5 Step Guide: Legionella Risk Management - Education Estates Managers

by Daniel Pitcher, on 25-09-2019
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What is the appetite for risk amongst managers of education estates with responsibility for health & safety? We would expect such organisations to operate on the basis that risks to health and safety should be ‘as low as reasonably practicable’. For example, when there is a smashed window, missing or broken paving slab or a blocked fire exit these obvious issues would be fixed promptly to avoid injury to pupils / students, staff and visitors.

However, when managing the Legionella risk within an educational organisation the hazards contained within water systems are not always visible. Moreover, hazards are hidden around the building; lost behind panelling, within the building fabric, under floors, in ducts, in ceiling voids, roof spaces, behind fixtures or furniture and even in your office!


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Legionella is a naturally occurring bacteria that lives in water. When favourable conditions are allowed to develop within buildings the bacteria can proliferate and potentially colonise the water system. When water is used, i.e. a running tap or flushing a toilet, very fine droplets of water are released, known as aerosol, which can carry the bacteria in the air. If a person breathes in aerosol that contains Legionella bacteria they may develop legionellosis, which is a collective term for diseases caused by the Legionella bacteria, such as Legionnaires’ disease, Pontiac fever and Lochgoilhead fever. Legionnaires’ disease is a potentially fatal form of pneumonia to which certain groups are more susceptible than others and, although anyone can catch Legionnaires’ disease, new-born babies, males, smokers, over fifties, immuno-compromised and those with underlying health issues are more at risk.


It is a requirement of the Management of Health & Safety at Work Regulations and Control of Substances Hazardous to Health Regulations that suitable & sufficient management processes, training, risk assessment and monitoring arrangements are in place for health and safety issues, of which Legionella risk management is included.


The HSE Approved Code of Practice [ACoP] L8 and the associated HSG274 Technical Guidance are available for all, especially those identified as being responsible for the management of Legionella.


We’ve prepared a five step guide for managers of educational estates i.e. those responsible for managing Legionella risk within their organisation e.g. school, academy, college or university.


One: Management, Communication & Training.

Inadequate management, poor communication and insufficient Legionella training have been identified as contributory factors when it comes to outbreaks of Legionnaires’ disease. ACoP L8 outlines the need to:

  • Appoint a Responsible Person; who must have sufficient authority, knowledge and competence.

  • Prepare a Written Scheme of Control / Water Safety Plan; which details management roles, responsibilities, communication pathways, Legionella training and operational control processes for water risk systems [including design, operation, monitoring, maintenance].

Education estates managers can take early intervention when it comes to pitfalls of Legionella risk management by attending a quality training course. Training should not only list the requirements of the various legislation and guidance but also provide a practical approach as well. E.g. what does a typical water system comprise, where the potential issues can be found and why do they occur?


Two: Independent Advice

The Management of Health and Safety at Work Regulations state that organisations should have ‘access to competent health & safety advice’. If the required subject knowledge and/or level of competence does not exist within the organisation, then duty holders may seek to employ a specialist adviser to contribute towards overall health & safety management.


These ‘expert specialist advisors’ must demonstrate their own competency and knowledge and be able to demonstrate impartiality, integrity and sound reasoning, with evidence, for any proposed course of action or advise given. To help demonstrate impartiality, this expert specialist advisor could be an Authorising Engineer [Water], acting as an auditor to monitor effectiveness and performance of the educational organisation without the competing influence of commercial interests. The AE[W] can also complete competency appraisals for those involved in the management of Legionella.


Examples of the consequences of taking advice from those with vested interest include a client who was advised that cold water storage tanks should be cleaned every 3 months and the upselling of unnecessary water sampling or water treatment systems.


Three: Legionella Risk Assessments

The findings of the Legionella risk assessment will underpin and define the written scheme of control / Water Safety Plan required to manage the risk of legionella. The need for a suitable and sufficient risk assessment is absolute in order to support the development of an effective written scheme of control.


It is therefore important to choose your Legionella risk assessment provider carefully. The HSE’s ACoP L8 highlights membership of the Legionella Control Association as suitable pre-selection criteria – of which there are over 300 members nationally. A further degree of reassurance can be gained by looking at UKAS accredited risk assessment providers, currently UKAS lists only a handful of companies nationally that are accredited.


Choosing the risk assessment provider wisely can save money, time and effort through potentially ‘hidden’ savings i.e. elimination of inappropriate actions and reduce unnecessary remedial work from those suppliers who have a vested interest.


In our previous blogs we have discussed what a Legionella risk assessment should include and what makes a good risk assessor.


Four: Written Scheme of Control / Water Safety Plan

Formulate a plan for water safety management (aka Written Scheme / Water Safety Plan) that includes:

  • Policy statement including scope and purpose;
  • Details of roles, responsibilities & communication pathways for those involved;
  • Process for ensuring training and competency;
  • Legionella Risk assessment and risk assessment review;
  • Description of the control strategy for safe operation of the water systems;
  • Procedures for carrying out the control strategy;
  • Procedures for monitoring the effectiveness of the control strategy;
  • Contingency procedures for foreseeable eventualities of concern, for example where monitoring shows that the control strategy has not been consistently applied or that it is ineffective;
  • Review process for reviewing the effectiveness of the control measures and management arrangements;
  • Details of the documentation and records to be maintained.


As an example, it may be helpful to consider the requirement for a ‘description of the control strategy for safe operation of the water systems’. What happens to the water system in the buildings during breaks i.e. summer, Christmas or Easter holidays? Some buildings may remain operational throughout the year but others may be vacant or only partially occupied, so how are they managed?


A well thought out Written Scheme of Control is the guide to successful water safety management for the educational organisation.


Five: Water Hygiene Audit

Our final step, Water Hygiene Audit, a key element in successful management! Auditing is often-overlooked; perhaps due to budget constraints and the difficulty in assigning value to the process of an audit? However, in steps 2 and 4 we’ve alluded to auditing in the need for ‘reviewing the effectiveness of the management arrangements and control measures in place’.

An audit completed regularly can provide assurance that matters are in hand and identify opportunities for improving effectiveness or efficiency.

An audit closes the circle providing the link between what we have in place and the goals we set out to achieve.

If you have questions regarding the issues raised above or you would like to speak with one of our consultants please click here to get in touch.

Editors Note: The information provided in this blog is correct at date of original publication - September 2019. 

© Water Hygiene Centre 2019



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About the author

Daniel Pitcher

With 21 years of independent consulting experience, Daniel established the Water Hygiene Centre in February 2009 to be a ‘centre of excellence’ dedicated to independent water safety consultancy. His experience spans auditing, training, development of Water Safety Plans, incident investigations, competent help support and acting as Authorising Engineer [Water] [AEW] for NHS Trusts, Health Boards, Local Government, Universities and Housing Associations.

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