Legionella policy

1. Purpose of the policy

1.1 This policy sets out Housing Leeds's approach to managing legionella risks associated with water systems.

2. Scope of the policy

2.1 This policy applies to any use or storage of hot or cold water that is owned, managed, maintained or controlled, to any extent, by the Housing Leeds service of Leeds City Council, that could result in the foreseeable risk of exposure to legionella bacteria.

2.2 The policy does not apply directly to buildings and homes under PFI management, or the Belle Isle Tenancy Management Organisation (BITMO). However, in these areas, the council has a responsibility to ensure that the minimum standards set out in this policy are in place and are sufficiently robust.

2.3 Water Risk Assessments to individual leaseholder homes are excluded from this policy.

3. Relevant legislation and guidance

3.1 Legislation and guidance:

• Health and Safety at Work Act 1974
• The Management of Health and Safety at Work Regulations 1999
• Control of Substances Hazardous to Health Regulations (COSHH 2002)
• The Construction (Design and Management) Regulations 2015
• Legionnaires' disease. The control of legionella bacteria in water systems. Approved Code of Practice and guidance L8 (Fourth Edition)
• Technical Guidance HSG274
• Homes (Fitness for Human Habitation) Act 2018
• Equalities Act 2010

3.2 Relevant social housing regulations:

• The Social Housing (Regulation) Act 2023
• The Safety and Quality Homes Consumer Standard
• The Transparency, Influence, and Accountability Consumer Standard
• The Neighbourhood and Community Consumer Standard
• The Tenancy Consumer Standard
• The Decent Homes Standard
• Tenant Satisfaction Measures (TSMs)

4. Sanctions

4.1 Leeds City Council accepts its responsibilities in accordance with the regulatory standards, legislation and codes of practice of legionella.

4.2 Failure to comply with these statutory obligations may result in:

• prosecution by the Health and Safety Executive under Health and Safety at Work Act 1974
• prosecution under Corporate Manslaughter and Corporate Homicide Act 2007
• regulatory notice from the regulator of social housing
• loss of confidence by stakeholders in the organisation

5. Strategic context

5.1 This policy supports the Leeds City Council 'Best City Ambition' of tackling poverty and inequality and improving quality of life for everyone who calls Leeds home, through our three pillars of Health and wellbeing, Inclusive growth and Zero carbon.

5.2 This policy also contributes to the key themes of the Housing Strategy and in particular:

• Improving housing quality
• Child and age friendly housing
• Thriving and inclusive communities
• Safe and strong communities
• Health and housing

5.3 This policy also contributes to the delivery of the Housing Leeds Asset Management Strategy and Leeds City Council Health, Safety and Wellbeing policy 2024/25.

5.4 This policy should be read in conjunction with the Leeds City Council tenancy agreement.

6. Background and definition

6.1 Legionellosis is a collective term for diseases caused by legionella bacteria. Legionnaires' disease is the most serious condition which is a fatal form of pneumonia. Other similar but less serious illnesses include Pontiac fever and Lochgoilhead fever. These diseases are usually contacted by exposure to legionella bacteria inhaled via small droplets of water suspended in the air.

6.2 Legionella bacteria are widespread in natural water systems such as rivers and ponds. However, the conditions are rarely right for people to catch the disease from these sources. Outbreaks of the illness occur from exposure to legionella growing in purpose-built systems where water is maintained at a temperature high enough to encourage growth. These water systems include:

• mains cold water services
• cold water storage tanks and cold-water distribution systems
• hot water storage systems including Calorifiers or hot water cylinders
• non-storage hot water systems
• water outlets such as taps, showers or aerosol generating sources
• thermostatic mixing valves (TMV's)
• any other plant and systems containing water which is likely to exceed 20°C and which may release droplets of water during operation or when being maintained

6.3 Legionnaires' disease develops in water that is stored between 20°C and 45°C as these temperatures favour the growth of legionella bacteria and other micro-organisms. Infection is caused by breathing tiny airborne droplets of water contaminated by the bacteria and not by drinking contaminated water.

6.4 In water below 20°C, the bacteria remain dormant and multiply only when temperatures reach a suitable level. The organisms will not survive in temperatures above 60ºC.

6.5 Legionella bacteria need nutrients to support growth, and these can be provided by:

• sludge, scale or rust that has accumulated in reservoirs, hoses or pipe work
• foreign bodies allowed into tanks through poor housekeeping or maintenance (such as rodents and insects)
• pipe and connection materials that have been allowed to deteriorate
• a biofilm coating on hard surfaces or lying on the water surface

6.6 Factors which increase the risk

6.61 Not keeping water storage tanks and down-service pipework maintained, with biofilms being kept in check.

• not maintaining stored hot water supply above 60°C , and distribution below 50°C
• not maintaining the cold-water supply at 20°C or below
• not maintaining the flow of water through all outlets
• not flushing infrequently used outlets
• having the presence of dead ends in the system
• not adequately managing and recommissioning void (empty property) sites

6.7 At risk groups

6.71 People of all ages and health conditions can be at risk of contracting Legionnaires' disease although Infection occurs more frequently in men than women. The higher risk groups include those over 45, smokers and heavy drinkers, people with diabetes, chronic respiratory, heart, liver or kidney disease, or whose immune system is impaired.

6.72 Under normal conditions, the disease cannot be passed from one person to another.

7. Objectives

7.1 As a landlord, we must meet the legal obligations which require us to deal with the risks associated with legionella bacteria within the properties we own or manage.

7.2 This policy forms part of our wider organisational commitment to driving a health and safety culture amongst staff and contractors as detailed within the Leeds City Council Health, Safety and Wellbeing policy.

7.3 We are committed to reducing, so far as is reasonably practicable, the foreseeable risks of exposure of any person to legionella bacteria. Housing Leeds will aim to achieve this policy commitment set out in the publication "Legionnaires' disease. The control of legionella bacteria in water systems. Approved Code of Practice and guidance L8 (Fourth Edition)".

7.4 This will include:

• providing a high level of care and customer service to all tenants
• ensuring that a safe environment is in place for all stakeholders utilising the service
• appointing one or more Responsible Person (Legionella) to have responsibility for managing identified in-scope water use and storage systems
• carrying out suitable and sufficient risk assessments of all work-based activities and in-scope water systems to identify and evaluate foreseeable risks of exposure to legionella bacteria
• recording the significant findings of each assessment
• maintain records of maintenance, inspection and testing for a period of at least five years
• allocating sufficient resource to ensure that reasonably foreseeable risks of exposure to legionella bacteria are managed. This will include the appointment of suitable numbers of competent people to advise on legionella management matters and to assist with the development of the Legionella Management Plan
• undertaking periodic audits to ensure that all relevant duties under this policy and applicable legislation are being managed effectively

8. Implementation of the policy

8.1 Approach to risk assessments

8.11 The implementation of the policy is based on the categorisation of property types from archetypal information along with an assessment of the type of water system (for example from stored water to combi-boilers) and the occupants of the site (such as sheltered housing).

8.12 Based on this approach, higher risk archetypes will have a fully formed compliant Water Risk Assessment (WRA) conducted by a competent contractor along with temperature monitoring and regular cleaning of systems. Lower risk properties will have a desktop archetypal study with periodic information issued to tenants on how to minimise any risk from legionella.

8.3 Risk assessment categorisation

8.4 Water Risk Assessment (WRA) for high-risk sites

8.41 The purpose of the WRA is to evaluate the plant, equipment, operational and management of the building systems and their risk of bacteriological proliferation.

8.42 The WRA should include all hot and cold-water services, which will incorporate an assessment of the design, usage, and condition. All information will be recorded on pro-forma forms and collated within a comprehensive document.

8.43 The format and content of the WRA should be in line with the guidance in ACoP L8 and BS 8580-1: 2019 Water Quality - Risk Assessments for Legionella Code of Practice and as a minimum should include:

• name of the risk assessor, site responsible person and duty holder
• a description of the water system
• the risk identified with recommended actions, including a risk category and recommended timeframe for completion
• a schematic drawing of the water system identifying all relevant pipe links between key plant assets and building water distribution
• where hot water is discharged at more than 50°C and there is a risk of scalding the WRA should identify the need for thermostatic mixing valves or other forms of temperature control

9. Programme of work

9.1 For all properties on the WRA programme, we will carry out a periodic WRA review on designated higher risk properties. The frequency of the review has is determined on all archetypes below:

9.2 Water Risk Assessment (WRA) reviews

9.21 WRA's may also need to be reviewed if it is known or suspected that they are no longer valid. A WRA may no longer be valid where:

• there are changes to the water system or its use
• there are changes in the use of the building in which the water system is installed
• new information is available about risks or control measures
• the results of checks indicate that control measures are no longer effective
• a case of Legionnaires' disease/legionellosis is associated with the system

10. Empty (void) properties

10.1 If a property is to remain unused for an extensive period of time (over 2 weeks) during the 'void' period between tenancies, the below steps in the should be completed as part of the standard empty home process:

• shower heads and hose should be disconnected on the initial void safety check visit
• flush through of the hot and cold-water systems by running through all outlets (including showers) for at least two minutes prior to re-occupancy
• ensure any redundant pipework or 'dead legs' are removed
• check that the hot water is heating up correctly
• check that lids are in place and fitting correctly to water storage tanks
• clean any shower head, descale and disinfect during the 'final fix' (commission visit upon re-occupancy). If a shower head cannot be completely descaled it should be removed and replaced

11. Remedial actions

11.1 Where the WRA or any subsequent temperature monitoring or water testing identifies that there is a reasonably foreseeable risk of exposure to legionella bacteria Housing Leeds will ensure there is a robust process in place for the management of any follow-up works required following the completion of a WRA or ongoing monitoring. This will also include any issues identified during a void period.

11.2 Any repair or upgrade works to water systems are carried out by competent employees or contractors, and in liaison with the Responsible Person (Legionella), ensuring effective communication within Housing Leeds and with contractors.

11.3 Remedial actions shall be categorised into high, medium, and low priority based on the level of risk presented. The Responsible Person (Legionella) shall ensure that all recommendations are implemented upon completion.

12. Action in the event of a case of Legionnaires' disease

12.1 If it is suspected or confirmed that an employee, contractor, tenant, or member of the public has contracted Legionnaires' Disease originating from council housing premises there is a legal obligation to report this to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR).

12.2 An emergency action team will be set up to deal with any requirements for rectifying the situation. This could involve but not be limited to;

• shutting down water systems capable of generating and disseminating airborne water droplets
• decanting of residents
• clean and disinfection of the system
• microbiological analysis of the water system
• evaluation of monitoring and cleaning records
• provide full co-operation to any investigating agency
• dealing with media enquiries

13. Certification and documentation, data protection, record storage and retention

13.1 Housing Leeds maintain an electronic asset register of all properties owned or managed, setting out which properties require a WRA. We will also set out which properties require ongoing testing and monitoring.

13.2 The system is regularly updated to reflect any changes because of Right to Buy sales, new build properties, or acquisitions.

13.2 Regulations require that records are to be retained throughout the period for which they remain current and for at least two years after that period. Records kept in accordance with inspection, test or checks carried out should be retained for at least five years.

13.3 All legionella information such as WRA's, water testing records, remedial works, and certificates are uploaded onto the asset database by the appointed legionella contractors.

13.4 Sufficient data is passed to contractors to allow them to arrange access (where required into to a resident's home). Data sharing agreements are in place with contractors to ensure that data is held securely and only used for this purpose. Data shared with contractors includes:

• main tenants name
• address
• contact details
• any flags or alerts relating to resident's individual needs (i.e., contact via advocate)
• any flags or alerts relating to health and safety issues (i.e., dog registered at the property)

13.5 Access to all council storage systems is strictly controlled in-line with the requirements of the Information Commissioners Office.

14. Equality, diversity and inclusion

14.1 An Equality Impact Assessment has been carried out to determine whether the policy would have an impact on any member of staff, tenants or contractor workforce, which unfairly discriminates or disadvantages them in the context of the Equality Act 2010.

14.2 Adherence to the policy provides the same level of protection for all building users and no impacts have been identified that would adversely affect one group more than any other.

14.3 Where a tenant has or may have a protected characteristic under the Equality Act 2010, and in particular, where the tenant may be disabled, have mental health issues, language or learning difficulties, the council will make reasonable adjustments to the delivery of its services, to take specific needs into account.

14.4 Upon request to Housingleedsinformation@leeds.gov.uk, this policy can be made available in other accessible formats including translation to other community languages, braille and large print.

15. Communication of the policy

15.1 This policy will be communicated internally to key stakeholders and key staff. Where this policy has specific impact will be briefed individually or collectively as required.

15.2 Key content from this policy will be included in the Housing Leeds Tenants Handbook and also made available through the Leeds.gov.uk website. Key content will also be shared regularly with residents through targeted tenant emails, and through ad-hoc social media publications.

15.3 A full copy of this policy will be made available upon request via Housingleedsinformation@leeds.gov.uk.

16. Resident engagement

16.1 We are committed to providing a high level of customer care and positive communication is vital to the effective delivery of legionella management. This will support residents in their understanding of legionella, advise them of how they can manage the risks within their properties, and to encourage them to report any concerns about water safety.

16.2 Further monitoring of feedback will take place through resident surveys and this intelligence will be used to inform future reviews of this policy.

16.3 Periodic engagement with residents will take place to ensure that this policy, along with other policies, remain customer facing.

17. Tenant responsibilities

17.1 If tenants suspect their water supply could be infected, they should inform Leeds City Council by phone on 0800 188 400 or 0113 376 0410.

17.2 Possible signs of legionella include:

• cold water running warm
• water that is discoloured or contains debris
• a malfunctioning boiler or hot water system

17.3 Residents can also reduce their susceptibility to Legionnaires' disease by carrying out a number of simple tasks. These include:

• flushing through any showers or taps following a period of non-use, such as after a holiday
• cleaning shower heads and taps clean and free from a build-up of limescale, mould or algae growth

17.4 Residents wanting to report a non-urgent safety concern can do so by sending an email to buildingsafety@leeds.gov.uk.

18. Partnership approach

18.1 Contractors undertaking the WRA will be a suitably qualified and competent consultant, registered with the Legionella Control Association (or equivalent).

18.2 Housing Leeds will operate effective contract management arrangements with the contract manager responsible for delivering the service, including; ensuring contracts/service level agreements are in place, conducting client-led performance meetings, and ensuring that contractors' employers, public liability and professional indemnity and related professional memberships, accreditations and qualifications are up to date on an annual basis.

19. Roles and responsibilities

19.1 The roles and responsibilities for key stakeholders across Housing Leeds are detailed below;

19.2 Chief Officer of Housing will ensure that resources are made available to allow for the appropriate management of legionella across the councils managed housing stock. They will have ultimate accountability for the proper implementation of this policy.

19.3 The Head of Asset Management will work closely with the Deputy Head of Asset Management to implement this policy and to continue to seek assurances that legal obligations and policy measures are being adhered to and in line with budget.

19.4 The Deputy Head of Asset Management is responsible for the overall implementation, and regular review of this policy and ensuring its objectives are achieved. They will ensure that any compliance and/or HandS related issues are brought to the attention of the Chief Officer Housing and Senior Management Team and provide regular updates on service delivery against budget.

19.5 Senior Management Team (Housing) / Heads of Service should review reports and/or performance indicators to assure themselves that the measures detailed in the policy are being followed, thus ensuring that legal requirements are being met and that any significant risks have appropriate controls in place and are escalated to the directorate risk register.

19.6 Mechanical Service Manager (Service Manager Compliance) will be responsible for the day-to-day operational delivery of all aspects of this policy.

19.7 Responsible Person (Legionella) They will act as the organisations lead for Legionella Management and will manage the contract delivery of the service. They will provide technical advice and guidance to internal staff.

19.8 The Void Team Manager will ensure that an appropriate control regime is carried out to all empty properties during void works up until re-occupation.

19.9 Appointed External Contractors and Internal Service Providers will be responsible for managing a programme of Legionella risk assessments to establish and maintain records of the condition of water systems in Council buildings and assets under our control:

• issuing reports to the appropriate responsible person on the findings and results of the risk assessments and testing
• carrying out routine inspection and maintenance of water systems as determined by individual risk assessments, including: monthly water temperature checks, quarterly showerhead disinfection and annual water tank and calorifier inspections
• carrying out water system disinfections in accordance with BS 6700:1987
• providing expert advice on the management of water systems

20. Training

20.1 Housing Leeds will ensure that all staff who are actively engaged in the delivery of this legionella policy, inspections, assessments and remedial actions are suitably trained and have the relevant professional qualifications. All training undertaken by staff will be formally recorded and appropriate refresher training provided as required.

21. Policy review

21.1 A full policy review will take place in response to any changes in legislation, significant events that may impact on the policy, or at periods not exceeding two years.