 6.1 The Trust recognises that only with the help of managers and their deputies can the responsible and nominated persons maintain a safe regime of water quality safety in Trust premises. 6.2 The safe management of water systems requires appropriate training for estates and other personnel including training in practices and procedures with respect to the control of Legionella. 6.3 Managers who are responsible for Trust buildings, and their deputies, are to be provided with water safety awareness training regarding water system & water quality, and the appropriate precautions required to ensure the areas under their control are safe 6.4 Managers who are responsible for high hazard units in Trust buildings, and their deputies, are to be provided with specific water safety training to ensure the high hazard areas under their control are safe 6.5 Estates and other staff are to receive refresher training at suitable intervals to ensure that they can fulfill the requirements of their role in the management of water safety. 6.6 All training will incorporate safety procedures to be adopted when managers are made aware of increasing risks arising from known or new water safety hazards. These procedure will include arrangements for seeking the appropriate assistance from the Estates & Facilities Department and the Infection Control Team 7. Management of low usage water outlets 7.1 Appliances and water outlets that have a low level of usage are to be identified by ward/ department managers so that the risks arising from low usage can be addressed. 7.2 Ward/ department managers must report the location of infrequently used water outlets to the Estates Department (showers, baths, hand-basins, sinks, w.c s and drinking water dispensers). Reports can be made by: Identifying the infrequently used asset on the monthly water flushing reports; Contacting estates by telephone ( ) or by (1616@nhs.net ). 7.3 A flushing regime and associated record keeping are to be undertaken by ward/ department and cleaning staff under the supervision of the ward/ department manager. A flushing programme and recording of flushing of water outlets is to be undertaken by wards/ departments and records sent monthly to the Estates Department at Hope House ; Low use hot and cold outlets and appliances are to be flushed every day during cleaning. Run hot taps / outlet for 1 minute. Run cold taps / outlet for 1 minute H.T.M addendum. Note: Check flushing period requirements (Pseudomonas) 7

9 Daily flushing records are to be completed on Flushing of Water Outlets sheets; Flushing records are to be returned monthly to the Estates Department. Flushing of water outlets is to be undertaken so that the production of aerosols is controlled: Showerheads are to be removed from showers and water is to be slowly run into the shower drain; Taps and tap leavers should be opened slowly ensuring that the water is run without excessive splashing. Spa baths/ birthing pools are to be cleaned and disinfected: Cleaning/ disinfection records are to be recorded in the ward/ dept maintenance dairy. Reporting of flushing is to undertaken monthly by ward/ department managers Flushing of Water Outlets log sheets are to be sent monthly to the Facilities Department at Hope House; 7.4 A schedule of monthly, quarterly, half yearly and annual maintenance work is to be undertaken on the water system by the Estates Department (Refer Appendix 6). 8. Risk assessments 8.1 The primary objective of this policy is to ensure proper and effective control of water and air handling systems throughout the Trust s premises in order to maintain safe water systems and minimise the risk of Legionellosis. 8.2 To achieve these aims, risk assessments of the water systems will be undertaken biannually by named competent persons / companies employed by the Trust. These risk assessments will include: Surveying of all water systems and air handling systems; Identification of high risk areas; Identification of areas of non-compliance with ACOP L8, HTM & HSG 274; Preparation of written risk assessments; 9. Risk Minimisation programme 9.1 Issues of non compliance identified in risk assessments are to prioritised and costed. 9.2 A programme of remedial works is to be prepared to rectify items of non compliance. 9.3 Records of risk assessments and work undertaken are to be retained for 5 years. 9.4 A review of legionella procedures is to be undertaken to incorporate issued raised in the risk assessment. 9.5 The Deputy Responsible Person will lead & manage the programme of remedial works and will prepare an annual report on the remedial works undertaken and the progress made in the implementation of the programme. 8

10 10. Performance The following performance Indicators will be monitored for the management of water quality. Appendix 2 KPIs No. On-going maintenance issues affecting the delivery of the service Service assurance statements Assurance Framework & report (RR<15) Assurance Framework & report (RR 15) Monitored by: Deputy Responsible Person Deputy Responsible Person Deputy Responsible Person Monitoring frequency Quarterly Quarterly Annual Information reported to E&F Statutory Compliance Group E&F Statutory Compliance Group Risk Management Group/SWSG Deputy Responsible Person Quarterly Executive Team/ SWSG 11. Audit A review of management of water quality control will be coordinated annually by the Deputy Responsible Person (Water systems). The review will include comments on the policy and operational performance made by the Authorising Engineer ((Water Safety & Quality) in his annual report and will be taken to the Risk Management Group The review will incorporate an audit of the performance of the Trust in managing and controlling water quality and legionella control risks against the aims set out in this policy. It is to include a report on the operational performance in respect of monitoring, testing, dealing with incidents, remedial works, etc. 12. Policy Review 12.1 A formal review of the policy will be undertaken within 3 years of the date of issue or as necessary due to the publication of new legislation and guidance 12.2 This review will be coordinated by the Deputy Responsible Person (Water systems) and will address issues identified in the annual audit and performance review The policy shall be monitored by the Risk Management Group. 9

11 Appendix 1 Title: Terms of Reference Strategic Water Safety Group East Cheshire NHS Trust Authors Name: Head of Estates Operations (Deputy Responsible Person) Scope: Trust Wide Classification: Trust Organisation Structure and Minutes Replaces: Terms of Reference for The Water Quality Group To be read in conjunction with the following documents: Water Systems Policy Unique Identifier: Review Date: February 2016 (or earlier if required) Issue Status: V3 Issue No: 1 Issue Date: February 2015 Authorised by: Infection Control Group Authorisation Date: February 2015 Document for Public Display: No After this document is withdrawn from use it must be kept in an archive for 6 years. Archive: Date added to Archive: Officer responsible for archive: Director of Corporate Affairs and Governance Strategic Water Safety Group - Terms of Reference 1. Purpose The purpose of the Strategic Water Safety Group (the Group) is to monitor the Trusts water quality and systems in line with the Trust s Water Safety Policy and to provide technical and operational guidance to the Trust Infection Prevention & Control Group, the Trust Risk Management Group and to all those responsible for, or involved in, water systems. 2. Functions of the Group 10 To receive and review reports from those responsible for or involved in; water systems, the environment where water outlets exist and water quality within the Trust; As a result of the point above, to report and monitor issues relating to Legionella and Pseudomonas and update the Infection Prevention & Control risk register; To provide details and make recommendations on financial implications of water systems, the

12 environment where water outlets exist and water quality within the Trust; To provide guidance to the Trust on purchases of water related equipment; To be responsible for keeping up-to-date with all water quality and systems associated regulations, standards and guidance and to disseminate information to members of the group regarding changes in practice, regulation, standards or guidance; To recommend and implement policies or procedures that comply with current Legionella and Pseudomonas regulations, standards and guidelines; To monitor the Trust s compliance with the Legionella and Pseudomonas aspects of Care Quality Commission Outcome 10 (regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010); To form any sub-groups as necessary to conduct the business of the Group. 3. Reporting Arrangements The Strategic Water Safety Group is responsible to the Trust Infection Prevention & Control Group. Sub-groups which report into the Strategic Water Safety Group are shown in table 1: Table 1: Strategic Water Safety Group Structure. Assurance is required from all sub-groups prior to scheduled Strategic Water Safety Group meetings; assurance will be provided in the form of; sub-group meeting minutes, key performance indicators or written reports. Minutes of the Strategic Water Safety Group will be approved by the Infection Prevention and Control Group and can be made available on the Trust intranet if requested. Decisions made by the Group and policies and procedures which are reviewed and updated shall be put on the agenda of the Trust Infection Prevention & Control Group for final approval. 4. Chair The Group shall be chaired by the Trust s Responsible Person. The Lead may temporarily delegate chairmanship to a nominated deputy during times of absence. 11

13 5. Membership The membership shall include: The Trust Designated Person Director of Finance The Trust Responsible Person - Head of Estates The Trust Deputy Responsible Person Estates Operations Manager The Infection Control Doctor; Nominated Person for Infection Prevention and Control (Lead Infection Prevention & Control Nurse); Nominated Person for Clinical Areas (Matron for Medical Specialties); Nominated Person for Facilities Soft FM (Head of Facilities (Soft FM)); Nominated Person for Estates (Statutory Compliance Officer); Authorised Person (Estates Engineering Manager) The Trust s appointed Authorising Engineer (Water Safety); Community Decontamination & Infection Control (East Cheshire NHS Community Dental & Infection Control Lead). In the event that any of the aforesaid cannot attend a Strategic Water Safety Group meeting, they must send a representative or deputy from the relevant function/service. 6. Quorum Attendees must include the Group s Chair (or nominated deputy), the Infection Control Doctor, the Nominated Person for Infection Prevention and a Clinical Nurse or nominated deputy, to be quorate. 7. Majority A course of action requires support from the Group chair (or nominated deputy), the Infection Control Doctor and more than 50% of group members who attend the meeting. 8. Meeting Frequency The Group shall meet at quarterly intervals. 9. Agenda, Minutes and documentation A package will be prepared and sent to members of the Group a minimum of three business days in advance of a meeting. This package will include the following: Agenda for the upcoming meeting; Minutes of the previous meeting; Any other documents/information to be considered at the meeting. Action Log(s) ` 12

14 Appendix 2 ECNHST Flow Chart for the Management of Legionella Designated Person Maintenance / Records / Temperatures Drawings / Managing risk Chair Estates Water Group Meetings 13

15 Appendix 3 ECNHST Flow Chart for Assurance Reporting Risk Management Committee S.W.S.G Responsible Person(s) (Legionella) Staff & Users of ECNHST Estates Water Group 14

16 Frequency: monthly Appendix 4 Appliance Task Test Record Calorifier Measure flow and return Record on log sheet temperature Measure inlet temperature Sentinel tap mixer valve Temperature over 55 o C Record on log sheet after I minute Sentinel tap mixer valve Measure mixed water Record on log sheet temperature Measure temperature after 2 Sentinel cold water tap Temperature under 20 o C Record on log sheet minutes Frequency: Every 3 months Appendix 5 Appliance Task Test Record Fixed flexible showerheads & hoses Calorifier Sentinel tap mixer valve Sentinel tap mixer valve Sentinel cold water tap Frequency: six monthly Dismantle, clean & disinfect Or Replace with new Measure flow and return temperature Measure inlet temperature after I minute Measure mixed water temperature Measure temperature after 2 minutes Poor condition: Replace with new Temperature over 55 o C Temperature under 20 o C 1 Record task on log sheet. 2 Record defects & report to responsible person Record on log sheet Record on log sheet Record on log sheet Record on log sheet Appendix 6 Appliance Task Test Record Domestic cold water tanks Measure temperature Temperature under 20 o C (remote from ball valve) E&F Zeta Building Management System Temperature under 20 o C E&F Zeta Building Management Domestic cold water tanks Measure temperature (at ball valve) System Ultrasonic humidifiers; Check operation of UV lamps Fogging systems Spray humidifiers / air Clean & disinfect washers & make up tanks Frequency: Annual Appendix 7 Appliance Task Test Record Review risk assessment Calorifier(s) Blow down Review drain water 1 Take bacteria samples condition 2 Note drain water condition HW Representative taps Measure temperature Record tap temperatures (on rotational basis) CW Storage tanks 1 Visual inspection 2 Remedial works (where Assess tank condition necessary) CW Representative taps Measure temperature Record tap temperatures (on Distribution pipework Clean and disinfect pipework, spray heads & make up tanks rotational basis) 15