Water Safety Policy

Water Safety Policy

Version Tracking

Contents

1.INTRODUCTION

2.PURPOSE

3.SCOPE

4.DEFINITIONS

5.DUTIES AND RESPONSIBILITIES

Trust Board

Chief Executive

Board Level Director (Medical Director)

Head of Infection Prevention (Trust Responsible Person),

Director of Redevelopment

Authorising Engineer (Water) [External Specialist]

Competent Person (Water)

The Hospital Company (THC)

Carillion Services Ltd (CSL) (representing The Hospital Company; THC)

Local Management

6.PROCESS

7.TRAINING REQUIREMENTS

8.REFERENCES AND ASSOCIATED DOCUMENTATION

9.EQUALITY IMPACT STATEMENT

10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

QUICK REFERENCE GUIDE

This policy must be followed in full when developing or reviewing and amending Trust procedural documents.

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

1.The Trust Board, Chief Executive and Medical Director hold accountability and responsibility for water safety in the Trust

2.Responsibility is devolved in line with delegated authority to the Director of Redevelopment and Head of Infection Prevention.

3.Appropriate levels of investment in the estate and personnel to facilitate the implementation of suitable water safety precautions will be identified and deployed.

4.A programme for the assessment and review of water safety riskswill be developed and implemented.

5.Appropriate Water Safety Plan(s), procedures and control measures to mitigate water safety risks will be developed and implemented.

6.A programme of appropriate water safety training will developed and implemented for all relevant staff.

8.The Trust will co-operate with all other organisations, including the Hospital Company and Carillion, who own or occupy facilities also occupied by the Trust.

1.INTRODUCTION

Portsmouth Hospitals NHS Trust is responsible for ensuring that the facilities within which its patients are treated and its staff and visitors occupy are as safe as reasonably possible for risk arising from the water systems.

This Water Safety Policy document sets out the Trust Board’s intent not only to satisfy its legal obligations, but to clearly define the roles, responsibilities and management arrangements to ensure minimum impact from water safety risks.

2.PURPOSE

The Trust Board is committed to:

a)Providing an environment that is safe and that minimises water safety risks for all patients, visitors and staff

b)Minimising the likelihood ofwater safety risks occurring.

c)Complying with relevant water safety and quality legislation.

d)Complying with mandatory and best practice guidance where reasonably practicable.

The Trust Board will:

a)Discharge its responsibilities as a provider of healthcare to ensure that suitable and sufficient governance arrangements are in place to manage water safety related matters.

b)Set in place a clearly defined management structure for the delivery, control and monitoring of water safety measures.

c)Provide appropriate levels of investment in the estate and personnel to facilitate the implementation of suitable water safety precautions

d)Facilitate the development of partnership initiatives with stakeholders and other appropriate bodies in the provision of water safety where reasonably practicable.

The Trust Board expects those tasked with managing aspects of water safety to:

a)Diligently discharge their water safety responsibilities as befits their position.

b)Set in place a programme for the assessment and review of water safety risks.

c)Develop and implement appropriate action plans, procedures and control measures to mitigate water safety risks.

d)Develop and disseminate appropriate guidance and training to staff and other stakeholders.

Develop and implement monitoring and reporting mechanisms appropriate to the management of water safety

The Trust Board will monitor the implementation of this policy through:

a)Periodic review of water safety risk assessments and reports.

b)Reports and recommendations from the Trust Water Safety Group

Periodic third-party water safety audit and report by the Trust’s Authorising Engineer (Water), AE(W) .

3.SCOPE

This water safety policy will be implemented throughout all premises, or parts of premises, that the Trust owns or occupies, or for which the Trust is responsible.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

4.DEFINITIONS

Water Safety

Aspects of the chemical, physical and microbiological condition of water supplied for domestic purposes (including consumption) and process requirements which has the potential to cause harm to human health.

Authorising Engineer (Water)

A professionally registered, qualified and suitably experienced person who is independent of the organisation(s) in the capacity of advisor in respect of Water Safety.

Responsible Person (Water)

A person named by the organisation(s) as being appointed so, having sufficient authority, competence and knowledge of the installation(s) to ensure that all operational procedures are carried out effectively and in a timely way.

5.DUTIES AND RESPONSIBILITIES

Trust Board

The Trust Board has overall accountability for the activities of the organisation, which includes water safety.

The Trust Board will ensure that they receive appropriate assurance that the requirements of current water safety legislation and the objectives of Department of Health water safety guidance are being met.

The Trust Board discharges the responsibility for water safety through the Chief Executive.

Chief Executive

The Chief Executive will, on behalf of the Board, be responsible for ensuring that current water legislation is complied with and where appropriate, Department of Health water safety guidance is implemented in all premises owned, occupied or under the control of the Trust.

The Chief Executive discharges the day to day operational responsibility for water safety through the Medical Director.

Board Level Director (Medical Director)

The Medical Director is responsible for ensuring that water safety issues are highlighted at Board level.

This responsibility will extend to the proposal of programmes of work relating to water safety for consideration as part of the annual business planning process.

This will include the management of the water related components of the capital programme and future allocation of funding.

At an operational level the Medical Director will;

• Assist the Chief Executive with Board level responsibilities for water safety matters.
• Ensure that the Trust has in place a clearly defined water safety policy and relevant supporting Water Safety Plans and procedures.
• Ensure that all work which has implications on water safety in new and existing Trust buildings is carried out to a satisfactory technical standard and conforms to all prevailing statutory and mandatory water safety requirements.
• Ensure that all water installations and equipment are maintained and tested in accordance with the latest relevant legislation/standards, and that comprehensive records are kept.
• Ensure co-operation between other employers where two or more share Trust premises.
• Ensure through senior management and line management structures that full participation in staff awareness initiatives is maintained.
• Ensure that agreed programmes of investment in water safety are properly accounted for in the Trust’s annual business plan.
• Fully support the Water Safety Group function.

In line with delegated authority, the Medical Director has chosen to devolve these duties to the Head of Infection Prevention and the Director of Redevelopment but accepts that he retains accountability as the Medical Director.

Head of Infection Prevention (Trust Responsible Person),

The Head of Infection Preventionwill undertake to carry out all duties as delegated by the Medical Director.

In addition, the Head of Infection Prevention will be responsible to

• Allocate adequate management time and resources to ensure that the water safety risk is controlled at all times;
• Promote the co-operation of all employees through clear senior management commitment, staff consultation and by the provision of awareness and training programmes;
• Monitor this policy to ensure that objectives are being achieved. It will be reviewed, and if necessary amended in light of legislative or organisational change;
• Monitor performance and continually seek improved performance in the control of the water safety risk.
• Work in close co-operation with all key parties to be able to effectively control risks in relation to risks arising from water systems;
• Ensure appropriate action is taken in the event of an outbreak or suspected outbreak of Legionnaires’ disease.

Director of Redevelopment

The Director of Redevelopment will undertake to carry out all duties as delegated by the Medical Director

In addition, the Director of Redevelopmentwill be responsible to;

• Comply with the relevant requirements of The Health and Safety Commission’s Approved Code of Practice & Guidance, “The control of Legionella bacteria in water systems" - L8 and HSG 274 and Health Technical Memorandum HTM 04-01, “The control of Legionella, hygiene, ‘safe’ hot water, cold water and drinking water systems” as amended;
• Ensure regular review of all systems identified as being at risk from bacteriological contamination and identify, record and risk assess such systems;
• Ensure that schemes are prepared to eliminate or adequately control the risk of bacteriological contamination and to prevent an outbreak;
• Implement, manage and monitor the bacteriological control measures and freely communicate findings to relevant stakeholders;
• Ensure that when any new and refurbished systems are designed, installed and commissioned that they are in line with current good practice guidance to eliminate or adequately control the risk of bacteriological contamination.
• Maintain records of the Legionella control measures implemented for all premises owned or occupied by the Trust.
• Share any suitable information in relation to any 3rd party audits and assessments and work programmes in relation to bacteriological management and control.
• Ensure those persons appointed to carry out the control measures and strategies are suitably qualified, instructed and trained and their suitability assessed.

Authorising Engineer (Water) [External Specialist]

As required an Authorising Engineer (Water) will be commissioned by the Director of Redevelopment to provide specialist support as deemed appropriate.

The Authorising Engineer (Water) will be required to demonstrate competence in their particular field of expertise.

Competent Person (Water)

Installers and maintainers of Water systems will be commissioned by Carillion FM or the Trust and must be able to demonstrate a sound knowledge and specific skills in the specialist service being provided. This may include the installation and/or maintenance of water systems equipment/services such as:

• Water storage tanks, vessels, calorifiers and connecting pipework above and below ground
• Ancillaries such as pumps, valves, meters, heaters
• Sanitary appliances and associated taps, thermostatic mixing valves and other fittings
• Fire fighting services
• Water treatment and filtration installations for domestic, industrial, clinical and process requirements
• The following services might be provided by competent persons;
• Risk assessment and recording of system layout, condition and compliance.
• Installation, maintenance and decommissioning and removal.
• Commissioning, cleaning and disinfection of systems prior to being taken into use following installation or maintenance

The Hospital Company (THC)

In respect of this water safety policy, for the PFI facilities, The Hospital Company (THC) is responsible for:

• The design and construction of appropriate facilities at the redeveloped Queen Alexandra Hospital.
• To appoint and monitor an appropriate and competent facilities management provider to ensure that the PFI facilities provided remain fit for purpose and are maintained in good order and in compliance with the obligations set out in the PFI Project Agreement.
• Cooperating with the Trust Board and its representatives in maintaining a safe environment for patients, visitors and staff and complying with this policy and all relevant water safety legislation and applicable guidance.

Carillion Services Ltd (CSL) (representing The Hospital Company; THC)

In respect of this policy, for the PFI facilities, Carillion Services Ltd is responsible to:

• Appoint a Responsible Person for water as required under The Health and Safety Commission’s Approved Code of Practice & Guidance, “The control of Legionella bacteria in water systems" - L8. Notify the Trust of the appointment.
• Prepare and comply with its operational policy and related procedures, taking account of the requirements of the Trust’s policy and procedures.
• Comply with the relevant requirements of The Health and Safety Commission’s Approved Code of Practice & Guidance, “The control of Legionella bacteria in water systems" - L8 and HSG 274 and Health Technical Memorandum HTM 04-01, “The control of Legionella, hygiene, ‘safe’ hot water, cold water and drinking water systems” as amended;
• Ensure regular review of all systems identified as being at risk from bacteriological contamination and identify, record and risk assess such systems;
• Ensure that schemes are prepared to eliminate or adequately control the risk of Legionella contamination and to prevent an outbreak;
• Implement, manage and monitor the bacteriological control measures and freely communicate findings to relevant stakeholders;
• Undertake the control measures in accordance with the stipulated frequencies and durations.
• Maintain records of the Legionella control measures implemented for all premises covered by the PFI Concession Agreement.
• Compile and maintain detailed and accurate records in respect of all maintenance, repair and other matters relating to water safety.
• The appropriate maintenance of the facilities.
• Competently carry out necessary repairs and remedial works.
• Ensure that when any new and refurbished systems are designed, installed and commissioned that they are in line with current good practice guidance to eliminate or adequately control the risk of bacteriological contamination.
• Share any suitable information in relation to any 3rd party audits and assessments and work programmes in relation to bacteriological management and control.
• Ensure those persons appointed to carry out the control measures and strategies are suitably qualified, instructed and trained and their suitability assessed.
• Cooperating with the Trust Board and its representatives in maintaining a safe environment for patients, visitors and staff and complying with this policy and all relevant water safety legislation and applicable guidance.

Local Management

Matrons, Heads of Service and Departmental Managers are responsible to:-

• Monitorwater safety within their respective workplaces and helping to ensure that contraventions of precautions do not take place.
• Ensure that this document and relevant water safety instructions are brought to the attention of staff through local induction and on-going staff briefings.
• Ensure that nominated staff attend training and briefing sessions as set out in the water safety training matrix (to be developed).
• Notify the Development Team and Infection Control Team of any proposals for ‘change of use’ within their area that may have an impact on water safety.
• Ensure staff at all levels understand the need to report all water fittings that are taken out of regular use.
• Ensure that all water fittings that are not in regular use are part of a documented flushing regime including who is responsible for flushing the fitting.

6.PROCESS

Not applicable to this policy document

7.TRAINING REQUIREMENTS

Suitably qualified staff will be appointed to key roles and will maintain their competence as required through on-going training, development opportunities and where necessary formal CPD.

8.REFERENCES AND ASSOCIATED DOCUMENTATION

Legionnaires' disease. The control of legionella bacteria in water systems

Approved Code of Practice and guidance, Health and Safety Executive 2013 (as amended)

Legionnaires' disease, Technical guidance, HSG274 parts 1,2 & 3, Health and Safety Executive 2014 (as amended)

Health Technical Memoranda (HTM) 04-01 (including addendum) 2013, Department of Health

9.EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

Our valuesare the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace.

Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.

We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Respect and dignity

Quality of care

Working together

No waste

This policy should be read and implemented with the Trust Values in mind at all times.

Water Safety Policy

Version: 1.1

Issue Date: 13 October 2015

Review date: 30 September 2018 (unless requirements change)Page 1 of 10

10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

• Water Safety Group
• Infection Prevention Management Committee

• Water Safety Group
• Infection Prevention Management Committee

This document will be monitored to ensure it is effective and to assurance compliance.