FM SERVICES MANAGEMENT

Transcription

1 "WATER SAFETY PLAN" Incorporating Legionella safe hot water, cold water, drinking water and ventilation systems Management and Control BOOK 2 FM SERVICES MANAGEMENT This document was formally approved by The University Health and Safety Committee on: Date: 17 th June 2016 Name: Andrew Burgess Signed:. Version: 1 Issue: 1 Effective from: June 2016 Review required before: June 2017 Page 1 of 114

2 CONTENTS i. DISTRIBUTION CONTROL ii. DOCUMENT MANAGEMENT 1. WATER SYSTEM AND PLANT DESIGN INSTALLATION AND MAINTENANCE 1.1 Supplies from a water undertaker 1.2 Primary Water Supplies 1.3 Water Treatment Requirements 1.4 General Design and Installation Considerations 1.5 Cold Water Storage 1.6 Hot Water generation and storage 1.7 Hot and Cold Water Distribution Systems 1.8 Showers and TMV 1.9 Baths and TMV/TMT 1.10 Non-Touch Taps 1.11 Aerators and Flow straighteners 1.12 Expansion and Pressurisation Vessels 1.13 Greywater Systems 1.14 Rainwater Harvesting 1.15 Temporary Water Supplies 1.16 Ice Making Machines - ice used for internal use only 1.17 Other Systems (Irrigation Systems, Lathes, Cutting Tools, etc.) 1.18 Portable Wet Evaporative Cooling Point-of-use Air Conditioning Units 1.19 Steam Shut-downs 1.20 Adiabatic Coolers 2. PLANNED MAINTENANCE PROGRAMME TASKS 2.1 Planned Maintenance Programme - Task Frequencies (To be carried out by University Maintenance Department Staff) 2.2 Planned Maintenance Programme Task Frequencies - To be carried out by others 2.3 Temperature monitoring accuracy 2.4 Instrument Calibration: 2.5. Planned Maintenance Programme - Detailed PPM Task Specifications and Associated Processes (See Appendix 1) 3. AD-HOC RISK MANAGEMENT AND CONTROL PROCESSES WITH ASSOCIATED CERTIFICATES OF CONFORMITY APPENDIX 1: APPENDIX 2: APPENDIX 3: PLANNED MAINTENANCE PROGRAMME - DETAILED PPM TASK SPECIFICATIONS AND ASSOCIATED PROCESSES AD-HOC R I S K M A N A G E M E N T AND C O N T R O L PROCESSES WITH ASSOCIATED CERTIFICATES OF CONFORMITY PERMIT TO USE PORTABLE WET EVAPORATIVE COOLING POINT-OF-USE AIR CONDITIONING UNIT Page 2 of 114

3 i. DISTRIBUTION CONTROL This Water Safety Plan (WSP) has a controlled circulation and should not be copied or circulated without the permission of the Water Safety Group (WSG) Chair. Confirmation that each Departmental Responsible Person and their Deputy have read and understood this WSP and recorded on each Letter of Nomination enclosed in Appendix 1. While the WSG have delegated responsibility to department leads and framework contractors to ensure that information contained herein is disseminated to all appropriate parties; including at induction via specific instruction to work to the WSP. Page 3 of 114

4 ii. DOCUMENT MANAGEMENT Whilst this document is developed in such a way as to ensure that all aspects of Water Quality Management are addressed, its construction is such as to allow for ease of use and it is thus divided into the following sections which can be considered in isolation: Targeted Departments Document No. Document Title FM Services Hard Soft FM FM H&S Schools & Sports Contractors Commercial Imago & Campus Living Book 1 Book 2 Book 3 Book 4 General Considerations FM Services Management Projects & Capital Management Contingency Measures NB - Hard FM Services are related to Building mechanical and electrical services. While Soft FM Services are related to but not limited to cleaning, catering, accommodation, security, This WSP shall be used in conjunction with current version of the following University Policies: i. Domestic Services ii. General Sport Policy policy-and-management/ iii. Catering equipment and Irrigation systems (Grounds and Gardening) Page 4 of 114

5 iv. H&S policy v. vi. Capital Specifications - Page 5 of 114

6 1. WATER SYSTEM AND PLANT DESIGN INSTALLATION AND MAINTENANCE Management of water systems and associated end-of-line fittings to reduce the risk of microbial growth including opportunistic pathogens such as Legionella sp. is vital to staff, student and public safety. It requires on-going maintenance and surveillance of control measures employed. The plant and equipment used in the University s buildings which have water in the system and can affect the water supply or the atmosphere must be monitored regularly and be subjected to the following regime: i. The systems must be carefully designed so as to minimise aerosols and the material used in construction would not harbour or provide nutrient for bacteria. They must be designed to be readily drained and cleaned. ii. The systems must be maintained in a clean and sound condition and must be easily and safely accessible. iii. All plant and distribution pipe-work (where accessible) must be clearly labelled. iv. The water quality must be maintained by ensuring the systems are kept in a good condition by either regular cleaning and disinfecting on a regular dosage of water treatment. v. Careful monitoring of the precautions in place as outlined in the WSP. vi. Records must be kept of the maintenance performed and the results obtained via the PPM programme in place. 1.1 Supplies from a water provider: The following factors should be taken into consideration in the initial stages of the design: i. The water provider s requirements. ii. The estimated daily consumption and the maximum and average flows required, together with the estimated time of peak flow. iii. The location of the available supply. iv. The quality, quantity and pressure required. v. The cold water storage capacity required. vi. The likelihood of there being any contaminated land on site. vii. The proposed method of storage and probable number and purpose of direct connections to pressure mains. viii. The minimum and maximum pressures available at the service connection. ix. Details of the physical, chemical and microbiological characteristics of the water supply and scope of any possible variations in such characteristics. x. The possibility of an alternative service connection from some other part of the water undertaker s network, including pressure details. 1.2 Primary Water Supplies: Page 6 of 114

7 Water supplied for such domestic purposes as consist in or include, cooking, drinking, food preparation or washing shall be regarded as wholesome as it applies to the supply of water for those domestic purposes, if the following requirements are satisfied: i. That the water does not contain any micro-organism or parasite; or any substance at a ii. concentration or value which would constitute a potential danger to human health See The Water Supply (Water Quality) Regulations 2000 and The Water Supply (Water Quality) (Amendment) Regulations 2011 and the University s Biological Contamination Measured Parameters. That the water does not contain any substance at a concentration or value which, in conjunction with any other substance it contains would constitute a potential danger to human health. Guidance Note 1: No connection to any part of the University s Primary water supply shall be made without the written authorisation of the appropriate Responsible Person (Capital for schemes and FM for operational). 1.3 Water Treatment Requirements: i. All water supplied to University properties must comply with current legislation on water quality. ii. The need for water treatment, and the treatment processes used shall depend on the purposes for which the water is to be used and the quantity required for each purpose. iii. Where continuous water treatment is installed, the commissioning records should include details of settings of the equipment, dosing rates and requirements for testing. iv. Levels of disinfectant shall be agreed with via the University DAP prior to commissioning the plant and equipment. v. To prevent the accumulation of biofilm during construction and testing, continuous dosing of water systems with appropriate biocides, such as chlorine dioxide, should be considered. Such treated systems should be regularly flushed to ensure that the biocide reaches all parts of the systems, and particularly outlets. Dosing with an appropriate level of biocide as soon as water hits a pipe or storage vessel (when system is first subjected to pressure testing), along with regular flushing, can control the accumulation of biofilm more effectively. 1.4 General Design and Installation Considerations: Domestic water systems and associated equipment which utilise water and can affect the water supply, the atmosphere and the user, shall be properly designed, installed, commissioned, monitored regularly and be subjected to the following regimen: i. All designs must be in accordance with all relevant and current Guidelines, British Standards, 'best-practices' and engineering specifications. ii. The systems shall be carefully designed to, where practicable, eliminate or minimise aerosol production and excessive water retention. They must also be designed to be readily drained, cleaned, and where necessary, suitably disinfected. iii. No materials used in construction shall include those that are known to harbour or provide nutrient for bacteria. Plastic pipe-work shall be avoided wherever practicable Page 7 of 114

8 and copper shall be used wherever possible. Any materials that come into contact with the water shall comply with the requirements of the Water Supply (Water Fittings) Regulations The list of products and materials that have been assessed for compliance with the Water Supply (Water Fittings) Regulations 1999 requirements are listed on the WRAS website Further information on the selection of materials can be found in BS 8558:2015 and BS6920 iv. The installation of non-tmv mixing taps is the preferred control option following a risk assessment. v. All TMVs and TMTs installed must be compliant with the TMV3 Approved Scheme and installed in accordance with all relevant and current Guidelines, British Standards, 'best-practices' and engineering specifications. The list of currently approved TMVs and TMTs is to be found on the WRAS website NB TMVs and TMTs will only be installed following assessment and acceptance by the WSG representative. University policy is to not fit these where possible unless significant risk has been identified by the aforementioned assessment. vi. The systems shall be maintained in a clean and sound condition and must be easily and safely accessible. vi. All systems shall be frequently used (at least 2 x Weekly throughout and DAILY in all specified high-risk areas), or suitably flushed to simulate the necessary usage frequency, in order to avoid stagnant water which will increase the potential of bacterial growth and proliferation. The 'users' of facilities shall undertake regular evaluations of usage frequency and implement suitable and sufficient control measures so that that the correct actions are regularly monitored and reported upon. vii. As far as reasonably practicable, no flexible hoses shall be fitted to any new buildings or refurbishments commissioned by or on behalf of the University - unless for requirement of specific specialist equipment. Then there is requirement for WRAS approved only and agreement via the WSG. Since some flexible hoses are unsuitable for use in domestic water, because they support microbial growth, give the water a very strong, unpleasant, taste and odour or release toxic substances into it. Hose materials may encourage the growth of Legionella bacteria. Flexible hoses are typically steel braided with a synthetic rubber inner lining such as EPDM (ethylene propylene diene monomer). Several reports indicate that high levels of Legionella bacteria have been found in water samples taken from water outlets fed by flexible hoses, confirmed by testing of the hoses. These revealed colonisation of the lining. The lining of the material in these reports was EPDM. However, it is possible that other lining materials (and washers within the couplings) could be similarly affected. New lining materials such as PE (polyethylene), PEX (cross-linked polyethylene), LLDPE (linear low-density polyethylene) and PVC C (post-chlorinated PVC) are now on the market and others are likely to follow. However, their long-term performance regarding the growth of microorganisms is still unknown. Changes in this situation may be reflected in future guidance. Flexible hoses used in potable water supply systems should be identified and risk assessed for the possibility of contamination with harmful microorganisms. An action plan shall be developed, which gives priority to areas of highest risk (i.e. those with persons vulnerable to infection). Depending on the risk assessment, the action plan shall address replacement of flexible hoses with hard or soft bendable metal pipes. Where flexible hoses must be used (e.g. on essential equipment such as Page 8 of 114

9 hi-low baths) they must be lined with a suitable alternative to EPDM, as well as being Water Regulations Advisory Scheme (WRAS) approved. Care should be taken to avoid kinking or distorting them during installation. Where items such as flexible hoses are present at the moment then they will remain unless deemed necessary to remove. viii. In new and existing premises it is essential that the needs of individual requirements are carefully considered. In new premises, the provision, correct siting and installation of showers and wash-hand basins, particularly in accommodation where users are unlikely to make use of them requires assessment. For existing premises, and subject to a risk assessment, permanent removal of disused or infrequently used outlets and their associated pipework will be considered. ix. Tap design has evolved. In older installations, thermostatic control of water temperature was achieved by a separate thermostatic mixing valve (TMV) (commonly called a "t-shaped" TMV), typically located behind the sanitary assembly panel to which a wash-hand basin or other assembly was fitted, which then supplied water to the hot connection of a manual mixing tap or separate tap. Many new installations now include thermostatically controlled thermostatic mixing taps which are usually manually controlled (on and off) and can be adjusted to further reduce outlet temperature to fully cold. For some applications, remote sensor-operated taps are available (many sensor taps also have the option of auto-flushing programmes and can be linked to the University s building management system). In some instances these developments have led to a more complicated internal tap design which may increase the need for additional routine maintenance (including decontamination) to mitigate the risk of contamination. NB - The installation and/or use of this type of tap is not recommended by the WSG. Written authorisation for specific installation shall require sign-off by the WSG Chair or his nominated Deputy. x. All plant and distribution pipe-work (where accessible) shall be clearly labelled and adequately insulated. 1.5 Cold Water Storage: i. Cold water storage tanks shall be constructed from non-deleterious materials which must be WRAS approved. ii. Cold water storage tanks shall be designed and installed in accordance with the current Water Supply (Water Fittings) Regulations 1999, installed in appropriate and suitable locations to allow easy and safe access to facilitate inspection and maintenance. iii. Sectional Cold Water Storage tanks shall be designed with external assembly flanges and self-draining profiles, since this arrangement facilitates easy cleaning of internal surfaces. iv. Externally located Cold water storage tanks shall be suitably protected from environmental conditions, particularly the local high ambient temperatures for all new buildings and, where practicable, for existing installations. v. Cold water storage tanks shall be protected from the ingress of light, insects and birds. Page 9 of 114

10 vi. vii. viii. Cold water storage tanks shall be sized and arranged so as to minimise retention time of stored water (24hrs maximum), and therefore to increase the rate of stored water exchange. Cold water storage tanks shall be subjected to a periodic need test which requires the user to question the presence of each unit and consider its removal if the services it supplies can be, equally well, supplied by converting the systems to domestic Mains fed only (as part of review for reduction of risk where applicable). Each unit shall be subjected to a benchmark drop-test designed to ascertain the capacity and demand requirements of each system, in order to ensure that excessive volumes of water are not unnecessarily stored. This activity shall be completed before the second anniversary of this Policy being ratified. Subsequent drop-tests will be required only where demand requirements of the building have noticeably changed from the initial assessment; gauged by change of occupants, building use or both. Where tank capacity is >120% of the criteria set out in Paragraph 1.5vi, the tank(s) shall be scheduled for replacement at the earliest opportunity. Where tank capacity is >100% but <120% of the criteria set out in Paragraph 1.5vi. the tank(s) capacity shall be reduced by fitting a drop-arm and float arrangement at the earliest opportunity. Eliminating storage within a system would also allow the negation of the necessary PPM Programme tasks and their replacement with much less onerous, more infrequent and less costly tasks to be carried out. NB the need test will reflect any change from the routine process carried out by the University to determine capacity of the CWSTs for all areas in the past. ix. All associated pipework and valves shall be adequately insulated and clearly labelled to identify their purpose. x. The use of delayed-action ball valves shall be fitted (where practicable) in order to help avoid stagnation of water. xi. Where Cold water storage tanks are linked in parallel, each feed to each tank shall be fitted, where practicable, with a water meter in order to allow for confirmation of equal and uniform usage from all tanks in the configuration. xii. Various arrangements of pumping systems are indicated in BS 8558:2015. Where booster pumps are to be installed, a break cistern will be required between the mains supply pipe and the pumps. This is required in order to comply with the Water Supply (Water Fittings) Regulations 1999 with regard to prevention of backflow. Control of the pump(s) should be fully automatic in operation and controlled by pressure sensors. Where two or more pumps are installed, the design flow should be achieved with one pump stationary (or out of service). Automatic control should be provided to cyclically and sequentially control all pumps to ensure that each is regularly brought into service. Page 10 of 114

11 xiii. Cold water storage tanks shall be maintained in good condition, clean from excessive corrosion, sludge deposition, scale deposition. xiv. Stored water shall be maintained at a temperature of <20 o C (or <2 o C from the supply). xv. Where indicated and when it is deemed necessary and practicable, Cold Water Storage Tanks shall be upgraded, refurbished, modified or replaced so that they may comply with current Water Supply (Water Fittings) Regulations Following these works, each tank shall be cleaned and disinfected in accordance with BS 8558:2015 and ACoP L8 prior to it being allowed back into service. xvi. Cold Water Storage Tanks shall be subjected to periodic monitoring to include: 1. Temperature monitoring: a. Continuously by a suitably calibrated BMS system where installed. b. When more than one CWS direct-supplied outlet, supplied by the tank, is found to be >20 o C during the monthly sentinel outlet temperature monitoring task. 2. Regular general physical inspections the frequency of which shall depend on current PPM Programme or risk assessment, where different. xvii. Cold Water Storage Tanks should not be subjected to unnecessary, anniversary-based clean and disinfections. Instead, they shall be subjected to a clean and disinfection, when the results of the monitoring indicate the need. Please refer to Section 7 - Engineering Contingency Measures for further information. 1.6 Hot Water generation and storage: i. Hot water generation and storage units shall be installed in appropriate and suitable locations to allow easy and safe access to facilitate inspection and maintenance. ii. Where more than one hot water generation unit is used, they shall be connected in parallel, taking care to ensure that the flow can be balanced so that the water temperature from all the units exceeds 60 C at all times. iii. The combined storage capacity and heater output must be sufficient to ensure that the outflow temperature, at continuous design flow (at least 20 minutes) from calorifiers or other heaters, should not be less than 60 C. This applies to both circulating and noncirculating hot water systems. iv. Plate heat exchanges shall, where practicable, be installed without buffers vessels. Where buffer vessels are used, they shall not receive the CWS feed directly but should, instead, be directed to the plate heat exchange HWS return supply. All buffer vessels fitted, shall be subjected to a regular temperature monitoring programme and contents maintained at 60.0 o C. v. The positioning of the control and high limit thermostats, cold feed and return water connections must ensure that these temperatures are achieved. vi. Means should be taken to prevent warm water entering the cold-feed. A check valve shall be provided in the cold feed, as close to the unit as practicable, to prevent such circulation. However, the installation of such a check valve shall not be carried out in systems that use the cold feed for expansion. In these cases, the installation of a U- bend or S-bend in the cold-feed, sufficient distance from the connection to the unit, so that water which is warm is not displaced (on heating up) beyond the bend and the vertical pipe rise shall be carried out. vii. The practice of terminating the air vent over the Water Storage Tank shall be Page 11 of 114

12 viii. ix. discouraged. The vent should be arranged to discharge over a separate tun-dish arrangement, with a visible Type A air gap, sited at a level that takes account of the hydrostatic head of the system. The calorifier or water heater should be provided with a suitable safety valve of appropriate size and vacuum release arrangement. Where water quality indicates the need, cathodic protection from galvanic action by means of sacrificial anodes shall be provided. Calorifiers and buffer vessels (where necessary) shall be fitted with a de-stratification pump, where necessary, in order to avoid temperature stratification of the stored water. Some semi-storage/high-efficiency calorifiers are supplied with an integral pump that circulates water in the calorifier. De-stratification pumps shall not be fitted to this type of units. x. A single circulating pump shall normally be installed in the return with a sealed spare xi. xii. xiii. pump on a bracket adjacent. If, for reasons of reliability, two pumps are installed in parallel they shall be arranged to have individual non-return and service valves and be controlled such that each one is brought into operation twice a day via the BMS. When units are isolated from the system (for whatever reason), the associated distribution system shall be subjected to DAILY flushing. However, this is only necessary when the unit isolated is the sole supply of HWS to that distribution system. Where more than one unit supplies the distribution services, the isolated unit shall be drained down (where applicable) and allowed to remain drained whilst off line. A suitably sized drain shall be connected to the base of each calorifier (where practicable). Calorifiers, buffer vessels and all other hot water generation units, other than instant water heaters of <15 litres (listed below) shall be maintained at the following temperature profiles at all times: a. Stored and Flow at 60.0 o C b. Return at 50.0 o C ( 55 C in Clinical Areas) c. Distribution and at point of supply at >50 C for direct-supplied outlets ( 55 C in Clinical Areas) or to thermostatically controlled valves and/or taps (measured at sentinel outlets). d. Drain at 50 o C. In order to ensure that the temperatures required for achieving thermal disinfection (>60ºC for the Flow and 50 for Distribution ( 55 C in Clinical Areas) ) are maintained, it is important to ensure that: 1. Where the Timers are fitted and operated and cannot be overridden, it is important to ensure that the units are allowed to operate at a temperature of (min) >60ºc for at least 1 hour from when they come on line, before any water is drawn from them and that they are subjected to at least one-hour at >60 o C in any 24 hour period. 2. Where a building is to remain un-occupied (indefinitely due to shut-down), the calorifier should be emptied, and pasteurised before being allowed back on-line. If a facility is to be closed, it is the responsibility of the facility manager to notify of the impending facility closure by submitting a completed copy of Section 1 of Permit No. 4 'Notification of Closure of Facility and Permit to Re-occupy' to the Responsible Person (FM) at least one week (where practicable) prior to the Facility closure. Process No. 6 Calorifier Pasteurisation should also be followed. Page 12 of 114

13 xiv. Units shall be subjected to regular check for Flow and Return temperature monitoring. This can be carried out manually or remotely via a BMS system where available (all new builds and major refurbishments shall be enabled to allow for BMS monitoring). xv. In addition, units installed in systems supplying large multi-occupancy areas, shall be subjected to a check for Flow and Return temperature when more than one HWS direct-supplied outlet, supplied by the unit, are found to be at <50 C for all areas during the monthly sentinel outlet temperature monitoring task. In addition, HWS System units shall be subjected to an annual 24hr temperature profile under normal operating conditions, where a BMS system is not installed. xvi. Pasteurisation of calorifiers and buffer vessels shall be carried out in the event of major modifications or after a period out of service, before the calorifier is returned to service. Pasteurisation shall also be carried out when the stored water temperature falls below 45.0 o C for more than 1 hour before the Calorifier or buffer vessel is returned to service. xvii. Cistern-type water heaters shall be maintained such that the cold tank part of the heater is kept clean and at the correct temperature, and the hot tank part maintained at a temperature of >60.0 o C allowing for distribution temperatures of >50 o C ( 55 C in Clinical Areas). A screened vent and an insect/rodent overflow screen shall be fitted to the tank part of the units. xviii. Units shall be subjected to regular inspections for water quality, physical condition, temperature and bacterial activity (where requested). xix. Units shall be subjected to a regular blow-down and flush via the drain point and the condition of the initial drain water reported. xx. Return and shunt pumps shall be serviced or replaced as required. xxi. Low volume water heaters of <100 - >15 litres and combination boilers shall be allowed to operate so that the furthest outlet from each unit is 50 o C measured at the point of supply to direct-supplied outlets or to thermostatically controlled valves and/or taps. xxii. Instant water heaters of <15 litres, including combination boilers, usually store small water volumes, and because of this they do not usually need to be operated within the temperature profile and limits prescribed for larger systems ( 60 o C for the flow and 50 o C for the return and 50 o C for outlet - 55 C on the return and outlet in Clinical Areas) which are necessary for thermal disinfection. These units can, therefore, be operated at safe temperatures of 41.0 o C (+/-1 o C) although they should be switched-on at all times to ensure and encourage adequate use. Infrequent use of these units (less than twice-weekly) would increase the potential of bacterial growth and proliferation (as would be the case in all infrequently used areas throughout the system both hot and cold), although particularly in this case because of the low temperatures where operated. xxiii. Return and shunt pumps shall be overhauled on an "as required" basis following specific risk assessment. 1.7 Hot and Cold Water Distribution Systems: i. The design and installation of the hot and cold water distribution system shall comply Page 13 of 114

14 with the Water Supply (Water Fittings) Regulations 1999 and BS 8558:2015. ii. The design of the pipework shall ensure that there is no possibility of a crossconnection between installations conveying potable water and an installation containing non-potable water or water supplied from a private source (untreated). There shall be no possibility of backflow towards the source of supply from any tank, cistern or appliance, whether by back siphonage or otherwise. iii. The selection of water outlets is important. This choice should be based on a risk assessment of infection-control and scalding issues, should be capable to receiving POU filters without contravening Water Regulations compliance and it is important to ensure that they are easy to use and practical for the existing space. iv. All cold distribution pipework, mains and tank down feeds shall be located, as far as is practicable, to minimise heat gains from their environment. Pipework shall not be routed through hot ducts or run adjacent to heat sources, such as radiators. v. All pipework shall be insulated, except for any exposed final connections to facilities, and should be arranged to eliminate or minimise dead-legs. vi. As far as possible, the objective shall be to design the cold water systems to ensure that the inlet, outlet and surface water temperatures of cold water storage tanks are not greater than 2 C above that measured at the main water meter. Also, at cold water draw-off points, a temperature of not greater than 2 C above the temperature measured in the source Cold water storage tanks shall be reached within two minutes. vii. Any pumps requiring replacement, must be replaced with pumps of equal rating in order to ensure that an increase in water velocity is avoided as it can potentially increase the rate of biofilm shearing from existing pipework. viii. Stagnation shall be avoided. Hot and cold water services shall be sized to provide sufficient flow at draw-off points. The aim shall be to promote turnover of water by means of; the design of the distribution circuitry, adequate usage and avoidance of disused areas. ix. Where practicable, separate drinking water systems shall be provided directly from the town main or site main (from break-tanks) without local storage. Otherwise, all supplies to drinking water systems shall be of potable quality. The supply shall not be softened to less than 70ppm of total hardness. Additionally, it shall be established that the usage is sufficient to avoid deterioration in water quality, for example, that the inlet water temperature does not exceed 20 O C and that the outlet does not remain unused. Where the temperatures recorded fall outside the recommended temperature limits, the monitoring must be supported with microbiological analysis for the presence of E.coli and presumptive coliforms from the source and representative outlets. Note: The use of Water Bottle Dispensers shall not be allowed and any units that are currently installed shall be planned for removal. x. The equipment shall be positioned so that the warm air exhaust does not impinge directly on taps or hoses supplying cold water. xi. The domestic hot water system shall not be used for heating purposes. This includes all radiators, towel rails, heated bedpan racks etc, whatever the pipework configuration. xii. Central common blending systems shall not be used, since the length of distribution pipework containing water in the temperature range that supports bacterial growth and proliferation would far exceed the maximum permissible lengths mentioned Page 14 of 114

15 below. xiii. Water temperatures and levels of ClO2 / M101 at a representative number (directsupplied sentinel outlets) shall be measured at monthly intervals. Temperatures shall be measured after two minutes for the CWS and one minute for the HWS at full flow and be maintained at <20 o C and >55 o C (NHS Clinical) / 50 C ( Other areas) respectively. xiv. Temperature and levels of ClO2 monitoring shall be supported with regular microbiological sampling when considered necessary and as directed by WSG. xv. Scalding control. The temperature from all such outlets shall be measured on a regular basis and maintained at: o C (+/-1 o C) for showers o C (+/-1 o C) for basins o C (+/-1 o C) for baths o C (+/-1 o C) for bidets xvi. Warning! Hot Water notices in public areas will be installed to indicate and warn users of the potential of scalding. xvii. IF a TMV is fitted the pipe-work length from the TMV to the outlet shall be restricted to a maximum of two metres. It is preferable that TMTs are used, wherever practicable, in order to maintain lengths of pipe-work carrying blended water to minimum. xviii. All TMVs and TMTs shall be fitted with strainers, isolation valves and non-return valves. xix. All TMVs shall be accessible (as far as reasonably practicable). xx. All TMVs and TMTs fitted to baths, bidets and showers shall be inspected and subjected to a fail-safe test on a regular basis (carried out as described in the manufacturer s instructions). xxi. TMVs and TMTs fitted to facilities shall also be subjected to a regular inspection and as required strip-down, cleaning and disinfection as indicated by the results of the inspection programme. xxii. All systems shall be frequently used (at least 3 x Weekly throughout), or suitably flushed to simulate the necessary usage frequency, in order to avoid stagnant water which will increase the potential of bacterial growth and proliferation. The 'users' of facilities shall undertake regular evaluations of usage frequency and implement suitable and sufficient control measures so that that the correct actions are regularly monitored and reported upon The process shall be reported via, the COMPASS System - Usage Evaluation and Flushing module. However, a paper pro-forma Flushing Sheets shall be used should the COMPASS system not be available for any reason. xxiii. Where infrequently used facilities are deemed by the department staff to be no longer required, they should be notified, via the COMPASS System, to the FM Department and the WSG for removal. xxiv. Where a building or sections of the system remain unused for long periods of time ( i.e. greater than one week), steps shall be taken as follows: 1. Flush all water facilities (including toilet and urinal cisterns) thoroughly on a Weekly basis (2xWeekly or more frequently if deemed necessary) whilst the building or areas is not in use. 2. Flush all water facilities (including toilet and urinal cisterns) thoroughly at least one day prior to the building being used. Page 15 of 114

16 3. If the facilities within a building are to remain unused for a prolonged period (more than one month), then the system shall, where practicable, be drained down (including all vessels) and cleaned and disinfected (any calorifiers/buffer vessels are to be pasteurised) prior to being allowed back on-line. Where this is not practicable, all associated facilities shall be flushed on a Weekly basis. However, the frequency of flushing must be verified by supporting biological analysis monitoring. 4. Consideration shall be given to isolating the unused sections from the system and possibly removing pipe-work and fixtures completely to avoid "dead-legs". xxvii. In addition to the flushing regime described above, careful consideration should be given to the usage requirements of the system and any required system changes made accordingly. If it is deemed that the facilities are currently being used seasonally or remain unused for prolonged periods of time, then the following should be considered: 1. Re-engineer the system so that all CWS throughout the system are provided directly off the MCWS supply. This action will enable the isolation and removal of any cold water storage tanks. 2. As part of the re-engineering of the CWS, it is also recommended that any water storage calorifiers are isolated and removed from the system and replaced with the required number of mains fed instantaneous, point-of-use or multipoint water heaters. 3. The absence of water storage vessels will reduce the inherent risk of storing stagnant water although it would not negate the need for flushing the remaining system.. xxv. The water in a self-contained eyewash station must be refilled, disposed, and maintained in accordance with manufacturer s instructions. Emergency showers should also be flushed Weekly (to a suitable drain / bucket minimising aerosol) to clean the line and verify proper operation. xxvi. Trace Heating: The installation of trace heating as a control measure shall only be considered as a last resort should alternative rectification works not prove successful. Where fitted the thermostats and pipework shall be maintained under manufacturers and PPM instructions. 1.8 Showers and TMV: i. All showers (shower-heads and associated hoses) shall be maintained in a good and clean condition and free from excessive scale and dirt deposition. ii. Any showers fed via TMVs shall be maintained and operated at 41 o C (+/-1 o C) iii. Shower heads which are provided with a means for adjusting the flow, for example fine spray, pulsating flow etc, selected by utilising different sets of nozzles, shall not be installed as this will exacerbate possible stagnation problems. Where present, these should be replaced with shower heads with fixed nozzles. iv. Central common blending shower-block systems shall not be used and all pipe-work length from the TMV to the shower-head shall be restricted to a maximum of two metres. Page 16 of 114

17 v. Where common blending shower-block systems are already in place, each system shall be fitted with a solenoid valve (at the furthest point from the mixer valve), programmed to automatically purge water for a three minute period each day. vi. All showers shall be subjected to regular temperature monitoring. The temperature monitoring shall be supported with regular microbiological sampling where considered necessary. vii. All shower-heads shall be inspected on a regular basis and de-scaled, cleaned and disinfected. To allow for adequate maintenance to be carried out, "target" units must be selected and subjected to specified monitoring frequencies. viii. Where biological results indicate significant local bacterial contamination, the contaminated shower shall be either removed from use or fitted with a suitable Pointof-Use filter to enable continued use of the facility. Where such filters are fitted, they should be changed according to manufacturer s instructions. 1.9 Baths and TMV/TMT: i. All temperatures outside the recommended limits must be notified to the FM Department, as a fault, immediately. ii. All TMVs/TMTs shall be inspected on a regular basis and de-scaled, cleaned and disinfected. To allow for adequate maintenance to be carried out, "target" units must be selected and subjected to specified monitoring frequencies Non-Touch Taps: i. The installation and/or use of this type of tap is not recommended by the University. Written authorisation for specific installation shall require sign-off by the WSG Chair. ii. Based in local risk assessments, non-touch taps installed shall be maintained and serviced on a regular basis. Where deemed to be necessary, the maintenance shall include but not be limited to the checking of operational integrity, operating temperatures and status of fail-safe process. The units shall also be cleaned and disinfected on an As Required basis and the process shall include the cleaning and disinfection of all strainers, filters, aerators, flow-straighteners and flow-restrictors. To allow for adequate maintenance to be carried out, "target" units must be selected and subjected to specified monitoring frequencies. iii. All new non-touch taps installed shall be capable of being programmable to enable automatic flushing of these outlets to be implemented. The units must be capable of automatic flushing of at least 30 seconds. iv. The mechanical parts of these units shall be accessible for easy maintenance. v. Should allow for a pasteurisation cycle to be carried out. vi. These units shall not be fitted or installed with flexible rubber hoses Aerators and Flow straighteners: i. Devices such as aerators and flow straighteners fitted to the tap have been shown to exacerbate the problem of localised bacterial contamination by providing the nutrients which support microbial growth, providing a surface area for oxygenation of water and leaching nutrients. Subject to local risk assessments, it is important to consider the Page 17 of 114

18 ii. removal of these devices wherever practicable. If it is not practicable to remove these devices, these should, instead, be introduced and maintained onto an adequate and periodic cleaning and disinfection programme. The frequency of this task shall be dependent on the condition of the devices and based on local risk assessments. To allow for adequate maintenance to be carried out, "target" units must be selected and subjected to specified monitoring frequencies. Owing to their high surface-area-to-volume ratio and location at the tap outlet, certain designs of flow straighteners may present a greater surface area for colonisation and support the growth of organisms. Therefore, when selecting new taps, where possible flow straighteners should be avoided/not included Expansion and Pressurisation Vessels: i. All new and replacement expansion/pressurisation vessels fitted shall be of the flowthrough type. ii. Expansion vessels shall be located on the cold feed rather than on the hot water side of the system. The length of pipework between the expansion vessel and cold feed shall be as short as practicable, e.g. less than 1 metre. iii. All existing expansion vessels, where not being replaced, shall be of the flow-through type. Where pressurisation vessels are of the single entry type they must be fitted with appropriate flow-through valves or drain valves to facilitate flushing of the unit. The flushing frequency shall be determined by assigning "target" units which shall be subjected to specified monitoring frequencies Greywater Systems: i. Greywater systems shall comply with BS : Greywater systems Part 1: Code of practice and BS : Greywater systems Part 2: Domestic greywater treatment equipment Requirements and test methods Rainwater Harvesting: i. Rainwater harvesting systems shall be avoided, where practicable, or installed and maintained in compliance with BS 8515: Rainwater harvesting systems - Code of Practice Temporary Water Supplies: The University, or others on its behalf, when providing and managing temporary water supplies, shall comply with their duties under the Health and Safety at Work etc. Act a and BS 8551: Provision and management of temporary water supplies (not including provisions for statutory emergencies). This provides clear practical guidance on how to install temporary supplies, whether by connection to the mains or tanker-fed, and how the distribution system should be disinfected and tested to ensure that the water is wholesome. It also considers the safe storage of bottled water, though not the maintenance of the dispensers. Page 18 of 114

19 1.16 Ice Making Machines (Maintained by Sports Staff) - ice used for external use only (to treat injuries) and should not be used for consumption: i. The University shall only allow the installation of instant ice making machines. ii. The University shall service each unit in accordance with manufacturers instructions. iii. The User must carry out daily checks of the condition of the unit and records of the checks made should be carried out by the person in charge of the area. iv. The User shall clean and disinfect the unit on a monthly or two weekly basis. v. All staff handling ice, those cleaning ice machines or equipment and any persons in charge of those staff should know these requirements. Training should ensure all hazards and controls are understood. It should include instruction on how to carry out cleaning, the use of cleaning equipment and a demonstration of how to handle ice without causing contamination. vi. Managers and staff carrying out checks need to be trained, in addition to that above, on how to carry out checks and how to record problems that arise and the action taken to deal with it. vii. Health and safety training should also be included, for instance, the switching off of electrical power to machines before cleaning. viii. Ice is defined as food under the Food Safety Act 1990 and must be made, stored and handled so that it is not contaminated, a requirement of the Food Safety (General Food Hygiene) Regulations The provision of suitable training is the responsibility of the department utilising the equipment ix. Some micro-organisms are known to survive at low temperatures and surveys of ice used in drinks have shown high levels of bacteria present in up to 50% of samples. Some ice has even been found to contain various pathogenic bacteria, including E. coli and Legionella pneumophila and there can also be other contaminants. Ice can be contaminated by: 1. Bacteria including pathogenic bacteria from the incoming water supply, people, raw foods and other objects that may come into contact with the ice such as contaminated scoops; 2. Chemicals including misused cleaning and maintenance chemicals; 3. Physical contaminants including dust, dirt, people, etc. x. In order to control the potential of microbiological and other contamination, the following actions shall be considered and implemented: 1. Connect the machine directly to the mains water supply, not to a storage water tank, ensuring that the supply pipework is as short as possible and insulated from passive heat gain, particularly in locations where the supply pipework is directly next to the cooling fan. The use of Point-of-Use (POU) filtration may be considered, following a Risk Assessment. 2. Site the machine in a clean room, away from sources of contamination such as human waste (in sluice rooms) and cleaning chemicals. 3. Use the ice machine in accordance with the manufacturers instructions, as regards ambient temperatures, ventilation, water, electrical and drain connections. 4. Service the machine in accordance with the manufacturer s instructions, or at least twice a year. This is particularly essential in hard water areas where scale can build up and become a possible harbourage for micro-organisms. Page 19 of 114

20 5. Clean and disinfect the machine in accordance with the manufacturer s instructions, usually at least monthly or two weekly. This should include disposal of all ice in the machine. A suitable, non tainting disinfectant should be used. 6. Ensure the correct use of chemicals. The machine should be cleaned with a non- abrasive cleaner, rinsed with fresh water, wiped around the inside with an anti- bacterial cleaner, (food use), rinsed again with fresh water and re-started. NB. The inner surfaces of ice making machines are particularly prone to the growth of moulds if not regularly cleaned. 7. Wear clean clothing and ensure hands are clean before washing the ice machine Other Systems (Irrigation Systems, Lathes, Cutting Tools, etc.): i. All lathes and cutting tools shall be maintained in a good and clean condition and free from excessive corrosion and dirt deposition. ii All lathes and cutting tools shall be flushed or emptied on a daily basis or used without coolant. iii. All lathes and cutting tools shall be subjected to a Monthly cleaning and disinfection if organic coolant is utilised. iv. Irrigation systems shall not use untreated water or untreated grey water unless tested fit for purpose. Local Policies should also be consulted as referenced in Section 2.3 Limitations of this WSP of BOOK 1- General Considerations Portable Wet Evaporative Cooling Point-of-use Air Conditioning Units: i. These units are considered to pose a significant Risk of Legionellosis because of their mode of operation, which includes the wetting of medium and the production of aerosols, which, if not maintained correctly, can increase the potential of bacterial growth and proliferation. For this reason, The University do not recommend the use of Portable wet evaporative cooling point-of-use Air Conditioning Units.. Use of such units can be authorised by the University's WSG following correct submission of Permit No. 2 - Permit to Use Po rtable Wet Evap orative Coolin g Poin t -of-use Air Conditioning Unit (Appendix 6). ii. Authorised units must be subject to a suitable and sufficient PPM Programme as described by the manufacturer of the unit. iii. Authorised units must be cleaned and disinfected before each use and a disinfection certificate section of pro-forma Permit No. 2 completed. iv. Only sterile water shall be used to fill and top-up the unit's reservoir. v. The unit must be emptied of water after each use and filled with fresh sterile water at the beginning of each use. vi. The Unit must be cleaned and disinfected, as per manufacturer's instructions, on a weekly basis. vii. The WSG shall be advised, by the FM Department or others, of the unauthorised use of this type of unit. Page 20 of 114

21 1.19 Steam Shut-downs: At the time of publishing this document there are currently no such systems in place at the University. However, if any are installed the following should be considered: i. When a site/system is subject to a steam shut-down, it is important to ensure the hot water is quickly purged and replaced with cold water for the duration of the works and whilst the steam shut-down persists. This will ensure that the hot water is not allowed to cool which would increase the potential of bacterial growth and proliferation during this process. The microbiological impact on the system when filled with cold water during this process is lower than when hot water is allowed to cool. This only applies when steam shut-down lasts less than 24 hours. In situations where the steam shut-down lasts more than 24 hours, the system must be disinfected. Local Policies should also be consulted as referenced in Section 2.3 Limitations of this WSP of BOOK 1- General Considerations Adiabatic Coolers: i. All adiabatic coolers shall be maintained in a good and clean condition and free from excessive corrosion and dirt deposition. ii. Flexible hoses must not be used to connect the adiabatic cooler to the mains iii. Water supplies to adiabatic coolers shall be treated with chlorine dioxide at > ppm (mg/l) chlorine dioxide. iv. Levels of chlorine dioxide to be tested on a weekly basis during the cooling season. v. Weekly PPM to check the operation of the spray bars and that the drain from the bunded tank under the cooler is running freely so as to prevent any ponding during the cooling season. vi. Carry out monthly Legionella water analysis during the cooling season. vii. At the end of the cooling season we will isolate & drain down the water supply to the adiabatic cooler which will generally be every October, reinstating the supply in March. Dr T Makin evaporative cooler Legionella risk assessment December 2007 Page 21 of 114

22 An adiabatic cooler is an evaporative cooler that is typically employed as part of a balanced ventilation system. A fan within the unit draws air through a cellulose based wetted media which saturates and cools the air using the principle of adiabatic (evaporative) cooling. Adiabatic coolers typically presents a low risk of creating conditions that are conducive to the growth and dispersal of Legionella bacteria when the following criteria are maintained: a. Quality of influx air Wet bulb temperature below 25OC Low level of organic and microbial contamination b. Quality of water supplied to the cooler Low level of microbiological contamination Temperature below 20OC Low scaling potential c. Installation and operation should take place in accordance with the manufacturers specifications. In particular there should be no modifications to the cooler that may affect: Process controls Air flow rate. The face velocity of the efflux air should not exceed 1.6m/sec in order to Page 22 of 114

23 reduce the release of aerosols from the wetted media Cooling media (CelDEK) Materials of construction Adiabatic coolers should be installed and commissioned by an approved/competent person, and the maintenance regime should be carried out in accordance with the manufacturer s instructions. It is important that a risk assessment is carried out after the unit has been installed in order to assess risks that may be generated by local conditions. The risk assessment should be reviewed in the event of any changes to the cooler or local conditions that may influence the growth and dispersal of Legionella bacteria. The overall risk of Legionella infection from an adiabatic cooler can only be determined after the unit is installed and operational. The risk assessment should be reviewed periodically particularly in the event of changes to the water system or its use, following changes in ambient conditions that may predispose the cooler to microbial contamination, and when results of analysis indicate that control measures are no longer effective. The key principles to be considered in controlling the risk of Legionella infection from an adiabatic cooler are: Avoidance of stagnant water and the build up of biofilm Maintaining temperatures outside the growth range for Legionella of 20 O C to 45 O C Avoidance of corrosion and scaling Controlling the formation and release of aerosols Use of a biocide Stagnant water supports the accumulation of biofilm and Legionella bacteria as it facilitates heat gain in the water, and avoids the shearing forces created by moving water that can reduce the build up of layers of biofilm. When the adiabatic cooler is in cooling mode the filter pads are kept wet using a water re-circulation system in which water, controlled by a solenoid valve and a level probe, is circulated over the pads by a centrifugal pump from a trough at the base of the unit. Continuous movement of the water through the system will help prevent stagnation of water in the trough and other parts of the re-circulatory pipework. A good re-circulating flow of water can also help reduce the accumulation of biofilm on the cellulose matrix. As the units are installed externally they may become filled with rain water that can become stagnant when the unit is not operating. The cooler is fitted with low level sensors, and when it is first operated it should automatically purge any residual water to waste. The slope in the trough should further ensure that all retained water drains to waste. At the end of the cooling mode or whenever the cooler is stopped, a drain valve should open and empty the cooler of water. If the cooler is running continuously in cooling mode the drain valve will automatically operate periodically to prevent the build up of dissolved salts in the re-circulating water. In addition there are a number of other failsafe mechanisms that should ensure water is not retained within the unit. These features are important to prevent stagnation of water in the system. In order to ensure that they function correctly it is important that the unit is maintained in accordance with the manufacturer s recommendations. Biofilm can accumulate in stagnant water, but can also develop on wetted surfaces such as within the cellulose media in the adiabatic cooler. Many microorganisms that comprise biofilm, including Legionella bacteria, cannot survive in the absence of water, as they do not produce spores or cysts that protect the organism from desiccation and subsequent death. Complete drying of the media would reduce the number of viable microorganisms in the biofilm and should kill any exposed Legionella bacteria. Adiabatic coolers have an optional programme that drains the water from the system and operates the fan to dry out the cellulose pads for 30 minutes every 24 hours. In order to reduce the opportunities for Legionella bacteria to develop within the biofilm in the cellulose media, this programme should be operated at least twice weekly. In installations where increased amounts of biofilm develop, this programme should be made mandatory. Extension of the drying period beyond 30 minutes may be required in order to achieve complete drying and effective killing of susceptible bacteria in the media. Microbiological analysis of the re-circulating water by dip-slide will provide some indication of the efficacy of the drying programme in reducing the microbial population attached to the cellulose media. Maintaining temperatures outside the growth range for Legionella bacteria Legionella bacteria are able to multiply at temperatures between 20 O C and 45 O C, and their optimum growth temperature is around 37 O C. The propensity for Legionella bacteria to cause infection also increases as the temperature approaches the optimum for growth. Water requires energy in order to evaporate, and it can take energy in the form of heat from the ambient air thereby cooling the air. In the adiabatic cooler, water evaporating from the cellulose media cools the air as it passes through the honeycomb structure. The re-circulating water will accept some heat from the passing air, but as the wet bulb temperature in the UK is generally low, available data from adiabatic cooler shows that the water temperature should Page 23 of 114

24 rarely increase beyond 20 O C (<20 O C on 99% of occasions), and so would not actively support the growth of Legionella bacteria. In order to reduce the risk of Legionella growth, it is important to ensure that evaporative coolers are not supplied with water that exceeds 20 O C and water quality should also be high i.e. preferably potable quality water. Furthermore, the cooling units should not be in close proximity to heat generating plant that can raise the temperature of the air entering the unit, or raise the temperature of the re-circulating water. At raised temperatures the rate of evaporation is high and the evaporative cooler is programmed to drain, flush and be replenished with fresh water approximately every two hours. This should reduce the temperature of the re-circulating water (providing the make-up water is <20 O C) and also prevent the over-concentration of dissolved salts in the water, which can lead to scaling. As part of the routine monitoring programme the temperature of the re-circulating water should be checked at least weekly. Iron, e.g. in the form of iron oxide (rust), is an essential factor required for the growth of Legionella bacteria. It is important therefore to ensure that water systems do not accumulate significant quantities of iron corrosion deposits. Scale deposits provide an environmental niche that can become readily colonised with biofilm and Legionella bacteria. Scale has good insulating properties that can protect microorganisms from raised temperatures and it can also impede the full effect of water treatment biocides. Scale deposits will accumulate on surfaces within the water system when calcium and magnesium hardness salts become concentrated in water. In wet cooling systems evaporation of warm water increases the concentration of total dissolved solids including hardness salts. Over-concentration of these salts, plus other factors such as alkalinity, can lead to scaling. Microorganisms can colonise the many small fissures that develop in the scale. Avoiding over-concentrating dissolved solids in water will prevent scale deposits from forming. The adiabatic cooler can monitor the number of occasions that make-up water is added to the unit to compensate for water lost through evaporation. This can provide an indication of how concentrated the dissolved solids are where the chemical composition of the water is known. At a pre-determined concentration factor of between 2.2 and 5.7, the cooler can be set to drain all water in the system to waste, and to replenish the system with fresh water. In addition to this safeguard, the cellulose media should be visibly inspected periodically to ensure that excess scale is not forming in the media. Analysis of the chemical composition of the make-up water is required in order to calculate the concentration factor at which scale will form in the system. Aerosols are readily generated within turbulent water systems, and where the water is contaminated with Legionella the aerosols can facilitate the dispersal of the bacteria over large distances. Contaminated aerosols of 5 micron diameter can bypass host defence mechanisms and enter the deepest regions of the lung where Legionella infection can commence. With a 100mm media pad in place the face velocity of the air passing through the pad should be 1.6m/sec at max fan speed setting. Independent data from the University of Aachen (March 2002) indicate that test microorganisms deliberately added to the re-circulating water were not detected by air sampling devices in the exhaust air from the unit. Aerosols are more readily discharged from evaporative coolers and other wet cooling systems when the fan speed generates high face velocities. Unsubstantiated data suggests that aerosols should not be discharged if face velocities remain below 3m/sec. The maximum face velocity generated by the adiabatic cooler on maximum available fan speed is 1.6m/sec and so aerosol dispersal should be minimal. Face velocities may increase where sections of the media become damaged, and so it is important that the media is inspected periodically for any external damage. Under normal circumstances treatment of the re-circulating water with a biocide should not be necessary in order to control Legionella bacteria, as water temperatures in most cases should be below 20 O C, and water is continuously circulated and regularly dumped to prevent stagnation. Operation of the drying mode (i.e. water drained with fan operating) can further control Legionella and some of the microorganisms that comprise the biofilm. However, biocide treatment may be required where water temperatures rise to a level that may support the growth of Legionella bacteria, where there is a raised organic load in the ambient air which will accumulate in the water and provide nutrients for microbial growth, and where dipslide testing or visual inspection indicates the presence of excessive amounts of biofilm. The use of insect filters and appropriate positioning of the cooler can reduce the organic load in the air influx. In these circumstances consideration should be given to continuous dosing or shot dosing of the re-circulating water with a suitable biocide to prevent build-up of biofilm and Legionella. Non-oxidising biocides are generally preferred in evaporative coolers, as they are not lost due to evaporation from the re-circulating water, as can occur with oxidising biocides, and unlike oxidising biocides they will not encourage corrosion of the unit, and are less likely to denature the cellulose media. Where oxidising biocides are to be used they should not exceed 1ppm in the treated water. If treatment with a biocide is necessary, weekly dip-slide testing should assess its efficacy. Under normal circumstances and where the control measures discussed in this generic risk assessment are fully effective, it is unlikely that Legionella bacteria would proliferate and be disseminated from an adiabatic cooler to the extent that they would present a risk of infection. It is important however that the control measures are inspected in accordance with the manufacturer s instructions, and that aspects of water quality are regularly monitored in order to ensure that opportunities for Legionella bacteria to grow and colonise the system do not occur. Page 24 of 114

25 2. PLANNED-MAINTENANCE PROGRAMME TASKS In order to ensure that the devised Risk Management Programme is effective in minimising or controlling the risk of Legionellosis, the University (or others on its behalf) will undertake a number of periodic inspection and monitoring tasks. The actual frequency of the tasks adopted, should depend on a number of criteria such as the type of building, type of occupants and history of the plant/system. For the specific current frequencies employed across the various University buildings, please refer to the PPM Programme Schedule below, As-Required is determined by the results of each visit and is dependent on various measured parameters such as; physical condition, biological activity (if applicable), temperature, usage frequency etc. and decided by the University or its representative All necessary procedures must be pre-agreed prior to commencement. 2.1 Planned Maintenance Programme - Task Frequencies (To be carried out by University Maintenance Department Staff): TO BE CARRIED OUT BY FM DEPARTMENT STAFF (OR OTHERS ON THEIR BEHALF VIA CONTRACTED WORKS) PPM TASK USAGE EVALUATION AND FLUSHING PPM TASK FREQUENCIES Note: Frequencies detailed below are selected to reflect the recommended requirements of the most recent Risk Assessment and should be altered as required to address prevailing risks. LEG denotes tasks pertaining to RESIDENTIAL UNIVERSITY BUILDINGS WEEKLY ( MORE FREQUENTLY IF REQUIRED) Water Quality Management & Control only ACADEMIC BUILDINGS WEEKLY ( MORE FREQUENTLY IF REQUIRED) POINT-OF-USE FILTER INSTALLATION/CHANGE MONTHLY MONTHLY PR8 HOT & COLD WATER DISTRIBUTION WATER STORAGE TANKS Temperature Monitoring Chlorine Dioxide / M101 Level Monitoring General inspections of water outlets Cleaning and disinfection of faucets Cleaning and disinfection of distribution system MONTHLY SENTINEL OUTLETS (PLUS 20% REPRESENTATIVE OUTLETS) MONTHLY SENTINEL OUTLETS & SOURCE MONTHLY AS PART OF LEG 01 LEG PR9 MONTHLY SENTINEL OUTLETS 01 (PLUS 20% REPRESENTATIVE OUTLETS) MONTHLY 02 SENTINEL OUTLETS & SOURCE MONTHLY 01 AS PART OF LEG 01 AS REQUIRED AS REQUIRED PR5 AS REQUIRED AS REQUIRED PR5 & 7 24hr Drop-Test AS REQUIRED AS REQUIRED 05 Temperature Monitoring 6-MONTHLY / WHEN DCWS ARE AT >20 O C 6- MONTHLY / WHEN DCWS ARE AT >20 O C 03 Page 25 of 114

26 Visual Condition Inspections 6-MONTHLY 6-MONTHLY 04 CISTERN TYPE WATER HEATERS (If present) Clean & Disinfection Temperature Monitoring Inspection of cold tank section Cleaning & Disinfection ANNUALLY QUARTERLY PR3 ANNUALLY 6-MONTHLY 11 ANNUALLY ANNUALLY 12 AS REQUIRED AS REQUIRED 13 *Where tanks have been disinfected as result of identified bacterial contamination, all associated down services must be sampled for similar bacterial contamination and similarly cleaned and disinfected INSTANT WATER HEATERS Water heaters of <15 litres storage capacity LOW VOLUME WATER HEATERS Water heaters of >15 litres storage capacity, including Combi boilers CALORIFIERS TO INCLUDE: i. Indirect ii. storage calorifiers (all vessels 75 litres) Direct Gas fired calorifiers iii. Plate heat exchangers Where multiple calorifiers are linked, the monitoring must include the flow and return of EACH unit and not just common flow & return. TMVs/TMTs INCLUDING SHOWER MIXERS PPM TASK (Continued/ ) PPM TASK FREQUENCIES RESIDENTIAL UNIVERSITY BUILDINGS ACADEMIC BUILDINGS LEG Temperature Monitoring 6-MONTHLY 6-MONTHLY 16 Temperature Monitoring 6 MONTHLY 6-MONTHLY 14 & 15 Temperature Monitoring Automatic (Where BMS is fitted) Manual (Where BMS is not fitted) General visual inspections and Drain Sludge Flushing (All Calorifier types) Pasteurisation Indirect storage Calorifiers Direct Gas fired Calorifiers Expansion Vessel Flushing (If not flow-through type) Temperature monitoring & general condition inspection Servicing Fully bodied immersion Showers & Baths Non-full (Including Fail-Safe checks) Clean, Descale & Disinfection bodied immersion Staff areas *CONSTANT ON BMS / MONTHLY BY ENGINEER MONTHLY 6-MONTHLY Extend to annual if evidence shows no sludge present ANNUALLY & AS REQUIRED AS REQUIRED WEEKLY *CONSTANT ON BMS / MONTHLY BY ENGINEER 06 MONTHLY ANNUALLY 07 ANNUALLY & AS REQUIRED AS REQUIRED Where reasonably practicable. Where this is not reasonably 10 practicable, the University shall aim to replace units with Flow- through type units at the earliest opportunity 6-MONTHLY ANNUALLY 6-MONTHLY (MINOR) / ANNUALLY (MAJOR) / AS REQUIRED To Manufactures specification ANNUALLY ANNUALLY PR MONTHLY (MINOR) / ANNUALLY (MAJOR) 17 / AS REQUIRED To Manufactures specification AS REQUIRED AS REQUIRED 18 Strainer cleans and disinfections AS REQUIRED AND AS PART OF SERVICING AS REQUIRED 19 AND AS PART OF SERVICING Page 26 of 114

27 SHOWERS Temperature Monitoring & General Condition Inspection Clean Disinfection/Replacement & 4-MONTHLY 4-MONTHLY 19 4-MONTHLY / AS REQUIRED 4-MONTHLY / AS REQUIRED 20 Glass Trap Cleaning MONTHLY QUARTERLY 21 AIR CONDITIONING/ AIR HANDLING DRINKING FOUNTAINS AND ICE MAKING MACHINES Cleaning & Disinfection of Drip Tray, Chiller Batteries and internal Surfaces Mobile AC units clean and disinfection QUARTERLY & AS REQUIRED 6-MONTHLY & AS REQUIRED MONTHLY MONTHLY 23 Temperature Monitoring MONTHLY MONTHLY TRACE HEATING Inspection and Monitoring AS REQUIRED AS REQUIRED 09 Page 27 of 114

28 PPM TASK PPM TASK FREQUENCIES RESIDENTIAL UNIVERSITY ACADEMIC BUILDINGS BUILDINGS General Inspections of the ADIABATIC operation of the spray bars COOLERS WEEKLY DURING COOLING SEASON. 24 and drain from the bunded (To be completed tank prior to bringing Chlorine dioxide level in to use and WEEKLY DURING COOLING SEASON 24 monitoring during cooling season. Biological analysis MONTHLY DURING COOLING SEASON 24 LEG 2.2 Planned Maintenance Programme Task Frequencies - To be carried out by others: USAGE EVALUATION TO BE CARRIED OUT BY OTHERS (BUT NOT PART OF CONTRACTOR WORKS) PPM TASK USAGE EVALUATION AND FLUSHING RESIDENTIAL UNIVERSITY BUILDINGS WEEKLY (MORE FREQUENTLY IF REQUIRED) WEEKLY (MORE FREQUENTLY IF REQUIRED) PPM TASK FREQUENCIES ACADEMIC BUILDINGS WEEKLY (MORE FREQUENTLY IF REQUIRED) WEEKLY (MORE FREQUENTLY IF REQUIRED) POINT-OF-USE FILTER INSTALLATION/CHANGE 2-MONTHLY 2-MONTHLY PR8 DRINKING FOUNTAINS AND ICE MAKING MACHINES Biological Analysis (E. Coli & coliforms) 6-MONTHLY LOCATIONS DETERMINED BY WSG LEG PR9 PR9 PR1 2.3 Temperature monitoring accuracy: i. Where designated sentinel outlets are fitted with TMV/TMT, the temperature of the hot and cold supply must be measured by surface (contact) temperature measurement prior to the TMV/TMT if possible. ii. If contact probe is to be used for temperature monitoring through copper pipework, Temperatures must be collected as described in BSRIA Application Guide AG 4/94 Guide to Legionellosis Temperature measurements for hot and cold water services. The temperature measurements shall be carried out at different times during the day in order to allow indicative temperature monitoring of the vessel during a typical daily usage profile. 2.4 Instrument Calibration: Temperature and chemical measurement equipment and water sampling equipment for carrying out monitoring works shall be calibrated on an annual basis and the certification of calibration appropriately provided and appropriately retained by the FM department. Page 28 of 114

29 Calibration service providers shall be accredited via UKAS calibration and accredited to ISO Temperature measurement equipment used by staff shall be held by the Department lead Planned Maintenance Programme - Detailed PPM Task Specifications and Associated Processes (See Appendix 1): Page 29 of 114

30 3. AD-HOC RISK MANAGEMENT AND CONTROL PROCESSES WITH ASSOCIATED CERTIFICATES OF CONFORMITY In order to ensure that the devised Risk Management Programme is effective, the University (or others on its behalf) shall undertake certain Ad-Hoc and As Required tasks which will be required periodically. The execution of such tasks shall depend on a number of criteria such as: the condition of systems; the status of control measures; biological activity; etc. Ad-hoc and As Required tasks, shall include but not be limited to: PROCESS Process No. 1 Process No. 2/Permit No. 3 Process No. 3 Process No. 4 Process No. 5 Process No. 6 Process No. 7 Process No. 8 Process No. 9 Process No. 10 Process No. 11 Certificate of Conformity No. 1 Certificate of Conformity No. 2 Certificate of Conformity No. 3 Certificate of Conformity No. 4 DESCRIPTION Microbiological Sample Collection Protocol Small sized pipework installation projects and associated components pre and post installation cleaning and disinfection and Permit for Release into Use of new installations of small sized pipework installation projects and associated components Water storage tank cleaning and disinfection Water storage tank drop-test Domestic water services disinfection Calorifier Pasteurisation Domestic Water HWS distribution system pasteurisation Point of Use (POU) filter installation and replacement Dead Legs/Areas of Low-Flow Usage Evaluation & Flushing Management of Drinking Fountains Notification of Closure of Facility and associated and Permit to re-occupy* (*Where facility is NOT subject to modification / refurbishment) Cold Water Storage Tank Cleaning and Disinfection Using Chlorine Dioxide as the disinfecting agent (ClO2) Spray method Cold Water Storage Tank Cleaning and Disinfection Using Chlorine Dioxide as the disinfecting agent (ClO2) Soaking Method Distribution Services Disinfection Using Chlorine dioxide as the disinfecting agent (ClO2) Calorifier Pasteurisation Page 30 of 114

31 Certificate of Conformity No. 5 Domestic Water HWS Distribution System Pasteurisation For detailed Ad-hoc Risk Management and Control Processes with associated Certificates of Conformity see Appendix 2. Page 31 of 114

32 APPENDIX 1 PLANNED MAINTENANCE - DETAILED PPM TASK SPECIFICATIONS AND ASSOCIATED PROCESSES Page 32 of 114

33 Legionellosis Management And Control PPM Programme Task No: LEG 01 Advice Note: N/A Task: Distribution and Outlet Temperature Monitoring Frequency: AS SPECIFIED IN SECTION 1 Limits: MAINS Temperature: CWS Temperature: HWS Temperature: Blended Temperature: <20 o C within 2 minute <20 o C within 2 minute 55 o C within 1 minute in clinical areas 50 o C within 1 minute in other areas 41 o C (+/- 1 o C) for basins/showers 44 o C (+/- 1 o C) for baths. 38 o C (+/- 1 o C) for bidets. If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. General i. Water temperatures at all outlets, both CWS and HWS, shall be measured at least once annually and a representative number direct-fed Sentinel outlets (outlets not fitted with TMV or TMT) shall be measured at regular intervals. Temperatures shall be measured after two and one minute at full flow respectively. Note: Where designated sentinel outlets are fitted with TMV/TMT, the temperature of the hot and cold supply must be measured from binder points or by surface (contact) temperature measurement. If contact probe is to be used for temperature monitoring through copper pipework, a 2 o C temperature adjustment must be added to the recorded temperature before reporting temperature on the Log-sheet. The temperature measurements shall be carried out at different times during the day in order to allow indicative temperature monitoring of the vessel during a typical daily usage profile. CWS i. The outlet temperature measured after allowing the water to run for 2 minutes shall not exceed 20 o C. Where the temperature exceeds 20 o C, the cold water temperature at the point of supply shall be measured. When the supply temperature is between 18 o C and 25 o C, the measured outlet temperature, after running the tap for 2 minutes, shall be less than 2 o C higher than that at the point of supply. ii. Any tap which fails this test must be considered as a potential risk and the whole cold water system shall be investigated. This should be identified as on or off-campus Page 33 of 114

34 supply issue. If the on campus point of supply exceeds 25 o C, the site FM shall be alerted. If the off-campus point of supply temperature exceeds 25 o C, the water company shall be alerted. iii. On each monitoring visit, the temperature of the mains water source must be measured, including any cold water storage water tank when the CWS temperature at the selected outlets tested is measured and found to exceed 20 o C. HWS i. The outlet temperature measured after allowing the water to run for 1 minute shall exceed 55 o C in clinical areas and 50 C in other areas. Where the temperature fails to reach the required temperature, the source shall be measured and adjusted as necessary, and the Responsible Person (FM) informed as appropriate. ii. On each monitoring visit, the temperature of the source supply (Calorifier etc.) must be measured. This must include the "flow" and "return" temperatures of each Unit in the system. Blended Outlets The INITIAL and MAXIMUM outlet temperature measured shall NOT exceed: a. 41 o C (+/-1 o C) for showers. b. 41 o C (+/-1 o C) for washbasins. c. 44 o C (+/-1 o C) for bath. d. 38 o C (+/-1 o C) for bidets. Where the temperature exceeds the required temperature, the source shall be measured and adjusted as necessary, and the Responsible Person (FM) informed as appropriate. Page 34 of 114

35 Legionellosis Management And Control PPM Programme Task No: LEG 02 Advice Note: N/A Task: Chemical Sampling (ClO2 and Microchem M101 Level Monitoring) Frequency: AS SPECIFIED IN SECTION 1 ClO2 Level: Between 0.15 and 0.5 mg/l ClO2 Limits: M101 Level: Between mg/l Cl If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. Chlorine Dioxide Chlorine dioxide is an oxidising biocide capable of reacting with a wide range of organic substances. Levels of 0.5 mg/l can, if properly managed, be effective against planktonic and sessile legionella (biofilm) in domestic water systems. The Drinking Water Inspectorate prescribes a maximum value for total oxidants in drinking water supplies which is the combined chlorine dioxide, chlorite and chlorate concentration. This should not exceed 0.5 mg/l as chlorine dioxide. There are a number of commercial systems available that release chlorine dioxide into water systems and it may be necessary to contact the local water company in order to check that the installation complies with the requirements of the Water Regulations and, for Scotland, the Water Supply (Water Quality) Regulations and the Private Water Supplies Regulations 1992, as amended. Using a suitably calibrated electronic chlorine dioxide comparator, the following areas are checked at regular intervals: i. DAILY - the quantity of chemicals in the reservoir; ii. DAILY - the rate of addition of chlorine dioxide to the water supply; iii. DAILY - the concentration of chlorine dioxide at dosing points - between 0.25 and 0.8ppm (Note: 0.8ppm must be consider as the maximum allowed level at point of injection and it is only allowed at this level at this point in order to allow for the minimum levels to be achieved at the point of delivery). Any level fluctuations must only be tolerated within this range and care must be exercised to ensure that the level of ClO2 at the nearest outlet does not exceed 0.5ppm.; iv. MONTHLY - the concentration of chlorine dioxide at the sentinel taps - the concentration should be between 0.1 and 0.5 mg/l; v. on an annual basis, the chlorine dioxide concentration at a representative number of outlets - the concentration should be between 0.1 and 0.5 mg/l. Page 35 of 114

36 Chemical sampling should be accompanied by: temperature of the outlet measured and usage evaluation of the same While chlorine dioxide is not affected by the ph or hardness of the water, it is sometimes difficult to monitor chlorine dioxide samples in domestic HWS due to its increased volatility causing the chlorine dioxide reserve to be lost when taking a water sample. The results from these analyses shall be forwarded to the Responsible Person (FM) with any pertinent comments or recommendations. Microchem M101 MICROCHEM M101 is a solid water treatment product specifically designed for use in potable applications. The MICROCHEM M101 active ingredients are set out in the DWI Approved Products List. MICROCHEM M101 is a chlorine biocide for secondary disinfection of hot and cold water services and potable applications. The level shall be set to achieve 1.6 1ppm at the dissolver/tank and then a target of ppm at outlets. HOW MUCH TO USE The exact dosage and control rates for using MICROCHEM M101 will vary. The supplying Consultant should be contacted for further guidance. PROPERTIES Appearance: Solid White Odour: Chlorine Odour ph: g/l MONITORING Weekly Check dosing pump operation Check dissolving board operation Check Chemical level change jar if required. Monthly Record dissolving board inlet water pressure Record dosing pump settings Record water meter reading Record timer program settings Record redox / free chlorine monitor reading and set points Clean and inspect redox / free chlorine probe Calibrate redox / free chlorine probe if required Page 36 of 114

37 Test and record free chlorine reserve at the following points: - point of injection / dosing - at redox / free chlorine probe assembly - sentinel and representative outlets Quarterly Clean and inspection of dissolving board & dosing pump to include: - Wash out dissolving board sump - Adjust PRV to ensure 25psi dynamic pressure on water supply - Clean and descale dissolving bowl and nozzle - Clean float valve & check operation - Check solenoid valve operation - Check and verify chemical dissolving and sump filling stages - Check and clean dosing pump injection fitting and dosing lines - Restore equipment to service Chemical sampling should be accompanied by: temperature of the outlet measured and usage evaluation of the same While chlorine dioxide is not affected by the ph or hardness of the water, it is sometimes difficult to monitor chlorine dioxide samples in domestic HWS due to its increased volatility causing the chlorine dioxide reserve to be lost when taking a water sample. The results from these analyses shall be forwarded to the Responsible Person (FM) with any pertinent comments or recommendations. Page 37 of 114

38 Legionellosis Management And Control PPM Programme Task No: LEG 03 Advice Note: N/A Task: Water Storage Tank Temperature Monitoring Frequency: AS SPECIFIED IN SECTION 1 Limits: INCOMING MAINS TEMPERATURE: STORED WATER TEMPERATURE: <20 o C <20 o C If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. Using a calibrated thermometer, measure and report the following: i. Ambient (external temperature) ii. Tank room temperature iii. Stored water temperature (Temperature of the tanked water should be monitored via the drain point if practicable) iv. Supply temperature Guidance Note 2: Remember to measure and record temperature reading from as far away from the ball cock as possible. Care must be taken as not to contaminate the stored water by the use of unclean temperature probes. Page 38 of 114

39 Legionellosis Management And Control PPM Programme Task No: LEG 04 Advice Note: N/A Task: Water Storage Tank Visual General Inspection Frequency: AS SPECIFIED IN SECTION 1 Limits: WATER SUPPLY (FITTINGS) REGULATIONS 1999 COMPLIANT If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. i. Using a calibrated thermometer, measure and report the following: Ambient (external temperature); Tank room temperature; Stored water temperature (Temperature of the tanked water should be monitored via the drain point if practicable); Supply temperature ii. Visually inspect tank room for bird and/or rodent infestation and state amount: 0 = None; 1 = slight and 10 = heavy iii. If insulation allows for inspection of the external condition of the tank walls, inspect for corrosion pitting and leaks. iv. Visually inspect internal walls of tank for signs of scale deposition, corrosion and slime deposits. v. Visually inspect tank and associated valves/pipework for leaks. vi. Visually inspect bottom of tank for sludge deposition and state amount: 0 = None; 1 = slight and 10 = heavy vii. Visually inspect water surface for; dirt, oil films, insects and state amount: 0 = None; 1 = slight and 10 = heavy viii. Visually inspect for slimy deposits on the internal walls of tank and state the colour of substance and state amount; 0 = None; 1 = slight and 10 = heavy ix. Visually inspect for algae growth indicated by either green or red plant like growth on water surface i. Visually inspect the insulation for signs of wear and tear and areas where the insulation has been removed ii. Visually inspect that the lid is correctly fitted and that any bolts are securely tightened. iii. Visually inspect that all insect/rodent screens fitted are clear from debris so that water can flow easily. iv. Visually inspect all valves for correct operation, signs of corrosion and leaks. v. Visually inspect all booster pumps fitted for correct operation. Page 39 of 114

40 vi. vii. Indicate the date that the tank was last cleaned and disinfected and indicate whether it was disinfected as routine or due to adverse conditions. Visually inspect internal compartment and if hollow tube supports are found in the Tanks this should be identified to the FM department. Page 40 of 114

41 Legionellosis Management And Control PPM Programme Task No: LEG 5 Advice Note: N/A Task: Storage Calorifiers 24 hr Temperature Profiling Frequency: AS SPECIFIED IN SECTION 1 FLOW TEMPERATURE: 60 o C RETURN TEMPERATURE: 50 C ( 55 C in Clinical Areas) Limits: DRAIN TEMPERATURE: 50 O C COLD FEED TEMPERATURE: <20 o C If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. Operating temperatures of storage calorifiers must be maintained within the following limits: FLOW TEMPERATURE: 60 o CRETURN TEMPERATURE: 50 C ( 55 C in Clinical Areas) DRAIN TEMPERATURE: 50 O C COLD FEED TEMPERATURE: <20 o C i. Where the unit is monitored using BMS, collect the readings of all the fields listed above, for at least a 24hr period and consider the results. Adjust control parameters as necessary. ii. Where the unit is not monitored using BMS, attach a data-logger on the flow, return, and cold feed (as close to the unit as practicable) and collect temperature data for at least a 24hr period and consider the results. Adjust control parameters as necessary and the frequency and duration of temperature logging dependent upon results. Page 41 of 114

42 Legionellosis Management And Control PPM Programme Task No: LEG 06 Advice Note: N/A Task: Storage Calorifiers Manual Temperature Monitoring Frequency: AS SPECIFIED IN SECTION 1 FLOW TEMPERATURE: 60 o C RETURN TEMPERATURE: 50 C ( 55 C in Clinical Areas) Limits: DRAIN TEMPERATURE: 50 O C COLD FEED TEMPERATURE: <20 o C If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. i. Measure and record the Set temperature setting of the thermostat (if fitted and calibrated). Temperature to exceed 60 o C. ii. Measure and record the Flow temperature using a contact thermometer or fitted gauge. Temperature to be taken from Flow pipework as close to the Calorifier as possible. Temperature to exceed 60 o C. iii. Measure and record the Return temperature using a contact thermometer or fitted gauge. Temperature to be taken from Return pipework as close to the Calorifier as possible. Temperature to exceed 50 C. ( 55 C in Clinical Areas) iv. Isolate Cold Feed and open drain point and measure and record temperature. Temperature to exceed 50 o C. ( 55 C in Clinical Areas) v. Measure and record the Cold Feed temperature using a contact thermometer or fitted gauge. Temperature to be taken from Cold Feed pipework one metre from the Calorifier as possible. Temperature NOT to exceed 20 o C. Page 42 of 114

43 Legionellosis Management And Control PPM Programme Task No: LEG 07 Advice Note: N/A Task: Storage Calorifiers General Visual Inspection including drain flushing Frequency: AS SPECIFIED IN SECTION 1 NO CORROSION Limits: NO SLUDGE DEPOSITION CORRECT TEMPERATURE LIMITS If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. i. Ensure operational status of Calorifier by checking the status of the associated isolation valves ii. If the Calorifier is OFF, indicate the date it came Off-line iii. Confirm status of Inlet Valve and Confirm status of Outlet Valve iv. Confirm the operational status of the circulation pump(s) and destratification pumps v. Visually inspect Calorifier and associated valves for leaks vi. Visually inspect all pipework for signs of corrosion and leaks, and visually inspect the condition of insulation fitted. Visually inspect all valves for correct operation, signs of corrosion and leaks. Visually inspect all pumps fitted for correct operation and leaks vii. Measure and record the temperature setting of the thermostat (if fitted) viii. Measure and record the Flow and Return temperature using a contact thermometer or fitted gauge. Temperature to be taken from flow pipework as close to the Calorifier as possible. ix. Isolate CW feed and open drain point into a bucket and collect approximately the 1st litre of water discharged. Measure and record the condition, viscosity and colour of this water. x. Check for colour, viscosity and sludge deposition amount. Measure and record the temperature of the water collected. xi. Using a contact thermometer, measure and record the temperature of the calorifier at; the top, middle and bottom. If there is more than 10 o C difference between the top temperature and the bottom temperature then the calorifier is suffering from temperature stratification. If a contact thermometer cannot be used, then measure and record the difference in the flow temperature and the drain temperature. xii. Visually inspect the insulation for signs of wear and tear and areas where the insulation has been removed xiii. Visually inspect that any gauges fitted are operating correctly. Compare against calibrated instruments. Page 43 of 114

44 xiv. xv. xvi. Open the CW feed valve and then open the drain point allowing enough water to flow through so that any water discoloration is removed. Indicate the date that the calorifier was last pasteurised and indicate whether it was disinfected as routine or due to adverse conditions Indicate the date of the last insurance inspection, if applicable. Page 44 of 114

45 Legionellosis Management And Control PPM Programme Task No: LEG 08 Advice Note: N/A Task: Circulation and destratification pumps visual inspections and servicing Frequency: AS SPECIFIED IN SECTION 1 Limits: CORRECT OPERATION If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. i. Check circulating pumps for adequate performance to ensure a minimum circulating temperature of 50ºC. ii. In case of a standby pump being available for immediate connection into the HWS circulating system, switch on to ensure that the standby on backup pump can be brought into service. It is not permissible to shut down the pumped circulation system. To do so will lead to the loss of the required system temperature. Page 45 of 114

46 Legionellosis Management And Control PPM Programme Task No: LEG 9 Advice Note: N/A Task: Trace Heating Monitoring Frequency: AS SPECIFIED IN SECTION 1 Limits: CORRECT OPERATION If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. NOTE 1: There is currently Trace Heating fitted for frost protection on the CWS pipework in some areas while Trace Heating is also fitted to hot water within areas to keep the temp above 50 degrees centigrade. NOTE 2 The installation of trace heating as a control measure shall only be considered as a last resort should alternative rectification works not prove successful. i. Check electrical trace heating to ensure that it maintains the water temperature above 5ºC for the CWS and 50ºC on the HWS. Care should be taken to ensure there are no hot spots on the CWS also. ii. All of the fitted frost protection kits come complete with a built-in thermostat to ensure that when the ambient temperature drops below 5 C the Trace Heating cable activates and remains in operation until the ambient temperature exceeds 10 C. The built-in thermostat ensures that the frost protection system only operates when required to stop pipes freezing throughout winter and remains dormant during the summer. iii. On HWS = Check electrical trace heating to ensure that it maintains the water temperature above 50ºC. Care should be taken to ensure there are no cool spots. Page 46 of 114

47 Legionellosis Management And Control PPM Programme Task No: LEG 10 Advice Note: N/A Task: Expansion Vessel Flushing (Non Flow-Through types only) Frequency: AS SPECIFIED IN SECTION 1 If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. Doubts have been expressed about the desirability of using single entry expansion vessels on hot water systems. The use of single entry expansion vessels effectively forms a vertical dead-leg through which there is no flow of water and concern has been expressed about the possibility of bacterial growth within the vessel. It is considered preferable therefore, that an expansion vessel with both inlet and outlet connections should be installed, wherever practicable, so that the water content of the vessel is constantly changed. This will also allow for compliance with BS 6144 and BS Where expansion vessels are of the single entry type they must be fitted with appropriate drain valves to facilitate flushing of the unit weekly. Care must be taken to avoid damage to the diaphragm. Page 47 of 114

48 Legionellosis Management And Control PPM Programme Task No: LEG 11 Advice Note: N/A Task: Cistern Type Water Heaters Temperature Monitoring Frequency: AS SPECIFIED IN SECTION 1 UNIT TEMPERATURE: 60 o C Limits: OUTLET TEMPERATURE: 50 o C within 1 minute If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. i. Measure and record the Set temperature setting of the thermostat (if fitted and calibrated). Temperature to be at least 60 o C. ii. Measure and record the temperature of the furthest outlet supplied by the unit. Temperature to be at least 50 C within 1 min. Page 48 of 114

49 Legionellosis Management And Control PPM Programme Task No: LEG 12 Advice Note: N/A Task: Cistern Type Water Heaters Inspection of Tank Section Frequency: AS SPECIFIED IN SECTION 1 Limits: WATER SUPPLY (FITTINGS) REGULATIONS 1999 COMPLIANT If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. i. If casing allows for inspection of the external condition of the unit walls, inspect for corrosion pitting and leaks. ii. Visually inspect tank and associated valves/pipework for leaks. iii. Visually inspect bottom of tank for sludge deposition and state amount: 0 = None, 1 = slight and 10 = heavy iv. Visually inspect internal walls of tank for corrosion and state amount: 0 = None, 1 = slight and 10 = heavy v. Visually inspect water surface for; dirt, oil films, insects and state amount: 0 = None, 1 = slight and 10 = heavy vi. Visually inspect for slimy deposits on the internal walls of tank and state the colour of substance and state amount; 1 = slight and 10 = heavy vii. Visually inspect for algae growth indicated by either green or red plant like growth on water surface viii. Visually inspect the insulation of the unit (if practicable) for signs of wear and tear ix. Visually inspect that the lid is correctly fitted x. Visually inspect that all insect/rodent screens fitted are clear from debris so that water can flow easily. xi. Visually inspect that the ball valve opens and closes correctly xii. Visually inspect all pipework for signs of corrosion and leaks, and check the condition of insulation fitted. xiii. Indicate the date that the tank was last cleaned and disinfected and indicate whether it was disinfected as routine or due to adverse conditions. Page 49 of 114

50 Legionellosis Management And Control PPM Programme Task No: LEG 13 Advice Note: N/A Task: Cistern Type Water Heaters Clean and Disinfection Frequency: AS SPECIFIED IN SECTION 1 MINIMUM LEVEL OF Free Cl INITIALLY: 50ppm Limits: MINIMUM LEVEL OF Free Cl AFTER 1HR 30ppm MAXIMUM LEVEL OF Free Cl AT END <1ppm If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. i. Clean Tank and remove all deposits of scale, corrosion and sludge deposition using a combination of hand scraping and brushing together with application of chemicals to dissolve or soften the scale (where necessary). Vacuum out all loose debris and deposits. ii. The tank section of the unit shall be filled with fresh water and free chlorine solution to give a minimum free chlorine concentration of 50ppm (50mg/l). iii. Draw chlorinating agent from all outlets supplied by the unit (there may only be very few outlets) and ensure the presence of at least 50ppm free chlorine at each outlet. After 1 hour, check and if level of free chlorine is below 30ppm (30mg/l), repeat steps ii & iii. If level (mg/l), after one hour flush system with fresh water and put to drain. Page 50 of 114

51 Legionellosis Management And Control PPM Programme Task No: LEG 14 Advice Note: N/A Task: Low Volume Water >15 litres Temperature Monitoring Frequency: AS SPECIFIED IN SECTION 1 UNIT TEMPERATURE: 60 o COUTLET TEMPERATURE: Limits: 50 o C within 1 minute If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. i. Measure and record the Set temperature setting of the thermostat (if fitted and calibrated). Temperature to be at least 60 o C. ii. Measure and record the temperature of the furthest outlet supplied by the unit. Temperature to be at least 50 C within 1 min. Page 51 of 114

52 iii. Legionellosis Management And Control PPM Programme Task No: LEG 15 Advice Note: N/A Task: Combination Boiler Temperature Monitoring Frequency: AS SPECIFIED IN SECTION 1 UNIT TEMPERATURE: 60 o COUTLET TEMPERATURE: Limits: 50 o C within 1 minute If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. i. Measure and record the Set temperature setting of the thermostat (if fitted and calibrated). Temperature to be at least 60 o C. ii. Measure and record the temperature of the furthest outlet supplied by the unit. Temperature to be at least 50 C within 1 min.. Page 52 of 114

53 Legionellosis Management And Control PPM Programme Task No: LEG 16 Advice Note: N/A Task: Instant Water <15 litres Temperature Monitoring Temperature Monitoring Frequency: AS SPECIFIED IN SECTION 1 Limits: UNIT/OUTLET TEMPERATURE: outlet is not fitted with a TMV Comfort Temperature and 41 o C if If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. i. Measure and record the Set temperature setting of the thermostat (if fitted and calibrated). ii. Measure and record the temperature of the nearest outlet supplied by the unit.. iii. iv. Measure and record the Set temperature setting of the thermostat (if fitted and calibrated). Temperature to be at least 60 o C. Measure and record the temperature of the furthest outlet supplied by the unit. Temperature to be at least 50 C within 1 min.. Guidance Note 3: Units of this type, because of the limited stored water volume, do not usually need to be operated within the temperature profile and limits prescribed for larger systems ( 60 o C for the flow and ( 50/50 o C for the return and outlet ) which are necessary for thermal disinfection. It maybe possible to operate these units at safe temperatures of 41.0 o C although they should be switched-on at all times to ensure and encourage adequate use. Infrequent use of these units (less than 2 x Weekly) would increase the potential of bacterial growth and proliferation (as would be the case in all infrequently used areas throughout the system both hot and cold), although particularly in this case because of the low temperatures operated Page 53 of 114

54 Legionellosis Management And Control PPM Programme Task No: LEG 17 Advice Note: N/A Task: Thermostatic Mixing Valves/Taps Temperature Monitoring Frequency: AS SPECIFIED IN SECTION 1 Limits: FROM THE TMV/TMT TO THE TMV/TMT areas). 41 o C (+/-1 o C)) for whb. 41 o C (+/-1 o C) for showers. 44 o C (+/-1 o C) for baths. 38 o C (+/-1 o C)) for bidets. >50 C HWS to the TMV/TMT (>55 C in clinical <20 o C CWS to the TMV/TMT If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. SHOWERS, BATHS AND BIDETS i. Measure and record the Initial and Final outlet temperature, of each shower and bath ii. fitted with a Thermostatic Mixing Valve/Tap (TMV/TMT or otherwise). measurements shall be carried out immediately and after allowing the water to run for 1 minute at full-flow respectively. The Initial and Final outlet temperature measured shall not exceed: a. 41 o C (+/-1 o C) for showers. b. 44 o C (+/-1 o C) for baths. c. 38 o C (+/-1 o C) for bidets. Where these temperatures are exceeded, the TMV/TMT shall be adjusted in order to allow the unit to operate within the recommended temperature limits described above. Using an electronic and calibrated thermometer with a suitable contact probe, measure and record the temperature of the HWS and CWS supply pipes of each TMV/TMT. The temperature of the CWS shall not exceed 20 o C and the temperature of the HWS shall not be less than 50 o C (55 C in clinical areas). The measurements shall be carried out following task 1. (i). The SINKS AND BASINS AND OTHER NON FULL BODY IMMERSION OUTLETS i. Measure and record the Initial and Final outlet temperature, of the HOT water outlet of each sink, basin and other non-full body immersion outlets fitted with a Thermostatic Mixing Valve/Tap (TMV/TMT or otherwise). The measurements shall be carried out immediately and after allowing the water to run for 1 minute at full-flow respectively. The Initial and Final outlet temperature measured shall not exceed 41 o C (+/-1 o C) Where these temperatures are exceeded, the TMV/TMT shall be adjusted in order to allow the unit to operate within the recommended temperature limits described above. Page 54 of 114

55 ii. iii. Using an electronic and calibrated thermometer with a suitable contact probe, measure and record the temperature of the HWS supply pipe ONLY of each TMV/TMT. The temperature of the HWS shall not be less than 50 C in all. The measurements shall be carried out following task 2. (i). Measure and record the COLD water outlets of each sink, basin and other non-full body immersion outlets fitted with a Thermostatic Mixing Valve/Tap (TMV/TMT or otherwise). The measurements shall be carried out immediately and after allowing the water to run for 2 minutes at full-flow respectively. The outlet temperature measured shall not exceed 20 o C. Page 55 of 114

56 Legionellosis Management And Control PPM Programme Task No: LEG 18 Advice Note: N/A Task: Thermostatic Mixing Valves/Taps General Condition Inspections & servicing Frequency: AS SPECIFIED IN SECTION 1 Limits: FROM THE TMV/TMT TO THE TMV/TMT areas). 41 o C (+/-1 o C)) for whb. 41 o C (+/-1 o C) for showers. 44 o C (+/-1 o C) for baths. 38 o C (+/-1 o C)) for bidets. >50 o C HWS to the TMV/TMT(>55 C in clinical <20 o C CWS to the TMV/TMT If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. i. Inlet check valves (if fitted): Measure inlet pipework surface temperature for indication of ii. iii. iv. cross-flow. A more effective test can be considered if appropriate, utilising drain points positioned between isolating and check-valves. Temperature measurements: a) fail-safe; b) adjustable/pre-set maximum, Operate flow controls and measure blended temperature. Measure maximum and minimum blended temperature. For thermostat and pressure-balanced mixers, blend temperature should stabilise quickly and remain within +1 o C of set value. For manual mixers, refer to commissioning data. Thermal shut-down (TMV/TMT): Operate mixer at blended temperature, then isolate cold supply. Valve must shut down in accordance with the manufacturer s data. Temperature control: Operate mixer at blended temperature, then open other local cold outlets off common supply. Measure shift in blend temperature with reference data compiled at the commissioning stage. v. Strainers: Isolate and visually inspect and clean as necessary. vi. vii. viii. Flow control(s): Operate fully and check for effective closure. If time delay is incorporated, measure length of flow cycle. Automatic drain valve (if fitted): Check effective operation. Mixing valve: a) temperature control; b) flow control(s); c) inlet check valves. Where specified by manufactures guidance and/or site conditions and inspection confirms the requirement, carry out visual inspection of internal serviceable mechanisms. Clean or renew components as necessary. Lubricate as indicated in manufacturer s data. Refer to manufacturer s data for recommended procedures and cleaning agents/lubricants. For products of (serviceable) cartridge construction, fit and commission exchange units if required. Service displaced units in workshop as part of rolling planned maintenance procedure. Page 56 of 114

57 i. Supply pipe-work: Visually inspect for damage leaks, etc. and rectify. ii. For all new installations, record the supply pressures to allow the appointed person to compare these pressures and temperatures to confirm agreement with commissioning data. x. Controls: Operate inlet valves and check individual flow rates of hot and cold water supplies. If valve is stripped down and reassembled all parts should be greased as recommended in the manufacturer s maintenance instructions. xi. Thermostat: Check mixed water outlet setting. Ensure thermometer bulb is immersed in flowing water if measurement taken at shower head xii. Temperature limiter: Measure mixed water outlet temperature at limit safety stop. Limiter setting 41 o C. xiii. Inlet check valves (where fitted): Check operation. Non-return valves may have been removed if operating with balanced pressure supplies). Page 57 of 114

58 Legionellosis Management And Control PPM Programme Task No: LEG 19 Advice Note: N/A Task: Thermostatic Mixing Valves/Taps Clean, Descale and Disinfection Frequency: AS SPECIFIED IN SECTION 1 Limits: 100ppm free chlorine for 30 minutes minimum If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. When site conditions are found to result in scale build-up within a valve, the valve should be descaled and disinfected as per this specification to a frequency determined by site tests and inspections. i. Each TMV/TMT shall be removed from its location and replaced with a new or previously ii. iii. iv. serviced TMV/TMT. The removed TMV/TMT shall be taken to a suitably equipped work- shop for service. Alternatively the task shall be carried out in-situ where possible. Preferably at the work-shop or in-situ, each TMV/TMT shall be dismantled and physically cleaned from all scale deposits and scale deposition (using a suitable descaling solution where necessary). All components shall be disinfected (this applies to all cleaned and new components). All components shall be flushed with clean water and immersed in a Sodium hypochlorite (100 mg/l free chlorine) for 30 minutes minimum. Remove components from disinfectant solution and rinse with clean water to remove presence of disinfectant. Reassemble, refit and test operation of valve, including fail-safe test. Rinse in clean water, allow to drip-dry and store in a cool and dry place. Page 58 of 114

59 Legionellosis Management And Control PPM Programme Task No: LEG 20 Advice Note: N/A Task: Shower Temperature Monitoring Frequency: AS SPECIFIED IN SECTION 1 FROM THE TMV 41 o C (+1 o C) for showers. Limits: TO THE TMV >50 C HWS to the TMV (>55 C in clinical areas). <20 o C CWS to the TMV If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. i. Measure and record the Initial and Final outlet temperature, of each shower fitted with a Thermostatic Mixing Valve (TMV or otherwise). The measurements shall be carried out immediately and after allowing the water to run for 1 minute at full-flow respectively. The Initial and Final outlet temperature measured shall not to exceed 41 o C. ii. Where this temperature is exceeded, the TMV shall be adjusted in order to allow the unit to operate within the recommended temperature limits described above. iii. Using an electronic and calibrated thermometer with a suitable contact probe, measure and record the temperature of the HWS and CWS supply pipes of each TMV. The temperature of the CWS shall not exceed 20 o C and the temperature of the HWS shall not be less than 50 C (55 C in clinical areas).. The measurements shall be carried out following task 1. (i). Page 59 of 114

60 Legionellosis Management And Control PPM Programme Task No: LEG 21 Advice Note: N/A Task: Shower Head Replacement / Clean and Disinfection Frequency: AS SPECIFIED IN SECTION 1 Limits: New shower head Sodium hypochlorite (100 mg/l free chlorine) for 30 minutes minimum If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. SHOWER HEAD REPLACEMENT i. Examine shower head for signs of dirt, scale and slime deposition. ii. If any of the above is considered to be significant, replace existing shower head with new, packaged shower head and dispose of the old shower head in an appropriate manner. SHOWER HEAD CLEAN AND DISINFECTION i. Each shower-head and associated hose (where fitted) shall be removed from its location and replaced with a new or previously serviced shower-head. The removed unit shall be taken to a suitably equipped work-shop for service. Alternatively the task shall be carried out in-situ where possible. ii. At the work-shop, each shower-head and associated hose shall be dismantled and physically cleaned from all scale deposits and debris deposition (using a suitable descaling solution where necessary on the shower-head only). iii. Rinse in clean water iv. All components shall be disinfected (this applies to all cleaned and new components). All components shall be flushed with clean water and immersed in a Sodium hypochlorite (100 mg/l free chlorine) for 30 minutes minimum. v. Remove components from disinfectant solution and rinse with clean water to remove presence of disinfectant. vi. Allow to drip-dry and store in a cool and dry place.. Page 60 of 114

61 Legionellosis Management And Control PPM Programme Task No: LEG 22 Advice Note: N/A Task: Air Conditioning/Air Handling Glass trap cleaning and disinfection Frequency: AS SPECIFIED IN SECTION 1 Limits: Sodium hypochlorite 100mg/l free chlorine for 30 minutes minimum If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. i. Each glass trap shall be removed from its location and taken to a suitably equipped work-shop for service. ii. At the work-shop, each glass trap shall be dismantled and physically cleaned from all scale deposits and scale deposition (using a suitable descaling solution where necessary). iii. Rinse in clean water. iv. All components shall be disinfected (this applies to all cleaned and new components). All components shall be flushed with clean water and immersed in a Sodium hypochlorite (free chlorine) 100 mg/l disinfectant solution for 30 minutes minimum. v. Allow to drip-dry and store in a cool and dry place. Page 61 of 114

62 Legionellosis Management And Control PPM Programme Task No: LEG 23 Advice Note: N/A Task: Air Conditioning/Air Handling General Inspection / Clean & disinfection Frequency: AS SPECIFIED IN SECTION mg/l Sodium hypochlorite (free chlorine) for 3 minutes minimum (using Limits: spray) If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. i. Report on the operational status of the unit. ii. Visually inspect the condition of the external surfaces of the unit and comment. iii. Visually inspect (if possible) the condition of the internal surfaces of the unit and comment. If practicable, isolate unit in order to allow for thorough internal inspection to be carried out. iv. Visually inspect the condition of all traps fitted and comment. v. Visually inspect (if possible) the condition of the drip-trays of the unit and comment. If practicable, isolate unit in order to allow for thorough internal inspection of the drip-trays to be carried out. Alternatively, remove drip-trays from the system and inspect. vi. Visually inspect (if possible) the condition of the eliminators of the unit and comment. vii. Visually inspect (if possible) the condition of the filters fitted and comment. viii. Visually inspect (if possible) the condition of the humidifier components of the unit and comment. ix. Visually inspect (if possible) the condition of the Chiller battery fitted and comment. x. Visually inspect (if possible) the condition of the Heater battery and comment. xi. Using clean cloth, wipe over the unit components to be disinfected. To disinfect, spray the components with a Sodium hypochlorite (free chlorine) solution of 500 mg/l strength, using small hand spray. Allow to stand for 3 mins only. Spray with fresh clean water. Dry area with clean and clean cloth. Guidance Note 4: On completion of cleaning, the ductwork should not be fogged with chemicals. This treatment has no lasting biocidal effect and is responsible for initiating the breakdown of the galvanised coating of ductwork. This will result in accelerated corrosion of the inside of the duct, with the products of corrosion being shed into the air stream. It will also significantly shorten service life. Page 62 of 114

63 Legionellosis Management And Control PPM Programme Task No: LEG 24 Advice Note: N/A Task: Adiabatic coolers monitoring and maintenance Frequency: AS SPECIFIED IN SECTION 1 Limits: If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. i. All adiabatic coolers shall be maintained in a good and clean condition and free from excessive corrosion and dirt deposition. ii. Flexible hoses must not be used to connect the adiabatic cooler to the mains. iii. Water supplies to adiabatic coolers shall be treated with chlorine dioxide at > ppm (mg/l) chlorine dioxide. iv. Levels of chlorine dioxide to be tested on a weekly basis during the cooling season. v. Weekly PPM to check the operation of the spray bars and that the drain from the bunded tank under the cooler is running freely so as to prevent any ponding during the cooling season. vi. Carry out monthly Legionella water analysis during the cooling season. vii. At the end of the cooling season we will isolate & drain down the water supply to the adiabatic cooler which will generally be every October, reinstating the supply in March. Page 63 of 114

64 APPENDIX 2: AD-HOC RISK MANAGEMENT AND CONTROL PROCESSES WITH ASSOCIATED CERTIFICATES OF CONFORMITY Page 64 of 114

65 APPENDIX 2.1: AD-HOC RISK MANAGEMENT AND CONTROL PROCESSES Page 65 of 114

66 Water Quality Management And Control PPM Programme Process No. 1 Task: Microbiological Sample Collection Protocol If the Maintenance Staff or appointed contractor cannot, at any stage, comply with any part of this Specification, then an alternative Specification shall be agreed which, both; meets the requirements of current legislation and the needs of the Site. MICROBIOLOGICAL SAMPLING METHODOLOGY Guidance Note 5: Microbiological sampling shall be carried out in order to consider two distinct areas of water quality management & control: a) localised bacterial contamination; and b) systemic bacterial contamination. Localised contamination is detected by collecting and analysing a 'pre-flush' sample consisting of the unadulterated collection of a sample of the water present at the outlet achieved by running the tap without flushing or cleaning the tap and collecting the water dispensed. Systemic contamination is detected by collecting and analysing a 'post-flush' sample consisting of the water collected following spraying the outlet with a disinfectant solution equivalent to 10,000ppm free chlorine, leaving disinfectant in contact with the tap for at least 2 minutes then flushing the outlet for another 2 minutes before collecting the sample. These two types of samples are useful in determining the location of the contamination detected and in determining the appropriate remedial corrective action required to remove the identified bacterial contamination. In order to allow for an correct level of investigative biological analysis monitoring, a statistically significant number of samples must be collected. In High Risk Areas this number must be at least 10% of all designated 'sentinel' outlets To allow for adequate 'trending' of results, at least 30% of outlets (selected by IPC), from the number of outlets discussed above, must be selected and 'fixed' so that they are sampled at each sample collect run. The remainder of samples can be made-up of randomly selected outlets. Microbiological Sampling must be carried out in accordance with the HPE "Examining food, water and environmental samples from healthcare environments - Microbiological Guidelines: April 2013" and BS 7592: Sampling for Legionella bacteria in water systems Code of practice. TYPE OF SAMPLE LOCATION AND FREQUENCY OF SAMPLE i. As required following failure of control measures. TVCC ii. Annual TVC, E. Coli and Coliforms sampling in Kitchen areas as determined by listing from Contracts Manager. iii. Monthly from location with associated historical contamination issues at the University sites. The sample locations list shall be developed by the FM department and agreed by H&S. Pre and Post flush sample to be collected as described in Process Legionella i. Monthly in Village area or any areas with biocide treatment as a measurement of system efficacy. ii. Following specific request by the FM, Capital or H&S. iii. Following persistent TVCC failures ( Persistent confirmed at Page 66 of 114

67 the discretion of H&S). iv. Changes to the system. v. As part of the following processes: 1. Permit No. 1: Permit to occupy facility owned by others; 2. Permit No. 3: Permit for Release into Use of new installations of small sized pipework installation projects and associated components; 3. Permit No. 4: Notification of closure of facility and Permit to re-occupy; and 4. Permit No. 5: Permit for Hand-over and occupation of new builds. vi. Under contamination investigation procedures. vii. During an outbreak or suspected outbreak of Legionnaires disease. viii.under particular WSG requirements/instructions. The sample locations list, type of sample and frequency of sampling shall be determined by the WSG. Pre and Post flush sample to be collected as described in Process Sample locations shall be selected by the WSG and instructed to the FM department, who shall arrange collection of the samples. Microbiological samples shall be collected under the following circumstances: 1. As required by WSG and/or Infection Prevention and Control Committee. 2. As a measurement of the efficacy of the Chlorine dioxide system. 3. When the PPM Programme indicates failure of control parameters. 4. When HWS and CWS outlet temperatures are persistently outside the recommended temperature limits. 5. As part of BUILDING/Area OPENING procedures. 6. Re-sampling following positive biological results. 7. During a suspected outbreak. 8. During an outbreak (as instructed by the outbreak investigating officer). Microbiological samples can be analysed for the following organisms: 1. E. coli 2. Coliforms 3. TVCC 4. Legionella spp. HEALTH AND SAFETY CONSIDERATIONS Sampling of water may occur in a wide variety of locations. Each location and reason for sampling has its own risks associated with it, and it is important to make an assessment of Page 67 of 114