Taking on individuals without demonstrable evidence of the necessary competence and expertise is fraught with danger, and – should a serious incident occur – leaves the client organisation, such as an NHS Trust, open to serious consequences – in the worst case facing prosecution.
After an outbreak of Legionnaires’ disease in 1976 in Philadelphia, the UK’s Health and Safety Executive (HSE) produced a guidance note (EH48), while in 1991, the Health and Safety Commission published the Approved Code and Practice for the Prevention of Legionellosis; the second edition was published in 1995. In 1998, there was specific guidance issued for hot and cold water systems. In 2001, everything was combined into one guidance document, the first edition of the HSE’s Approved Code of Practice and Guidance, L8, within this there were various levels of document: laws, regulations, approved codes of practice, and technical guidance. In 2013/14, the HSE published the latest ACOP L8 and HSG274 Legionnaire’s disease Technical guidance, which provide more detailed guidance on Legionella risk assessment, control measures, and managing potential contamination sources.
A response to a series of outbreaks
In May 2016 the Department of Health produced the first edition of Health Technical Memorandum HTM 04-01: Safe water in healthcare premises, as a response to a series of Legionnaires’ disease outbreaks in the 1990s, both in the UK and other countries. These led to increased public awareness of the risks associated with Legionella, and prompted calls for tighter regulations and enforcement. There were subsequent updates to this HTM in 2013 and 2016 to reflect advances in knowledge and technology. It is an important guidance document in the UK for the management of Legionella bacteria in healthcare facilities’ water systems.
An evolving picture
Legionella risk assessment in the UK has evolved over time, with a focus on risk identification, management, and prevention. The regulations and guidance have been regularly updated to reflect new scientific evidence and best practice, and the responsibility for managing the risk of Legionella contamination has been firmly placed on building owners and managers. Against this backdrop, the UK Government has launched several initiatives aimed at improving Legionella risk management – including the development of a national register of cooling towers and evaporative condensers, and the establishment of the HSE in January 1975 – as an independent body to enforce health and safety legislation in all workplaces, including the Legionella regulations. Overall, Legionella risk assessment and management continue to be a priority for public health and safety in the UK.
A history of Legionella risk assessments
The first Legionella risk assessments in the UK were produced in the late 1980s by a combination of different organisations – including the HSE and various private consulting firms. The HSE developed guidance for risk assessment and management following the enactment of legislation (the COSHH Regulations) in 1989, requiring employers and building owners to assess and manage the risk of Legionella in their buildings. This scenario has continued without regulation ever since. Now, we have numerous organisations providing ‘the most competent’, ‘high quality’, ‘highly trained’ risk assessors – as their marketing people and websites will tell you – but as AEs we know some risk assessors are good, some are acceptable, and some are poor. So, how can you select a competent risk assessor?
Risk assessor competence
The ‘ACOP L8’ states that training is an essential element of an employee’s capability to carry out work safely, but it is not the only factor: instructions, experience, knowledge, and other personal qualities, are also relevant in order to perform a task safely. This is vague, and no detailed assessment of competence is given. HTM 04-01 states that it is recommended that those engaged to undertake any risk assessments associated with water safety should be able to demonstrate their experience and competence to the Water Safety Group (WSG).
To help demonstrate competence, risk assessors can obtain relevant qualifications, such as the City & Guilds Accredited Programme in Legionella Management and Water Treatment, or the NEBOSH National Certificate in Occupational Health and Safety, which covers Legionella risk assessment and management. Assessors can also attend training courses offered by organisations such as the Water Management Society or the Legionella Control Association and others to keep up to date with the latest industry standards and guidelines.
Need for practical experience
In addition to training and qualifications, assessors should have practical experience in conducting risk assessments, and be able to provide references and examples of their work. It is so important to select a competent risk assessor. He/she will be tasked with a job which is essential in ensuring that your water systems are safe and compliant with relevant regulations and codes of practice. Legionella risk assessments are required by law, and are an important part of the risk management process for preventing the spread of Legionnaires’ disease.
Here are some key reasons why it is essential to select a competent risk assessor:
Minimising liability: If a Legionnaires’ disease outbreak is traced back to your water systems, you could be held liable for any resulting illnesses or deaths. A competent risk assessor will help you minimise this risk by identifying potential hazards, and recommending appropriate control measures.
Cost-effectiveness: A competent risk assessor will help you prioritise control measures based on the level of risk, which can save you time and money in the long run. For example, they may recommend simple control measures, such as adjusting water temperatures, rather than more expensive measures such as replacing systems and pipework.
Selecting a competent risk assessor is crucial to ensure the safety of your water systems, and protecting public health.
You will get what you pay for
In our experience you will normally get what you pay for. We have seen risk assessments being offered by organisations for healthcare premises for as little as £40. While we all know funds are restricted, it is always worth paying for the job to be done properly, which could save a lot of time and money longer term. The HSE’s ACOP L8 states: ‘The duty-holder must ensure that the person who carries out the risk assessment and provides advice on prevention and control of exposure must be competent to do so.’
As the duty-holder, or if you have dutyholder responsibilities for employing a risk assessor, you need to see the ‘risk assessor’ qualifications and competencies in order to clearly demonstrate that you have followed the Approved Code of Practice, L8. Although many companies employ extremely competent risk assessors, others have new staff members with limited qualifications and experience, without the competence required to undertake a risk assessment within a large, complex hospital or other healthcare facility
A good example of competence
A good example of competence would be a risk assessor who has undertaken several City & Guilds or other recognised qualifications, has successfully passed, say, five- three- and two-day courses in Legionella control and risk etc, keeps themselves up to date via a minimum 30 hours’ CPD annually, has risk assessed hospitals for several years, can list a number of hospitals of a similar size to your healthcare facility, and can provide examples of his/her risk assessments, and names of referees who can be contacted. Conversely, a poor example would be a risk assessor who sat a one-day Legionella risk assessment course five years ago, has undertaken no CPD, possesses no other professional competencies, and may never have undertaken a risk assessment within a hospital or other healthcare facility. We have seen such instances, and there is a risk you could employ such an individual unless you specifically request, and then assess, the risk assessor’s qualifications and competencies
Vague claims
In fact, we frequently see risk assessment companies that state: ‘The risk assessor’s qualifications are available on request’, or ‘Risk assessor competence has been checked and established using the procedure detailed in the company’s Legionella risk assessor training and competency programme’. That sounds great, but you do need to obtain and review the assessor’s qualifications and competency details. Equally vital is to ascertain the competence of those who have checked and established your proposed risk assessor’s competency, and delivered their training, to give you confidence in their capability.
Procurement of services
Often, as a part of procurement of services, a tender specification for Legionella risk assessors is created. This should provide a clear and detailed description of the services required, the deliverables expected, and the criteria for selecting a qualified contractor. Here are some elements that should be considered in a tender specification for a Legionella risk assessor:
Scope of services: A description of the work to be performed, including the types of water systems to be assessed, the number of sites to be assessed, and the frequency of assessments.
Qualification requirements: A list of the qualifications and experience required of the Legionella risk assessor. This may include specific certifications, such as membership of a relevant professional body, or accreditation to a relevant standard, as well as experience in performing Legionella risk assessments, and referees who can be contacted.
Deliverables: A description of the expected deliverables, including a written report of the Legionella risk assessment that clearly identifies potential sources of Legionella bacteria, assesses the level of risk, and recommends appropriate control measures. Example risk assessments should be requested and reviewed to ensure the report is easily understandable, and delivers on guidance recommendations.
Timeframe: A clear description of the timeline for the project, including deadlines for the submission of the Legionella risk assessment report, and any interim progress reports.
Cost: A detailed breakdown of the costs associated with the project, including any expenses that may be incurred during the assessment process.
Insurance requirements: A description of the insurance requirements for the Legionella risk assessor, including public liability insurance and professional indemnity insurance.
Contract terms: A detailed description of the terms of the contract, including payment terms, termination clauses, and confidentiality agreements.
Detailed description of the services required
Overall, a tender specification for Legionella risk assessments should provide a clear and detailed description of the services required, as well as the criteria for selecting a qualified contractor. By providing clear guidelines and expectations you can ensure that you receive accurate and reliable Legionella risk assessments that comply with relevant regulations and standards.
Water management contractor competence
The competence of contractor staff should also be assessed, including their training, experience, knowledge, and other personal qualities, to carry out work safely. Since 2016 HTM 04-01 has stated that all persons working on water systems – form managers to operatives – must undertake specific water hygiene training. (see HTM 04-01, Part B, section 6.29). This should not be confused with Legionella training, and should detail 15 key issues related to hygienic methods of working on water systems, and explain how not to contaminate your water supplies. It also recommends health screening of personnel. How many of your contractors or in-house staff have undertaken such training? It is wise to check that your contractors have actually undertaken water hygiene training.
We often see comments such as: ‘We only use Legionella Control Association (LCA) contractors’; this can be a good starting point, but this in no way absolves you from checking the competence of these contractors. The LCA does not check the competence of contractor staff. The Association in fact has an agreement for service-providers to follow a Code of Conduct. The small print states: ‘Compliance with relevant health and safety regulations (including avoidance of, or reduction of risk to, exposure to Legionella bacteria) is the sole responsibility of the statutory duty-holder, being the person in control of the premises or systems where any relevant risk is present’.
ACOP position
The HSE’s Approved Code of Practice, L8, also states: ‘Employing contractors or consultants does not absolve the duty-holder of responsibility for ensuring that control procedures are carried out to the standard required to prevent the proliferation of Legionella bacteria’.
If, for example, a contractor is opening tanks, taking photographs and temperatures of outlets in augmented care areas, or breaking into your drinking water supplies to work on TMVs, should this person not at least have water hygiene training, as stipulated within HTM 04- 01? If not, there is a much higher risk of them infecting your water supply. If such an individual is undertaking works within augmented care areas housing very vulnerable patients, would they be aware that they should not be doing so – particularly if working on drinking water systems – if, for example, they are suffering from one of the many illnesses that cause diarrhoea? These are among the reasons that a water hygiene course is now recommended in HTM 04-01.
Historically, water treatment contractors undertook tank cleaning and disinfections along with system disinfections, and installation of secondary water treatment systems etc. This, however, has changed, with such companies now undertaking everything from TMV in-service testing to AE(W) services, and everything in between. While water treatment companies now appear to be synonymous with all things water-related, how many of you check the competencies of the individuals working for them?
Examples of questionable works carried out
To show what can happen if the water treatment company’s personnel lack the necessary expertise and competence, let us take as an example one such individual being asked to inspect a pair of cold water storage tanks (CWSTs). The contractor promptly arrived and undertook an inspection; the resulting report stated that the tanks showed signs of light sediment to the tank bases, with no biofilm growth. The company recommended a disinfection, and a further inspection the following year. Within the accompanying report was the customary single picture of the base of the CWST (see Figure 1). Based on the picture, the contractor said a disinfection was not required, but seemingly failed to spot substantial corrosion to the tank upper braces and bolts, which really needs to be attended to well within the next 12 months (see Figure 2). Did the Responsible Person check the operative’s qualifications before employing them to undertake the work, and indeed was the operative competent to inform the RP that the tanks were fine to leave for a further year? This contractor has membership of the LCA, and the RP has paid for a report which is of no real value. Worse still, the report and recommendations have given the RP a false sense of security that these tanks are in good condition, when clearly they are not
Importance of impartiality
The issue of using a water hygiene company that provides risk assessment and remedial work services has been well documented in BS 8580-1:2019. Water quality – Risk assessments for Legionella control – Code of practice, where it is stated: ‘The risk assessor should be able to demonstrate impartiality and independence when carrying out Legionella risk assessments. The risk assessor or assessing organisation should not allow commercial, financial, or other pressures to compromise impartiality, and should be able to demonstrate valid reasons for any proposed course of action. It should be clear, for example, why a recommendation has been made to clean cold water storage tanks.’
Dirty utility area experience
Another risk assessor we came across was working in a hospital’s dirty utility area, measuring the blended hot water temperature from a washhand basin, which he had designated as a sentinel point. He did not select an unblended sluice outlet located nearby. Without disclosing my position as the Trust AE (Water), I asked why he was doing this, rather than measuring the inlet temperature to the associated TMV. He said he had been told to take the hot water temperature from an outlet. I asked if there were any other issues of note in the area, and was told ‘no’. He had failed to notice three redundant branch pipes under a sink (see Figure 3), an infrequently used washhand basin with equipment piled on top of it, and a redundant sink (Figure 4)
Assessment of contractors
So, how do we assess the competence of such contractors? Good quality training is a good start on the road to competence, and certified training such as from City & Guilds or ILM may give you some assurance that training is adequate. Training is only the start of this journey, however; the operative must then gain experience through working with other experienced operatives, thus building up competence over time – by being corrected and allowed to slowly undertake more work on their own, until finally being deemed competent by their superior, and from this point on being allowed to work unsupervised, with only occasional checks made on the quality of their work. This should all be logged on a competency matrix, and available on request.
Contractor training
What about in-house training? It has been a long-standing issue that water treatment specialists provide their own training for their operatives, either as additional support for accredited training, or quite often entirely in-house training.
We have seen one-hour courses written by contractor staff with very limited competence. Often courses are not tested, which leaves candidates unenthusiastic, checking their phones, or looking out the window. We regularly see in-house certificates that any of us could knock up on a PC in 10 minutes.
The main reason for this potentially poor training is a) cost – such external training courses are expensive, and the operative is not working while attending such courses, so a substantial investment in the operative is required, and b) box ticking – to show that training has been provided.
In-house training should not be dismissed out of hand; as previously stated, some specialist companies do have some very competent staff, but if you are willing to accept such training, you must ensure you are complying with the duty you have under L8 to ensure that the staff you are employing are competent.
Scrutinise ‘in-house’ certificates
If contractor staff are all in-house trained, then you need to look at the business’s in-house certificates. It is not unusual to receive a PDF that incorporates the person’s name, date of the training, and the trainer’s name, or the MD’s name, and usually a list of Legionella-related headings such as ‘Cleaning and disinfection of CWSTs and systems’, ‘CWST inspections’, ‘TMV maintenance’, ‘Temperature monitoring’, and ‘Shower clean and disinfection etc’. In some cases these training courses have all been completed on the same day, which may indicate the quality of training provided.
Take one of these headings – ‘TMV maintenance’, and you might be shown an in-house certificate with a raft of other training listed, alongside the date, and the name of the trainer. This training could be a 15-minute ‘toolbox talk’ undertaken by an unqualified operative. Would you be satisfied with this certificate – indicating that this is the only training this operative has had on TMVs? What information is it providing you that gives you the confidence that this operative is competent to undertake this task?
Sufficient data to make a judgment call?
When reviewing in-house training you need a little more information to make any kind of judgment call. Remaining with TMVs, and what was the duration of the individual’s training – a day, half a day, or 30 minutes? Each timeframe gives you a different level of comfort. Who undertook the training, and what qualifications does this person possess to give such training? Again, the information provided gives you a different level of comfort. Was this training tested at the end of the course? Was this a practical test, including a strip-down and service of a valve which was cleaned, disinfected, and reassembled, or was the training simply via a PowerPoint presentation with a multiple choice question set? Or, in fact, was there no test at all, and did the trainer have to wake the operative at the end of the course to give them their certificate? The latter example may seem a bit flippant, but with the in-house certificate you receive, some of these eventualities are entirely possible. We would much sooner you asked these questions of the water treatment specialist, than answered them in court subsequently
Competence takes time
Here we are referring just to the necessary training; the required competence levels, are, however, only achieved over time. By physically undertaking the work and being corrected by an experienced, competent person, the operative should receive a competency matrix. This should state that – after training – the operative has worked supervised, with their work corrected for a set number of weeks, before being upgraded to work unsupervised. At this point they should require only minimal checks to ensure they are not taking short cuts, or developing poor habits. Finally, the date that the operative was deemed competent to work on their own for external customers should be clearly stated.
It should be remembered that if the contractors you use undertake inadequate works on your behalf, the liability will remain with you. The ACOP L8 states that ‘the duty-holder should take all reasonable steps to ensure the competence of those carrying out work who are not under their direct control’, so, our advice is: ‘be careful’.
Steve Mount
Steve Mount provides consultancy advice, risk assessments, auditing, and training, to a wide variety of clients, including NHS primary care Trusts, other healthcare organisations, and facilities management companies. He is a Fellow of IHEEM, an IHEEM-registered Authorising Engineer (Water), a member of the IHEEM Water Technical Platform, and a Clinical and Professional Advisor for the Care Quality Commission (CQC). Working for several NHS Trusts and healthcare organisations has given him experience and insight into the requirements for compliance of large establishments.
He regularly delivers City & Guilds-accredited training, and lectures to a wide range of organisations, with the emphasis on Legionella awareness and compliance. He formed Steve Mount Associates in January 2006 following a 25- year career in microbiology and UKAS-accredited Legionella analysis.
The company provides a range of professional Legionella management, training, and consultancy services, and is fully independent, with no links to any water treatment company or chemical supplier.
Harry Evans
Harry Evans BSc (Hons), MRICS, MRSPH, MIHEEM, MCABE, is an IHEEM-registered AE (W), chairman of the NHS Estates Training Advisory Group (TAG), and an Authorising Engineer (Water) for HDE Authorising Engineers. He is a chartered professional with over 40 years’ experience incorporating the design and maintenance of commercial, industrial, and healthcare premises. Over the years he has gained qualifications, expertise, and experience of a wide range of building and engineering services. He started his NHS career in 2000, initially in a Capital Design role at Salford Royal NHS Foundation Trust, before taking on the role of head of Operational Estates for Salford, a position he held for over 12 years. He was appointed as AE Water for Equans in 2015, and now divides his time between Equans and his own private consultancy practice, HDE Authorising Engineers, where he provides AE services to the NHS and other organisations throughout the UK.