Legionella risk assessments done right

If you are the hotel manager, maintenance manager or property owner you have a legal responsibility and accountability to ensure that occupiers of your premises are suitably protected from water safety risk. You may have appointed, or been appointed as, the Responsible Person. This essential blog is aimed at helping you understand a little more of how a risk assessment can help you and what it must include.

A good risk assessment is a vital part of an effective strategy for the minimisation of risks associated with legionella proliferation in water systems within buildings. In this article we review what a Legionella risk assessment should include to comply with regulations and guidance.

Common failures

There’s nothing new about the concept of Legionella risk assessments but the approach to completing one can vary greatly. When working with clients invariably we review the risk assessments they’ve commissioned with contractors or consultants and often we find the same failings. In practice a report might fall foul of more than one of these mistakes:

Failure 1:  Non-assessment – These come in three types, first we have the “subjective assessment of risk” where there is no structured method of risk evaluation, such as a risk scoring matrix. Another example is the “Flawed assessment of risk”. Often when there is a risk scoring system it can be flawed or illogical, for example many assessors fail to consider occupant susceptibility. The third example may be hard to believe but we have seen examples of so-called risk assessment reports in which there is no indication of risk at all.

Failure 2:  Condition Survey – Badged as a risk assessment, condition surveys are typified by reports that focus on identifying every minor fault or defect and stipulating that all must be rectified regardless of the risk posed in each case, in some cases without a valid indication of risk at all [see Failure 1];  As a Responsible Person you may be encouraged to use the same company to carry out both the risk assessment and any associated remedial works. However, using just one company raises the possibility that the risk assessment will be partisan. For example, the assessor may suggest the need to undertake unnecessary remedial work, knowing this remedial work will result in the sale of additional services. Often these actions pass unquestioned, either due to a lack of time or knowledge on the part of the Responsible Person.

Failure 3:  Asset List – Exactly what it says, this is a catalogue that lists every outlet in the building;

Failure 4:  Wish List – Here the risk assessor places unworkable time scales on the risk minimisation actions and/or fails to properly prioritise their recommendations. BS 8580 indicates that risk assessors should be able to justify all of their actions and prioritise them according to risk, for any identified risk there might be short term actions to manage it and longer term actions to eliminate or reduce it;

Failure 5:  Half-a-job – The risk assessment in which not all risk systems are included i.e. air handling units, swimming pools, spa baths and those other risk systems listed HSG 274 Part 3. It’s important that the scope of the assessment is agreed before work commences.

To avoid these mistakes, it’s important to consider carefully your choice of provider, keeping the delivery of Legionella risk assessments separate from the contract to undertake any subsequent remedial work.

Identification, assessment and review of risks

The HSE reissued ACoP L8 in 2013 followed by the supporting technical guidance known as HSG274, which comes in three parts:

• Part 1 – The control of legionella bacteria in evaporative cooling systems;
• Part 2 – The control of legionella bacteria in hot and cold water systems;
• Part 3 – The control of legionella bacteria in other risk systems.

The ACOP L8 and HSG274 suite of documents, offers advice on managing water systems. Including the need to carry out a risk assessment to identify the risks and the means to control them.  The HSE have detailed a checklist in each of the HSG274 documents outlining the most common requirements when assessing risk, some of the more interesting requirements include:

• Details of management processes;
• Assessment of the training and competence of those associated with risk management and those involved in control and monitoring activities;
• Identification of roles and responsibilities;
• Evidence of proactive management and follow up to the previous risk assessment;
• An assessment on the validity of the schematic diagram.

Plainly, risk assessments are not just looking at water systems! Service providers must ensure that the requirements detailed in the HSG274 checklists are included in their risk assessment methodology.

To further compliment the guidance, the HSE refers to the British Standard Institution’s BS 8580:2010 ‘Water quality. Risk assessments for Legionella control. Code of Practice’.  This standard is applicable to any premises or work activity where water is used or stored that could cause a reasonably foreseeable risk of exposure to Legionella bacteria. The methodology of the standard covers risk assessments completed for the first time, review and auditing of control measures.

Risk assessments completed to BS8580:2010 methodology should include the following:

• An assessment of:
  • occupant susceptibility;
  • management processes;
  • processes for monitoring data;
  • record keeping;
  • inherent risk and actual risk.
• A repeatable means of assessing the level of risk, such as a scoring system or matrix
• A comparison of the assessed risk to the acceptable level of risk
• Recommendations designed to reduce the risk to the ALARP level, as required.

Again, this is not an exhaustive list, but here we’ve highlighted the need to consider the level of acceptable risk. ALARP should be considered for each water system as it may vary. This encourages a more pragmatic approach to managing the risk from Legionella bacteria helping to ensure that resources are neither wasted nor under-deployed

Legionella risk assessment reporting

To complete the process the assessor will prepare a formal risk assessment report. BS 8580:2010 indicates that reporting should involve the following:

1. Firstly, if the assessor identifies any imminent dangers these should be communicated urgently to the responsible person without waiting for the written report.
2. The written report be clear and unambiguous in its findings and should detail:

• • The results of the risk assessment including tests, measurements, checks and recommended remedial works;
  • An explanation of the scope of the assessment;
  • Identify the key people including duty holder and the responsible person;
  • Be sufficiently detailed to allow an understanding of the key issues and actions required to control it the risk;
  • The report should be written in such a way as to be readily understood by the intended recipients.

Managers will primarily be interested in what they need to do following the risk assessment. For this reason, the report should contain detailed recommendations, listed in order of priority with a suggestion of the reasonable timescale for completion. Using this information, a plan can be developed for implementation taking account of the available resources and the requirements of the risk assessment.

Summary

When it comes to these assessments and what they should include, there is clear guidance from both the HSE and BSi that is applicable to all Legionella risk assessments wherever they are carried out. Hospitality & leisure premises are no different in this respect. The manager responsible is required to check the competency of risk assessors, including external service providers. BS 8580:2010 states that the assessor should have “specialist knowledge of Legionella bacteria, relevant water treatment and the water systems to be assessed” and that they “should be able to demonstrate impartiality and integrity”.

This feature is from the Water Hygiene Centre