Legionella bacteria is quite common but usually exists in relatively low numbers. If allowed to grow and multiply it has the potential to become a health concern. Inhaling contaminated water droplets suspended in the air can cause the potentially fatal, pneumonia-like Legionnaires' Disease. It can also cause the similar but less serious conditions of Pontiac Fever and Lochgoilhead Fever.

Under certain conditions any building's water system could be a potential source for legionella growth. Poorly managed, they can provide an environment where legionella bacteria can flourish.

To effectively manage the risks from legionella Falkirk Council will:

• assess the risks from legionella in all Council properties
• ensure systems are in place to manage the risks from legionella
• audit management systems to ensure they are effectively implemented
• provide employees with appropriate information, instruction and training to safeguard themselves and others
• appoint competent person(s) to provide specialist and technical advice on the management of legionella in Council properties

This How To supports the implementation of the Council's Wellbeing policy and is part of the Council's safety management system.

Chief Executive Officer

The Chief Executive Officer is the ultimate duty holder regarding legionella management within the Council and has responsibility for ensuring adequate management processes including resourcing. This responsibility is further delegated to specific officers engaged in the management of legionella as outlined below:

Head of Investment, Assets & Climate

This role has the delegated responsibility to act as the dutyholder for all operational properties and common areas of housing properties within the Council's portfolio.

Head of Housing & Communities

This role has the delegated responsibility to act as the dutyholder for all housing properties within the Council's portfolio.

Housing Operations Manager

Is the Council's Responsible Person for legionella management in housing properties within the Council's Portfolio and is responsible for:

• Ensuring risks associated with legionella in these properties is adequately assessed
• Ensure tenants are informed of any risks and any basic precautions they need to undertake

Property Compliance Manager

Is the Council's Responsible Person for Legionella Management in Operational Premises. In addition to, for operational properties, they will:

• Ensure there is a legionella risk assessment program in place
• Ensure that contractors undertaking work regarding legionella and water systems are appropriately competent and monitored
• Provide performance reports on Legionella Management to the Property Compliance Board, as agreed with the Head of Investment, Assets and Climate
• Ensure legionella risk assessments are appropriately maintained and provided to Premises Managers
• Ensure a Planned Preventative Maintenance programme for legionella management is in place for operational buildings
• Ensure an audit programme for the Premises Managers Handbook is in place which covers legionella management
• Lead the response to confirmed or suspected Legionella outbreaks and instances where significant failures in Legionella management arrangements are identified.

Maintenance and Facilities Manager

The Maintenance and Facilities Manager will ensure that:

• Relevant works undertaken at their direction meeting the requirements in the Design section of this document.

Construction and Design Manager

The Construction and Design Manager will ensure that:

• Relevant works undertaken at their direction meeting the requirements in the Design section of this document.

Manager (Asset Management)

The Manager (Asset Management) will ensure that:

• Any responsibilities for leased commercial properties are established in the relevant lease document and communicated to relevant parties.

Legionella Compliance Officer

The Legionella Compliance Officer will:

• Ensure legionella risk assessments meet the requirements of Falkirk Council
• Ensure a written scheme of control is prepared for each premises
• Develop and maintain a Legionella Management Plan for these premises
• Act as the Council's competent person for legionella management

Facilities (Soft FM)

The Facilities Manager (Soft FM) will:

• Ensure there is an appropriate regime for routine legionella checks in Educational buildings (schools and ELCs) during periods of prolonged shutdown (such as school holidays)

Premises Managers

Premises managers play a key role in the onsite management of legionella. They will:

• Ensure they have access to the most current version of the premises legionella risk assessment
• Ensure routine checks for legionella management as outlined in the Premises Managers Handbook are completed
• Allow access to contractors for works related to legionella management

Employees

All employees have a duty to assist the Council is discharging its statutory health and safety obligations and will enable the implementation of this How To where identified as appropriate. Additionally, where an employee has control over an asset (such as a vehicle wash bay) that is covered under Legionnaires' Disease – Technical Guidance – Part 3, they must ensure that appropriate management arrangements are in place to comply with this information.

The Property Compliance Manager is responsible for ensuring competent person(s) are appointed to provide specialist and technical advice on the management of Legionella for Council workplaces.

The Property Compliance Manager will ensure a current Legionella risk assessment is available for all Council workplaces. The most current Legionella risk assessment will be made available electronically to Premises Managers and other relevant employees as required.

The risk assessment process will include:

• an appraisal of the maintenance records to confirm that the water system(s) have been serviced at appropriate intervals and any remedial actions completed within a reasonable timescale
• an appraisal of how effectively duty holder responsibilities have been allocated
• an appraisal of the competence of individuals with any involvement in Legionella management on the premises
• an appraisal of the Legionella management activities routinely carried out at the premises
• a visual inspection of the system to identify possible sources of contamination

The findings of the risk assessment will be detailed in a report and include:

• the scope of the risk assessment and a description of the premises, its occupancy and the system(s) assessed
• the qualifications and experience of the assessor(s)
• details all duty holders responsible for, and those who carry out, routine Legionella management activities
• a schematic diagram of the hot and cold water system(s) identifying:
• mains water inlets and drinking water supplies
• cold water storage tanks
• hot water generation and storage vessels
• hot and cold water outlets
• little used outlets
• drinking water outlets
• sentinel points on each system
• showers and any aerosol generation
• dead legs
• external taps
• a summary of risks identified, their risk rating and recommendations for remedial or corrective actions
• practical, prioritised recommendations for any additional controls or improvements needed to existing controls to reduce any risks identified to as low a level as is reasonably practicable
• a recommendation for whether microbiological monitoring is required and, if so, the frequency of sampling
• training requirements for those responsible for carrying out regular Legionella management activities; including the frequency for refresher training
• a recommendation for how often the risk assessment should be reviewed

Where Falkirk Council has leased a non-domestic property to another party the Manager (Asset Management) will ensure that any responsibilities regarding Legionella risk assessments are clearly defined in the lease.

The Premises Manager will ensure they are able to access the most current Legionella risk assessment. If they do not have a current Legionella risk assessment available, they should contact the Property Compliance Manager to ensure that one is conducted.

Design

Any modifications to existing water systems or installation of new water systems will be designed, managed and maintained to comply with:

• The Construction (Design and Management) Regulations 2015
• The Building Regulations 2010 (and associated amendments)
• The Water Supply (Water Fittings) (Scotland) Byelaws 2014
• The Private Water Supplies (Scotland) Regulations 2006
• BS EN 806 (Parts 1–5) – Specifications for installations inside buildings conveying water for human consumption
• BS 8558 – Guide to the design, installation, testing and maintenance of services supplying water for domestic use within buildings and their curtilages
• CIBSE Guide G Public Health and Plumbing Engineering

This will be the responsibility of the Construction and Design Manager or the Facilities and Maintenance Manager depending on the scope of the works. Where the Council has leased a non-domestic property to another party the Manager (Asset Management) will ensure that any responsibilities in relation to modification of water systems are clearly defined in the lease.

Planned Preventative Maintenance

Maintaining the condition of water systems is important to prevent legionella bacteria from flourishing. A programme of planned preventative maintenance will be put in place. Records of planned preventative maintenance carried out will be maintained and readily available (see Record Keeping).

Managing legionella in other risk systems

Where the Council utilises other risk systems for legionella (for example, emergency showers, spa pools, whirlpool baths or vehicle wash bays) the employee in control of the relevant systems must ensure that it is either covered in a legionella risk assessment for an operational property or make appropriate arrangements to ensure it is managed effectively in line with the requirements of Legionnaires' Disease – Technical Guidance – Part 3 (see Maintenance for spa baths, pools and other water systems).

Microbiological Monitoring

Microbiological monitoring will be carried out:

• where there is any indication that management controls are not being carried out effectively
• if appropriate temperatures are not being consistently achieved throughout the system
• if there has been an incident involving legionella, water quality or any damage to the water system(s)
• as recommended by a Legionella risk assessment

At Council workplaces the Premises Manager will ensure arrangements are in place to carry out the following regular checks of the water systems, as detailed in the Premises Manager Handbook:

• weekly flushing of little used outlets
• monthly temperature checks at hot and cold sentinel points
• monthly temperature checks at calorifier(s)

The Premises Manager will also ensure records are maintained on the EVOTIX Assure system and any faults or where temperatures are not being consistently achieved are reported to Property Repairs via the PROFESS system as detailed in the Premises Manager Handbook.

The risk of Legionella multiplication increases in schools during holiday periods when buildings are closed, or their use is greatly reduced. The Facilities Manager (Soft FM) will ensure arrangements are in place to carry out temperature checks and flush little used outlets at appropriate intervals during holiday periods.
Where the Council has leased a non-domestic property to another party the Manager (Asset Management) will ensure that any responsibilities in relation to routine checks of water systems and remedial actions are clearly defined in the lease.

All employees with responsibilities for Legionella Management should have a clear understanding of their role. The Property Compliance Manager and Housing Operations Manager Appropriate will ensure that appropriate training is made available to employees who require it.

Line Managers will ensure relevant information, instruction and training is provided to any employee whose role is likely to involve any aspect of Legionella management.

At Council workplaces the Premises Manager will ensure that those responsible for carrying out the regular legionella management activities (see Routine Premises Checks) complete the training as detailed in the premises' Legionella risk assessment. The Premises Manager will also ensure refresher training is carried out at appropriate intervals.

Auditing

The Property Compliance Manager will implement a programme of audits to monitor whether Legionella management control measures are being effectively implemented within Operational Premises.

The Property Compliance Manager will identify any remedial or corrective actions needed where any failures in Legionella management control measures are identified. Remedial and corrective actions will be recorded on the EVOTIX Assure system.

Service Directors will ensure remedial or corrective actions are completed.

Line managers will ensure that records of all initial and refresher training, and their dates, are maintained and are readily available.

Records of Legionella risk assessments, monitoring, maintenance and repairs of water systems are maintained and are readily available. For Council workplaces the Building Design Manager is responsible for ensuring arrangements are in place for maintaining records. For all Council housing stock this will be the responsibility of the Property & Asset Manager.

The Premises Manager will ensure that records of routine premises checks (see Routine Premises Checks) are maintained and are readily available. These checks will be recorded in the SHE Assure System.

The Property Compliance Manager will ensure that records of Premises Manager Handbook audits are maintained on the EVOTIX Assure system and are readily available.

Records will be held in line with the Council's records retention scheme.

Incident Management

Where a known or suspected outbreak of Legionnaire's disease associated with an operational Premises or significant failures of planned preventative maintenance or routine premises checks is identified, the Property Compliance Manager will convene an incident management team (IMT). This team will include: the Property Compliance Manager, Legionella Compliance Officer, relevant Premises Manager and other identified relevant individuals able to contribute effectively.

The role of the IMT will be to the most effective approach to managing and rectifying identified issues and any required reporting to external bodies (such as the Health & Safety Executive).

The Housing Operations Manager will ensure risks associated with housing properties are assessed and relevant information related to these premises regarding legionella management is communicated to tenants. 
 
The risks identified by the risk assessments for residential settings are likely to be low; in which case no further action may be necessary. Where the risk assessment identifies that a system of routine checks is required the Housing Operations Manager will ensure these are put in place. 
 
For all Council housing stock this will be the responsibility of the Housing Operations Manager.

Hot and cold water services should be cleansed, flushed and disinfected in the following situations:

• on completion of a new water installation or refurbishment of a hot and cold water system  
• following installation of new components, especially those which have been pressure tested using water by the manufacturer (see the manufacturer's instructions)  
• where the hot and cold water is not used for a prolonged period and has not been flushed as recommended or the control measures have not been observed  
• where routine inspection of the water storage tanks shows evidence of significant contamination or stagnation  
• if the system or part of it has been substantially altered or entered for maintenance purposes  
• following water sampling results that indicate evidence of microbial contamination of the water system  
• during, or following an outbreak or suspected outbreak of legionellosis linked to the system  
• where indicated by the risk assessment