Legionella Management and Control Standard

Scope

This Standard outlines the systems and procedures UCL has in place to control Legionella bacteria within UCL’s water systems.

UCL has a duty of care to all students, staff and visitors across its entire estate and this Standard shall be applicable to all UCL UK buildings, as listed in the UCL Buildings Register.

The only exception to this is with regards to leasehold buildings where UCL does not hold maintenance or repair obligations. In such areas, the UCL ‘Responsible Person – Legionella – Operation’ shall ensure that the landlord is carrying out such tasks to the same level of conformity and diligence as defined in this Standard. Where UCL has members of staff and students using these leasehold buildings then there is a duty of care to ensure that the duty holder in those buildings has adequate risk assessments in place for controlling the risk of Legionella or that UCL completes an assessment for the area under its control.

Legal requirements

The Health & Safety at Work etc Act 1974, The Management of Health & Safety at Work Regulations 1992 and The Control of Substances Hazardous to Health (COSHH) Regulations 2002 require UCL to:

• Identify and control the risks to students, staff and visitors from exposure to Legionella bacteria

UCL will comply with The Health and Safety Executive (2013) Approved Code of Practice “Legionnaires’ disease, The control of legionella bacteria in water systems, L8 (4th Edition)", referred to hereafter as "L8".

Definitions

• L8: The Health and Safety Executive (2013) Approved Code of Practice “Legionnaires’ disease, The control of legionella bacteria in water systems, L8 (4th Edition)”
• Legionella: Legionnaires' disease 

Legionella

Legionnaires' disease is caused by a bacterium called Legionella pneumophila.

People catch Legionnaires' disease by inhaling small droplets of water suspended in the air which contain the bacteria.

Certain conditions within water systems increase the risk of Legionella proliferation:

• A suitable temperature for growth  (20oC to 45oC)
• A source of nutrients for the organism e.g. sludge, scale, rust, algae and other organic matter
• A way of creating and spreading breathable droplets e.g. the aerosol created by a cooling tower, showers or spray taps

Management responsibilities

Roles and responsibilities

The principal responsibilities for the management of health and safety are stated in the UCL Safety Policy. Specific responsibilities relating to the management of Legionella are stated below.

UCL Council – Duty Holder

UCL Council, as the employer, has the ultimate responsibility for health and safety and is the duty holder for UCL.

UCL Council has delegated the duty of the day-to-day running of UCL, which includes the management of health and safety, to the President and Provost. 

The President and Provost

The President and Provost is the duty holder responsible to UCL Council for the day-to-day duty holder responsibilities of UCL in all of its activities, including the management of Legionella.

The role takes overall responsibility to ensure that the Legionella Management and Control Standard is implemented and that appropriate funding is made available to carry out works and management activities.

The Council has constituted the Work Health & Safety Committee (WHSC) to determine a policy framework for health and safety and the executive arrangements therein, which includes the management of Legionella.

University Management Committee

The University Management Committee ("UMC") is responsible to the Council for the planning, consultation and dissemination of the arrangements made within this Legionella Management and Control Standard and shall maintain details of appointees with responsibilities for the control of Legionella, within riskNET, and the reporting of relevant information.

UCL Safety Services

UCL Safety Services is responsible for the provision of independent competent safety advice and for reviewing departmental organisation and arrangements.

UCL Director of Estates

The UCL Director of Estates has responsibility for the strategy and budget allocation for the control of Legionella risks at UCL.

The Director of UCL Estates through the Director, Facilities & Infrastructure and Faculty Directors, is responsible for day-to-day management control of Legionella risks with technical support from Safety Services.

Director, Facilities & Infrastructure

The Director, Facilities & Infrastructure is responsible for the allocation of finances and resources for the assets under their control which are subject to the potential proliferation of Legionella.

They allocate resources to ensure training and competency is sufficient for the Responsible Persons to undertake their duties.

Head of Engineering - Responsible Person - Legionella Governance

In all instances, the term ‘Responsible Person’, and the associated duties, applies equally to any nominated Deputy formally appointed to act on all occasions when the nominated Responsible Person is unavailable.

The Head of Engineering has managerial responsibility for the governance of Legionella risk compliance and providing supervision for the implementation of the precautions through:

• Managerial responsibility for the UCL Standard and Standard Operating Procedure (SOP) for the management of UCL’s Legionella risks and water hygiene
• Appointing, in writing, ‘Responsible Persons’ to be responsible for the day-to-day management of UCL’s water hygiene, Legionella risks and compliance with current regulations, UCL Standard and SOP
• Ensuring that the Responsible Persons are aware of their roles and responsibilities and that they are competent to carry them out

The full details, expectations and requirements of this role are contained within the UCL Legionella SOP, which is controlled by UCL Engineering, Maintenance and Infrastructure.  The SOP forms part of this Standard.

Responsible Person - Legionella - Operation

The Responsible Person – Legionella – Operation has been delegated the primary role to act as administrator in the management of Legionella in accordance with the UCL  Standard and has managerial responsibility for supervising the implementation of this UCL Standard, the SOP, and the management of the water systems under the control of UCL Estates.

In leasehold buildings (or areas) where UCL does not hold the maintenance or repair obligations, the UCL ‘Responsible Person – Legionella – Operation’ shall ensure that the landlord is carrying out such tasks to the same level of conformity and diligence as defined in L8 and this Standard.

The full details, expectations and requirements of this role are contained within the UCL Legionella Standard Operating Procedure.

Responsible Person - Legionella - Review and Change

The Responsible Person - Legionella - Review and Change is a duty holder and has been delegated the managerial responsibility for reviewing the compliance and performance against this Standard.

The Responsible Person - Legionella – Review and Change is responsible for:

• Producing and developing the UCL Standard and UCL Standard Operating Procedures for Legionella management on behalf of the Head of Engineering, and periodically auditing their implementation
• Supervising the implementation of this Standard and the management of any changes, additions to, or replacements of existing systems, or any new installations to the water systems under the control of UCL Estates

The full details, expectations and requirements of this role are contained within the UCL Legionella Standard Operating Procedure.

Responsible Person - Legionella - Landlord

The Responsible Person - Legionella - Landlord is the term given to describe the landlord (and/or Landlord's Agent) in buildings to which UCL is a leaseholder.

The Responsible Person - Legionella - Landlord is a duty holder and has managerial responsibility for the water systems under their control. This includes managerial responsibility for the supervising and management of any changes, additions to, or replacements of existing systems, or any new installations to the water systems under their control.

UCL Estates

Project Managers, University Project Officers and the consultants they appoint are responsible for ensuring systems are designed and installed in compliance with the documents contained in the Reference section of this document, and the UCL Standard and Standard Operating Procedure.

The Responsible Person – Legionella – Review and Change is to approve each stage of any design.

The Project Manager and University Project Officer are responsible for:

• Ensuring that the water system conditions are maintained throughout the project including controls such as weekly flushing of unused areas and chlorination of altered pipework during the works no sooner than one week prior to occupancy or re-occupancy
• Ensuring that plant and services are capable of meeting any increased demand where a system is extended and for the provision of as-fitted drawings at the time of handover together with all commissioning data

No system will be accepted unless the Responsible Person – Legionella – Review  Change has given the final written approval.

Contractors (and employing managers of contractors)

Those who employ contractors to work on water systems shall be responsible for ensuring the work complies with the requirements of this Standard and that the works comply with relevant water regulations and L8.

Reasonable enquiries are to be made to confirm the competency and training of contractors in the area of work before entering into contracts for the treatment, monitoring, and cleaning of water systems and other aspects of water treatment and control.

• Contractors must be made fully aware of the duties and responsibilities assigned to them and are to be familiar with this UCL Standard
• Contractors directly involved with the management and control of Legionella must be registered with the Legionella Control Association and a copy of their registration certificate held on file
• Only UCL Approved Contractors are permitted to work on UCL water systems
• Contractors are to have completed the necessary UCL Safety Questionnaires and that their responses have been assessed
• Contractors are to comply with the UCL Safety Policy ‘Safety Rules for Contractors employed on UCL Premises’ and sign the document accordingly

Work on water systems includes connection to, modification, or maintenance to the water system.

Heads of Departments (other than UCL Estates), Responsible Person – Legionella Governance

Heads of Departments are responsible for identifying, assessing and controlling the risks from any water systems installed within their department and/or departmental equipment that could present of risk of exposure to Legionella bacteria.

In general, the supply of hot and cold water services is the responsibility of UCL Estates, except under some leasehold agreements when a landlord or managing agent will hold this responsibility. 

In addition, subject to agreement by the Responsible Person (Operation), UCL Estates may also be responsible for certain identified items of department equipment, upon acknowledged receipt of a UCL Estates Data Collection Sheet (Asset Register request).

Where departmental equipment is not managed by UCL Estates, a local inventory of both specific items and types of equipment that could present a risk of exposure should be maintained by the Appointed Person (Statutory Testing) to ensure that all equipment is assessed and subject to appropriate controls.

Departments can seek advice/input on their assessments and controls by emailing safety@ucl.ac.uk and/or UCL Estates or Estates Competent Persons.

Departments are responsible for reporting the following to the Estates Customer Helpdesk stating that the issue is a “Legionella risk”:

• Any little used outlets e.g. taps, showers or sluices
• Any taps, showers or sluices that are no longer required
• When any water system is taken out of use e.g. when a laboratory is to be used as office space and the sinks are retained but not used
• When any permanent or temporary installations are installed that use water and which may pose a risk of Legionella bacteria e.g. experimental rigs

The UCL Estates Responsible Person (Operation) will be responsible for arranging the removal of outlets within all areas that are no longer required.

Water systems and the identification of little-used outlets within common areas e.g. toilets will remain the responsibility of UCL Estates Facilities & Infrastructure department. UCL Estates will be responsible for amending the schematic drawings as appropriate and deciding if the changes warrant the Legionella risk assessment to be reviewed and amended.

Where there are little used outlets it will be the department’s responsibility to ensure they are flushed at least weekly and the activity recorded in compliance with the requirements of L8 e.g. taps, showers or sluices. 

Appointed Person – Statutory Testing

The Appointed Person - Statutory Testing will maintain a list of specific items of equipment or types of equipment that could present a risk of exposure to Legionella bacteria. This list should identify who is responsible for the management of the equipment (department or Estates) as regards control of Legionella. Where equipment is under the sole management of the department, it should confirm that an appropriate assessment has been carried out and measures are in place to control identified risks.

Records

Records must be kept to confirm compliance with regulations and this Standard and retained for the periods stated.

• The water hygiene risk assessment must be complete to conform with L8. The report will categorise the level of risk of the building and the appropriate management control necessary to mitigate risks in that building
• The person or persons responsible for conducting the water hygiene management control measures must provide sufficient information and documentation to comply with L8 as a minimum
• Any significant findings and action points of the risk assessment must be prioritised and actioned accordingly
• Deviations of readings that are likely to lead to non-compliance are to be reported directly to a Responsible Person for management action. The competent persons are to take all immediate action to reduce/mitigate non-compliance
• These records must be retained throughout the period for which they remain current and for at least two years after that period
• The results of any monitoring, inspection, test or check carried out, and the dates. This should include details of the state of operation of the system i.e. in use/not in use
• These records must be retained for at least five years

Training

Legionella awareness training will be provided at 3 levels to suit the different roles of staff:

• Management
• Technical/maintenance
• Refresher training as required

The training for maintenance staff shall ensure that they are made aware of the fittings that can be used and the materials that harbour bacteria and other micro-organisms, or provide nutrients for Legionella growth.

Training records/evidence of competence must be provided by contractors.

Monitoring and review

The Estates Standard Operating Procedure(s) and risk assessments detail the procedures for preventing, monitoring and controlling risk. These documents along with this Standard shall be reviewed annually to ensure they remain up to date.

References

• Control of Substances Hazardous to Health Regulations 2002 (COSHH)
• Health & Safety at Work etc. Act (1974)
• The Health and Safety Executive (2013) Approved Code of Practice “Legionnaires’ disease, The control of legionella bacteria in water systems, L8 (4th Edition)”, The technical guidance is published separately under HSG274 pt1,2,3
  • Part 1: The control of legionella bacteria in evaporative cooling systems (HSE)
  • Part 2: The control of legionella bacteria in hot and cold water systems (HSE)
  • Part 3: The control of legionella bacteria in other risk systems (HSE)
• Management of Health and Safety at Work Regulations 1999
• The Health Protection (Notification) Regulations 2010
• TM13 Minimising the Risk of Legionnaires Disease 2013
• Water Supply (Water Fittings) Regulations 1999
• Water Supply (Water Quality) Regulations 2000
• The Notification of Cooling towers and Evaporative Condensers Regulation 1992
• BS8580 Risk Assessments for Legionella Control 2010
• BS 6700:2006 Design, installation, testing and maintenance of services supplying water for domestic use within buildings and their curtilages
• UCL Design Brief for Mechanical, Electrical & Vertical Transport Services
• Water Regulations Advisory Scheme
• HSE Legionnaires’ disease A guide for employers IAC27(rev2) 01/01 C300
• HSE Essential information for providers of residential accommodation INDG376 05/03