Legionnaire's Disease is a potentially deadly disease caused by the legionella organism. The organisms can live in water systems used for air conditioning, showers, and cooling systems. Like with all the other risk assessments practices make on a regular basis, it should be a consideration but there is no mandatory requirement* or system for this so far.
*Legal point of clarification - there is no mandatory requirement to employ an agency to do a legionella risk assessment. The need for practices to do a "suitable and sufficient" risk assessment is covered under the Health and Safety at Work Act 1974 section 4 (duties of Landlords and those in control of premises). To comply with this act there is a need to (among other things) take account of the approved HSE code of practice L8
This leaflet Legionnaire's Disease - a guide for employers, produced by the HSE (Health and Safety Executive) is informative and will enable most pratices to feel confident that they know enough to make a reasonable judgement and risk assessment.
Risk assessment: Hot and cold water supply/Legionnaires' disease
Water systems can harbour legionella bacteria which is the cause of Legionnaires' disease (which is a potentially fatal pneumonia) and other related diseases.
Infection is caused by breathing in small droplets of water contaminated by the bacteria. Everyone is potentially susceptible to infection but some people are at higher risk, e.g. those over 45 years of age, smokers and heavy drinkers, those suffering from chronic respiratory or kidney disease, and people whose immune system is impaired.
Legionella bacteria can contaminate and grow in hot and cold water systems. They survive low temperatures and thrive at temperatures between 20°C-45°C if the conditions are right, e.g. if a supply of nutrients is present such as rust, sludge, scale, algae and other bacteria.
They are killed by high temperatures.
It is important to balance the risk between likelihood of legionella bacteria building up in the water system, and the risk of scalding vulnerable people, such as the elderly, children or disabled people. Should the water be coming out of the hot water taps at too high a temperature, the risk of scalding is very high.
Risks exist in cases where water droplets could be inhaled, e.g. in a shower.
Preventing and controlling the risk:
- Maintaining the hot water system at or above 60°C (at which the bacteria cannot survive) but beware of the risk of scalding.
- Flush infrequently used pipes through regularly (e.g. turn showers on weekly)
- Ensure water storage tanks are covered and are inspected/ flushed/ descaled/ disinfected periodically.
- Ensure that monthly checks are carried out on taps to ensure that the cold water temperature is below 20°C after running for up to two minutes the hot water temperature is at least 50°C within a minute of running the water.
- Note also that the HSE encourages the restriction of hot water outlets to 44°C maximum in non-domestic premises where "vulnerable" people may have access, (to reduce the risk of scalding) this would include the washing facilities available to the public at the Medical Centre.
For the attached risk assessment, the tap water temperatures were checked using a thermometer in mid flow of the running water from the tap.
xxx Medical Centre has a hot water supply provided by three wall mounted Combi-boilers, thus has no water storage tank in the premises, and vastly reduces the risk of legionella bacteria settling in the water system.
The air conditioning units are located in the pharmacy and in the reception back office. These are split-systems, which cool the air by the use of gases, and are regularly services. As they are not condensing units with drip trays, the risk of legionella bacteria is minimised. The Air-con units are serviced regularly and the gases renewed to ensure effective operating throughout the year.
The findings of this risk assessment show that the likelihood of legionella bacteria settling in the water supply throughout the building is low, due to regular use of the system throughout with high water storage temperatures and having a relatively modern layout for the water services. (i.e. no condensing unit, no water tank). As a result, no further action will be necessary.
The CQC publication “Essential Standards of Quality and Safety”
The CQC publication “Essential Standards of Quality and Safety” sets out what health care providers should do to comply with the section 20 regulations of the Health and Social Care Act 2008. The principle is that CQC (and patients) will know that the standards are being met if certain outcomes are being achieved.
Outcome 10 is Safety and Suitability of Premises. This relates to Regulation 15 of the Health and Social Care Act which says:
(1) The registered person must ensure that service users and others having access to premises where a regulated activity is carried on are protected against the risks associated with unsafe or unsuitable premises, by means of—
(a) suitable design and layout;
(b) appropriate measures in relation to the security of the premises; and
(c) adequate maintenance and, where applicable, the proper—
(i) operation of the premises, and
(ii) use of any surrounding grounds,
which are owned or occupied by the service provider in connection with the carrying on of the regulated activity.
(2) In paragraph (1), the term “premises where a regulated activity is carried on” does not include a service user’s own home.
The Outcome that patients should expect if the essential standards are being met is described by CQC as:
People who use services and people who work in or visit the premises:
- Are in safe, accessible surroundings that promote their wellbeing. This is because providers who comply with the regulations will:
- Make sure that people who use services, staff and others know they are protected against the risks of unsafe or unsuitable premises by:
–– the design and layout of the premises being suitable for carrying out the regulated activity
–– appropriate measures being in place to ensure the security of the premises
–– the premises and any grounds being adequately maintained
–– compliance with any legal requirements relating to the premises
- Take account of any relevant design, technical and operational standards and manage all risks in relation to the premises.
The CQC standards include “prompts” for providers to consider when deciding if they comply or not. One of these prompts relates to legionella control, i.e. to be compliant, a GP practice would have to make sure that anyone using their service or premises “can be confident that …the management of risk includes the prevention and control of Legionella”. In appendix B, the CQC lists all the guidance which providers need to take into account; providers “should reflect the key expectations of these publications for their service, as they relate to the essential standards of quality and safety.” Within appendix B, the following documents are listed that relate to legionnaires disease:
- All currently valid Health Technical Memoranda (HTMs) published by the Department of Health
- All currently valid Health Building Notes (HBNs) published by the Department of Health
- Legionnaires Disease: The control of legionella bacteria in water systems, approved code of practice and guidance (Health and Safety Executive, 2000)
- Controlling legionella in nursing and residential care homes (Health and Safety Executive, 1997)
The key one is the HSE 2000 code of practice.
As employers, practices do have to carry out a risk assessment for legionnaires disease. The HSE code of practice states “A simple risk assessment may show that the risks are low and in such case no further action will be necessary. Examples include small, domestic-type water systems where temperatures and turnover are high, or where instantaneous water heaters are used.” Guidance from the HSE makes it clearer: “If you decide that the risks are insignificant, your assessment is complete. You need take no further action other than to review the assessment periodically in case anything changes in your system.” When I drew this to PCT’s attention, they agreed that there is no legal requirement for a third party specialist to carry out an assessment, but added that the assessment should be carried out by a suitably qualified/competent person – this isn’t quite what the code of practice says, it’s that the “duty holder” (i.e. the employer) has to have access to competent help and advice.
CQC is not asking for anything new or different from what practices should already be doing as employers. It is for the practice to assess its risk and take appropriate action.
Legionnaires’ disease and water safety in Primary Care Routine
Information from Matthew Richardson, Specialist Nurse – Infection Prevention and Control.
Primary Care practices have a duty to ensure that their water systems do not pose a risk to the health and safety of employees and visitors from legionella bacteria.
All water systems in Primary Care practices require a risk assessment. However, not all systems will require elaborate control measures and responses and actions should be proportionate to the identified risk. A simple risk assessment may show that the risks are low and being properly managed to comply with the law. It is likely to that most practices will not require anything more than a basic local risk assessment and simple in-house control measures.
This document is a summary designed to introduce Primary Care practices to the requirements around water safety and help practices to determine whether external consultation is proportionate and necessary.
With thanks to West Hampshire CCG for this informaiton.