Legionella Management Policy

This policy relates to all buildings and properties that YHG has a maintenance and repair responsibility for. This includes domestic dwellings, both single and multi-occupancy, specialised housing such as sheltered, retirement living, extra care and supported housing and non-domestic premises such as offices, commercial units, and community centres.

Where properties are managed by third parties (e.g., Agency Managed Supported Schemes, PFI Schemes) the management of Legionella will fall under the scope of this policy so far as the YHG statutory responsibilities detailed in the terms of the management agreement.

Approved Codes of Practice (ACoP): documents approved by the HSE that give practical advice and recommendations on how to comply with regulations. ACoPs have “special legal status” meaning in the event of prosecution for a H&S breach you must evidence how you have complied with the ACoP.

Health & Safety Executive (HSE): Non-departmental public body in the United Kingdom responsible for the encouragement, regulation and enforcement of workplace health, safety and welfare, and for research into occupational risks in England and Wales and Scotland.

Duty Holder: the owner, person and/or organisation that has responsibility for the building and water systems, with accountability for the safety of employees and staff. Legionella Water Risk Assessment

(WRA): a physical survey of all water related plant and storage systems to check whether conditions are present which could encourage Legionella bacteria to multiply. Written Scheme – a risk management document identifying measures to be taken to control water systems and reduce the risk of Legionella bacteria. Legionella Management Plan

(LMP): a document designed to register and detail how water systems will be managed and what activities will be undertaken to ensure people remain safe from Legionella exposure. Legionella Control Association

(LCA): a voluntary organisation for which members have to demonstrate their adherence to a recommended Code of Conduct for the control of Legionella bacteria in water systems.

Consultation has taken place with the following. Their feedback has been considered and the policy update:

• Equality Impact Assessors Group
• Chief Property Officer
• Director of Housing & Customer Service.

Legionnaire’s disease is a form of pneumonia which if not diagnosed and treated promptly can lead to organ failure, brain damage and death in some cases. The disease is contracted when airborne droplets of water containing Legionella bacteria are inhaled and penetrate the lungs infecting the alveoli (air sacks).

Anyone can contract Legionnaire’s disease however there are certain “at risk” groups which are more susceptible, this includes those with a weakened immune system, the elderly, smokers, alcoholics, and those with existing respiratory conditions. Statistically men over 50 are more susceptible than women of the same age and children are rarely affected.

Low numbers of Legionella bacteria are commonly found in natural water sources such as rivers and lakes and can make its way into man-made water systems. If conditions are favourable the bacteria will multiply, increasing the risk of exposure.

Favourable conditions include those where the temperature of the water is within a certain range, there is nutrients in the water for the bacteria to feed off and/or where water becomes stagnant. The risk of exposure is heightened further where there are water systems that create a spray of water, e.g., showers.

ACoP L8 and HSG274 Part 2 provide guidance on the measures to be undertaken to identify and assess sources of Legionella risk, manage the risk, prevent, or control the risk; and periodically check that control measures continue to be effective. The aim of the control measures is to remove or reduce the favourable conditions for Legionella bacteria growth and therefore reduce the risk of Legionella exposure.

Possible sources of Legionella risk, and therefore the systems and components that require assessing and managing include:

• Mains cold water services
• Cold water storage tanks & cold-water distribution systems
• Hot water storage systems including Calorifiers or hot water cylinders
• Non-storage hot water systems
• Water outlets such as taps, showers or aerosol generating sources,
• Thermostatic mixing valves (TMV’s)
• Any other plant and systems containing water which is likely to exceed 20C and which may release droplets of water during operation or when being maintained.

ACoP L8 places several requirements on Employers and Duty Holders as to the action they should take to appropriately manage Legionella. ACoP L8 is supported by several Health & Safety Executive (HSE) guidance documents which translate the requirements within ACoP L8 into specific actions that should be undertaken to evidence compliance with the ACoP. For YHG the most relevant guidance document is HSG274 Part 2.

A Duty Holder in the context of ACoP is the person or organisation that is in control of a premises and is responsible for maintenance and repair. YHG therefore has both Employer and Duty Holder responsibilities under ACoP L8.

YHG’s duties under ACoP L8 can broadly be considered to be:

• To take reasonable steps to assess hot and cold-water systems to identify possible sources of Legionella risks. This is most achieved through a Legionella Water Risk Assessment (WRA)
• To ensure that if the WRA shows that there is a reasonably foreseeable Legionella risk a “Written Scheme” is produced. This will detail the actions required to remove, reduce, or control the risk
• To take all reasonable and practicable action to remove the risk, where this is not possible a Legionella management regime should be in place. The nature and frequency of which will be in line with HSG274 Part 2 and the Written Scheme
• To ensure that the effectiveness of the Legionella management regime is periodically checked, and that action is taken in the event of non-conformity with ACoP L8
• To maintain records of all activity undertaken to identify and assess sources of Legionella risk, remove the risk and the management regime in place to manage the risk
• Ensure the roles and responsibilities for Legionella Management are clearly defined, and that those with responsibilities are competent to do so.

The following section details the actions taken and measures that are in place and/or will be taken to ensure YHG fulfils its under duties under ACoP L8 as set out above.

These actions and measures demonstrate YHGs commitment to ensuring a safe environment within which our customers can live and within which our staff can work, as well as satisfying our legal obligations.

The Legionella Management Policy will be supported by a Legionella Management Plan (LMP)

Legionella Water Risk Assessments (WRAs)

The purpose of a WRA is to identify and assess the risk of exposure to Legionella bacteria from the hot and cold-water systems on the premises and any precautionary measures needed to remove, reduce, or manage the risk.

YHG will ensure a WRA is carried out to the hot and cold-water system at all the following buildings:

• Any multi occupancy blocks with a hot and/or cold-water system serving multiple dwellings, e.g., a block with a tank fed cold water system
• Any building classed as a workplace, e.g., Offices, Community Centres, Agency Managed schemes.

The format and content of the WRAs should be in line with the guidance in ACoP L8 and BS 8580-1: 2019 Water Quality - Risk Assessments for Legionella Code of Practice and as a minimum should include:

Name of the risk assessor, site responsible person and duty holder

A description of the water system

The risk identified with recommended actions, including a risk category and recommended timeframe for completion

A schematic drawing of the water system identifying all relevant assets and pipe runs.

ACoP L8 advices that WRAs should be regularly reviewed but does not define a specific review period. For consistency YHG will ensure all WRAs are reviewed every 2 years as a minimum. Procedures will be in place to ensure all WRAs are reviewed in time.

The WRA should be reviewed sooner if it is believed the content of the assessment may no longer be valid. This may result from:

• Changes in the water system or its use
• Changes in the use of the building in which the water system is installed,
• The availability of new risks or control measures
• The results of management regimes indicating that control measures are no longer effective
• A case of Legionella is associated with the system.

Where the WRA shows that there is a reasonably foreseeable Legionella risk, it should be supported by a Written Scheme that details the actions required to remove, reduce, or control the risk. YHG will have procedures in place to detail how actions are managed, logged and tracked through to completion.

The current version of ACoP L8 guides Duty Holders towards carrying out a WRA in single occupancy domestic dwellings, though provides no clear guidance on the percentage that should be completed and within what timeframe. YHG will consider working towards the completion of some form of WRA to domestic dwellings to identify any Legionella risks associated with water temperature and/or system design.

• A % of Sheltered, Retirement Living and Extra Care Schemes, due to the residents being considered a Legionella “at risk” group
• A % per archetype of properties with electric heating (e.g., storage heaters) and some form of stored water (e.g., hot water cylinder)
• Void properties.

This approach will be detailed further in the LMP.

Legionella Management regime

Where the WRA shows that there is a reasonably foreseeable Legionella risk, it should be supported by a Written Scheme that details the actions required to remove, reduce, or control the risk. Where even through all reasonable and practicable action it is not possible to remove the risk a Legionella management regime should be put in place. The nature and frequency of which will be in line with HSG274 Part 2 (specifically Table 2.1 Checklist for Hot and Cold-Water Systems) and the Written Scheme and will include measures such as water temperature monitoring and system clean and disinfection.

The YHG Compliance Team will manage the delivery of the Legionella management regime with processes in place to ensure the correct nature and frequency of control measures. 

When a property becomes void all hot and cold-water outlets are flushed by running the taps for 2 minutes on the 1st day of the void works and then again every 7 days after that until occupation.

Non-conformity with ACoP L8

In the event of a non-conformity with ACoP L8 YHG have a duty of care to ensure appropriate and timely corrective action is taken. The timeframe within which YHG are notified and the timeframe for completing remedial actions will depend on the severity of the non-conformity. For non-conformities identified on a WRA these will be addressed within the timeframe recommended by the risk assessor.

Any suspected cases of Legionella will be reported by a medical practitioner to the relevant Local Authority. If a YHG property or building is suspected to be the source of the infection, then YHG will be required to comply fully with the investigation. At the point of investigation notification SHG will contact their appointed water hygiene contractor for support and guidance on the procedure to follow.

Certification & Documentation

YHG shall keep appropriate and up to date records and certification relating to the management of Legionella for a period of at least 5 years.

The records that are to be kept shall include (but are not limited to).

• An up-to-date list of properties and buildings that require a WRA and management regime, including previous completion dates and next due dates
• WRAs
• Written Schemes
• Temperature monitoring records
• TMV servicing records
• Shower clean records
• Clean and Disinfection Certificates
• Results of any Legionella sampling
• Up to date building schematic drawings
• Records evidencing the review and action of any non-conformities.

All records of activity undertaken by the water hygiene contractor will be available to YHG via a web-based portal that all relevant staff have access to. All other records will be held within the YHG systems.

Asset Data & Reconciliation

YHG will hold and maintain an accurate record within the Orchard Housing Management System of all buildings that require an WRA and that form part of the Legionella Management regime. The record will include the completion date and next due date of the WRA, and specific details of the Legionella Management regime activity carried out at each site, again with the completion date and next due date.

Processes will be in place to ensure Orchard records are updated to reflect any property divestments, acquisitions (including new builds), equipment installations and removals and any changes to maintenance and repair responsibility.

YHG will work toward ensuring that where the responsibility Legionella management falls to a third party (e.g., Agency Managed Supported Scheme, PFI Schemes) action is taken to ensure evidence is obtained that the necessary regime is being delivered.

Contractor Competence, Quality Control and Performance

YHG must be able to satisfy themselves that all those carrying out WRAs and the Legionella Management regime are competent to do so.

YHG will employ a water hygiene contractor to complete WRAs and Legionella management regime activities (e.g., temperature monitoring). To give assurance on competency the appointed water hygiene contractor should as a minimum be a member Legionella Control Association (LCA).

The water hygiene contractor will be required to evidence that all operatives working on YHG properties are appropriately qualified and competent. The Compliance Team will maintain a record of all operatives and their qualification details.

The performance of water hygiene contractor will be managed by the Compliance Contract Managers, supported by a suite of internal metrics and KPI dashboards. Monthly Operational Meetings are held with the contractor within which performance is discussed and documented, with procedures in place to take more formal action to address performance issues if required.

YHG will work to ensure that the appointed water hygiene contractor has an internal audit regime in place to audit a minimum of 5% of YHG works, the results of which will be shared and discussed as part of operational contract review meetings.

In addition, YHG will also work towards implementing a desk top accuracy and completeness assessment on a percentage of completed WRAs, with any errors or missing information being referred to competent contractor, for resubmission.

Training

Suitable and sufficient Legionella awareness training will be maintained for all relevant employees. The frequency and content will be detailed within the LMP. Where there are specific tasks that staff are required to undertake, e.g., flushing, completion of WRA in void, the training will cover practical guidance on how to complete these tasks.

The roles and responsibilities for key stakeholders across YHG is detailed below.

Note - these are the roles and responsibilities in specific relation to the delivery of this policy only. The LMP will provide further details on the roles and responsibilities of all staff with day-to-day responsibility for the management of Legionella, including the role of the Duty Holder and Responsible Person/s.

Chief Executive

will need to ensure that resources are made available to allow for the appropriate management of Legionella. They will have ultimate accountability for the proper implementation of this policy and the LMP however will discharge their responsibilities to the Chief Property Officer and Head of Compliance & Building Safety. They should however retain an oversight on progress/performance.

Board Members

should review reports and/or performance indicators to assure themselves that the measures detailed in the policy and LMP are being followed, thus ensuring that YHG is meeting its legal requirements.

The Chief Property Officer

will work closely with the Head of Compliance & Building Safety to implement this policy and LMP and to continue to seek assurances that legal obligations and policy measures are being adhered to and in line with budget.

Head of Compliance & Building Safety

is responsible for the overall implementation, and regular review of this policy and ensuring its objectives are achieved. They will also lead on the writing and implementation of the LMP. They are also responsible for compliance performance reporting to the Chief Property Officer, Board, and the Chief Executive. They will ensure that any compliance and/or H&S related issues are brought to the attention of the Chief Property Officer and provide regular updates on service delivery against budget.

Compliance Operations and Contract Manager (Asbestos & Legionella)

will be responsible for the day-to-day operational delivery of all aspects of this policy and the LMP. They will support the Head of Compliance & Building Safety in the writing and implementation of the LMP. They will act as the organisations lead for Legionella Management providing technical advice and guidance to staff. They will ensure that YHG continue to work in line with the most up to date industry guidance.

Head of Learning & Development

will ensure that a suitable and sufficient Legionella awareness training is maintained for all relevant employees.

Head of Repairs & Maintenance

will ensure that an appropriate flushing regime is carried out to all empty properties during void works.

Head of Housing/ Supported Housing/Older Persons Services

will ensure that an appropriate flushing regime is carried out to all empty properties following void works, up until occupation.

The risks of not following this policy are that YHG will not comply with the requirements of ACoP L8, leading to a potentially detrimental impact on the safety of customers and staff. This may result in:

• Prosecution by the Health and Safety Executive under Health and Safety at Work Act 1974
• Prosecution by the Local Authority under the Housing Act 2004
• Prosecution under Corporate Manslaughter and Corporate Homicide Act 2007
• A judgement of serious detriment by the Regulator of Social Housing
• Reputational damage
• Loss of confidence by stakeholders in the organisation.

YHG shall keep appropriate and up to date records and certification relating to the management of Legionella for a period of at least 5 years.

All WRAs will be stored at a property or building specific level within Documotive.

YHG will work towards ensuring documentation regarding the ongoing Legionella management regime is also held with YHG systems. There should be no requirement to retain any records which contain personal data on customers.

This Policy will be applied in a way which ensures equality of treatment for all customers without discrimination, or victimisation on account of any protected characteristic as defined within the Equality Act 2010. In drafting this policy YHG has had regard to its public sector equality duties under s149 of the Equality Act 2010, namely the need to:

• eliminate discrimination, harassment, victimisation, and any other conduct that is prohibited under the Act
• advance equality of opportunity between people who share a relevant protected characteristic and persons who do not share it
• foster good relations between persons who share a relevant protected characteristic and persons who do not share it.

The policy pays regard to diversities around access to and delivery of any services.

On request YHG will provide translations of all its documents, policies and procedures in various languages and formats including computer disc, braille, large print, and tape.

An Equality Impact Assessment (EIA) has been undertaken on this policy and a copy is available upon request.

This policy will be communicated internally to staff via Youggle. Key stakeholders and key staff where this policy has specific impact will be briefed individually or collectively as required.

The policy will be shared with customers upon request. YHG will also look to provide Legionella awareness information to customers at the start of a new tenancy and make further guidance available, e.g., on the website.

Suitable and sufficient Legionella awareness training will be maintained for all relevant employees. Where there are specific tasks that staff are required to undertake, e.g., flushing, completion of WRA in void, the training will cover practical guidance on how to complete these tasks. All training delivered will be recorded in Helix.

All staff with operational involvement with the delivery of this policy and the LMP will need to have and maintain suitable and sufficient system training, e.g., Orchard and Documotive.

The Head of Compliance and the Compliance Contract Manager (Asbestos & Legionella) should hold a relevant industry recognised qualification and will also need to proactively maintain their Continued Professional Development to keep up to date and abreast of industry change and guidance.

The completion of WRAs in line with their due date forms part of the “Health & Safety – Customer’s Homes” balanced scorecard KPI. This is reported monthly to Board, ELT and SLT.

Several KPI dashboards are available and used to monitor the performance of the contractors.

This policy will be reviewed every two years, or sooner if required by statutory, regulatory, best practice, emerging developments, or circumstances arising from reviews of other Group wide policies. The policy will be reviewed by the Head of Compliance.