Plumbing equipment manufacturer reminds facilities managers they can automate some Legionella prevention
An outbreak of Legionnaires disease in the West Midlands has prompted a plumbing equipment manufacturer Intatec to remind facilities managers that Legionella precautions can be automated. As lockdown eases, many businesses are encouraging people back into the workplace with multiple COVID precautions, but there could be another bug lurking waiting to claim unsuspecting victims and that’s Legionella. Domestic and commercial water systems are designed to combat the microbes and bacteria that thrive in tepid water, but the systems rely on hot water being stored over 60 degrees and all hot and cold taps being used regularly. Stuart Gizzi, managing director at Intatec, says: “It’s upsetting to learn that people are getting ill from Legionella when it is so very easily preventable. The early symptoms are similar to COVID, so for anyone suffering from it, there’s an extra worry. It’s a serious disease that has a 10% fatality rate. “We don’t know the circumstances around the West Bromwich outbreak, and Dr Adrian Philips, consultant in communicable disease control at the Public Health England Midlands Health Protection Team has said they don’t currently have a direct link between the cases, but the evidence they have points to the possibility that there is a common source. “Legionella thrives at around 20 – 45 degrees celsius and can occur when taps and showers have been left unused for a considerable period of time, which means washrooms in empty offices are particularly vulnerable after lockdown. “Ideally, caretakers or building managers should really have been running every tap every few weeks, which depending on the size of the building, can be a pretty big job. But there are products that automate the process. Some of our infrared taps can be set to automatically turn on to run enough water through to prevent the build-up of bacteria, even when the hot water systems are off. “Being the first person to use a long-turned-off tap can be risky, but it really shouldn’t be. “Building and facilities managers should take recommissioning buildings seriously and take care of themselves when they’re doing it.” For similar articles please visit our features section.
How can Legionella be prevented in care and nursing homes?
Dave Lancaster from Uponor, provider of total solutions for the safe transportation of water around buildings, discusses the importance of safeguarding patients and residents against the risk of Legionella. Legionnaires’ disease is a serious form of pneumonia, which can result in potentially fatal consequences for vulnerable patients and residents in your care and nursing homes. The illness is caused by Legionella bacteria which is widely distributed in natural water bases such as ponds and lakes , but can also breed in any stagnant water between 25 °C and 45 °C, including hot and cold-water systems. It is imperative that care and nursing homes have a Legionella control scheme in place to help prevent the contamination of water transportation systems within the building. Such measures include temperature control regimes, disinfection measures and regular monitoring and reporting. In line with this preventative action, it is equally crucial that care home managers take appropriate steps to minimise the health risks to patients and residents by doing what they can to reduce the likelihood of Legionella bacteria breeding within a property’s plumbing and heating systems. Danger zones Being aware of ‘danger zones’ in older systems is crucial. This is when ongoing repairs or re-routing of water pipes result in ‘dead-legs’ – runs of pipework that are not commonly in use – or ‘blind-ends’ – lengths of pipe which have been terminated and are no longer in use – lead to the stagnation of water and provide the ideal environment for the breeding of Legionella bacteria. For that reason, it’s important that if you are aware that a length of pipework forming part of your system is rarely used or has been capped off, you take action to have them removed to prevent the spread of potentially deadly bacteria. That said, systems within care homes that have been built more recently are not without risk either. This is because a key requirement of a modern building is to use more efficient water outlets and reduce water consumption, which can often lead to oversized supply pipe work. Unless the pipe network has been specifically designed to adapt to these reduced flows, there is a high risk of stagnant water. Know your pipes When it comes to designing or selecting a new water system with an installer or perhaps by yourself, there are steps you can take to help minimise the risk of Legionella. Traditional copper piping, which will be found in many older systems, can harbour bacterial growth on the internal wall of the pipe. By switching to more modern piping, such as MLCP (multi-layer composite), which has a much smoother internal surface, you can reduce this risk. What’s more, any small crevices where two pipes connect (often seen on more traditional piping methods) can increase a likelihood of bacterial growth, creating the ideal condition to harbour and cultivate Legionella. By opting for modern pipes, which are sealed on the inside and provide a smoother and more hygienic connection, you can further reduce the chance of bacteria growth within the new system. Installation Finally, choosing the correct pipework configuration is also crucial. ‘Loop’ installations flush water through the whole local pipe network every time any water outlet is opened, and is therefore the most effective method for reducing the possibility of Legionella. This type of system also enables the use of a consistent pipe size throughout, requires fewer connections and fittings, and eradicates runs of pipework which are not used, preventing stagnation and subsequently the risk of Legionella bacteria. For more information on preventing Legionella and on Uponor’s range of solutions, visit: uponor.co.uk
Legionella, the care home menace – a coroner’s perspective
Coroner Nicholas Rheinberg writes for Care & Nursing Essentials magazine about the cases he has experienced where Legionella caused the deaths of care home residents, and details his recommendations on how to reduce risks… Should any of us have cause to consider the phenomenon of Legionnaires’ Disease we may possibly think of exotic locations abroad rather than anything that we might encounter locally. The very title conjures up pictures of desert scenes, perhaps with the odd palm tree thrown in for good measure. It may be only a few of us who associate the disease with an otherwise clean, well-run care home, nursing home or hospital. However, these are just the places where without proper precautions the legionella bacteria may thrive. “The bacterium Legionella pneumophila and related bacteria are common in natural water sources such as rivers, lakes and reservoirs, but usually in low numbers. They may also be found in purpose-built water systems such as cooling towers, evaporative condensers, hot and cold water systems and spa pools.” Alarmingly, a mains water supply may also contain legionella bacteria but whether or not this is so, any water supply may become contaminated with the bacteria. Once colonised within a water system, the bacteria will multiply at temperatures ranging from 20 to 45 degrees centigrade. It does not take a genius to realise that designing a water system to dispense water at 38 degrees centigrade so as not to scald a care home resident creates the ideal temperature to allow legionella to multiply. TMVs (thermostatic mixing valves) unless regularly cleaned and treated may be found to house colonies of legionella. The disease is contracted by breathing in droplets of water contaminated with Legionella. An aerosol effect is created when, for instance, a shower is run or even a tap turned on, allowing an individual in close contact with the water spray to inhale the bacteria. Certain individuals are more susceptible to the disease than others. The elderly, those with a compromised respiratory system or immune system are particularly at risk – in other words the typical resident of a care or nursing home. Unfortunately, the water systems in most care and nursing homes are rarely designed with legionella control and prevention in mind. Typically long lines of hot and cold water piping will be laid out in parallel with the inevitable result that hot water pipes are cooled by the cold water pipes and cold water pipes are heated by the hot water pipes rendering both liable to achieve temperatures at some point in the run within the 20 to 45 degree range. Homes espousing green credentials may use solar panels to pre-heat water but the resulting reservoir of water may well be maintained within the critical temperature range. Allowing water to stagnate creates a particular danger and so a room that is kept empty for any length of time, a toilet that is not regularly flushed or a shower that is used only occasionally may allow legionella to breed at dangerous levels. Reducing the risk of Legionella During my time as a coroner, I have had the sad duty of holding inquests into the deaths of individuals who have died of Legionnaires’ disease in what up to the time of disaster appeared to be an entirely safe domestic setting. And so what must you do as an owner or manager of a home? The HSE provides a wealth of practical advice, including the need to carry out risk assessments ensuring that as far as possible the risk is properly monitored and managed. Temperature monitoring is especially important. Legionella is dormant at temperatures under 20 degrees and is killed at temperatures over 60 degrees. If there is a suspicion that legionella may be present it may be wise to have water samples tested. This is an area where specialist input has the potential to save lives. There are many companies offering advice and assistance in relation to legionella prevention and control and arranging for such a company to inspect a home’s water system and training staff may prevent disaster and avoid the ordeal of the scrutiny of a coroner’s court and the possibility of prosecution by the Care Quality Commission to say nothing of the knowledge that your lack of appropriate precautions may have led to the death of someone in your care. by Nicholas Rheinberg, LL.B, LL.M, M.A, Dip Crim (cantab), Coroner
The Control of Legionella in Care Homes
Introduction The term ‘care home’ may be used to describe a wide range of properties of varying size and complexity catering for people with a wide range of needs. Whilst care providers tend to specialise in a particular group or type of residents, the common factor is that these establishments provide residential accommodation in an environment that caters specifically for those who are less able to live independently and care for themselves. These include homes for the elderly, physically disabled, children with special needs and those with mental health needs. Nursing homes are a special type of care home with the ability to provide more advanced levels of medical care. Care homes may be run independently or as part of a group. There are many commercially run homes but there are also homes run by charities and local authorities. Often care home managers are very specialised in the type of care provided, alternatively they may also have a more generalist managerial skill set. In both cases they are unlikely to possess a specialist knowledge in water systems safety. Like other businesses and service providers care home 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. Vulnerable Residents Due to the nature of care homes residents are often vulnerable to a wide range of risks. This includes the risk posed by waterborne pathogens and scalding by hot water. Legionnaires’ disease and other waterborne pathogens are more of a threat to older people and those with underlying health concerns. With respect to scalding, guidance from the HSE tells us that “those at risk include children, older people, people with reduced mental capacity, reduced mobility, a sensory impairment, or people who cannot react appropriately, or quickly enough, to prevent injury.” Complex Water Systems Care homes often require bigger and more complex water systems than typical households due to the number of residents and the components and services needed e.g. size and complexity of the building, multiple en-suite facilities, assisted bathrooms, commercial grade catering facilities, high rate of hot water consumption during periods of peak demand. Larger and more complex water systems can be more difficult to keep under control and represent a greater potential for problems. Standards? The HSE’s Approved Code of Practice [ACOP] “Legionnaires’ disease, the control of Legionella bacteria in water systems”, L8 [4thEdition], applies to all duty holders that own or operate equipment or systems where there is a reasonably foreseeable risk of expose to Legionella bacteria. Due to the vulnerable populations and more complex water systems the standards and the control measures applied to care homes may need to be more involved than those applied to other establishments such as schools and offices, for example. Of course, any organisation that undertakes medical services or procedures should look to the specific healthcare guidance contained in the Department of Health’s Health Technical Memorandum [HTM] 04-01. It could be argued, however, that most care homes occupy a middle-ground between general-needs accommodation and healthcare. What needs to be in place? Regardless of the level of care or the standards to be applied, the key to managing the risk is the implementation of five key steps, as advocated under the HSE’s Approved Code of Practice [ACOP] L8: We have looked at these requirements in previous blogs, please follow the links provided for more information. It is the risk assessment that identifies the level of risk and therefore informs the written scheme and the control measures defined within it. The assembly of a competent risk assessment team is therefore of paramount importance. The team should comprise both care professionals and water hygiene specialists to understands not only water system installation but also the operational requirements and user profile. What can go wrong? A quick round up of related news articles reveals that water hygiene problems are not uncommon in care home environments. The summary below links to some interesting articles and highlights the deficiencies reported in each case: Failure to appoint a ‘Responsible Person’: Reports stated that the management at St Christopher’s Hospicein Sydenham had failed to appoint a competent person to manage the risk from Legionellosis. A patient died from Legionnaires’ disease and a worker at the hospice who also contracted the disease spent 18 days in a coma. This is a poignant reminder that Legionnaires’ disease does not only affect the most vulnerable individuals. Inadequate Risk Assessments: A water treatment company were prosecuted for providing inadequate risk assessments to care homes in Wales. Nursing homes were rated as low risk, and there was no evidence that regular temperature readings were taken. DEBA UK were fined £24,000 and ordered to pay full costs of over £17,000 In another unrelated example a care home failed to comply with an improvement notice that required a risk assessment to be carried out. Mother Redcaps Care Home Ltd were ordered to pay over £40,000. Devise, implement and manage a scheme of control measures: Following the death of a resident in an elderly persons’ care home run by Reading Borough Council, an HSE spokesperson indicated that the council’s failings were “systemic” and that “the control and management arrangements were not robust, and the legionella training of key personnel fell significantly below the required standard”. Similarly, in this report BUPA were fined £3m after failing to implement measures to monitor and control hot and cold water systems during refurbishment works. Selecting and monitoring contractors: In this final example, Four Seasons Healthcare had engaged a specialist contractor to maintain the hot and cold water systems, however, they admitted to not having undertaken any checks on the contractors “level of technical expertise” and were fined £600,000 for safety breaches. Click here to read another article that provides further details.
Compliance is in the air – and water
Did you know it’s a legal requirement to provide clean fresh air and water to your residents? Gary Nicholls, MD of Swiftclean Building Services, and co-author of TR/19, the widely recognised industry guide to ventilation hygiene, outlines what you need to do to comply. When running a care home, you have several legal responsibilities that may not be immediately obvious. Several of these are concerned with your air and water supplies. Legionnaires’ disease is a ‘flu-like illness, caused by water-borne legionella bacteria, and to which the elderly, frail or infirm are particularly vulnerable. Some people will recover from it, but it can be lethal. In order to ensure a safe, clean water supply you must comply with the requirements of L8, Approved Code of Practice and guidance for the control of legionella, issued by the HSE. You also have a legal duty under Control of Substances Hazardous to Health Regulations 2002 to provide a safe environment for employees as well as residents and visitors. Care homes which have served other purposes in the past are particularly vulnerable to outbreaks of legionella, often because the plumbing system has been changed and adapted over the years to accommodate the new purpose. You must be sure that there are no ‘dead’ areas in the system where water does not circulate freely. You must, by law, have an up to date risk assessment for legionella, and it is wise to review this regularly. Any pipework, taps or showerheads that have not been used for more than a week, perhaps while a room is unoccupied, must be flushed through before use again, without causing undue spray to occur. Water tanks must also be kept clean and adequately screened from the effects of solar gain. Tepid water provides an ideal breeding ground for legionella. Tanks should be cleaned regularly and any rust, debris, birds or rodents removed. If necessary the tank should be disinfected, refurbished or replaced to ensure a clean water supply. Water from your system in some cases should be tested regularly to detect the presence of legionella. All work must be carried out in accordance with Legionella Control Association (LCA) code of conduct. The penalties for negligence in legionella control are severe; limitless fines for the organisation and, if neglect is proven, a possible custodial sentence for the responsible person. Another essential area for compliance is the annual testing of fire dampers. These are sets of steel louvres which are installed within ventilation ductwork at the point where the ductwork passes through a fire-resistant rated internal wall. The opening in the wall creates a potential opening through which fire can travel, using the ductwork as a channel. The louvres should shut automatically to close off this route, delaying or halting the fire, so there is time to evacuate residents and staff to safety. Because they are a potential lifesaver, you must have fire dampers tested annually, in accordance with BS:9999. Your kitchen extract ductwork is also a potentially serious fire hazard. As food is cooked for your residents, airborne fat, oil and grease travel through the extract ductwork. As it cools, it leaves grease deposits on the insides of the ductwork. A surprisingly thin layer of this grease can represent a fire hazard. The grease itself can fuel a fire, while the ductwork provides a chimney through which it can spread to other parts of the building. The grease layer must be controlled within an average of 200 microns across the surface of the ductwork; this is about half the thickness of an average business card. Even an otherwise spotless kitchen can harbour grease deposits within the ductwork, so it must be removed regularly, in accordance with TR/19, the leading guidance document for ventilation hygiene, which is issued by the Building & Engineering Services Association (BESA.) TR/19 contains handy tables to tell you how frequently your ductwork should be cleaned, depending on the rate of grease build-up or initially on how often and for how many hours the kitchen is used for cooking. In a care home, there will obviously be a fairly high demand for meals and consequently, quite heavy use of the kitchen. It is essential that the kitchen ductwork is also accessible for TR/19 compliance cleaning, so if there are insufficient access points, you may need to have additional access doors retrofitted. Your laundry extract system may also pose a fire risk. During the drying process for bedding, clothes and other items, lint, fibres and dust collect in the ventilation ductwork for the driers. An accumulation of dust, lint and fibres is highly flammable and drier extract fires are all too frequent in the UK. These fibrous deposits must be removed on a regular basis, this time in compliance with Regulatory Reform (Fire Safety) Order 2005, in order to minimise this fire risk. If you have a mechanical ventilation system, that should also be cleaned regularly in accordance with TR/19, simply to ensure fresher air and a healthy indoor environment. This also requires you to classify your ventilation systems according to the function they serve as high, medium or low. If you have a clinically sterile area, this would probably need a high classification, while bedrooms and living areas would be medium. A boiler room might need a low classification. To provide ventilation, kitchen extract or laundry ductwork cleaning you will need a specialist provider, especially if additional access doors are required to be retrofitted. As compliance in these areas is a legal responsibility, you must have your compliance clearly documented. You may need this evidence in your defence, should the worst ever happen. It is worth bearing in mind that where there is negligence proved, your insurance company is unlikely to pay out, so it may be impossible to continue your business. We provide robust documentation of all our services. This includes before and after photography so you can demonstrate that you have complied with your legal responsibilities. You may need this as a defence against prosecution. You should always
