It is a legal requirement to have a Legionella risk assessment for water systems where there is a duty of care. If there is no risk assessment present the right time to complete one is now!
Once a Legionella risk assessment is in place, the HSE’s ACoP L8 (2013) tells us to review it “regularly” in case any changes have occurred, or there is a reason to suspect the risk assessment is no longer valid.
Legionella Risk Assessment - what does the guidance say?
The HSE has removed the two-year assessment frequency, to align with other similar legislative documents. This encourages us to keep our risk assessments relevant, up-to-date, and proportionate to the risks identified.
The British Standard publication BS 8580-1:2019 describes what a Legionella risk assessment should include. It also describes that the risk assessment should not be a “one-off exercise” and be a “live document”, this supports the ideals laid out in the ACoP L8. It prompts us to act in “anticipation of, rather than in response to, changes”.
The Department of Health document HTM 04-01 tells us that where new healthcare premises are planned or existing premises are to be altered or refurbished, the Water Safety Group [WSG] should be consulted at the earliest possible opportunity, and risk assessments should be completed for all projects.
So all relevant guidance documents are “singing from the same hymn sheet”, Legionella risk assessments should not only be in place, but reviewed regularly, treated as live documents, and updated as required.
A simple way of identifying the need to update your risk assessment is to use the Water Hygiene Centre’s Legionella Risk Assessment Review Tool, which can clearly illustrate how up-to-date your risk assessments are, for each water system or building.
How soon should you complete your risk assessment?
By using a Risk Assessment Review Tool, it is easy to see when a change has occurred and therefore, when the risk assessment is no longer valid.
Some change criteria are easier to identify than others, such as following a case of legionellosis, whereas others, such as a “change in the water system” require extra thought.
Although no guidance states in black and white the answer to this question, perhaps a ward refurbishment, removing a cold water tank, or pressurising the hot water system would constitute a significant change. In these examples, it is easy to pinpoint a time to review and act. Removal of a single wash basin is not a substantial change, but when several small changes have occurred a balance is tipped towards a re-assessment.
In each case, the review criteria are by definition, predicting a likely change in risk assessment findings, which typically will impact your written scheme of control and monitoring and maintenance tasks.
Best practice suggests completing a risk assessment in a timely fashion, especially following a system installation or refurbishment (as advised in HTM 04-01). Identifying risk at the earliest opportunity allows time for review and change minimising the risk exposed to users.
Trying to minimise risk, or undertake “snagging” after the building is brought back into use, can be a costly and highly disruptive exercise. This affects the water system and the operation of the building or area it supplies.
We continue to highlight well-documented risks during the commissioning stages, which could have been easily reviewed and dealt with before opening the building to users, Examples of risks included:
- Flexible hose connections fitted to clinical wash basins behind IPS panels (See photo above);
- Hot water tertiary loops not circulating;
- Insufficient pipework insulation contrary to the design specification;
- Over-storage of cold water;
- Inadequate disinfection and water sampling records;
- Inaccessible assets behind IPS panels due to citing of sanitary ware.
What difference does it make?
As well as the examples above, problems can be caused when a Legionella risk assessment has not been updated in time;
- When any new risk system is identified or where a risk system has changed, the Water Safety Plan or Written Scheme will often need to be updated and a revised regime of checks and inspections applied. Where this does not happen, regular checks are missed which can cause irreparable damage or expensive, time-consuming remediation;
- Where changes have occurred, have hot and cold water storage requirements been re-assessed? Any change in a water system or its use will affect turnover time, which may reduce water flow, increasing the risk of biofilm growth in the system;
- Where a use change has occurred in a building, or the susceptibility of the users has changed, disproportionate control measures may be applied to reduce the residual risk of a system For example, a healthcare building may warrant increased frequency of checks than a general public building;
- The use of an invalid or outdated Legionella risk assessment could lead to an HSE improvement notice.
Conclusion
It is easy to identify the right time to undertake a new Legionella Risk Assessment by undertaking regular reviews.
This will enable you to remain up-to-date and compliant, but also ensure the right control measures are in place in time and resources are not wasted.
We have also learned that renewing risk assessments promptly after a change has occurred can not only save money and disruption later on but more importantly, eliminate any unnecessary Legionella risks at the earliest opportunity.
Editors Note: The information provided in this blog is correct at date of original publication - October 2017. (Revised August 2024).
© Water Hygiene Centre 2024
