Legionella Policy.pdf - North Somerset PCT

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Contents 1 Purpose page 3 2 Scope page 3 3 Background page 3 4 Responsibilities page 4 4.1 The Chief Executive & Board 4.2 Director of Public Health 4.3 All Employees 4.4 Estates & Facilities 4.5 Health & Safety Manager 5 Water temperature and Legionella bacteria proliferation page 5 6 Intermittently/Infrequently used Outlets and Showers page 5 7 Monitoring and Record Keeping page 6 8 Planned Preventative Maintenance (PPM) Schedule page 6 9 Control Methods page 7 10 Action in the Event of a Suspected Outbreak or Incident page 7 11 Further Information Appendix 1 - Design & Installation of Building Services page 9 Appendix 2 – Legionnaire’s Disease page 12 Appendix 3 – Principal Legislation page 15 Appendix 4 – Guidance page 18 Doc File Reference Issuer: Policy No: Issue Date: Issue No: Review Date: Page: Legionella Policy F&P 239 11/2009 1 12/2010 2 of 20
1. Purpose To provide NHS North Somerset with a safe place of work in which the management and control of Legionella is such that the risk of infection to employees and patients is so far as reasonably practical reduced to a minimum. The overall aim of this policy is to describe the responsibilities undertaken by the PCT and their staff or agents acting on their behalf in the commissioning and maintenance of effective strategies for the control of the risk from Legionella bacteria. Through the arrangements described in the Management and Control Procedures and written schemes, operate and maintain safe water systems in which legionella bacteria are kept to a safe and acceptable limit and maintain compliance with the Health and Safety Executives Approved Code Of Practice entitled Legionnaires' disease: The control of legionella bacteria in water systems (L8). In so doing, fulfill the requirements of the Health and Safety at Work ACT 1974. 2. Scope NHS North Somerset recognises it has statutory responsibilities as an employer and a healthcare provider under the Health and Safety at Work Act, the Management of Health and Safety at Work Regulation and the Control of Substances Hazardous to Health Regulations. The intention is to use the requirements of these regulations as a minimum standard for the prevention of bacteria growth within building and building services and to prevent patients, visitors and staff being exposed to Legionella bacteria. 3. Background Legionella Pneumophila and other bacteria can cause an infection known as Legionellosis. Legionnaire’s disease is a pneumonia that principally affects those who are susceptible, due to age, illness, immunosupression, smoking, etc, and may be fatal. However it is a significant health issue for anyone who is exposed to the aerosols of the bacteria. Legionella bacteria are present in water systems and do not pose a health concern if the appropriate control measures are in place and maintained. The risk from Legionella bacteria increases if the water in the systems is stagnant (i.e. in ‘dead legs’ or when the system in not in use for a period of time) and bio-film can develop on the inside of the water pipes, this biofilm provides nutrients and encourages proliferation of the bacteria. Legionella proliferation can be suppressed by controlling the water temperature and by keeping the flow of water through the system consistent. It is not possible to contract Legionnaires disease by drinking or bathing in contaminated water. The spores of the bacteria have to be airborne and breathed in to cause the pneumonia associated with Legionnaires disease. The PCT recognises its duty of care to its staff, patients and visitors and the responsibility for the environment. Through this policy the PCT intends to carry out all activities in a manner that demonstrates care for staff, patients, visitors and the environment whilst continuing to provide the highest standards of healthcare. Doc File Reference Issuer: Policy No: Issue Date: Issue No: Review Date: Page: Legionella Policy F&P 239 11/2009 1 12/2010 3 of 20
Page 1: North Somerset Control of Legionel
Page 5 and 6: • Receive and review annual repor
Page 7 and 8: Inspection/cleaning of ventilation
Page 9 and 10: Appendix 1 Design and Installation
Page 11 and 12: Air Conditioning Systems and Air Ha
Page 13 and 14: Legionella - The known species The
Page 15 and 16: Appendix 3 Principal Legislation AC
Page 17 and 18: Management of Health and Safety at
Page 19 and 20: Recent research has shown that ther

Legionella Policy.pdf - North Somerset PCT

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