The private or independent healthcare sector is largely made up of hospitals and clinics which are run independently of the National Health Service [NHS]. They are normally run by a commercial company, although some of these are also run by charities or other non-profit organisations.
Private Healthcare sites may also include mental health facilities, rehabilitation centres, care homes and many other types of site specific facilities.
Despite Covid-19 being the overwhelming healthcare concern in the UK and Worldwide since early 2020, Legionnaires' Disease prevention must remain a key concern to Private Healthcare providers.
A significant recent example of a Legionnaires' Disease incident involved BUPA and the associated consequences of local Legionella risk management failings - https://www.bbc.co.uk/news/uk-england-essex-44483283
Regulation and Guidance
In common with all non-healthcare businesses, private healthcare operators have a duty of care to protect residents, staff, visitors and anybody else who may be affected by their undertaking from foreseeable risks to their health, safety and wellbeing.
All Health estates are assessed against a set of legal requirements and governance standards – the associated principles of health and safety are enshrined within the Health and Social Care Act 2008 [Regulated Activities], Regulations 2014 and specifically Regulation 12[h] and Regulation 15 of the Act. Failure to comply with the aforementioned ‘Regulation’ or ‘Act’ is an offence and as such the CQC have ‘enforcement powers’ to ensure compliance to accepted standards. Such enforcement powers include: issuing time-defined warning notices, prosecution and cancelling a provider’s registration – removing its ability to provide regulated activities.
Despite Legionella risks being ever present for providers, extensive guidance is available. Health Technical Memorandum [04-01] sets out the standards for water safety within health estates by acknowledging within its three parts [A, B and C] the regulatory requirements of the Health and Social Care Act as well as the role of the Health and Safety Executive [HSE] for the safe management of healthcare estates.
There are many commercially run private healthcare sites and the skills and competencies of staff within these varying sites may well be adequately specialised and relevant to ensure good water hygiene management practices are implemented, alternatively, staff may also have a more general managerial skill set and be unlikely to possess a specialist knowledge in water systems safety.
So, can we simply identify the measures within a checklist to provide assurance both individually at site level and at a more strategic level? Regardless of the level of care or the standards to be applied, the key to managing Legionella risk is the implementation of the following five steps, as advocated under the HSE’s Approved Code of Practice [ACoP] L8:
- Appoint a manager to be responsible for others;
- Identify and assess sources of risk
[i.e. carry out Legionella risk assessments];
- Prepare a scheme to prevent or control risk
[i.e. a water safety plan];
- Implement, manage and monitor the scheme of precautions;
- Keep records of the precautions.
In their most skeletal form, the aforementioned five steps are no less fundamental to an individual property or organisation’s safe operation today than when initially documented in earlier editions of ACoP L8. The document elaborates on these points whilst also detailing specifically the nature and make up of a ‘Written Scheme’ or in healthcare parlance, the ‘Water Safety Plan’:
- For preventing or controlling the risk from exposure;
- Ensuring proper implementation and management;
- Specifying measures undertaken to ensure that it remains effective.
More recently BS8680:2020 Water Quality – Water Safety Plans – Code of Practice has been issued to provide unequivocal recommendations and guidance on the development of a Water Safety Plan [WSP]. The standard is intended to be used as a code of practice to demonstrate current good practice and compliance and private healthcare providers should now be looking to integrate the document’s evolutionary approach into their own water compliance system.
At a Local Level What Should Be Undertaken?
Private Healthcare providers may also follow a basic checklist for reducing the risk from Legionella [and other waterborne pathogens] in association with the aforementioned HSE and DoH guidance:
- Have specifically appointed person[s] responsible for Legionella [water safety] control;
- Ensure the current Water hygiene risk assessment is available at local level, understood by the appropriate manager[s] and with a management plan in place to act on any findings;
- Ensure a logbook system is in place detailing the site’s communication pathway, planned preventative maintenance tasks undertaken and frequencies, including records, contingency measures and any other relevant information. Note: the logbook system should be appropriate to the site it concerns;
- Ensure all identified relevant person[s] have sufficient legionella training and experience to be able to carry out the role competently and other relevant staff are trained to be aware of the importance of their role in controlling Legionella;
- Keep hot water hot and circulating at all times: 55°C - 60°C throughout the entire hot water system;
- Keep cold water cold at all times. It should be maintained at temperatures below 20°C throughout the system to all outlets [this may not be possible when the ambient temperature is high, but every effort should be made to ensure that cold water entering the premises and in storage remains as cold as possible];
- Run all outlets including showers in all areas [healthcare or otherwise] for several minutes to draw through water [until it reaches the temperatures stated in points 5 and 6)] at least twice a week [or daily if augmented care area] if rooms are unoccupied, and always prior to occupation;
- Keep shower heads/hoses, taps and other facilities dispensing water clean and free from scale;
- Clean, drain and disinfect hot water generators on an annual basis;
- Clean and disinfect all water filters regularly, as directed by the manufacturer, at least every three months;
- Inspect water storage tanks and visible pipe work routinely. Ensure that all coverings are intact and firmly in place, and disinfect with 50mg/l chlorine and clean based on condition;
- Ensure any TMV’s installed are suitably inspected and maintained on a 6 monthly basis;
- Identify any ‘other’ system via the current water risk assessment and ensure relevant PPM tasks are implemented;
- Ensure that when carrying out system modifications or new installations they do not create pipework with intermittent or no water flow, and disinfect the system following any work;
- Keep records of all water systems reading such as temperature, pH and chlorine concentrations and ensure they are checked regularly by the appropriate manager;
- Consider and undertake microbiological sampling to aid demonstration of monitoring compliance and safe water systems.
*The aforementioned checklist is not exhaustive and is more appropriate for smaller sites. Healthcare sites of significant size would require a significantly more detailed approach.
In summary, we may ask ourselves if we have learnt our lesson since the mid-1970’s when Legionnaires' Disease first came into public consciousness. Simply put, despite the wealth of straightforward health and safety advice both from regulators such as the Health and Safety Executive, learned societies and other Healthcare industry bodies, this largely avoidable disease continues to be a concern for Estates and Facilities Managers and occupiers alike.
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Editor’s Note: The information provided in this blog is correct at date of original publication – May 2021
© Water Hygiene Centre 2021