Nursing Homes – Legionella Control

Here at Quantum compliance, we are an innovative, UK-based health and safety consultancy that provides a range of consultancy services including Legionella Risk Assessments and Legionella Awareness Training. Our team of qualified and experienced consultants are well equipped to assist care home managers in carrying out their duties in respect to the control of bacteria.

Care and nursing homes specifically present an elevated risk of Legionnaires’ Disease infections due to the vulnerable nature of the occupants. Under UK health and safety law the operators of such establishments have a duty to control the risk from Legionella bacteria and in doing so provide a safe environment for those in their care. Philip Lonsdale, Quantum’s Technical Manager for Water Safety explains…

Briefly put, Legionella is a naturally-occurring waterborne bacteria that exploits suitable conditions within building water systems wherever they arise. The bacteria is an opportunistic pathogen causing a range of illnesses, the most widely-known illness being Legionnaires’ disease, which can prove fatal. Once a water system becomes colonised, bacteria numbers may increase to level where they pose a risk to human health.

The disease is transmitted via tiny droplets of water containing the bacteria; which when inhaled deep into the lungs can result in an infection. This is a particular concern for the elderly and others with impaired immune response, who are more at risk and therefore care home operators, are expected to achieve high standards of risk management, similar to those applied in hospitals.

Conditions that encourage the growth of Legionella bacteria include warm water temperatures, poor hygiene and infrequent or intermittent water use. Knowing the preferences of the bacteria assists in developing clear and effective means of control. The basic principles of Legionella control are as follows:

  • Water temperatures between 20°C and 50°C should be avoided. In simple terms, this means keeping hot water hot and cold water cold.
  • Water should be kept moving through the system, keeping water age* to a minimum. Storage tanks and water heaters should be sized appropriately according to the demand for water. Non-essential water services should be removed and essential infrequently-used outlets (e.g. outside taps) should be flushed regularly.
  • Water systems should be maintained in hygienic condition. This means that outlets should be kept clean, especially showers. Storage tanks and water heaters should be routinely inspected and cleaned and disinfected as required.
  • Legionnaires’ disease can only occur where there is means of creating and disseminating breathable droplets and therefore, wherever practical, non-spray or low spray options should be adopted.

There are several sources of official guidance in respect to the control of Legionella bacteria, these include:

  • The Health & Safety Executive’s Approved Code of Practice (ACOP) L8 (Fourth Edition) 2013
  • The Department of Health’s Health Technical Memorandum HTM04-01, Parts A & B
  • The Health & Safety Executive’s HSG274 Technical Guidance, Parts 1, 2 & 3.
  • British Standard BS 8580:2010 “Water Quality – Risk Assessments for Legionella control – Code of Practice”

Management of health and safety is cited as a common failing in cases where outbreaks of Legionnaires’ disease have occurred. The first step in controlling the risk should be to ensure that a robust management system is in place. This includes appointing individuals to take specific responsibility for managing the risk and carrying out the control measures, carrying out a risk assessment and devising suitable control measures (a control programme), implementing the control programme, monitoring its effectiveness, keeping records and ensuring that a suitable review / audit programme is in place. These arrangements should be documented; this is often referred to as “the written scheme of precautions” or “written scheme”.

Personnel appointed to carry duties under the written scheme should be competent. They should have the required authority, resources and equipment, knowledge, skills, training and other qualities to perform the duties or tasks required of them correctly. Suitable training should be provided and refreshed regularly.

A risk assessment is required in order to identify and evaluate the risk of exposure to Legionella. The risk assessment should involve a detailed survey of the site water services. Such a survey will allow any defects to be identified and an appropriate action plan to be prepared. The findings of the risk assessment should be documented and it is also advisable to produce a simple yet accurate drawing of the water systems (e.g. a schematic drawing). The assessment report should include both recommendations for remedial actions to repair any defects and also details of the ongoing precautions required to control the risk. This then becomes an integral part of the written scheme.

It should be noted that the way that water systems are designed and installed can be as important as the manner in which they are operated and maintained. This is particularly important for designers of residential care premises, whether new-build or refurbished, who should ensure compliance with the design standards of the guidance documents listed above. Designers should generally opt for the more stringent requirements wherever the documents differ.

Water systems should be designed in such a way that the risk of Legionella colonisation is minimised. This includes amongst other factors some key requirements:

  • Storage tanks, water heaters and distribution pipework should be sized appropriately, ensuring regular turnover and low water age;
  • Buildings and water systems should be designed and installed with consideration for their maintenance requirements. Most importantly, a suitable means access should be provided to allow inspections, servicing and repairs;
  • Hot and cold water systems should be capable of achieving and maintaining the correct water temperatures;
  • Both hot and cold pipework should be properly insulated to assist with maintenance of the correct water temperatures;
  • High usage outlets should be positioned downstream of intermittent or infrequently used outlets, this ensures that fresh water is regularly drawn to the extremities of the system;
  • Water systems should be carefully commissioned prior to handover. Water heaters should be set to the correct temperature and recirculating hot water distribution systems require balancing to ensure that hot water is distributed at the required temperature to all points of use;
  • The risk of scalding must also be addressed. The use of thermostatic mixing valves (TMVs) to control hot water temperatures at the outlets is widespread. These devices should be positioned as close as possible to the outlet and should be accessible for routine maintenance. Centrally blended systems are not recommended.

The requirement to act on this guidance is based in law, the person in control of the premises (known as the “Duty Holder”) has a duty to:

  1. Appoint a Responsible Person;
  2. Undertake Risk Assessments to identify and evaluate the risk;
  3. Prepare a scheme for controlling the risks;
  4. Implement and manage the scheme; and
  5. Keep records.

These duties are enforced within:

  • Section 3 (2) of the Health & Safety at Work Act 1974 (HSWA)
  • Management of Health & Safety at Work Regulations 1999 (MHSWR)
  • Control of Substances Hazardous to Health Regulations 2002 (COSHH)
  • The HSE’s Approved Code of Practice (ACOP), L8 (4th Edition) 2013.

The Appointed Person / Responsible Person is usually a senior member of staff with the required authority and access to resources to carry out the Duty Holders obligations. There will usually be a need to delegate tasks to other members of staff or even contractors. The more complex organisation the more complex the organisational structure is likely to be. However, complex, it is necessary to document this structure and ensure that all parties understand and agree to their role.

Managers will often have many duties, not limited to health, safety or facilities management. In these circumstances it can be challenging to set time aside for programme reviews with staff and contractors. Fortunately, both legislation and guidance make provision for duty holders and their appointed persons to seek assistance and specialist advice from either within their organisation or from external consultants. Selecting the right type of support is crucial to a successful programme. The British Standard BS8580:2010 advises that risk assessors should be competent and should be able to demonstrate impartiality and integrity along with possessing the required specialist knowledge of Legionella bacteria and the water systems to be assessed.

Quantum Compliance are a Legionella Control Association (LCA) registered company offering Legionella Risk Assessments, Training Services, Independent Consultancy and Analytical Services to the highest standards.

“*” Water age is a term used to describe the length of time that water remains within the building water system from water source (e.g. mains supply) to the point at which it leaves the outlets (i.e. taps, WCs, showers etc.).