Scope
This policy applies to any use or storage of hot and/or cold water that is owned, managed, maintained or controlled, to any extent, by the University of Bath that could result in the formation and/or transmission of water droplets (aerosols) which may be inhaled by any person, thereby creating a reasonably foreseeable risk of exposure to legionella bacteria.
Relevant legislation and guidance
The Health and Safety at Work Act etc. 1974
The Management of Health and Safety at Work Regulations 1999
The Control of Substances Hazardous to Health Regulations 2002
The Construction (Design and Management) Regulations 2015
Note: There are specific water quality and water hygiene regulations that apply to mains-fed water storage and supply systems which will also need to be considered when implementing this policy.
Definitions
The HSE identify that the following water use and storage systems each present a reasonably foreseeable risk of exposure to legionella bacteria:
- cooling systems with cooling towers, evaporative condensers or dry/wet cooling systems
- hot and cold water systems
- spa baths
- other plant and systems containing or using water, or water-based solutions, where any or all of the following apply
- the water temperature in all or some parts of the system may be between 20–45 °C, which is suitable for legionella bacterium growth
- there is a means for creating and spreading breathable droplets (aerosols)
- water is stored and/or re-circulated
- there are deposits that can support bacterial growth, such as rust, sludge, scale, organic matter and biofilms
Domestic hot and cold water systems
Water systems that are considered to be an inherent part of a building’s services. Examples (this list is not definitive) could include general hot and cold water supplies, wet heating systems, sanitary water supplies, emergency drench showers, Point of Use Water Heaters directly connected to either the mains water supply or a mains-fed water storage system, building sprinkler systems, hydrants, fire hoses and mains-fed water fountains.
Faculty/departmental equipment
Any specialist water systems or equipment that is independent of a building’s water supply. Examples (this list is not definitive) could include stand-alone water or wave tanks, rain water harvesting systems, water baths, humidifiers, re-circulating water vacuum systems, horticultural watering and misting systems, washing machines with sumps, coolant used with engineering and other experimental equipment, hoses and spray heads.
Policy statement
The University of Bath is committed to reducing, so far as is reasonably practicable, the reasonably foreseeable risks of exposure of any person to legionella bacteria. The University will aim to achieve this policy commitment by following the principles set out in the publication 'Legionnaires’ disease. The control of legionella bacteria in water systems. Approved Code of Practice and guidance L8 (Fourth Edition). Health and Safety Executive (HSE)'. This will include:
appointing one or more Responsible Person (Legionella) to have responsibility for managing identified in-scope water use and storage systems
carrying out a suitable and sufficient risk assessment of all work activities and in-scope water systems to identify and evaluate foreseeable risks of exposure to legionella bacteria
identification of any particular “at risk” groups of people who may be at greater risk of harm if exposed to legionella bacteria
recording the significant findings of each such assessment
producing and implementing written arrangements (a legionella management plan) to avoid, so far is reasonably practicable, exposure to legionella bacteria. Where it is not possible to avoid this risk then the plan will identify the measures for controlling the risk of such exposure and to ensure that such controls remain effective
keeping appropriate records of any management and any associated monitoring activities
allocating sufficient resource to ensure that reasonably foreseeable risks of exposure to legionella bacteria are managed. This will include the appointment of suitable numbers of competent people to advise on legionella management matters and to assist with the development and implementation of the legionella management plan
providing suitable and sufficient information, instruction, training and supervision to relevant employees to enable them to perform their duties under this policy and any associated procedures and to reduce the risk of legionella growth and transmission and foreseeable exposure of any person to legionella bacteria
ensuring that all new water systems are designed, specified, installed and commissioned so as to avoid, where reasonably practicable, the foreseeable exposure of people to legionella bacteria or, where avoidance is not practicable, to ensure that such risks are reduced to a tolerable level
carrying out a legionella risk assessment on all new buildings following handover from the Principal Contractor. The assessment findings will be incorporated into the building's legionella management plan
managing all works on existing domestic hot and cold water systems to ensure that foreseeable risks of legionella exposure are managed
ensuring that all work on domestic hot and cold water systems are only carried out by suitably competent people.
undertaking periodic audits to ensure that all relevant duties under this policy and applicable legislation are being managed effectively
Responsibilities
The Vice-Chancellor (VC) has the overall day to day responsibility for health and safety matters at the University and therefore acts as the duty holder for legionella management at the University. The VC delegates responsibility for undertaking aspects of these duties through line management and identified roles.
The following people are identified as having specific responsibilities under this policy (in addition to any other responsibilities under other health and safety policy) for the control of legionella issues in those water systems, and for those relevant persons, that fall within their budgetary control:
1. Domestic hot and cold water systems
The Directors of Campus Infrastructure, Sport and Campus Services have been appointed as the specific Responsible Person (Legionella) for those domestic hot and cold water systems whose maintenance and upkeep falls within their budgetary control. Each of these appointed Responsible Person (Legionella) will ensure that:
suitable resources are allocated for the management of legionella risk in domestic hot and cold water systems. This includes the written appointment of relevant people within their line management chain to deputise for them where necessary and the allocation of sufficient budget to manage legionella risk at east in accordance with legal requirements
suitable and sufficient risk assessments are undertaken of all in-scope systems
risk assessments are undertaken by suitably competent persons
a bespoke legionella management plan is developed for each system by a suitably competent person. The legionella management plan will include:
- an appropriate schematic detailing the water system and its key components
- a written record of the system risk assessment. This will include consideration of any 'at risk' groups who might potentially be exposed to legionella bacteria
- a written schedule for minimising the risk of legionella within each system. This will include a prioritised action plan and a mechanism for escalating remedial work where the risk assessment, or any subsequent monitoring regime, identifies a significant risk of legionella growth or transmission
- a written schedule and procedures for inspection, maintenance and disinfection, where applicable, of each system
- a written schedule for monitoring the effectiveness of control measures for each system
Deans, Heads of Department and Directors are made aware of any control measures identified in the legionella management plan that they may be responsible for implementing (for example, the periodic flushing through of certain outlets)
the legionella management plan is implemented and is subject to periodic audit (at least annually)
submitting annual statements of reassurance to University Health and Safety Committee to confirm that legionella risks are being appropriately controlled
system risk assessments are reviewed at a maximum of two-year frequency
appropriate actions are taken to remediate any matters arising from system inspections, testing and monitoring
significant non-conformances are reported to the Duty-Holder as soon as is reasonably practicable
people working on in-scope systems are competent to do so and comply with this policy and all other relevant water hygiene and safety legislation
suitable and sufficient information, training, supervision and instruction is given to any person authorised to work on in-scope systems
Each Responsible Person (Legionella) may, subject to written agreements or contracts being in place, engage competent third parties (for example another Responsible Person (Legionella), external consultants or contractors) to carry out one or more of the tasks associated with managing legionella risk. The Directors of Sport and Campus Services have formally appointed the Director of Campus Infrastructure to manage legionella risk on their behalf.
However, it should be noted that this appointment does not remove the overall responsibility on the Directors of Sport and Campus Services for ensuring that legionella risk is managed in those in-scope systems that they retain any budgetary control, whatsoever, over.
A Water Hygiene Management Group has been convened to oversee operational legionella matters. This group is chaired by Campus Infrastructure with representatives from Campus Services, Sports and the Science and Engineering and Design Technical Directorates. An external Appointed Water Engineer has been appointed to support the management of water hygiene risks in university premises. Read the Terms of Reference for the WMG.
Deans, Heads of Department and Directors will:
cooperate with the Duty-Holder and appointed Deputy / Responsible Person (Legionella) to enable them to meet their responsibilities under this policy
ensure that any control measures they are responsible for implementing (for example, flushing through of certain local outlets) are carried out in accordance with the directions of the legionella management plan
alert the Responsible Person (Legionella) to any redundant or little used hot and cold water outlets within their areas
not permit alterations, additions or other works to be carried out by their staff or students or by contractors directly employed by their School, Faculty, Department or Directorate without first seeking written approval from the Deputy / Responsible Person (Legionella)
2. Faculty/department equipment
Deans, Heads of Department and Directors: Where a Faculty or School or Department or Directorate possesses and/or operates water systems or carries out works where there is a risk of legionella growth and/or transmission, then the relevant most senior manager will be deemed to be the Responsible Person (Legionella), under this policy, for that equipment. Where a Responsible Person (Legionella) role exists, then that person will be responsible for ensuring that:
equipment and/or systems that pose a foreseeable risk of legionella growth and/or transmission are identified
risk assessments are carried out for each such system or piece of equipment. The risk assessment should identify appropriate control measures to avoid, as far as is reasonably practicable, the growth and/or transmission of legionella bacteria or, where this is not reasonably practicable, to reduce the risk of legionella exposure to a tolerable level. Control measures should also consider any “at risk” groups who might be exposed
a written scheme is prepared for each type of equipment or system, and is implemented
suitable monitoring is undertaken (for example by including such checks in School, Faculty and Departmental Inspections) to ensure that the written scheme works and is being implemented correctly
Responsible Persons (Legionella) should appoint suitable deputies to assist them to meet their duties. Any such appointments should be made in writing.
Each Responsible Person (Legionella) may, subject to written agreement, engage competent third parties (for example another Responsible Person (Legionella), external consultants or contractors) to carry out one or more of the tasks associated with managing legionella risk. However, they cannot delegate the overall responsibility for ensuring that legionella risk is managed in those in-scope systems that they retain any budgetary control, whatsoever, over.
3. All systems
The HR Deputy Director: Safety and Employee Wellbeing will be responsible for providing advice and guidance to enable duty holders to fulfil their duties under this policy.
Monitoring
University Health and Safety Committee will be responsible for:
- monitoring and reviewing this policy. Reviews will be carried out every two years from the date of approval
- receiving and reviewing annual statements of reassurance from Duty-Holders
Further information and resources
Technical Guidance HSG274 Parts 1, 2 and 3
Legionnaires’ disease: A brief guide for duty-holders
HSE Resources: Guidance Documents, Videos and Useful Links
Document control
Approval date: September 2023
Approved by: UHSC
Date of next review: The next review is scheduled for September 2025