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General Policy
Estates, Facilities and Capital Services
Estates Compliance Manager
Head of Estates, Water Safety Group, External Authorising Engineer (Water)
Director of Property & Asset Management
07 March 2013
22 July 2022
22 July 2024

General Note

NHS Fife acknowledges and agrees with the importance of regular and timely review of policy/procedure statements and aims to review policies within the timescales set out. New policies/procedures will be subject to a review date of no more than 1 year from the date of first issue.

Reviewed policies/procedures will have a review date set that is relevant to the content (advised by the author) but will be no longer than 3 years.

If a policy/procedure is past its review date, then the content will remain extant until such time as the policy/procedure review is complete and the new version published, or there are national policy or legislative changes.


1.1 This policy is an integral part of NHS Fife’s approach to quality, safety and governance. The Health and Safety at Work Act etc (1974) and the Management of Health and Safety at Work Regulations (1999) place a duty on NHS Fife to publish, issue and implement a Water Systems Management Policy. This Policy outlines the principles to be adopted and implemented in order to achieve the objectives set out in the aforementioned legislation and other related legislative documents, specifically the Health & Safety Executive (HSE) Approved Code of Practice and Guidance on regulations (L8) Legionnaires Disease; Scottish Health Technical Memorandum 04-01 Water Safety for Healthcare Premises; and the Control of Substances Hazardous to Health Regulations 2002 (as amended) (COSHH).


2.1 Applicable to all NHS Fife owned premises and those where NHS Fife services are delivered.


3.1 Chief Executive

The Chief Executive of NHS Fife has overall executive responsibility for ensuring that effective arrangements are in place to manage all safety, health and risk matters within NHS Fife. This responsibility may be delegated to an appropriately senior manager.

3.2 Director of Property & Asset Management (Designated Person)

The Designated Person is responsible for ensuring:

Appointment of a Senior Operational Manager to support implementation of the following:

• The implementation and management of the policy and associated procedures across NHS Fife
• That NHS Fife staff are aware of and have access to the policy and associated procedures
• That NHS Fife staff understand the importance of compliance with the procedures associated with this policy
• That staff receive training commensurate with their role and responsibilities.
• That an approved water systems management structure is maintained within NHS Fife
• Advice is provided on the potential areas of risk and identify where systems do not comply with current legislation and guidance
• Advice is provided on the required procedures for the management of risk from water systems
• Monitoring of the implementation and efficacy of procedures adopted to control risk
• Changes in procedures are approved through the NHS Fife Water Management Group
• Adequate records are kept

3.3 Head of Estates (Senior Operational Manager)

The Senior Operational Manager is responsible for ensuring:

• Implementation of points above in cooperation with the Designated Person.
• Appointment of a Sector Senior Operational Manager to support implementation of this policy and associated procedures within each Estates sector in Fife and to ensure the Operational Plan in section 4 is upheld
• Implementation and chair of a Water Safety Group within NHS Fife, ensuring a multidisciplinary team of staff form a part of the group

3.4 Sector Estates Managers (Sector Senior Operational Manager)

• All relevant staff groups must be aware of the policy and implement the associated procedures and their designated responsibilities. Current procedures are contained within the NHS Fife Legionella Safety Policy GP/L1 and associated documents, particularly SOP 18 – Water Safety
• Estates Managers must ensure that they and all of their staff undertake appropriate training in line with their role requirements in relation to this policy, associated procedures and their implementation. Training for Estates staff will be delivered through Estates Dept statutory training plans
• Authorised Persons (Water) must be suitably trained and competent to be appointed to act as Authorised Person for the ongoing management of water systems management as per SHTM 04

3.5 Individual Managers and Members of Staff

• All managers across the organisation should make themselves and other staff familiar with this policy and associated documents. Further details contained within the ‘Water Systems Control of Legionella Memorandum’
• Managers have a duty to implement flushing regimes within their respective areas and keep records. All forms/record templates are available for use contained in this policy.
• Managers have a duty to follow the procedures for drinking water, ice machines, water coolers, hot water systems and associated temperature monitoring. Further details in the related documents of this policy.


4.1 The Senior Operational Manager must ensure that there is an operational plan and written scheme for which the Board is responsible, which is reviewed and updated at appropriate intervals. The operational plan must contain the following elements:

4.2 Schematic diagrams and descriptions of all the supply, storage and distribution systems within Board premises and a statement to enable authorised persons to locate the up to date as-fitted drawings.

4.3 Step-by-step instructions to operate, maintain, control and shut down the water supply, storage and distribution systems within Board premises.

4.4 A schedule of possible emergency incidents causing loss of the water supply from the water undertaker. Each item in the emergency incident schedule should include guidance on operational procedures to re-establish a stable wholesome water supply.

4.5 Engineering Risk Assessment

A risk assessment shall be carried out on hot and cold water tanks and distribution systems, calorifiers and air conditioning plant. Where risk of Legionella contamination is established, work shall be carried out immediately to decontaminate the system by a specialist Contractor who shall provide evidence of decontamination by means of certification from an independent accredited laboratory.

Measures shall be taken to assess any remedial action required to the physical system to ensure any contamination does not reoccur.

Where a risk assessment indicates significant clinical risk and significant engineering risk the Infection Control Team and Estates will jointly review and decide whether or not a more frequent Legionella testing regime requires to be adopted. This review will include test points, frequency of testing and measures to reduce risk. The frequency of testing and location of test points will be determined by risk assessment and in conjunction with the Water Safety Group, taking into account the physical characteristics and the occupants of the premises.

4.6 Analysis of water samples for the presence of Legionella will be carried out by an appropriate laboratory with relevant UKAS accreditation with the interpretation of results carried out by experienced microbiologists.

To break the connection and reduce the risk of Legionella strict procedures for management of the water supply are essential. Simple precautions, listed below, form the basis for the control of Legionella in NHS Fife premises.

(a) Remove taps and outlets which are not needed

(b) Hot water from calorifiers kept at min 60°C, water in the circulation pipe work at min 50°C or above.
(c) Keep pipes carrying blended water to a maximum of 300mm where practically possible.

(d) Hot water temperature to be between 50°C and 60°C within one minute

(e) Cold water temp must be below 20°C within two minutes

(f) Avoid water stagnation

(g) Carry out regular maintenance

(h) Where water systems are drained, disinfect before the system is returned to operation

(i) Where system consistent performance problems have been found, review the need for water treatment

(j) Where areas are closed, regular flushing must be carried out. All relevant staff are expected to be familiar with these simple precautions.

4.7 Training

All staff that are responsible for the management of water systems, i.e. Responsible Persons, Authorised Persons, Competent Persons, Maintenance technicians and External Authorising Engineers will carry out regularly, a suitable accredited water management course.


The key risks involved in implementation of this policy are:-

5.1 Lack of staff awareness of this policy, resulting in non-compliance

5.2 Lack of robust organisational arrangements around policy implementation

5.3 Failure to implement and maintain the required procedures associated with the policy


6.1 It is recommended that this document is read in conjunction with the following:
• NHS Fife - Control of Legionella Water management Memorandum
SOP 18 Water Safety Procedure


7.1 The Water Supply (Water Quality) (Scotland) Regulations 2010. SI 2010 No 95. HMSO, 2010.

7.2 The Public Health (Notification of Infectious Diseases) (Scotland) Regulations 1998 si1998 No 1550 (S.155)

7.3 The Water Supply (Water Fittings) Regulations 1999, SI 1999 No 1148. HMSO, 1999.

7.4 The Scottish Water Byelaws 2004, under section 70 of the Water (Scotland) Act 1980(a) for preventing waste, undue consumption, misuse or contamination of water supplied by them.

7.5 HTS D08: Thermostatic mixing valves (healthcare premises). HMSO, 1997 (Revision in preparation).

7.6 Scottish Health Facilities Note 30: Infection Control in the Built Environment. Health Facilities Scotland.

7.7 Scottish Health Technical Memorandum 64: Sanitary assemblies. Health Facilities Scotland.

7.8 Water Supply (Water Fittings) Regulations 1999 guidance document relating to Schedule 1: Fluid Categories and Schedule 2 Requirements for Water Fittings [See Regulation 4(3)]. Department for Environment, Food & Rural Affairs (Defra) (1999)

7.9 BS1710: 1984 Specification for identification of pipelines and services. British Standards Institution, 1984

7.10 BS6700: 2006 Specification for design, installation, testing and maintenance of services supplying water for domestic use within buildings and their curtilages. British Standards Institution, 1997

7.11 BS6920-1: 2000 Suitability of non-metallic products for use in contact with water intended for human consumption with regards to their effect on the quality of the water. Specification. British Standards Institution, 2000

7.12 BS EN 806-2: 2005 Specifications for installations inside buildings conveying water for human consumption. Design. British Standards Institution, 2005

7.13 ISO 11731: 2004. Water quality. Microbiological methods. Detection and enumeration of Legionella. International Standards Organisation, 2004

7.14 Application Guide 2/93: Water treatment for building services systems. BSRIA, 1993

7.15 Application Guide AG 4/94: Guide to legionellosis – temperature measurements for hot and cold water services. BSRIA, 1994.

7.16 FMS 4/99: Guidance and the standard specification for water services risk assessment. BSRIA, 1999.

7.17 Technical Note TN 2/98: Chlorine dioxide water treatment – for hot and cold water services. BSRIA, 1998.

7.18 Technical Note TN 6/96: Ionisation water treatment for hot and cold water services. BSRIA, 1996.

7.19 Hygiene for hydrotherapy pools. Health Protection Agency,1999

7.20 Management of spa pools: controlling the risks of infection. Health Protection Agency, 2006. default.htm

7.21 Water Regulations Guide. Water Regulations Advisory Scheme (WRAS), 2004.

7.22 Water Fittings and Materials Directory. Water Regulations Advisory Scheme (WRAS), 2005.

7.23 Guidelines for drinking water quality. World Health Organization (WHO)1993.

7.24 BS 8560-1:2019 Water quality – Risk assessments for Legionella control – Code of practice

7.25 BS 8680:2020 Water quality – Water safety plans – Code of practice

7.26 HSE Approved Code of Practice and Guidance on regulations L8, Legionnaires Disease

7.27 Scottish Health Technical Memorandum 04-01, Water Safety for Healthcare Premises

7.28 NHS Fife Risk Register / Risk Assessment Policy (GP/R7) and Appendices