Water safety policy

1 Introduction

Water is used for many purposes including drinking, washing, bathing, heating, and preparation of food and a multitude of other uses. This document contains the trust’s policy in relation water systems and water safety. Within the policy, details and reference will be made to legislation, good practice and recommendations that should be followed to ensure the safety of patients, staff and others. Water systems are defined as any building services or any equipment or devices that contain water. The quality, quantity and adequate control of water is vital to the well-being of patients, staff and others.

In some healthcare areas the loss of the water supply may lead to serious situations developing whilst causing inconvenience and the inability to function normally in many other areas.

There are a number of water borne pathogens that can significantly impact healthcare provision including organisms such as Pseudomonas aeruginosa and Stenotrophomonas. However, one of the more recognised hazards associated with water systems is Legionella bacteria. This bacterium is common in all water systems. The optimum temperature for multiplication of the bacterium is 37C.

The multiplication rate can be considered insignificant below 20C and above 50C it will survive for a matter of hours and a matter of minutes at 60C. Sediment, sludge, scale and rust are a nutrient source for the bacteria and therefore maintaining water systems in a clean condition is necessary. Keeping water moving and keeping water either hot or cold reduces the risk of Legionella.

While previously healthy people may develop Legionnaires’ disease, there are several factors that increase susceptibility:

increasing age, particularly over the age of 50 (children are rarely infected)
men are approximately three times more likely to be infected than women (this may change with altered smoking habits)
existing respiratory disease that makes the lungs more vulnerable to infection
illnesses and conditions such as cancer, diabetes, kidney disease or alcoholism, which weaken the natural defences
smoking, particularly heavy cigarette smoking, because of the probability of impaired lung function
patients who are immunocompromised as a result of illness or treatment (for example, those on immunosuppressant drugs that inhibit the body’s natural defences against infection)

The safe management of water systems is a requirement of a number of legislative bodies or guidance including the Health and Social Care Act (2008), health and safety executive and the NHS. These bodies have published several legislative and guidance documents on legionella and water safety, and these are listed in section 10 of this policy. These documents set out the precautions to be taken to ensure water safety including the precautions to control legionella. The legal documents set out the requirement to:

identify and assess sources of risk
prepare a scheme for preventing or controlling the risk
implement and manage precautions
keep records of the precautions implemented

NHS guidance on water safety is principally issued in the form of health technical guidance. The current Health Technical Memorandum (HTM) 04-01 is intended to move trusts towards a holistic management of water systems via water safety groups (WSGs), water safety plans (WSPs) and other initiatives. These include the requirement to introduce systems to manage and minimise the risks to health from various aspects, ranging from clinical risks, microbial and chemical contamination, changes to the water system, resilience of the water supply etc.

The revised HTM also introduces a stronger emphasis on staff competencies and the implementation of water hygiene awareness training.

2 Purpose

Water systems and equipment utilising water can be hazardous and have the potential to cause illness, injury and death if they are not adequately designed, installed, commissioned, operated and maintained. The purpose of this policy is to ensure that staff, patients and others are exposed to minimum risk from water systems and that a supply of wholesome water is available to all buildings which are maintained by the trust.

These risks can be reduced by good design, the provision of suitable equipment, effective maintenance, the provision of procedures for the safe use and maintenance of water and adequate emergency plans.

3 Scope

There are significant risks associated with both the loss of the water supply and with the deterioration of water quality. This policy identifies where responsibility lies within the trust to maintain both the availability and quality of water which includes measures to control Legionella and other waterborne bacteria.

Hot water and surfaces heated by water can also present a scalding risk to ‘at risk’ patients. Areas with ‘at risk’ patients should have local procedures in place to manage these risks. This policy does not address the risks associated with scalding or drowning to ‘at risk’ service users which is covered by a separate policy, the trust’s prevention of scalding and drowning policy.

The trust has many differing arrangements in relation to the properties that are used by its patients and occupied by its staff. The accountability for the management of water systems is the organisation with the overall control of the building and other host organisations may have their own policies. Managers of trust services in these buildings should follow any local policies and procedures in addition to those outlined in this policy.

Where other organisations are in control of water systems in which the trust places its staff or patients, the trust shall ensure that, where practicable, appropriate precautions are being taken to minimise the risk from these systems.

This policy applies to all trust staff, contractors, volunteers and others who must comply with the policy and any supporting procedures.

The information in this policy shall be read in conjunction with other related policies. Some of the activities associated with the management and use of water systems overlap with other policies and procedures. Specific regulations and guidance cover the hazards of these activities and the precautions to be taken in relation to these. It is not the intention of this policy to provide details of these overlapping regulations and guidance or the related hazards.

4 Responsibilities, accountabilities and duties

4.1 The chief executive

The chief executive has the overall accountability for ensuring compliance with all statutory regulations. The responsibility for overseeing the operation and safe use of water systems is devolved to the water safety group (WSG), directors, managers, heads of department and trust staff as appropriate.

The trust has many differing arrangements in relation to the properties that are occupied or used by its patients and staff. The accountability for the management of water systems is the organisation with the overall control of the building.

4.2 Water safety group

The function of the trusts WSG (water safety group) is to provide a multi-disciplinary approach to assess and manage risks from water systems in the context of clinical risk to patients.

The WSG should ensure that appropriate expertise and competence is available to ensure the delivery of safe water for all uses throughout the trust. This group meets quarterly and reports into the infection prevention and control committee (IPCC) which has clearly identified lines of accountability up to the chief executive and to the board.

The aim of the WSG is to ensure the safety of all water used by patients or residents, staff and visitors, and to minimise the risk of infection associated with waterborne pathogens. Duties of the WSG include:

to ensure effective ownership of water quality management for all uses
to review clinical and environmental monitoring data
to determine and assess the risks associated with the patient population, staff and visitors and the engineering and bacterial risk assessment of all water systems to determine an overall risk
undertake the commissioning, development, implementation and review of a water safety plan (WSP) and to ensure that the WSP is kept under review including risk assessments and other associated documentation and to ensure all tasks indicated by the risk assessments have been allocated and accepted
to agree and review remedial measures and actions, and ensure an action plan is in place, with agreed deadlines, to ensure any health risks pertaining to water quality and safety are addressed
to act on early warnings of poor or unsuitable water quality (for example, taste, odour, flavour and appearance if intended for drinking
agree plans for the sampling and microbiological testing of water
review the results of water sampling and agree any actions to be taken
approving the procurement, design, and installation and commissioning of water services, equipment and associated water treatment
to review amendments when changes are carried out including new builds, refurbishments and recently decommissioned clinical departments or units
to ensure that new builds, refurbishments, modifications and equipment are designed, installed, commissioned and maintained to the required water standards
to ensure maintenance and monitoring procedures are in place
to oversee water treatment measures
monitoring of control measures and record-keeping methodology
to determine the best use of available resources
to be responsible for training and communication on water related issues
to oversee the supervision, training and competency of staff
ongoing review of this policy to ensure that it remains up to date and relevant

The WSG need to ensure that there is good liaison between the estates team or maintenance providers and clinicians to ensure that the water services are sufficiently used.

4.3 Directors or heads of department or service managers

The board of directors is responsible for having policies and procedures in place to support best practice, effective management, service delivery, management of associated risks and meet national and local legislation and or requirements in relation to water safety issues. The board of directors also monitor water safety themes and trends as reported by the infection prevention and control committee (IPCC).

Trust managers have a key responsibility in ensuring that there is a proactive approach to organising, planning, controlling and reviewing health and safety.

They have a responsibility to ensure that appropriate staff under their control are given suitable information, instruction and training about water systems. Managers shall ensure that all staff under their control are aware of and implement the procedures set out in appendix A of this policy and develop any local procedures necessary to protect service users and others. Managers who are members of the trusts’ Infection Prevention and Control Committee (IPCC).

WSG and have a responsibility to disseminate information and implement procedures approved by the WSG section of the committee. Further health and safety responsibilities of managers are given in the trust’s health and safety policy.

4.4 Head of estates and facilities

For buildings which under the control of the estates function, the responsibility for water systems is delegated to the head of estates and facilities. The responsibility includes water system design, modification, installation, testing, commissioning and maintenance.

This duty is further delegated to others within the estates team for work which is carried out under their control. Further responsibilities are delegated to others within the trust.

Duties of the head of estates and facilities include:

liaising with external bodies and other disciplines within the health service on matters relating to water quantity and quality and other issues related to water systems
keeping abreast of all current legislation and guidance. Reporting on the effectiveness of control measures
reviewing training requirements and ensuring that all operational estates staff training needs are identified and prioritised to enable staff to carry out their duties effectively and safely. Maintaining records of training
reviewing risk assessments and reviewing the arrangements for controlling legionella
to be an active member of the trusts’ WSG and to be a point of contact with other disciplines within the trust in relation to water systems, for example, control of infection, patient safety and health and safety managers
to appoint an independent external auditor to carry out periodic audits of the trusts’ precautions to minimise the risks associated with legionella in buildings

4.5 Estates managers or officers or technicians

Estate’s managers or officers and technicians are responsible for overseeing the maintenance of water systems. Duties of these include:

keeping abreast of all information relating to water systems and equipment
monitoring of the maintenance programme to ensure that it remains effective and relevant
monitoring of procedures and checking records to ensure that they are relevant and up to date and that the risks from water systems and equipment are minimised. Maintaining records of inspections, maintenance and repairs to all systems under their control
arranging for risk assessments, surveys and compliance audits to be carried out by an independent external auditor. Identifying areas of non-compliance with regard to current NHS guidance and advising the head of estates and facilities of the details, priorities and costs of any remedial works that are necessary
preparing where necessary, a schematic circuit or flow diagram of water systems and updating these as required
preparing operating and maintenance instructions for all items of plant
maintaining records of modifications to water systems
assist with training staff in matters relating to water systems
ensuring that any modifications to plant, buildings and equipment carried out under their control comply with current guidance
liaising with others, including the estates capital development team, on matters relating to the design, installation and commissioning of water systems
ensuring that areas that are not in use have their water systems drained down, or if this is impractical, all outlets are flushed regularly in line with current guidance
for all contracts under their control, ensuring that as fitted and schematic diagrams of all modified or new water systems and equipment are provided and retained on the property register and copies of commissioning results, maintenance and test instructions and details of any specific hazards pertaining to the systems and equipment are provided

4.6 Health and safety team

The trusts’ Health and Safety team carry out periodic audits of all buildings which are occupied by trust staff. This includes properties which are both in control of the trust and properties which are not in control of the trust. Duties of the team include:

advising staff of their duty to manage infrequently used water outlets
seeking assurance that water safety is managed for properties which are not in control of the trust

4.7 Infection prevention and control team

The trusts’ Infection Prevention and Control team carry out periodic audits of all buildings in which clinical activities take place. This includes properties which are both in control of the trust and properties which are not in control of the trust. Duties of the team include:

taking an active participation in the WSG
advising staff of any precautions to reduce the risks related to water systems, including medical and other equipment
advising staff of their duty to manage infrequently used water outlets

4.8 Competent persons

Competent persons are technicians, trades staff, maintenance operatives or assistants and contractors who are competent to service, maintain and clean water systems in a safe and effective manner. Their duties include:

ensuring that all procedures, safe working practices and permits to work are followed and that any personal protective equipment or clothing is used
prompt reporting of all defects, unusual occurrences and other anomalies
working with managers to identify hazards and reduce risks by following safe working practices
submitting written records of tests, inspections and repairs where required
attending training on legionella awareness, good water hygiene practice and applying the knowledge when carrying out tasks on water systems

4.9 All staff and trust contractors

All trust staff and contractors have a duty of care to comply with this policy and to ensure that water systems and equipment in their control are operated in accordance with this policy, any local procedures and manufacturer’s recommendations. Further guidance for staff is provided in appendix A of this policy.

5 Procedure or implementation

5.1 Water safety plan (WSP)

A water safety plan is a risk-management approach to the safety of water that establishes good practices in local water distribution and supply. It should identify potential hazards, consider practical aspects, and detail appropriate control measures.

The WSP should also be cross-referenced to the trusts’ security management strategy and business continuity plans.

5.2 Water system design

Guidance on the design of water systems is set out in the documents listed below:

Health Technical Memorandum 04-01: Safe water in healthcare premises (2016) Part A: Design, installation and commissioning.
HSG274 part 2 (2014). ‘The control of legionella bacteria in hot and cold-water systems’.

5.3 Water system operation and safety

Guidance on the safety aspects related to the operation of water systems is set out in the documents listed below:

Health Technical Memorandum 04-01: Safe water in healthcare premises (2016), Part B: Operational management.
HSE Approved Code of Practice. (ACOP) (L8- fourth edition 2013) ’The Control of legionella bacteria in water systems’.
HSG274 part 2 (2014) ‘The control of legionella bacteria in hot and cold-water systems’.
Health Technical Memorandum 04-01: Supplement (2017) Performance specification D 08: thermostatic mixing valves (healthcare premises).

5.4 Pseudomonas Aeruginosa and other water borne pathogens

Pseudomonas aeruginosa (P. Aeruginosa) is a gram-negative bacterium, commonly found in wet or moist environments. It is commonly associated with disease in humans with the potential to cause infections in almost any organ or tissue, especially in patients compromised by underlying disease, age or immune deficiency

Current legislation and guidance give comprehensive measures to control waterborne pathogens. Legionella control is generally associated with poor engineering configuration and maintenance, with no evidence of patient to-patient or patient-to-outlet transfer. However, P. Aeruginosa and other water borne pathogens may be transferred between patients and between the water outlets by both patients and staff.

The patient group with the highest risk from P. Aeruginosa are those who are designated as receiving augmented care where medical or nursing procedures render the patients susceptible to invasive disease from environmental and opportunistic pathogens and the risk from P. Aeruginosa to the trusts’ patient group has been deemed by the WSG to be very low risk on mental health wards and relatively low risk older persons rehabilitation wards and the hospice.

Therefore, the trust does not classify any of its patients as augmented care.

5.5 Schematic diagrams and asset registers

The effective management and maintenance of water supply and distribution systems is essential to maintain the quality of water. For buildings that are in control of the trust, up-to-date schematic diagrams and asset registers of equipment for each building are provided in the risk assessments. The risk assessments are retained electronically in the estates property records folder on the “estates shared” K drive. Drawings of buried water mains are also retained in the estates property records folder.

5.6 Water supply resilience

Interruptions to the water supply can disrupt healthcare activities. The trust has procedures in place to minimise the consequence of disruption, while at the same time ensuring that an adequate turnover of water takes place to prevent stagnation in storage vessels and distribution systems. The continued availability of water supply is essential to the functioning of healthcare premises. The temporary loss of water supply can lead to inconvenience and inability to function normally in many areas.

Water storage tanks are present in most of the trusts’ inpatient areas which buffer any short-term interruption of the main water supply. The estates emergency plan contains details of providers of water and what action to take in the event of a loss of water supply. Action that can be taken locally in the event of loss of water supply is contained in appendix A.

5.7 Maintenance strategy

The trust has many differing arrangements in relation to the maintenance of the water systems in properties that are occupied by its service users and staff. The accountability for the management of water systems is the organisation with the overall control of the building. It is recognised that there is a need to balance the resources that are available to the risk that is presented by water systems. The trust therefore operates a risk-based maintenance strategy for its water system.

5.8 Water treatment

A temperature control regime is the traditional means of controlling Legionella in hot and cold-water services. Hot and cold-water systems should be maintained to keep cold water, where possible, at a temperature below 20C, and to keep hot water stored at 60C and distributed so that it reaches the outlets at 55C within one minute.

In areas where control of the microbiological safety of water systems cannot be achieved throughout the system by maintaining temperatures, NHS guidance suggests that additional control methods may be considered.

Continuous disinfection of in the form of dosing of chlorine dioxide can be implemented as an additional control strategy where the WSG deem necessary.

5.9 Water sampling

The guidance related to where legionella samples should be taken from and the frequency at which monitoring should be carried out is to be determined by risk assessment. Sampling water for legionella should be carried out on water systems that have the greatest potential for proliferation of legionella bacteria and where the most susceptible persons are present.

The trusts’ WSG has previously approved recommendations for the sampling of water and monitoring for legionella based on a risk assessment basis. Action to be taken following receipt of a positive legionella sample test is set out in HTM 04-01.

5.10 Risk assessments

The risk assessment process for legionella needs to consider the likelihood and severity of hazards and hazardous events in the context of exposure (type, extent and frequency) and the vulnerability of those exposed. Although many hazards may threaten water quality, not all will represent a high risk. The aim should be to distinguish between high and low risks so that attention can be focused on mitigating risks that are more likely to cause harm (see BS 8580 for guidance on Legionella risk assessments). In a broader trust context, typical examples of issues to consider and control measures to reduce the risk include but are not limited to:

the susceptibility of those persons who may be exposed to water
the inherent risks associated with the design of the system and measures taken to reduce the risk by design
maintaining suitable and sufficient governance and accountability arrangements for water systems as set out in this policy
rectification of issues identified in previous risk assessments

Maintenance strategy control measures including:

monitoring of hot and cold-water storage, supply, distribution and outlet temperatures
maintaining water storage and distribution systems in a clean condition, for example, water storage tanks, shower heads and hoses
maintenance of water heaters and testing and maintenance of thermostatic mixer valves
sampling, monitoring and testing programmes for water quality
where there are known design issues and or additional control measures are required, such as continuous disinfection, procedures are required to monitor water quality

Operational control measures including:

monitoring of hot and cold-water storage, supply, distribution and outlet temperatures
the running of water from infrequently used water outlets, appendix A refers
both enabling safe access to and preventing unauthorised access to water supply equipment
maintaining education and training

The trust’s WSG receives reports and updates on any alterations, improvements and water sample results associated with water systems which are in control of the trust.

6 Training implications

6.1 Responsible persons (water systems) refresher training

How often should this be undertaken: Every 3 years.
Length of training: 1 Day.
Delivery method: Responsible persons update various methods.
Training delivered by whom: External body.
Where are the records of attendance held: ESR plus personal file.

6.2 Competent persons (water systems)

How often should this be undertaken: Every 3 years.
Length of training: As Required.
Delivery method: External.
Training delivered by whom: External body.
Where are the records of attendance held: ESR plus personal file.

All trust staff should be made aware of the key points within appendix A of this policy. This will be achieved by team brief or daily emails.

7 Monitoring arrangements

7.1 Compliance with policy

How: Audit.
Who: Health and safety lead.
Reported to: Responsible person and deputy responsible persons.
Frequency: Yearly.

7.2 Policy remains up-to-date

How: Monitoring of regulations and guidance.
Who: Head of estates and facilities.
Reported to: Infection control and prevention committee.
Frequency: Review Date.

7.3 Compliance with legislation and guidance

How: Audit.
Who: External auditor.
Reported to: Responsible person and deputy responsible persons.
Frequency: 3 monthly.

8 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

8.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 How this will be met

No issues have been identified in relation to this policy.

8.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

9 Links to any associated documents

10 References

Health Technical Memorandum 04-01: Safe water in healthcare premises (2016) Part A: Design, installation and commissioning (opens in new window).

Health Technical Memorandum 04-01: Safe water in healthcare premises (2016) Part B: Operational management (opens in new window).

HSE Approved Code of Practice. (ACOP) (L8- fourth edition 2013) ’The Control of legionella bacteria in water systems’ (opens in new window).

HSG274 part 2 (2014). ‘The control of legionella bacteria in hot and cold water systems’ (opens in new window).

HSG220- Health and Safety in care homes (2014) (opens in new window).

Healthcare associated infection (HCAI): operational guidance and standards (opens in new window).

Health Technical Memorandum 04-01: Supplement (2017) Performance specification D 08: thermostatic mixing valves (healthcare premises) (opens in new window).

11 Appendices

11.1 Appendix A Guidance for staff

This document contains guidance for staff on the trust’s water safety policy.

11.1.1 Guidance on hot water and hot surface temperatures.

Hot water systems have been shown to be a common source of legionella. It is for this reason that hot water systems distribute water above 50C and this is then reduced to a safer temperature at the point of use by thermostatic mixing valves.

There have been cases of severe scalding and death resulting from unsupervised bathing and exposure to hot radiators in high-risk areas. Full body immersion appliances such as baths and showers used by at-risk patients must have thermostatic mixing valves fitted.

Thermostatic mixing valves may only reduce the risk of scalding therefore all areas with ‘at risk’ patients must have local procedures to ensure persons at risk are adequately supervised particularly prior to and during bathing.

Staff should be aware of the risks and the potential danger and should report circumstances or changes in circumstances, which may increase the risk of scalding.

There are also hazards associated with hot surface temperatures to at-risk patients. Heaters and pipework should be controlled to a temperature below 43C or be fitted with protection so that at-risk persons cannot come into contact with the hot surfaces. As a minimum, precautions that can be taken to prevent scalding and burns include:

check the temperature of hot water with a thermometer when running baths and showers
checking the temperature of baths with a thermometer before allowing a patient to bathe
ensuring that “at risk” patients are adequately supervised
void placing patient’s furniture or beds adjacent to hot surfaces such as radiators.

Several services within the trust have issued guidance that exceeds the above minimum precautions. Further guidance is contained in the trust’s prevention of scalding and drowning policy.

11.1.2 Infrequently used water outlets, guidance on maintaining the bacteriological quality of water.

Keeping water moving and keeping water either hot or cold reduces the risk of legionella. Water outlets such as taps, and showers may become ‘high risk’ due to stagnant water if they are not used frequently. Consideration should be given to removing infrequently used showers, taps and any associated equipment that uses water. Should it not be possible to remove a water outlet, precautions need to be taken to reduce the risk of legionella from infrequently used outlets.

The guidance recommends that generally, for infrequently used outlets, flushing is carried out once a week but that in healthcare facilities the risk assessment, as agreed by the WSG, may indicate a higher frequency, and water draw-off should form part of the daily cleaning process. The procedure for such practice should be fully documented and covered by written instructions.

The trust policy is that any water outlet in an inpatient area that is not used for 3 days must be subject to a flushing regime and this extends to 7 days for non-inpatient areas

11.1.3 Procedure for infrequently used water outlets

Nominate staff in your area to open all little used water outlets (for example, hot and cold taps on, baths, showers, bidets, sinks, basins, etc.) for 3 minutes on a twice weekly basis for inpatient areas and 3 minutes once per week for non-inpatient areas. Unused toilets must also be flushed. The domestic services staff can carry this out on instruction from the ward or departmental staff. The accountability for this procedure rests with the manager of the area.

The form to record the flushing of little used outlets is available on the intranet estates page. Scan and e-mail the completed forms to: rdash.maintenancereports@nhs.net.

Where there is a known issue with the bacteriological quality of the water the frequency and duration may need to be increased. Any equipment that stores water should be cleaned or drained or replaced in accordance with manufacturer instructions and infection control protocols

Local guidance on emergency plans for loss of water supply.

All areas shall carry out a risk assessment for the failure of the water system or devices that regulate water temperatures. They shall identify the course of action to be taken on failure of hot and cold-water supplies and failure of a thermostatic mixing valve. Those responsible for maintaining your building will work in partnership to develop the risk assessment if requested to do so. There are many different types of hot and cold-water systems, and it is not possible to cover every situation and scenario in this document.

If an emergency does occur, reassure patients and keep them informed. The failure of the water supply is low likelihood and has a non-critical consequence for this area when failures are for 4 hours or less. Bottled drinking water can be obtained from a local 24-hour supermarket or will be supplied by water supplier

11.2 Appendix B Summary of maintenance strategy

11.2.1 Cold water storage tanks water tank inspections

Water tank inspections. Frequency, annually (summer).

Check the tank water temperature remote from the ball valve and supply (inlet) temperature. Clean and disinfect the tanks. Frequency, annually (summer).

11.2.2 Calorifiers and direct storage water heaters (for example, greater than 15 litres in volume) record flow temperatures highlighting any temperatures below 60C

Record flow temperatures highlighting any temperatures below 60C. Frequency, monthly.

Record return temperatures highlighting any temperatures below 50C. Frequency, monthly.

11.2.3 Combination water heaters (for example, containing an integral cold water storage compartment) record storage temperatures (record from nearest hot outlet) highlighting any temperatures below 55C

Record storage temperatures (record from the nearest hot outlet) highlighting any temperatures below 55C. Frequency, monthly.

11.2.4 Shower and spray taps

Dismantle, clean and descale removable parts, heads, inserts and hoses where fitted. Frequency, quarterly.

11.2.5 Cold water services

Record temperature at cold sentinel taps after 2 minutes of flushing, highlighting any temperatures 20C or above. Frequency, monthly.

11.2.6 Hot water services

Record temperature at hot sentinel taps after 1 minute of flushing, highlighting any temperatures below 55C. Frequency, monthly.

11.2.7 Legionella sampling

Legionella sampling should be carried out in accordance with BS 8554:2015 and sample analysis by a UKAS accredited laboratory. Three Legionella samples (or more if required later) are to be taken (one hot and one cold) as specified. Frequency, risk based.

11.2.8 Thermostatic mixer vale maintenance

Carry out in service test procedure. Frequency, 6 monthly.

11.3 Appendix C Borehole water supply

The trust has a borehole water supply that is subject to several treatment processes which include:

carbon filtering
ion exchange water softening
blending of softened water
disinfection.

Whilst the water quality is generally wholesome, it is not tested to drinking water standards and is therefore classed as non-potable. The borehole water supply is not used for drinking or the washing of persons or food preparation and is used to for the following:

laundry, supply for washing machines

The pipework supplying borehole water is identified by colour band which should be green, flint grey and black.

Document control

Version: 11.1.
Unique reference number: 191.
Ratified by: Corporate policy approval group.
Date ratified: 28 December 2023.
Name of originator or author: Head of estates and facilities.
Name of responsible committee or individual: Infection prevention and control committee and water safety group.
Date issued: 28 December 2023.
Review date: May 2025.
Target audience: All staff.

Page last reviewed: December 05, 2024
Next review due: December 05, 2025

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