Scottish Health Technical Memorandum

04-01:
Water safety for healthcare premises
Part A: Design, installation and testing

July 2014
 SHTM 04-01: Part A Design, installation and testing

Contents

page

Acknowledgements .......................................................................................... 6

Preface ............................................................................................................... 7
About Scottish Health Technical Memoranda........................................... 7
Structure of the Scottish Health Technical Memorandum suite ................ 8

Executive summary ........................................................................................ 10

Preamble ................................................................................................ 10
Introduction............................................................................................. 10
Aims of this guidance ............................................................................. 11
Recommendations ................................................................................. 11

1. Introduction .......................................................................................... 13
1.1 Preamble ................................................................................................ 13
1.5 General................................................................................................... 13
1.10 Legislation, standards and guidance ...................................................... 14
1.14 Model Engineering Specification ............................................................ 15
1.15 Exclusions .............................................................................................. 15
1.18 Definitions............................................................................................... 16

2. Source of supply .................................................................................. 17

2.1 General................................................................................................... 17
2.7 Supplies from a water supply authority ................................................... 18
2.11 Private supplies ...................................................................................... 19

3. Water treatment regimes ..................................................................... 21

4. Water softening .................................................................................... 22

5. Filtration ................................................................................................ 25
5.1 General................................................................................................... 25
5.5 Description ............................................................................................. 26
5.11 Capacity ................................................................................................. 27
5.12 Design features ...................................................................................... 27
5.19 Point-of-use filtration .............................................................................. 28

6. Metal contamination ............................................................................. 30

7. Water storage ....................................................................................... 31

7.1 General................................................................................................... 31
7.3 Extent of storage .................................................................................... 31
7.10 Location and form of storage .................................................................. 33
7.18 External storage ..................................................................................... 34
7.22 Internal storage ...................................................................................... 35
7.25 Construction of cisterns .......................................................................... 35
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7.38 Cistern rooms ......................................................................................... 39

7.43 Ancillary pipework, valves and fittings .................................................... 40
7.51 Water meters .......................................................................................... 41

8. Cold water distribution system ........................................................... 42

8.1 General................................................................................................... 42
8.13 Drinking water ........................................................................................ 50
8.15 Pumped systems .................................................................................... 53
8.25 Specialised systems ............................................................................... 54
8.26 Vending, chilled water and ice-making machines ................................... 54

9. Hot water services ................................................................................ 56

9.1 General................................................................................................... 56
9.9 Hot water heater types ........................................................................... 57
9.16 Storage calorifiers .................................................................................. 59
9.33 Unvented hot water systems .................................................................. 61
9.42 Hot water distribution system ................................................................. 63
9.50 Water temperatures and delivery devices .............................................. 65
9.59 Accommodation periodically used .......................................................... 69

10. Building and energy management systems ....................................... 70

11. Materials of construction ..................................................................... 71

11.1 General................................................................................................... 71
11.11 Steel pipes and fittings ........................................................................... 72
11.13 Stainless steel ........................................................................................ 72
11.14 Copper pipes and copper/copper alloy fittings........................................ 72
11.18 Plastics ................................................................................................... 73
11.27 Composite materials ............................................................................... 74
11.28 Iron pipes and fittings ............................................................................. 74
11.30 Lead ....................................................................................................... 75
11.31 Concrete ................................................................................................. 75
11.33 Asbestos cement pipes and fittings ........................................................ 75

12. Pipework installations.......................................................................... 77

12.1 General................................................................................................... 77
12.3 Sizing...................................................................................................... 77
12.5 Routeing of pipework .............................................................................. 77
12.10 Vents and drains .................................................................................... 78
12.14 Valves..................................................................................................... 79
12.16 Prevention of contamination ................................................................... 79
12.23 Frost protection ...................................................................................... 80
12.28 Flushing .................................................................................................. 80

13. Noise and vibration .............................................................................. 81

13.1 Pump noise ............................................................................................ 81
13.6 Other forms of system noise................................................................... 81

14. Water economy and energy conservation ......................................... 82

14.1 Water ...................................................................................................... 82
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14.4 Energy .................................................................................................... 82

14.8 BREEAM (Building Research Establishment Environmental Assessment
Method) .................................................................................................. 83

15. Water treatment .................................................................................... 85

15.1 Introduction............................................................................................. 85
15.4 Treatment options .................................................................................. 85
15.7 Purging the systems ............................................................................... 88

16. Testing and commissioning ................................................................ 89

16.1 Introduction............................................................................................. 89
16.2 Installation checks .................................................................................. 89
16.3 Inspection of joints .................................................................................. 89
16.9 Commissioning ....................................................................................... 90
16.23 Cold water installations........................................................................... 91
16.27 Hot water installations ............................................................................ 92
16.31 Pressure testing ..................................................................................... 94
16.33 Temperature testing ............................................................................... 94

17. Disinfection ........................................................................................... 96

17.10 Discharge of waste water used during disinfection procedures within
buildings ................................................................................................. 97
17.11 Thermal disinfection (of hot water service systems) ............................... 97
17.13 Maintaining control of systems ............................................................... 98

18. Documentation ..................................................................................... 99

18.1 General................................................................................................... 99

Appendix 1: Water consumption ................................................................. 100

Appendix 2: Water treatment ....................................................................... 109

Appendix 3: Chloramine (and chlorine) in public water supplies ............. 113

Appendix 4: Chlorine dioxide ...................................................................... 118

Appendix 5: Copper and silver ionisation .................................................. 120

References..................................................................................................... 122

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Disclaimer

The contents of this document are provided by way of general guidance

only at the time of its publication. Any party making any use thereof or
placing any reliance thereon shall do so only upon exercise of that party’s
own judgement as to the adequacy of the contents in the particular
circumstances of its use and application. No warranty is given as to the
accuracy, relevance or completeness of the contents of this document and
Health Facilities Scotland, a Division of NHS National Services Scotland,
shall have no responsibility for any errors in or omissions therefrom, or
any use made of, or reliance placed upon, any of the contents of this
document.

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Acknowledgements

Health Facilities Scotland would like to thank the Steering Group led by the
Department of Health for their efforts in producing the HTM 04-01 Part A.
document.

HTM 04-01 Part A has been updated and amended by Health Facilities
Scotland for use in NHSScotland as SHTM 04-01 Part A. Some updating has
been done to take account of experience in using the guidance and recent
developments affecting design and installation of domestic water services
arising from the impact of the discovery of Pseudomonas aeruginosa bacteria in
water supplies, including re-titling “Water safety for healthcare premises”. The
significant participation of the National Water Services Advisory Group is
gratefully acknowledged.

Note: This version (2.0) of SHTM 04-01 Part A has been updated to take
account of latest guidance forthcoming regarding measures to prevent build-up
of waterborne bacteria and biofilm such as Pseudomonas as it affects design
and specification of domestic hot and cold water systems and components.
(Notes 6, 15 and 17 and paragraphs 7.46, 9.54 and 10.1 particularly refer.

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Preface

About Scottish Health Technical Memoranda

Engineering Scottish Health Technical Memoranda (SHTMs) give
comprehensive advice and guidance on the design, installation and operation of
specialised building and engineering technology used in the delivery of
healthcare.

The focus of SHTM guidance remains on healthcare-specific elements of

standards, policies and up-to-date established best practice. They are
applicable to new and existing sites, and are for use at various stages during
the whole building lifecycle: Healthcare providers have a duty of care to ensure
that appropriate engineering governance arrangements are in place and are
managed effectively. The Engineering Scottish Health Technical Memorandum
series provides best practice engineering standards and policy to enable
management of this duty of care.

It is not the intention within this suite of documents to repeat unnecessarily

international or European standards, industry standards or UK Government
legislation. Where appropriate, these will be referenced.

Healthcare-specific technical engineering guidance is a vital tool in the safe and

efficient operation of healthcare facilities. Scottish Health Technical
Memorandum guidance is the main source of specific healthcare-related
guidance for estates and facilities professionals.

The core suite of eight subject areas provides access to guidance which:

 is more streamlined and accessible;

 encapsulates the latest standards and best practice in healthcare
engineering;
 provides a structured reference for healthcare engineering.

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Healthcare building life-cycle

Structure of the Scottish Health Technical Memorandum suite

The series of engineering-specific guidance contains a suite of eight core
subjects:

Scottish Health Technical Memorandum 00: Policies and principles (applicable

to all Scottish Health Technical Memoranda in this series)

Scottish Health Technical Memorandum 01: Decontamination

Scottish Health Technical Memorandum 02: Medical gases

Scottish Health Technical Memorandum 03: Heating and ventilation systems

Scottish Health Technical Memorandum 04: Water systems

Scottish Health Technical Memorandum 05: Reserved for future use

Scottish Health Technical Memorandum 06: Electrical services

Scottish Health Technical Memorandum 07: Environment and sustainability

Scottish Health Technical Memorandum 08: Specialist services

Some subject areas may be further developed into topics shown as -01, -02 etc
and further referenced into Parts A, B etc.

Example: Scottish Health Technical Memorandum 06-02 Part A will represent:

Electrical safety guidance for low voltage systems

In a similar way Scottish Health Technical Memorandum 07-02 will simply

represent: Environment and Sustainability – EnCO2de.

All Scottish Health Technical Memoranda are supported by the initial document
Scottish Health Technical Memorandum 00 which embraces the management
and operational policies from previous documents and explores risk
management issues.

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Some variation in style and structure is reflected by the topic and approach of
the different review working groups.

Health Facilities Scotland wishes to acknowledge the contribution made by

professional bodies, engineering consultants, healthcare specialists and NHS
staff who have contributed to the review.

Engineering guidance structure

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Executive summary

Preamble
Scottish Health Technical Memorandum (SHTM) 2027: ‘Hot and cold water
supply, storage and mains services’ and SHTM 2040: ‘The control of Legionella
in healthcare premises: a code of practice’ have both been revised, and have,
at the same time, been combined into this single document: SHTM 04-01:
‘Water safety for healthcare premises”.

The guidance has been revised in line with changes to relevant regulations,
standards and other guidance, and also technical developments.

SHTM 04 now supersedes SHTM 2027 and SHTM 2040 and absorbs
information from Scottish Hospital Technical Note 6: ‘The safe operation and
maintenance of thermostatic mixing valves’ and Scottish Health Guidance Note:
‘Safe’ hot water and surface temperatures.

Introduction
The development, construction, installation and maintenance of hot and cold
water supply systems are vital for public health. Healthcare premises are
dependent upon water to maintain hygiene and a comfortable environment for
patients and staff, and for clinical and surgical care.

Interruptions in water supply can disrupt healthcare activities. The design of

systems must ensure that sufficient reserve water storage is available to
minimise the consequence of disruption, while at the same time ensuring an
adequate turnover of water to prevent stagnation in storage vessels and
distribution systems.

This Scottish Health Technical Memorandum gives comprehensive advice and

guidance to healthcare management, design engineers, estate managers and
operations managers on the legal requirements, design applications,
maintenance and operation of hot and cold water supply, storage and
distribution systems in all types of healthcare premises. It is equally applicable
to both existing and new sites whether procured conventionally (i.e. owned by
the NHS) or via PFI/PPP funding. It is equally applicable to modifications and
changes to existing premises and a risk assessment should be carried out to
determine, highlight and record where it may not be reasonable or technically
possible to implement the SHTM 04-01 guidance.

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Aims of this guidance

This guidance has been written to:

 provide an overview for developing and maintaining a risk register;

 provide information on thermostatic mixing valve configurations, usage and
maintenance requirements;
 outline how quality and hygiene of water supply can preserve system
components and safe use by occupants;
 provide a point of reference to legislation, standards and other guidance
pertaining to water systems;
 provide a basic overview of possible bacterial contaminants;
 outline key criteria and system arrangements to help stop bacteria
proliferating;
 give an overview of some of the different water systems components and
their safe installation and operation;
 provide typical system layouts and individual component location;
 illustrate the importance of ‘safe’ delivery of hot water;
 illustrate temperature regimes for sanitary outlets used in healthcare
premises to reduce risk of occupant injury;
 identify key commissioning, testing and maintenance requirements for
referral by designers, installers, operators and management.

Recommendations
In healthcare facilities, there is a risk of scalding for vulnerable patients, the very
young, older people and mental health patients. Therefore, this guidance
strongly recommends that thermostatic mixing devices should be considered for
many hot water outlets. It is stressed that hot water outlets throughout for staff
use should also be fitted with thermostatic mixing devices unless otherwise
recorded in a risk register. Safe water and delivery devices are summarised as
follows:

Area/Activity Recommended Type of device (see MES D08

temperature (°C) for explanation of valve
types)
Staff bases, ward and 41 Type 3 Thermostatic
consulting rooms etc basins
In-patient, out-patient hand-
wash basins
General areas to which 41 Type 2 Thermostatic
patients and visitors may
have access

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Area/Activity Recommended Type of device (see MES D08

temperature (°C) for explanation of valve
types)
Paediatric baths 40 - to allow for the cold Type 3 Thermostatic
paediatric bath/sink
NB: paediatric nurses should
always use a thermometer
General baths 43 Type 3 Thermostatic
Showers 41 Type 3 Thermostatic
Assisted baths 46 - to allow for the cold Type 3 Thermostatic
mass of bath
NB: Nurses should always
use a thermometer before
immersing patients
Hair-wash facilities 41 Type 3 Thermostatic
Bidets 38 Type 3 Thermostatic
All sinks, kitchens, pantries, 55 - minimum required for Separate hot and cold taps or
slop sinks etc food hygiene and combination tap assembly
decontamination purposes Type 1; no preceding
thermostatic device
Office, staff-only access 43 Type 1
areas hand-wash basins

Hot water outlets provided for food hygiene and decontamination purposes
should be provided with a notice ‘Caution – Very Hot Water’

It is preferable that thermostatic mixing devices are fitted directly to the mixed
temperature outlet, or be integral with it, and be the method of temperature and
flow control.

Because of the complexity of hot and cold water systems found in healthcare
facilities and the responsibility of maintaining a temperature control regime at all
times, this guidance suggests that chemical and other water treatments that
have been shown to be capable of controlling and monitoring Legionella may
also be considered (for example chlorine dioxide or silver/copper ionisation).

Note 1: As well as complying with the recommendations outlined in this

document, the design and installation of the hot and cold water services, new or
extended, in any NHS premises must also comply with the Scottish Water
Byelaws 2004.

a. 1999, recommendations of the water suppliers in the Water Regulations

Advisory Scheme’s (WRAS) ‘Water Regulations Guide’, and any other
requirements of the local water authority;

b. the Health and Safety Executive’s Approved Code of Practice and

guidance document ‘Legionnaires’ disease: the control of Legionella
bacteria in water systems’ (commonly known as L8), which requires that
there must be a Written Scheme in place in respect of controlling Legionella
in water systems.

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1. Introduction

Preamble
1.1 Scottish Health Technical Memorandum (SHTM) 2027: ‘Hot and cold water
supply, storage and mains services’ and SHTM 2040: ‘The control of Legionella
in healthcare premises: a code of practice’ (NHSScotland Property and
Environment Forum, 1999) have both been revised, and have, at the same
time, been combined into this single document: Scottish Health Technical
Memorandum 04-01: ‘Water safety for healthcare premises’. The guidance has
been revised in line with changes to relevant regulations, standards, other
guidance and also technical developments. It absorbs information from Scottish
Hospital Technical Note 6: ‘the safe operation and maintenance of thermostatic
mixing valves and Scottish Health Guidance Note: ‘Safe’ hot water and surface
temperatures’.

1.2 Scottish Health Technical Memorandum 04 now supersedes Scottish Health

Technical Memorandum 2027 and Scottish Health Technical Memorandum
2040, and absorbs information from Scottish Hospital Technical Note 6 and
Scottish Guidance Note regarding ‘Safe’ hot water and surface temperature.

1.3 This Scottish Health Technical Memorandum gives comprehensive advice and
guidance to healthcare management, design engineers, estate managers and
operations managers on the legal requirements, design applications,
maintenance and operation of hot and cold water supply, storage and
distribution systems in all types of healthcare premises. It is equally applicable
to both new and existing sites.

1.4 In its new form, the document is divided in seven parts. This part (Part A)
outlines the principles involved in the design, installation and testing of the hot
and cold water supply, storage and distribution systems for healthcare
premises. Some variation may be necessary to meet the differing requirements
for the water authority (see Note 3); Part B covers operational management
while Parts C and D respectively cover TVC testing and Water Disinfection.
Part E refers to alternative materials and filtration comprising an updated
version of the former Scottish Hospital Technical Note (SHTN) 2. Part F covers
issues related to chloramination of water supplies and Part G provides advice
on the preparation of Written Schemes.

General
1.5 Current statutory legislation requires both ‘management’ and ‘staff’ to be aware
of their individual and collective responsibility for the provision of wholesome,
safe hot and cold water supplies, and storage and distribution systems in
healthcare premises. This applies whether premises are NHS owned or
procured via PFI/PPP and operated by Consortia Facilities Management staff or
subcontractors.

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1.6 Premises used for the delivery of healthcare are dependent upon water to
maintain hygiene through a safe and comfortable risk assessed environment for
all who may interface and support functional care delivery.

1.7 The development, construction, installation and maintenance of hot and cold
water supply systems are vital for public health.

1.8 Interruptions in water supply can disrupt healthcare activities. The design of
systems must ensure that sufficient reserve water storage is available to
minimise the consequence of disruption, while at the same time ensuring an
adequate turnover of water to prevent stagnation in storage vessels and
distribution systems.

1.9 Measures to control the spread of microorganisms in healthcare premises

include the regular use of alcohol-based hand-rubs, and this can result in a
significant reduction in the use of hand-wash basins. There has also been a
trend to providing an enhanced provision of hand-wash basins and this results
in reduced throughput of water to each. Under-use of taps encourages
colonisation with Legionella and other microorganisms such as Pseudomonas
spp. Designers should be aware of these issues and, accordingly, consider
how they might impact on the frequency of use of hand-wash basins (see also
paragraphs 5.4–5.6 in Part B on the extent of utilisation).

Legislation, standards and guidance

1.10 As well as complying with the recommendations outlined in this document, the
design and installation of the hot and cold water services, new or extended, in
any NHS premises should also comply with:

 the Scottish Water Byelaws 2004, recommendations of the water suppliers

in the Water Regulations Advisory Scheme’s (WRAS) ‘Water Regulations
Guide’, and any other requirements of the local water supply authority (see
Note 3);
 the Health and Safety Commission’s Approved Code of Practice and
guidance document L8, which requires that there must be a Written
Scheme in place in respect of controlling Legionella in water systems.
 The Scottish Water Byelaws 2004 are set out, along with the Department
for Environment, Food and Rural Affairs (DEFRA’s) (1999) guidance (see
References) and with the water industry’s interpretation of these provisions,
in the WRAS ‘Water Regulations Guide’. The WRAS is funded by the water
suppliers to provide advice on the Scottish Water Byelaws 2004 on a
national basis. WRAS also administers the WRAS “approval scheme” that
assesses and lists water fittings and materials for compliance with the
Regulations. The ‘Water Fittings and Materials Directory’ contains
information on suitable fittings and materials and is updated every six
months.

Note 2: Where SHTM 04-01 exceeds the requirements of the above, it shall
take precedence.

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1.11 Designers and installers of hot and cold water distribution systems are required
by the Scottish Water Byelaws 2004 to notify the water supply authority of any
proposed installation of water fittings and to have the water supply authority
consent before installation commences. It is a criminal offence to install or use
water fittings without their prior consent. Liaison with the local water supply
authority is strongly recommended at an early stage to avoid problems of
compliance in the design.

1.12 All materials used in the construction of systems referred to in this SHTM must
comply with the requirements of the Scottish Water Byelaws 2004 (Regulations
3-7: “Requirements for water fittings”) and be in accordance with relevant British
Standards and codes of practice. All materials in contact with wholesome water
supplies must be listed in the ‘Water Fittings and Materials Directory’.

1.13 Water quality is governed by the Water Supply (Water Fittings) Regulations
1999, building regulations, approved codes of practice and technical standards
intended to safeguard quality.

Model Engineering Specification

1.14 Model Engineering Specification C07, which is a procurement specification,
supports this SHTM and provides details of the extent of the work required.

Exclusions
1.15 Although many of this SHTM’s recommendations will be applicable, it does not
set out to cover water supply for fire-fighting services nor water supply for
industrial or other specialist purposes, other than to indicate precautions that
should be taken when these are used in association with domestic water
services. The point at which a “domestic” activity becomes an industrial
process, for example in food preparation, has not been defined, and the
applicability will need to be considered in each case.

1.16 This SHTM does not cover wet cooling systems such as cooling towers.
Guidance on these systems is given in the Health & Safety Commission’s
Approved Code of Practice and guidance document L8. Although none remain
within NHS Scotland estate there are some within close proximity to healthcare
premises where wind-borne aerosols could be drawn in via air intakes or
openable windows.

1.17 While some guidance on other water-service applications is included, it is not

intended to cover them fully. i.e:

 for sterile services departments, see SHPN 13: ‘Decontamination’;

 for hydrotherapy pools, see the Public Health Laboratory Service’s ‘Hygiene
for hydrotherapy pools’;
 for spa pools, see the Public Health Laboratory Service’s ‘Hygiene for spa
pools: guidelines for their safe operation. The report of a PHLS spa pools
working party’.

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Definitions
1.18 Definition of terms is as those contained in the Scottish Water Byelaws 2004.

Note 3: The water industry

Water supply
In Scotland, the various water supply authorities were not ‘privatised’ as in
England. The various regional authorities were combined into a single entity
‘Scottish Water’, remaining in the public sector and hereinafter referred to as
‘the water supply authority’. In April 2008 the retail function was deregulated,
with competition for business customers.
Regulatory authorities
The Water Services etc (Scotland) Act 2005 established the Water Industry
Commission for Scotland and the following of regulatory bodies which are also
relevant are summarised below:
a. the Water Industry Commission for Scotland, which regulates the state-
owned Scottish Water by the water companies, oversees the standards of
service provision and protects the interests of water consumers, ensuring
value for money; www.watercommission.co.uk
b. the Scottish Environment Protection Agency (SEPA) regulates the quality
and controls pollution of “controlled” waters (that is, most inland and coastal
waters) and protects the water resources in Scotland; www.sepa.org.uk
c. the Drinking Water Quality Regulator (DWQR) regulates the quality of
supply of drinking water. www.dwqr.org.uk

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2. Source of supply

General
2.1 Normally, the source of water supply to healthcare premises is by one or more
service pipe connections from the mains of the water supply authority. If the
quantity and rate of flow is inadequate, or if the cost of providing the service
connection appears to be uneconomical, alternative sources of supply such as
boreholes or wells may be investigated.

2.2 Where the constraint is only that of inadequacy of the water authority’s supply,
the healthcare building needs could be met by using a private supply as an
additional source to the water authority’s supply. In such cases, the water
authority’s supply should be the priority supply for drinking, culinary and special
hygienic services. By limiting the use of the private supply to services not
requiring the highest level of hygiene, the extent of treatment of the private
supply may be reduced. Private supplies used in this way must convey water
through a separate pipework system that is clearly labelled. Outlets served by
the private supply system should also be appropriately labelled.

2.3 Provision should be included for alternative water supply arrangements to meet
an emergency, regardless of the source or sources of supply finally adopted.
Alternative arrangements would include a second service connection from the
water authority or a private supply. In either case the alternative supply should
not be vulnerable to the cause of loss of the original supply. Direct physical
interconnection of pipework and valves of a water authority’s supply with any
private supply without adequate backflow protection is prohibited by the Water
Supply (Water Fittings) Regulations 1999. The water quality requirements
applicable to the main supply apply also to any alternative supplies.

2.4 The water authority must be advised if it is proposed to use any private supply
as well as the water authority’s supply, and advice should be sought on the
limitations imposed in respect of break cisterns and interconnection thereafter
as required by the Water Supply (Water Fittings) Regulations 1999.

2.5 In Scotland all water intended for human consumption is required by legislation
to comply with the quality standards laid down by the Drinking Water Quality
Regulator (DWQR) with powers as laid down in Section 7 of the Water Industry
(Scotland) Act 2002. DWQR can force the statutory water authority to comply
with the standards set out in the Water Supply (Water Quality) (Scotland)
Regulations 2001. These regulations apply to water sampled at the point where
the water is available for use and also embrace water used in the preparation of
food and beverages.

2.6 The responsibility for enforcing this legislation for public water supplies rests
primarily with the Drinking Water Quality Regulator and the water supply
authority and the legislation also covers private water supplies. In respect of
public water supplies, the water supply authority has a duty to provide a

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wholesome supply and to demonstrate – by monitoring – that the supplies meet

the standards required.

Supplies from a water supply authority

2.7 The following factors should be taken into consideration in the initial stages of
the design:

 the water supply authority’s requirements;

 the estimated daily consumption, and the maximum and average flows
required, together with the estimated time of peak flow;
 the location of the available supply;
 the quality, quantity and pressure required;
 the cold water storage capacity required;
 the likelihood of ground subsidence due to mining activities or any other
reason;
 the likelihood of there being any contaminated land on site;
 the proposed method of storage and probable number and purpose of direct
connections to pressure mains;
 the minimum and maximum pressures available at the service connection;
 details of the physical, chemical and microbiological characteristics of the
water supply and scope of any possible variations in such characteristics;
 the possibility of an alternative service connection from some other part of
the water authority’s network, including pressure details;

 the water authority’s (see Note 3) contingency plan in the event of no water
supply for whatever reason.

Note 4: Regulations require notification to the water supply authority of any

proposed changes and additions to the water supply system in the premises.
Prior to making any changes, a risk assessment should be carried out and
audited by an independent assessor.

2.8 These initial design investigations should normally reveal the need for any
further treatment, pressurisation and storage of the water authority’s (Note 3
refers) supply to meet healthcare building requirements and enable an estimate
of costs to be made.

2.9 BS6700: 2006, successor BS EN 806-1-5: 2000-2012 and BS8558: 2011 give
further guidance on the procedures that should be followed when carrying out
preliminary investigations in relation to new water supplies. (Paragraph 3.11 in
Part B also refers)

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2.10 During the design stage, close collaboration with the water supply authority
should be maintained, and consent must be sought on the final arrangements
before proceeding with the installation. These arrangements should include:

 siting of service connection, access chamber, metering, bypassing, flushing

out, physical security of service connection, installation and provisions for
the fire-fighting service;
 compliance with the Water Supply (Water Fittings) Regulations 1999.

Private supplies
2.11 Private supplies independent of the statutory water authority (see Note 3); are
also governed by the Water Supply (Water Quality) (Scotland) Regulations
2001 and 2010. A license is required from the Scottish Environment Protection
Agency (SEPA) before embarking on any private water supply scheme. If, for
any reasons of back-up or security of supply, there is a connection to the public
supply (regardless of whether, or how often, it is used), the installations must
comply with the Water Supply (Water Fittings) Regulations 1999. Private
supplies should be registered with the statutory water authority that has the
responsibility to monitor the wholesomeness of the supplies where these are
used for domestic or food production purposes.

2.12 The standards for private water supply quality are very similar to those for public
supplies. Reference should also be made to the Standing Committee of
Analysts’ (2002) ‘The microbiology of drinking water’.

2.13 SEPA keeps records and maps of all known sources of private water supply
together with details of the geological strata and water-bearing characteristics of
the area under its control.

2.14 The feasibility of such a private supply should be decided by comparing the
capital costs (of the construction of works, including mains, pumping plant,
treatment plant etc) and revenue costs (of electricity for pumping, water
treatment chemicals, direct and indirect maintenance and associated
management costs, regular water analysis tests etc) with the long-term cost of
water supply from the water authority over the predicted life-cycle of the
installation. Due consideration should be given to the long-term costs of a
private supply, and account should be taken of potential deterioration in water
quality and/or capacity of the private supply source.

2.15 Where consideration is being given to the use of a private supply, specialist
assistance should be sought to:

 confirm the long-term availability of water in sufficient quantity, which is

either of proper quality or suitable for treatment;
 confirm the long-term quality of water and define requirements for water
treatment;
 design and specify the works needed;

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 carry out a full evaluation of the costs and practicability of a private supply
compared to a connection from the water supply authority.

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3. Water treatment regimes

3.1 Provided water is supplied from the public mains and its quality is preserved by
correct design, installation and maintenance, it can be regarded as
microbiologically acceptable for use. It is exceptional, however, for a water
supply, either public or private, that is wholly ‘potable’ to be entirely free from
aquatic organisms, and consequently it is important that appropriate measures
are taken to guard against conditions that may encourage microbial
multiplication.

3.2 Reasons for treatment of water from the supply authority in healthcare premises
would be for processing for laundries, domestic hot water systems and steam
boiler feed water, where either the degree of hardness proves excessive or
exceptional softness causes corrosion. Most private supplies, however, are
likely to require some measure of treatment, and in many cases, the installation
of pumping and treatment plant needs to be extensive to ensure a constant
acceptable quality.

3.3 Treatment systems that are used in conjunction with potable water systems
should be selected with care. Addition of any substance must not cause a
breach of any requirements in the Water Supply (Water Quality) Regulations
2001 and 2010. Any substance should be approved in accordance with those
Regulations, for example, by being in the Drinking Water Quality Regulator’s list
of approved substances for contact with drinking water, which is included as an
appendix in the ‘Water Fittings and Materials Directory’.

3.4 Automatic water treatment systems should be fail-safe and have sufficient
instrumentation to monitor their operation. The water supply connections to the
equipment must be adequately protected against backflow. Monitoring by
means of building management systems should be considered.

3.5 In healthcare premises, both hot and cold water are considered to be potable
and therefore water treatment supplied to healthcare premises must comply
with current legislation on water quality.

3.6 Further details can be found in BSRIA’s Application Guide AG 2/93: ‘Water
treatment for building services systems’ (with amendments) and Parts D and E
of this SHTM.

3.7 The continuous chlorination of hot and cold water service systems, after initial
disinfection (see Section 17), to control the growth of Legionella is not
recommended because chlorine has a limited ability to penetrate biofilm and
inactivate sessile micro organisms.

3.8 Treatment using chlorine dioxide or copper/silver ionisation can be used

however, (but see Section 15, Appendix 5 and Part D of this SHTM).

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4. Water softening

4.1 Hard waters are unsuitable for many industrial and domestic purposes.
Treatment may therefore be necessary to remove or alter the constituents to
render the water suitable for particular purposes.

4.2 Hardness is due to calcium and magnesium salts in the water and is expressed
in terms of milligrams per litre as calcium carbonate (CaCO3). Temporary
(carbonate) hardness is related to the bicarbonate salts of calcium and
magnesium. Permanent (non-carbonate) hardness is related to the other salts
of calcium and magnesium, that is chlorides, sulphates, nitrates etc. The
generally accepted classification of waters is shown in Table 1, below.

Description Milligrams per litre (mg/litre as

CaCO3)
Soft 0 to 50
Moderately soft 50 to 100
Slightly hard 100 to 150
Moderately hard 150 to 200
Hard 200 to 300
Very Hard Over 300
Table 1: Classification of water hardness
4.3 When the temperature of water is raised, the hardness will be reduced by some
of the dissolved salts (temporary hardness) coming out of solution and forming
solids in suspension, some of which will be deposited on heating surfaces to
form an adherent lime scale, thus reducing the heat transfer rate.

4.4 The extent of treatment required to prevent scale formation will depend upon
the process for which the water is being heated; it may therefore be necessary
to achieve one of the following conditions:

 replacement of calcium and magnesium salts by their more soluble sodium

equivalents;
 removal of all salts, that is, demineralisation;
 where water of greater purity is required for specialised uses, it can be
produced from softened water by reverse osmosis or by demineralisation.

4.5 Softening is not considered necessary for palatability. In some instances the
softening process makes the water less pleasant to taste without affecting the
potability.

4.6 Epidemiological studies have shown that the incidence of cardiovascular

disease tends to be higher in areas with soft water supplies than in areas with
hard water supplies. The association is clearest where the soft water supplies
contain hardness below about 150 mg/litre (as CaCO3).

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The explanation is not known, but it is considered prudent, where possible, not
to drink water that has been artificially softened to concentrations lower than
this. Softened water may also tend to dissolve metals from pipes. Water
softeners containing ion-exchange resins may be subject to bacterial
contamination if not adequately maintained. Softeners using salt-regenerated
ion-exchange resins increase the sodium content of the water during softening,
and this may be undesirable for children and anyone on strict salt-restricted
diets. These concerns can be avoided if water intended for drinking and cooking
is not softened.

4.7 Waters having a hardness of up to 400 mg/litre have been used for public
supplies without preliminary softening. While it is accepted that supplies for
domestic purposes need not be softened, partial softening may be carried out
by the water supply authority (see Note 3).

4.8 The need for softened water in hospitals for domestic purposes other than
drinking and cooking should be considered on the merits of each case. If
treatment is considered essential, the extent of softening should be the
minimum to achieve an acceptable level. A generally acceptable level is
between 80 and 150 mg/litre, and not less than 60 mg/litre, but this should not
be taken as a requirement for hospitals as it may be impracticable to achieve.
The cost and difficulties of treatment may be prohibitive for certain waters if the
hardness value is particularly high and the content of magnesium is
appreciable.

4.9 Generally, within healthcare premises, softening of a hard water supply will be
required on feeds to the following:

 boilers and hot water supply systems – to prevent sludge and lime scale
building up in pipework and plant (see BS2486:1997);
 mixing devices and blending valves – to avoid clogging of control ports and
showerheads by lime scale;
 laundries – high maintenance costs and the uneconomic uses of soap or
detergents are caused by the presence of hardness.

Note 5: Problems often occur in thermostatic mixing valves whereby scale is

deposited as a result of hard cold water being heated in the blending process.

4.10 The most common water-softening process used for the protection of hot water
calorifiers is base-exchange softening. This process removes permanent and
temporary hardness from water. The technique uses an ion-exchange process
in which the calcium and magnesium ions in solution are removed and replaced
by an equivalent number of sodium ions. This method of water softening is not
recommended for drinking water or water for culinary use, since a raised level
of sodium is associated with heart disease.

4.11 Other water softening methods include physical water conditioning and
magnetic water conditioning. Physical water conditioners function by triggering
the growth of nuclei or seed crystals in the water. When the water is heated or
subjected to pressure change, dissolved salts precipitate onto these seeds to
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form crystals, which do not adhere to the sides of the pipes and are washed out
with the flow. Some hard scale will still form, but it will be dissolved provided
sufficient seeds are created. The main problem is to ensure an adequate supply
of the seed crystals, which have a relatively short life before they are absorbed
back into the water. The efficacy of these water-conditioning measures needs to
be considered.

4.12 For further details on processes which control scale formation in hot water
services systems, refer to BSRIA’s Application Guide AG 2/93: ‘Water treatment
for building services’.

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5. Filtration

General
5.1 Scottish Hospital Technical Note (SHTN) 2 (second edition) was published in
December 1999. Its guidance reflected examinations at the time of domestic
water systems in Scottish Hospitals where water had been supplied by the
water supply authorities who used chlorine as a disinfecting agent. It also dealt
with the adverse impact on copper tube installations in many parts of the
country and listed suitable alternatives.

These examinations revealed significant deposits of sediment and debris in

pipework that could provide an environment conducive to the development of
bacteria through, for instance, the generation of biofilms. Filtration was
recommended to:

 ensure that the domestic water supply and associated pipework was
maintained at a high standard of cleanliness throughout the system;
 reduce the accumulation of sediments that may promote the growth of
water-borne organisms.

SHTN2 has been updated and expanded to become Part E of this SHTM.

5.2 Filtration need not be provided for cold water for non-domestic use, for
example, fire-fighting, boiler-feed or other chemically treated or dosed systems
unless there is a significant and regular suspended solid carry over from the
public water supply.

5.3 Anecdotal evidence suggests that there has been some improvement in water
quality following recent examinations of domestic water systems in a number of
Scottish healthcare premises with reduced deposits of sediment and debris in
pipework and storage tanks. It should be stated, however, that organic matter
is a significant source of solids and, as this is a seasonal issue, the evidence
currently available should be treated with caution as it may have been derived
during periods of low organic contamination.

5.4 On-site filtration has been regarded by some as an optional provision despite its
inclusion being mandatory since 1999. It is stressed that opting out of installing
such plant should not be the default situation. Any decision to exclude filtration
would be dependent on careful consideration of the following issues. This list is
not exhaustive:

 whether a project comprises an additional building (or buildings) on an

existing site without filtration plant;
 a risk assessment taking into account the type of accommodation served;
 a risk assessment based on the type and vulnerability of patients served;

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 an assessment of the practicality of introducing filtration for the likes of a

ward refurbishment project that involved extending or upgrading part of an
existing (unfiltered) system;
 analysis of samples of incoming water supplies.

The last issue is particularly important. In existing premises, an examination of

maintenance records would determine whether strainers were routinely
becoming clogged as an indicator of a history of suspended solids being
present in the water authority’s incoming supplies.

Before the installation and maintenance of on-site filtration plant is dismissed as

an unaffordable burden, the following benefits and associated savings must
be balanced against capital and revenue costs of filtration plant.

 the requirement for periodic removal of sediment from storage tanks is

eliminated along with the precautions associated with working in confined
spaces;
 the need for a separate or divided storage tank to allow supplies to be
maintained during sediment removal is eliminated;
 cold water storage tank lids would not require to be completely and readily
removable for access to clean and de-sludge, leaving only the need to
provide inspection covers;
 the amount of suspended solids carried into the piping network would be
virtually eliminated as they would be retained within the filtration plant so
that strainers could be omitted from shower thermostatic mixing valve
assemblies. In filtration retrofit situations, existing strainer cartridges could
be removed. In these situations removal of strainers would also remove a
catchment for biofilm and bacteria build-up.

Description
5.5 Where it has been determined to install on-site filtration plant, the following
guidance will apply.

5.6 Where filtration is provided it is normally used to prevent ingress of suspended

solids into plant and pipework, and as such may be defined as the process of
separating solids from liquids using a porous medium. The medium can consist
of granular materials (sand, clay, carbon etc) assisted by chemical and/or
bacterial activity, woven meshes and screens made of metals, fabrics, ceramics
and polymeric membranes.

5.7 Filtration plant is usually specified by various criteria including minimum particle
size retained, expressed in microns (µm). ‘Absolute filtration’ of a given size
indicates that the plant can remove 99.9% of all particles above a given size.
‘Nominal filtration’ is normally taken to mean that 95% of all particles above a
specified size will be removed.

5.8 As a guide, suspended materials are normally classified according to Table 2,

overleaf.

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Material Particle diameter

mm µm
Pebbles >10 -
Gravel 10 - 2 -
Very coarse sand 2-1 -
Coarse sand 1 - 0.5 1000 - 500
Medium sand 0.50 - 0.25 500 - 250
Fine sand 0.25 - 0.10 250 - 100
Silt 0.10 - 0.01 100 - 10
Clay <0.01 <10
Colloid 10-4 - 10-6 0.1 - 0.001

Table 2: Particle size

5.9 In practice, water will contain a range of sizes of suspended particulates. The
rate of blockage by suspended solids for any given filter will depend on a
number of factors such as:

 throughput;
 concentration of suspended solids and other fouling debris;
 size distribution;
 shape of particles.

5.10 Particles less than 0.1µm are invisible microscopically. The smallest visible
macroparticle is approximately 40µm. Particles less than 0.001µm are
considered dissolved and in solution.

Capacity
5.11 To accommodate the variation in flow, and to allow for filter changes etc, the
equipment should be installed with redundancy built in.

Design features
5.12 The level of filtration where thermoplastic pipework systems are installed should
be 5 micron absolute.

5.13 The level of filtration where stainless steel pipework systems are installed
should be 0.5 micron absolute. If the stainless steel pipework manufacturer is
prepared to give a written guarantee offering a lifespan of the installation that is
not less that in CIBSE “Guide to ownership, operation and maintenance of
building services”, the level of filtration can be relaxed to 5.0 microns.

5.14 For small establishments (such as health centres and clinics), it will normally be
appropriate to use filters with cartridge or membrane elements (see also
paragraph 5.19). This form of filtration may also be appropriate for larger

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premises but would be a function of water quality, user demand and patient
category.

5.15 In larger establishments and those with high water usage, the filtration
equipment plant should be fully automatic in operation and include self -
cleaning and back-washing modes so that the filter medium does not become a
reservoir for organisms capable of contaminating the service pipework. To allow
for servicing of the plant, a bypass line with strainer filter should be provided,
complete with isolation valves and non-return valves. The bypass should be
provided with drains and vents to facilitate disinfection prior to bringing it into
service.

5.16 As an alternative to the installation of a bypass strainer, the provision of two

units to operate sequentially with automatic changeover on a regular basis will
minimise potential failures and maintenance. Precautions should be taken to
minimise stagnation of water in the dead-legs that may occur with this
arrangement – weekly flushing of dead-legs should take place.

5.17 All items in contact with water must be of materials that comply with the Scottish
Water Byelaws 2004 (for example, materials approved by the Water
Regulations Advisory Scheme and listed in the WRAS ‘Water Fittings and
Materials Directory’, having been assessed and shown not to have adverse
effects on water quality).

5.18 Parameters essential for the continued performance of the plant should be
automatically monitored, for example downstream pressures and automatic
cycling of back-washing facilities. These should be relayed to a building
management system.

Point-of-use filtration
5.19 Point-of-use filters have been found to provide protection from exposure to
bacteria such as Legionella and Pseudomonas by preventing the dispersal of
bacteria from showers and other water outlets. To be effective, the filter
membrane needs to have a nominal pore size of no greater than 0.1µm. Before
their use is contemplated, two factors should be considered:-

 the filters do not eradicate the organism, but prevent discharge to the
environment from the filtered outlet only;
 by retaining the organism within the pipework, it may be possible for the
organisms to multiply and regressively ‘seed’ other parts of the distribution
system.

Filters will also need to be changed routinely, depending on usage of the

outlets. Their use, therefore, should be considered only as part of an overall
regime of bacterial control to be used where the most vulnerable patients are to
be treated. Installation of point-of-use filters should be subject to risk
assessment and designers should be aware of the reduced flow that will arise
from increased resistance. This could be an issue on upper floors of premises
with a gravity-fed installation. Once a point-of-use filter has been installed it will
require to be retained in use thereafter unless a risk assessment deems
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otherwise. In new or refurbished installations taps should be provided that can

accommodate the later installation of point-of-use filters if the need arose.

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6. Metal contamination

6.1 Copper piping has not been routinely specified for Scottish hospitals since 1999
(Scottish Hospital Technical Note 2 refers) and the following section applies to
existing installations where extensions are being provided retaining the existing
specification or to very small, stand-alone facilities, or to temporary
accommodation with a short life-span.

6.2 Analytical results have shown that there can be a serious problem from lead
contamination of water supplies. The Water Supply (Water Quality) Regulations
2001 and 2010 set an upper concentration for lead in drinking water of 0.01
mg/litre to be achieved by 2013. This value is likely to be exceeded if lead pipes
are present or if copper pipes have been joined with solder containing lead. In
general, if hospital drinking water contains more than 0.01 mg/litre of lead,
remedial action should be taken. The use of lead solder is prohibited on all
plumbing installations where water is required to be wholesome.

6.3 Copper concentrations above 1 mg/litre may cause staining of laundry and
sanitaryware and increase the corrosion of galvanised iron and steel fittings.
Although the maximum allowable copper concentration in drinking water is
2 mg/litre, most supplies will give a level at the tap of less than 1 mg/litre.

6.4 Water supplies to certain specialist units such as maternity, neo-natal

paediatric, general paediatric and renal dialysis units (see the Renal
Association, 2002) should be monitored to ensure that water quality is within
acceptable limits. The designer should seek epidemiological advice to ascertain
the exact water quality requirements for specialist units.

6.5 Where the water supply is known to dissolve metals (that is, soft water), regular
sampling should be carried out at strategic sampling points to ascertain that the
level of metal contamination in the water supply to the premises, plus any
added during its passage through the distribution system, does not result in
limits above the stated safe levels. This will especially apply if the distribution
pipework includes a multiplicity of leaded solder capillary joints. In soft water
areas, metal contamination can occur by simple dissolution. Pitting corrosion
arising in hard water areas, as a result of deleterious carbonaceous films laid
down during the manufacturing process, does not normally give rise to elevated
copper levels in the water and is not nowadays a problem if independently
certified tubes to BS EN 1057: 1996 are used. Excessive use of acidic flux in
the making of capillary joints can lead to corrosion of copper plumbing,
especially if the system is allowed to stagnate after commissioning. WRAS
Information and Guidance Note 9-04-02: ‘Solder and fluxes’ (available on its
website http://www.wras.co.uk) gives further information on solders and fluxes.

6.6 If the proposed water supply is likely to take up metals in excess of acceptable
limits, it will be necessary to consider treatment of the water such as raising
hardness.

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7. Water storage

General
7.1 Where there is an interval of time between final testing and commissioning of
domestic hot and cold water systems, the systems should be drained dry until
put into use. This may be impractical and moisture could be retained on pipe
internal surfaces leading to the proliferation of harmful microorganisms.
Alternative procedures would comprise either pressure testing with air or inert
gas or leaving systems filled with over-chlorinated water – all subject to risk
assessments. This will include storage, where provided. The design and
installation of the system must be such as to facilitate effective draining.
Further guidance can be found in Part E of this SHTM.

Water is stored in healthcare premises for the following reasons:

 to provide a reserve supply during failure of the main cold water supply;
 to reduce the maximum demand on the cold water main;
 to provide accommodation for the expansion of any water subjected to heat,
that is, hot water and heating services;
 to reduce the pressure from that of the distribution system.

7.2 The purpose for which the storage is used can vary, but has only a minor effect
on its design. The following generally covers the range of uses:

 cold water services, domestic, laundry etc;

 cold water feed to hot water services;
 drinking water supplies;
 treated cold water for laundries, heating etc when local supplies are
unsuitable;
 break tanks on cold water supplies serving points of use where backflow is,
or is likely to be, harmful to health due to a substance representing a
serious hazard, for example, supplies to pathology laboratories;
 feed and expansion for heating service;
 fire-fighting.

Extent of storage
7.3 There is a conflict between the water supply authority’s desire to have 24 hours
water storage and the requirements of HSE L8 which recommends 12 hours,
the latter being intended to maximise turnover and avoid stagnation of stored
water. The requirements of each individual project require risk assessment and
discussed with the water supply authority at the earliest possible design stage.
Storage should be designed to minimise residence time in the cistern and
maximise turnover of water to avoid stagnation and deterioration of water
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quality. Storage volume should be calculated on the basis of peak demand and
the rate of make-up from source of supply. There may be more than one peak
period in each 24 hours. The interval between peak periods is important as it
affects the storage capacity based on the make-up flow. It also determines the
available time for maintenance if twin cisterns are not installed. Where multiple
storage tanks are to be incorporated the total storage should be split among the
two or more tanks that may be provided.

7.4 Appendix 1 is based on the results of studies into water consumption in various
types and sizes of hospitals. CIBSE Guide G: ‘Public health engineering’ gives
further guidance on sizing cold water storage. While it is accepted that the
desirable minimum for total storage will vary with the classification of the
particular health building, the upper limit of storage for a district general hospital
is 900 litres per bed per day and for a teaching hospital 1,350 litres per bed per
day, excluding provision for the staff residences, laundries and any special
storage for fire-fighting purposes.

7.5 It must be borne in mind that the overall pattern of healthcare is changing and
the data available now is a best estimate of what is required. The guidance in
Appendix 1 is known to overestimate water usage in healthcare premises and,
moreover, yields data in litres per second. Reference should be made to SHTM
04-01 Part E. (As an example, a hospital of between 400 and 600 beds might
consume 100,000m3 of water annually, that is, about 11 m3/h over a 24-hour
period. Peak hourly demand, however, may reach 50 m 3/h.)

7.6 A summation of the average daily consumption for each ward unit contained in
a building should be made. From the requirements of each building, the policy
of water storage for the whole complex should be decided. It does not always
follow that peak demands for each building will coincide, and therefore there
may be scope for applying a diversity factor to the whole site.

7.7 Where the water requirement is to be met from a private supply, the summation
for each building may require assessment on the basis of storing and using
water according to the minimum treatment of the water for each particular use.
Likewise, where the water is hard enough to require softening for certain
domestic and/or laundry purposes, separate storage will be required, and this
should be taken into account when assessing the total stored water.

7.8 Appendix 1 does not cater for water requirements for staff quarters or such
support services as laundries, bulk stores and workshops etc. The staff quarters
and industrial areas may be remote from the main hospital and supporting
departments. The laundry may serve a number of healthcare buildings as well
as the premises at which it is located. The storage requirement for such
accommodation should therefore be calculated separately and integrated with
the accommodation whenever this is practical. Appendix 1 provides data on
typical demands expected from staff residences.

7.9 Where new healthcare premises are to be built in separate phases, the water
storage, supply and distribution service for the whole premises should, as far as
possible, be planned and evaluated at the design stage. This will enable the

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total water supply requirement to be assessed in the planning stages, and

appropriate areas of accommodation (but not tank storage) to be allocated.

Location and form of storage

7.10 It is more convenient and more secure to house water storage cisterns at
sufficient height to provide adequate flow to all parts of the development by
gravity, thus avoiding reliance on pumps etc. This is achieved by siting cistern
rooms at roof level. Where buildings are widely dispersed, it is preferable to
install a number of smaller cisterns rather than building a water cistern tower.

7.11 The location of storage will depend on the total volume required, the topography
and layout of the site proposed for development, and the sources and adequacy
of the water supply. A limited site footprint may call for much higher buildings to
achieve the required accommodation. Depending on the supply water pressure,
it may be necessary to install pressurisation equipment to boost the incoming
supply. The cost of the supporting structure will have an important bearing on
the solution adopted.

7.12 A hospital built on a restricted site might need both central and local storage to
be provided in each building or in one of the buildings to serve other buildings in
the development. Local storage at high level should give an average supply of
about four hours if gravity-fed, but if the building structure will economically
accept greater tankage this should be adopted. The total supply should be
based on the average usage over 24 hours. There are some advantages in
locating central storage at low level, for example easier access for
maintenance, and reduced structural costs.

7.13 Where such storage is located in individual buildings and an adequate supply is
available from the water authority (see Note 3), a connection in accordance with
the Scottish Water Byelaws 2004 to each point of storage may be the most
economical arrangement. In such cases, interconnections between selected
points of storage should be provided to deal with emergency and maintenance
requirements, always providing that such interconnections do not contravene
the Scottish Water Byelaws 2004 and do not result in water stagnating within
the storage or distribution system. Where the development is widespread and a
water authority’s multiple connections are not the best solution, the general
arrangement might consist of a total storage reservoir, strategically sited,
serving cisterns located as conveniently as possible to the major centres of
usage.

7.14 To maintain good water quality, however, common practice favours the use of
smaller decentralised storage capacity as opposed to large central storage and
distribution. The use of smaller local cisterns helps to avoid the problem of
water stagnation in cisterns and also avoids long runs of distribution pipework
between cisterns and points of use. Shorter pipework runs reduce the amount
of heat gain in the cold water service en route to points of use.

7.15 Although the final assessment of the capacities of storage cisterns will emerge
from the design requirements of Appendix 1, the building’s structural design will

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influence the number of cisterns required and the cistern layout. Standard sizes
of tank should be used where possible.

7.16 Cisterns must not be located in any position where there is any likelihood of
flooding, excessive heat gain or any other factor that could affect the contents of
the cisterns. They should not be installed in any location where access for
general inspection or maintenance is restricted.

7.17 Separate systems should be provided for pathology and mortuary departments.

External storage
7.18 The ideal location for external cold water storage cisterns is the roof of the
highest building, provided the structural design can support the load. If concrete
water cisterns are to be considered, they should be designed to form an integral
part of the building structure. The materials of construction, however, must
comply with the Water Supply (Water Fittings) Regulations 1999.

7.19 Where storage is below ground, as distinct from being housed within a building,
it is essential to ensure that there is no risk of contamination. Investigations of
such risk require careful consideration of site conditions and should include
such aspects as flooding; subsidence; the location of sewers and drains and
other buried services; the maximum and minimum height of the water table in
the area; the natural drainage of surface water; ingress of contaminants such as
dust, debris etc; and, in the event of storage below a car parking area or roads,
the danger of oil/fuel seepage. The future development of the healthcare
building and probable extensions should also be taken into account in this
respect.

7.20 Storage below ground should be adopted only as a last resort, and cisterns
should be installed within a watertight bund allowing sufficient space all around
and beneath the storage vessel to permit inspection and maintenance. Any
underground construction arrangement, concrete or otherwise, not directly
against earth will reduce the risk of contamination. The tank chamber must
include provision for a sump to collect drainage water and any piping necessary
to pump out tanks to the site drainage. The Scottish Water Byelaws 2004
require any buried concrete reservoir to be designed, constructed and tested in
accordance with BS8007: 1987.

7.21 The economic depth for reservoirs constructed in concrete is a function of the
quantities to be stored. It should be considered at the outset of the planning
stage, and will be influenced by load-bearing characteristics of the locality and
take account of the outlet main’s position and particulars. If it is found necessary
to exceed a depth of 3.3m, a specialist should be consulted. A rectangular or
square concrete reservoir will generally provide a more economic proposition
than one or more circular reservoirs.

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Internal storage
7.22 As in the case of external storage, cisterns should be installed in positions
where they can be readily inspected and maintained and where they will not be
affected by frost or high temperatures.

7.23 It is essential in all cistern installations that a clear working space of not less
than 0.5m – but ideally 1m – is maintained around the cistern. Minimum
clearances of 0.5 m below and 0.75m above the cisterns are necessary to
facilitate erection, inspection and maintenance. A minimum of 0.5m should be
provided between the floor of the catchment basin and the underside of the
cistern.

7.24 Roof spaces in which cisterns are to be installed must have adequate trap
doors or other means of access and adequate lighting to facilitate inspection
and maintenance.

Note 6: Reference should be made to SHTM 08-07 “Confined Spaces: policies,

procedures and guidance” originally published by Health Facilities Scotland,
2012. Traditionally, access for internal inspection, cleaning, etc has been by
means of access panels in lids. This gives rise to difficulties in extracting
maintenance personnel in the event of illness where there is restricted space
between the top of a tank and the soffit. It is therefore recommended that a
preferred solution would be to specify side access panels in new build,
replacement and refurbishment situations

Construction of cisterns
7.25 All storage cisterns should be constructed in accordance with manufacturers’
recommendations and should comply with the Water Supply (Water Fittings)
Regulations 1999, be WRAS-approved, and comply with BS6700: 2006, BS EN
806-1-5 2000-2012 and BS8558: 2011. Glass-reinforced plastic (GRP) tanks
should comply with BS EN 13280: 2001. The WRAS Information and Guidance
Note 9-04-04: ‘Cold water storage systems – design recommendation for mains
supply inlets’ provides useful advice regarding the design of the inlet
arrangements to ensure compliance with the Regulations.

7.26 Depending on size and/or capacity, tankage should be divided into convenient
compartments suitably interconnected and valved to facilitate cleaning,
disinfection, repair, modification and inspection without seriously disturbing the
cold water service. Tank strengthening shall be by means of stainless steel tie-
bars and not baffle plates. Where multiple tanks are provided they should be
connected in series. Where tanks are connected in parallel and served via ball
valves it is impossible to divide the flow equally due to inequality of levels and
pipework configurations. A solution to this would be to use a pumped supply
with level sensors that would allow the tanks to be drawn down and refilled
together.

7.27 Separate cisterns should also be provided for storage of different water
supplies, for example cold water storage, recovered or recycled water, softened
water and fire-fighting water. Precautions must be taken to ensure that mixing
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does not take place between such supplies, and it should be noted that isolation
by means of shut-off valves between them is not acceptable.

7.28 Normally the materials used for storage cisterns serving healthcare premises
are predominantly GRP, but concrete or steel may also be considered. The
material selected should comply fully with the Water Supply (Water Fittings)
Regulations 1999. Pre-insulated sections are recommended where practical.

7.29 Sectional cisterns fabricated from GRP or pressed steel provide a convenient
means of bulk storage of water at atmospheric pressure. The components can
be readily transported to site and, subject to unit multiples, they can be erected
to give varying proportions of length to breadth and depth. It is also possible to
make provision for future extension in capacity by an increase in available base
area or, within limits, depth.

7.30 If sectional cisterns are selected, designs with external assembly flanges and
self-draining profiles should be used, since this arrangement facilitates easy
cleaning of internal surfaces of the cisterns.

7.31 The Scottish Water Byelaws 2004 lay down the minimum requirements for
potable water storage cisterns. Recommendations to comply with these are
given in the WRAS ‘Water Regulations Guide’. The requirements are indicated
in Figure 1.

Note 7: Cisterns should be sited away from heat sources and be protected from
heat gains by insulation. Adequate access should be provided for inspection
and maintenance (both internally and externally).

7.32 Each storage cistern or its compartment should also be provided with the
following:

 internal and external access ladders as necessary to comply with current

health and safety requirements;
 a full-way servicing valve at each inlet and outlet connection, except for
cisterns providing water to primary circuits or heating circuits, vent pipes,
overflow pipes, and warning pipes. Where practicable, all outlets should be
taken from the base of the cistern and be sited opposite to the inlet as
recommended in the Scottish Water Byelaws;
 a suitably-sized drain connection complete with isolating valve. The invert of
the drain connection should be positioned so as to provide maximum
drainage of the cistern.

7.33 Cisterns should be adequately supported on bearers placed under the

longitudinal or lateral cistern section joints. To avoid distortion, a flat section of
marine ply or equivalent should be sited between the support structure and the
cistern. Final siting should be in accordance with the manufacturers’
recommendations.

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Figure 1(i): General filtered potable water storage cistern arrangements

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Figure 1(ii): General unfiltered potable water storage cistern arrangements

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Note 8: Where an unfiltered tank is used with a side outlet, the tank should be
sized to take account of the contents from the top of the outlet.

7.34 The design may incorporate a watertight drip tray under the cistern to contain
condensed water or leakage so as to avoid damage to accommodation below.
The necessity for a drip tray or watertight bund with drainage will depend on
individual case requirements. The floor of the drip tray or bund should be
graded to a drainage sump complete with drain pipe. A single pipe should drain
off any overflow water from the sump and lead to a discharge point at ground
level where any water flow would be readily noticed. If it is not possible to
terminate the discharge pipe from the sump so that any discharge of water can
be seen, an audible alarm should be installed to warn of overflow conditions.
Cistern support levels should be constructed to keep the valves clear of the
water level in the drip tray or bund in the event of cistern leakage. Special
requirements apply to the supporting of GRP sectional cisterns on bearers, and
manufacturers’ recommendations should be observed. The cistern should be
provided with a warning pipe or a no less effective device to indicate leakage
through the inlet control valve if this should occur.

7.35 On no account should a cistern be installed on a concrete plinth (directly or on

steel beams) that is protected by an asphalt membrane. Subsequent irregular
settlement into the asphalt may lead to cistern distortion and leakage.

7.36 A consideration in deciding cistern shape and layout is the location of the
services duct. Whereas the cistern room may be positioned aesthetically in
relation to the building elevation, the duct serving it will be located to suit the
internal layout. The pipe route from the system to the service duct will require
access for inspection and protection from frost and heat gain.

Cistern rooms
7.37 GRP or steel cisterns should be installed in well-ventilated but draught-proof
housings constructed so as to prevent the ingress of birds, rodents and insects.
The housing accommodating the cistern and the positioning of the cistern within
the room must be designed to permit easy access for inspection and
maintenance.

7.38 Prefabricated GRP housings, protected from extremes of temperature by

thermal insulation, can provide an economical and aesthetic solution.

7.39 The load-bearing capacity of the main structure will limit the distributed load that
the cistern room and its contents can impose, and will ultimately limit capacity.
If, however, cisterns can be located above main service ducts or stairwells, this
will minimise the effects.

7.40 General space lighting should be provided in cistern rooms, together with
suitable power points for low voltage small tools and inspection lamps.

7.41 The contents and capacity of all cisterns should be clearly labelled in letters not
less than 100mm high on a white background.

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Ancillary pipework, valves and fittings

7.42 The arrangement of the cisterns in the room should be such that the pipework
runs are as short as possible, but accessibility and walkway clearance are
ensured. Flanges on parallel runs should be staggered.

7.43 Adequate allowance should be made in the pipework layout for possible future
cistern extension.

7.44 All cistern-room pipework and valves should be insulated and clearly labelled to
identify their purpose.

7.45 The use of delayed-action ball valves on large water storage cisterns should be
considered, since these help avoid stagnation of water in the cistern.

7.46 Strainers should be fitted within the water pipework system to protect
thermostatic valves etc against ingress of particulate matter. The installation of
these fittings should allow adequate access for maintenance/replacement, and
they should be provided with means of upstream and downstream isolation.
(see also paragraph 5.4, however) Strainers can be a source of Legionella and
other waterborne bacteria and should be included in routine cleaning,
maintenance and disinfection procedures (see Section 7, Part B).

7.47 Service isolation valves should be fitted to all pipework preceding sanitary
tapware and WCs etc for servicing, repair or replacement. Drain-valve provision
may also be appropriate for certain installations, for example, service pipework
to en-suite facilities etc.

Shower heads:

7.48 L8 requires shower heads to be disinfected (quarterly or) as necessary. This

imposes significant maintenance and cost burdens to be accommodated from
limited staff and financial resources.

The following options are available to NHS Boards:

 disinfect individual shower heads, progressively, one at a time;

 carry a float of shower heads, pre-disinfected, and replace those in use as
part of a campaign change whereby the displaced shower heads would be
disinfected in batches and become the next float. This could involve all
shower heads or involve economical or convenient batches, depending on
the number involved;
 remove shower heads due for disinfection, discarding them for replacement
by new shower heads.

The policy adopted will be influenced by the practicalities involved, the number
of shower heads to be dealt with and the overall alternative costs. Whichever
solution is decided upon will require to be auditable. This will involve the
provision of a unique identification for each shower.

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Flexible hose within shower assembly

7.49 The various options for disinfection or replacement of shower heads also apply
to the associated flexible hoses and reference should be made to paragraph
11.35 regarding the specification for linings. In the event that a disinfection
policy is followed the flexible hoses are regarded as an integral part of the
shower mixing valve assembly. The shower heads and hoses should be dried
following disinfection and stored in dry conditions until required for use,
otherwise the whole process will have been nullified. If a replacement policy is
adopted, the attached hose assemblies should be replaced along with the
shower heads.

Buffer vessels for cold water boosting sets

7.50 Buffer vessels are typically vertical in orientation and normally have a
diaphragm to separate the water from the gas space above. They introduce a
potential problem of colonisation by Legionella, as the plantroom space
temperature will exceed that of the incoming water. They should preferably be
of a design such that water flows through the vessel, entering at low level, and
discharging at a higher level below the water line. Interconnecting pipework
should be kept to a minimum, and the vessel should be insulated to minimise
heat gain. All materials in contact with water should be WRAS-approved (see
also paragraph 9.41).

Water meters
7.51 BS6700:2006, BS EN 806-1-5: 2000-2012 and BS8558: 2011 give guidance on
the design and installation of water meters.

7.52 Revenue meters are normally supplied and installed by the water authority,
whereas the consumer may install sub-meters.

7.53 Adequate sub-metering of water supplies should be provided so that supplies

can be monitored for individual heavy-use departments. Such monitoring will
assist in the detection of leaks or abnormal water demands. Water meters can
be connected to a Building Energy Management System (BEMS), which can
identify anomalous consumption and lead to the early detection of leaks.

7.54 Appropriate bypass arrangements with valves immediately upstream and

downstream should be provided; the bypass loop should be as short as
practicable and be arranged to be in the horizontal plane.

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8. Cold water distribution system

General
8.1 The design and installation of the cold water distribution system should comply
with the Scottish Water Byelaws 2004 and relevant parts of BS6700: 2006, BS
EN 806-2: 2005 and BS8558: 2011. A simple cold (and hot) water system is
shown in Figures 2(i), 2(ii) and 2(iii).

Note 9: All pipework to be insulated; isolating and control valves not shown; all
drains should discharge to waste via a type A “air” gap.

NB: In order to prevent back flow of dirty dishwater into mains water supplies
causing contamination, a WRAS fluid protection category 5 type “A” break tank
now requires to be fitted to all commercial dishwashers. Although it is the
responsibility of the purchaser of the equipment to comply, checks will be
carried out by Scottish Water to verify compliance.

8.2 The installation should be designed to avoid waste, undue consumption, misuse
and contamination. Every water fitting through which water is supplied for
domestic purposes should be installed in such a manner that no backflow of
fluid from any appliance, fitting or process can take place. An assessment of the
level of backflow contamination risk (the fluid category) should be made for
each fitting, appliance etc. The system should be designed and installed so that
each risk is adequately protected against backflow, either by means of the
design or by use of backflow prevention devices. Devices are listed in the
WRAS ‘Water Regulations Guide’ together with the degree of backflow
protection they provide.

8.3 The design of the pipework should ensure that there is no possibility of a cross-
connection between installations conveying potable water and an installation
containing non-potable water, recovered water or water supplied from a private
source. There should be no possibility of backflow towards the source of supply
from any tank, cistern, fitting or appliance, whether by back-siphonage or
otherwise.

8.4 From an early stage in the design process of the water installation, liaison and
consultation should take place with the designer of the building, the building
owner or his agent, the water supply authority and all other public and private
utilities, highway and local authorities, landowners and others involved. There is
a legal duty to notify the water authority of proposed installation work and have
its consent for the work before installation commences.

8.5 All cold water distribution pipework, mains and cistern down-feeds should be
located, as far as is practicable, to minimise heat gains from their environment.
Pipework should not be routed through hot ducts or run adjacent to heat
sources, such as radiators. Where hot and cold water pipes are run horizontally
together, the cold water pipe should be located beneath the hot water pipe to
minimise local warming by means of convection. Cold water pipe-runs should
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not be installed above ceiling-mounted radiant heating panels or similar

excessive heat sources. Where practical, installing cold water mains within a
different floor from other heat-conveying pipework will achieve complete
segregation and avoid unwanted increase of cold water temperatures.

8.6 All pipework should be insulated, except for any exposed final connections to
sanitary appliances, and should be arranged to eliminate or minimise dead-legs.

8.7 The superseded Water Supply (Water Quality) (Scotland) Regulations 1990
permitted cold water to be delivered at temperatures up to 25°C. Currently,
there is no standard for drinking water temperature in European or domestic
legislation. In normal circumstances it should be below 20°C, but there have
been recent reports in several NHS Board areas of temperatures at or well
above 25°C. This appears to be a function of reservoirs containing shallow
water and being more susceptible to the effects of solar heat. Anything above
20°C creates the potential for Legionella bacteria to breed. As far as possible,
the objective should be to design the cold water systems to ensure that the
inlet, outlet and surface water temperatures of cisterns and cold water
feed/header tanks for the hot water calorifiers are not greater than 2°C above
that measured at the main water meter. Also, at cold water draw-off points, a
temperature of no greater than 2°C above the temperature measured in cistern
and cold water header tanks should be reached within two minutes. However,
in view of the trend to higher incoming temperatures, it is recommended that
incoming temperatures are at least recorded and monitored via a BEMS
installation. This will warn as to any need to dump water or invest in the
provision of recirculation and/or cooling facilities, all measures of last resort.

Note 10: For the control of Legionella and other water-borne organisms, 20°C is
the quoted lower value above which multiplication of Legionella in particular
begins to take place (see Part B, Section 4).

8.8 The control of water temperature in the cold water service, however, will
essentially rely on good insulation and water turnover. Cold water services
should be sized to provide sufficient flow at draw-off points. Stagnation should
be avoided. Modern buildings have a high degree of energy efficiency that can
result in a build up of heat that is not readily dissipated. It is therefore
necessary to achieve separation of cold water service pipework from other heat
sources as void and vertical shafts temperatures can build up to the detriment
of keeping cold water distribution temperatures at required levels.

8.9 Pumped circulation of cold water and refrigerated cold water should normally
only be considered in specialist units where people are at particular risk as a
result of immunological deficiency; for example bone marrow transplant units
and certain oncology departments. Such systems require careful design. For
other accommodation the aim should be to promote turnover of cold water by
means of the design of the distribution circuitry.

8.10 In ward areas provided with en-suite facilities, the aim should be to supply
sanitary assemblies in series, with the WC connected to the final element.
Elsewhere, pipeline routeings should be run so that other outlets are connected
with a WC or flushing device, for example sluice hopper or pantry sink,
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providing the final element at the distal end of the branch – this may require
pipe routeing reversal. See Figures 3 and 4.

8.11 In other clinical areas, a similar arrangement for the distribution of cold water
should be adopted.

8.12 The cold water distribution system should be designed so that the pressure is
the same as that for the hot water service at draw-off points. This may require
the inclusion of pressure-reducing valves in the distribution pipework. If
unequal pressures exist in the hot and cold water supplies to combination taps
where water mixes in the body of the tap, a single check valve is required on
each feed pipe to the tap to prevent backflow of water from one to the other.

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Figure 2(i): Schematic layout of a domestic hot & cold water service system with high level storage

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Figure 2(ii): Schematic layout of a domestic hot & cold water service system with low level storage and booster pumps

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Figure 2(iii): Schematic layout of a domestic hot & cold water service system with low level storage, booster pumps and filtration plant

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Figure 2(iv): Schematic layout of a domestic hot & cold water service system with low level storage, booster pumps, filtration plant and plate
heat exchangers/buffer vessel(s)

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Notes for Figures 2(i) – 2(iv): The foregoing schematic diagrams are intended
to be generic but the following issues will require to be addressed whichever
design solution is adopted and should be subjected to risk assessment.
Solutions adopted in new build situations may not be appropriate in retro-fit
installations.

 plate heat exchangers may have a significant impact on boiler loading

whereas high efficiency semi-storage calorifiers may have a lesser impact.
The potential for switching off heating to accommodate peak domestic hot
water demands should be investigated. (For example, an underfloor heating
system could be temporarily switched off for a short period without being
noticed, taking advantage of the thermal inertia);

 in selecting plant, the most cost-effective use of boiler power should be

pursued along with the most appropriate use of available plant space. There
is thus a potential trade-off between the output of plate heat exchangers and
the size or capacity of related buffer vessels;

 the design of the domestic hot water system whether using high efficiency
semi-storage calorifiers or plate heat exchangers & buffer vessels with
associated controls will require to be matched to the domestic hot water
demand and output of the primary heat source;

 sizing of and pipework to the buffer vessel will require to be such as to

maintain the correct amount of “useable” hot water (in terms of avoiding the
Legionella bacteria colonising temperature range) for as long as possible,
coincidentally with the duration of the heat demand;

 it is necessary to ensure adequate recovery time is provided between

recurring peaks taking account of the impact on the sizing of the buffer vessel
and output available from plate heat exchangers;

 a balance has to be achieved between the size of plate heat exchange

equipment and available boiler power;

 the output from the plate heat/buffer vessel assembly (however sized) must
achieve and maintain output temperatures in accordance with the
requirements of this Scottish Health Technical Memorandum;

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Notes for Figures 2(i) – 2(iv) continued:

 depending on the relationship between the primary exchanger and buffer

vessel, subsidiary consideration should be given to the potential for abnormal
peak demands and the adverse impact these would have on return hot water
temperatures. Although not mandatory at the time of preparing this
document, consideration should be given to the fitting of flow restrictors to
ensure that return hot water temperatures are not compromised.
Consideration should be given to installing service valves with inherent flow
limiters at outlets. These will assist in balancing activities, ironing out peaks
and may assist in reducing wastage of water;

 careful consideration is required as to the method of introducing pipework

into the buffer vessels in order to minimise the possibility of entering cold
water diluting (reducing) the outgoing hot water temperature. A constant-
running destratification pump would provide a rapid recovery of hot water
increasing the output as the inflow of cold water diminishes.

Where bidets are required they shall comply with the requirements of SHTM 64.
They shall be Hospital pattern with flush grated waste, therefore no plug, and
shall have over-rim supply. Ascending spray type bidets shall not be installed.
Bidets shall be installed to meet the requirements of the relevant Water
Byelaws.

In smaller premises there is a risk of stagnation arising where two tanks are
installed. One alternative would be to substitute a pressure regulating bypass
for the second tank between the incoming main and the down service(s) to
eliminate unequal flow while still allowing facilities for maintenance. Another
alternative would be to have a single tank where filtered incoming supplies are
provided. This would require to be subject to risk assessment.

Where equal control of pressure within hot & cold water systems is critical,
pressure reducing valves should be fitted on the boosted cold water service and
also on the boosted cold water feed to the hot water generating plant. The
valves should be installed immediately after the pipework leaves the booster
pump manifold.

Ice-making machines should be of the automatic type, without a reservoir, that

make ice on demand. They should not be located at the end of a line to avoid a
build-up of microorganisms. They should be connected to a potable mains
supply upstream of a regularly used pipe run.

Drinking water
8.13 When separate drinking water systems have been provided the policy has
normally been to distribute directly from the mains without storage, with stored
cold water (down service) being used solely for supplies to WCs, hand-wash
basins etc. Providing drinking water without storage may not be appropriate in
healthcare premises because of the need to have some security of supply. The
advantage of separate drinking and cold water services chiefly lie in the
possibility of treating the latter (softening or other forms of treatment) without

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adulterating the drinking supplies. However, low water flows in dedicated

drinking water piping lead to stagnation, temperature build-up and the possibility
of exceeding the 20°C limits.

Softening will avoid the scale problems associated with thermostatic mixing
devices. (Problems often occur when scale is deposited as a result of hard cold
water being heated in the blending process.) However, this will be wasteful if
the cold water supply is to be used for WC flushing.

8.14 A possible strategy, therefore, is to have a drinking water system that also
provides WC flushing and, to some extent, this will assist water turnover and the
maintenance of water quality. The disadvantage of the concept, apart from
installation cost, is that the use of WCs, particularly in en-suite facilities, as the
mechanism for achieving good utilisation in the cold water service no longer
becomes possible (see paragraph 8.10). The concept for water turnover in en-
suite facilities could still be achieved, however, if the cold water service were
run in series to en-suite facilities with minimum dead-legs to draw-offs, with the
final connection on the system being a highly utilised outlet, for example a sink.

Many hospitals, however, now store all water in tanks arranged to contain water
of drinking quality, having sealed lids and screened vents. This offers complete
flexibility, avoids problems with stagnation and is recommended practice.

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Figure 3: Piping arrangements for an en-suite facility

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Pumped systems
8.15 Some water supply authorities are reducing pressure to reduce mains leakages.
Where the pressure of the water supply is inadequate, it will be necessary to
utilise pressurisation plant. Similarly, pumping or pressurisation may be required
for fire-fighting purposes.

8.16 Various arrangements of pumping system are indicated in BS6700: 2006, BS

EN 806-1-5: 2000-2012 and BS8558: 2011. Where booster pumps are to be
installed, a break cistern will be required between the mains supply pipe and the
pumps. This is required in order to comply with the Scottish Water Byelaws
2004 with regard to prevention of backflow. Any pump delivering more than 12
litres/min connected directly to the incoming main must be notified to the water
authority whose consent is required.

8.17 Control of the pump(s) should be fully automatic in operation and controlled by
pressure sensors for the following reasons:

 to reduce energy consumption;

 to prevent heat gain from the pump to the water, which could become
significant if large pumps are used;
 to reduce wear on the pumps and hence reduce maintenance.

8.18 Factors to be considered when selecting pumps are:

 quantity and pressure of water to be pumped;

 the number of units required to obtain the necessary output and to provide
adequate standby capacity;
 the desirability of speed variation;
 the degree of automatic sequence control required;
 the characteristics of the system on both the delivery and suction sides, and
in pumping efficiency and priming requirements;
 the type of materials used in manufacturing the pumps relative to the
chemical analysis of the water to be pumped;
 ferrous metal materials should not be incorporated in wetted areas.

8.19 The operation and shutdown of pumps may be controlled by various methods
depending on the circumstances, such as water-level float switches, pressure
switches, flow switches, electrode probes or pneumatic systems. Certain
services may also require the pumping equipment to be energised from the
emergency electrical service as recommended in SHTM 06-01: Electrical
services supply and distribution’.

8.20 Where two or more pumps are installed, the design flow should be achieved
with one pump stationary (or out of service). Automatic control should be
provided to control all pumps cyclically and sequentially to ensure that each is
regularly brought into service.

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8.21 The pumping sets for lifting to higher-level storage should be controlled from the
level in the high-level tanks by transmitting sensors, level switches or other
suitable devices. A low level alarm should be arranged to give a warning when
the storage volume of water falls to a predetermined low level.

8.22 The expansion vessels forming part of the pumping sets are typically
pressurisation vessels, are typically vertical in orientation and have either a
diaphragm or nitrogen fill in the upper space. They introduce a potential
problem of colonisation by Legionella, as the plantroom space temperature will
exceed that of the incoming water. They should be preferably of a design such
that water flows through the vessel, entering at low level, and discharging at a
higher level below the water line. Interconnecting pipework should be kept to a
minimum, and the vessel should be insulated to minimise heat gain. All
materials in contact with water should be WRAS-approved. It is important that
the expansion vessel is located on the cold feed rather than on the hot water
side of the system.

8.23 The plantroom should be constructed with a waterproof and non-dusting type of
walls, floors and ceilings. Floor should incorporate a slight fall to a drainage
trench that should terminate in a trapped gully. The trapped gully should
incorporate provisions either to avoid or replenish any trap-water-seal loss. The
plantroom will require adequate lighting, ventilation and heating (to prevent
freezing or condensation), with electric power points and/or provision for low-
voltage supplies for portable lighting and tools.

8.24 If heavy plant is to be installed which may, on occasion, need to be removed for
testing, maintenance or replacement, fixed lifting beams of suitable capacity
should be provided.

Specialised systems
8.25 Where water supplies are required for specialised systems such as endoscope
cleaning installations, dialysis units etc, the designer should consult the hospital
infection prevention and control team (IPCT) to establish any specific water
treatment requirements for the process, and also the local water supply
authority to clarify any special precautions that may be necessary, such as
backflow prevention devices. The advice of the water supply authority should
also be sought as to any possible variation in the quality of supply or possible
change in the source of supply (see also Health Building Note 07-01 (2008):
‘Facilities for renal services: Satellite dialysis unit’).

Vending, chilled water and ice-making machines

8.26 The water supply to this equipment should be taken from a potable supply via a
double check valve to prevent backflow and be upstream of a regularly used
outlet with the minimum of intervening pipe-run, that is, less than 3m. The
supply should not be softened. Additionally, it should be established that the
usage is sufficient to avoid deterioration in water quality, for example that the
inlet water temperature does not exceed 20°C.

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8.27 The equipment should be positioned so that the warm air exhaust does not
impinge directly on taps or hoses supplying cold water.

8.28 Reference should also be made to the Food Safety (Temperature Control)
Regulations 1995 and Food Safety (General Food Hygiene) Regulations 1995.
The Automatic Vending Association of Britain (AVAB) codes of practice should
be followed regarding hygiene and water quality and hygienic operation of
vending machines (http://www.ava-vending.org). Vending machines dispensing
carbonated drinks require special materials of construction which should be
WRAS-approved.

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9. Hot water services

General
9.1 Hot water services should be designed and installed in accordance with the
Scottish Water Byelaws 2004 and relevant parts of BS6700: 2006, BS EN 806-
2: 2005 and BS8558: 2011. The hot water system may be of either the vented
or the unvented type.

9.2 The basic components of a hot and cold service system as used within
hospitals are shown in Figures 2 (i)-(iv); most installations will have additional
features and components.

9.3 A vented system usually consists of a cold water storage cistern situated above
the highest outlets, which feeds a hot water storage vessel (for example a
calorifier or direct-fired boiler).

9.4 An unvented system usually has the hot water storage vessel connected to the
mains water supply via a backflow prevention device and a pressure-reducing
valve or supplied via a break-tank or booster pump set. The components of a
directly heated unvented hot water system are shown in Figure 4.

9.5 Hot water is taken from the top of the storage vessel, or water heater, and will
normally be circulated around the building in a piped distribution system. The
flow temperature should be set to 60°C and the minimum temperature of all
return legs to the vessel or water heater should be 50°C. Correct grading of
pipework is essential to maintain correct circulation. In all but very small
domestic installations, circulation is essential and trace heating should only be
used in existing installations to overcome local problems with circulation where
rectification would otherwise be disruptive to the operation of the
accommodation served. In all but domestic systems, if recirculation is not used,
some form of trace heating will be required. Such systems, however, should be
restricted to areas where backflow contamination is a potential problem, for
example pathology laboratories: these should be supplied from separate
systems. The individual outlets, taps, mixing valves or other outlet devices will
be served from the distribution system; this should be designed such that the
minimum temperature at the most distant taps or outlets is 55°C.

Note 11: The control of Legionella requires there to be a minimum temperature

of 50°C in hot water service systems (see Part B of this SHTM). A minimum of
55°C may be required for the operation of suitable fail-safe mixing devices
required to provide ‘safe’ hot water at the upper limit of the recommended
range. Hot water at 55°C is required for many applications such as washing in
kitchens and laundries.

9.6 A small number of localised hot water distribution systems can have
advantages over one large centralised system. With smaller systems, hot water
heaters are located closer to points of use and it is therefore easier to maintain
hot water distribution temperatures within recommended values. Balancing
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water flow rates in the hot water secondary distribution system becomes less of
a problem, and distribution losses are reduced. A small, localised hot water
distribution system may comprise a gas-fired water heater, a storage calorifier,
a semi-storage calorifier or plate heat exchanger. The adoption of localised hot
water distribution systems will require the provision of local plantrooms.

9.7 With large centralised hot water systems, it is more difficult to maintain
secondary distribution temperatures within recommended values; also, water
flow rates in large secondary distribution systems can prove difficult to balance.
At periods of low draw-off, detritus can lodge within the large horizontal
distribution pipes forming part of centralised systems.

9.8 There are also maintenance factors to be considered. With a central hot water
system, plant maintenance can be focused in one location, whereas with
localised systems there will be a number of plantrooms at remote locations.

Hot water heater types

9.9 In most healthcare premises, hot water storage vessels include the heating
source, which can be steam, high- or medium-pressure hot water, or electric
immersion heating elements. The flow to the pipeline distribution system is
normally taken from the top of the vessel, as too is the open vent, which may or
may not be combined. The cold feed and return pipe should be taken in at the
lowest point of a calorifier. Instantaneous water heaters for distribution systems
have similar pipeline connections. All water heaters must be WRAS-approved
and listed in the ‘Water Fittings and Materials Directory’.

9.10 Traditional design practice has been to provide a non-check-valved cold feed
and expansion pipe to the calorifier/water heater and an open vent discharging
over the cold feed cistern.

Achieving hydraulic balance is essential. The cold feed will be the neutral point
and the calorifier must always be under negative pressure to avoid pumping
over. With the circulating pump located on the flow pipework after the open
vent, the vent should be taken through the lid of the cold water storage tank and
sealed in place to maintain integrity. This will ensure that the system is free from
contamination, notably particulate matter. Systems require to be monitored to
provide early warning of rises in cold water temperatures due to malfunctions in
performance. Incorrect design or installation should be manifest during
commissioning before systems are put into use.

9.11 Most vessels have some means of access for inspection, either via a special
panel or by removing the heating coils/elements. When new calorifiers are
required, it should be specified that they have separate and adequately sized
access panels.

9.12 Where water quality indicates the need, cathodic protection from galvanic action
by means of sacrificial anodes should be provided.

9.13 The combined storage capacity and heater output must be sufficient to ensure
that the outflow temperature, at continuous design flow (at least 20 minutes)

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from calorifiers or other heaters, should not be less than 60°C. This applies to
both circulating and non-circulating hot water systems. The positioning of the
control and high limit thermostats, cold feed and return water connections must
ensure that these temperatures are achieved.

9.14 There are basically three types of water heater:

 instantaneous heater;
 storage calorifier;
 limited storage calorifier.

Instantaneous water heaters

9.15 This type of heater can be further subdivided into:

 instantaneous water heaters for single or multi-point outlets: these

devices are usually either electrically or gas heated. The general principles
and limitations of instantaneous water heaters are given in BS6700: 2006,
BS EN 806-1-5: 2000-2012 and BS8558: 2011. In essence:
 the hot water flow rate is limited and is dependent upon the heater’s
power rating;
 the water in instantaneous water heaters is usually heated to about
55°C at its lowest rate, and its temperature will rise and fall inversely to
its flow rate. Where constant flow temperature is important, the heater
should be fitted with a water governor at its inflow. Close control of
temperature is of particular importance for showers. To attain constant
temperatures on delivery, water flow and pressure must also be
controlled. Variations in pressure can cause flow and temperature
problems when the heater is in use, and when setting up or adjusting
flow controls;
 they are susceptible to scale formation in hard water areas, where they
will require frequent maintenance;
 this form of hot water heating should be considered only for smaller
premises or where it is not economically viable to run a hot water
circulation to a remote outlet;
 instantaneous-type water heaters for distribution systems: these
devices, which normally use steam or high/medium pressure hot water as
the primary heating medium, are designed to heat their rated throughput of
water rapidly from cold to the design outlet temperature. They can be used
either to feed directly into a hot water distribution system, or in conjunction
with a storage vessel which reduces the load on the heater during periods
of peak demand. This type of heater includes:
 hot water generators: these are vertical instantaneous water heaters
that contain modular helical primary coils normally served by steam,
medium temperature hot water (MTHW) or high temperature hot water
(HTHW). The unit incorporates a temperature control device, which
varies the rate of primary energy input so as to maintain a constant hot
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water flow temperature over a range of secondary flow rates through the
heater;
 plate heat exchangers: plate heat exchangers consist of a number of
rectangular plates sandwiched between two flat end plates and held
together by tie bolts. The plates have ports in all four corners that allow
entry and discharge of the primary and secondary liquids. Primary liquid
is directed through alternate pairs of plates while the domestic hot water
is normally fed in a counter flow direction through the remaining pairs of
plates. Each plate is sealed round the edges by a gasketing system, the
design of which should ensure that fluids cannot, under normal
operating conditions, either leak to atmosphere or mix. This type of heat
exchanger can be extended easily, or shortened, to suit changes in hot
water demand.

Storage calorifiers
9.16 Storage calorifiers are usually cylindrical vessels mounted either vertically or
horizontally; the base of a vertical calorifier should be convex, with the vessel
being supported on feet. The latter design is preferred, as it avoids the annular
space where the base joins the cylinder wall. Heater batteries are usually
located near the bottom of the cylinder, which can give rise to an area of water
beneath the battery significantly below the storage temperature. This “dead”
area can provide an ideal breeding ground for bacteria. Galvanised cylinders
are particularly susceptible to scale formation, which can also provide a source
of nutrition and shelter for bacteria.

9.17 As a result of this, galvanised cylinders are not permitted in new hospital
installations or for replacement.

9.18 The following points should be considered during the design process (see also
paragraphs 9.28–9.29):

 the entire storage volume should be capable of being heated to 60°C

without permanent pockets of lukewarm water;
 the shell lining should be resistant to bacterial growth;
 sufficient access to ensure adequate cleaning of the shell must be provided;
 a suitably-sized drain should be connected to the base of the calorifier.

Limited storage calorifiers

9.19 These calorifiers can either have an independent heating facility such as oil or
gas burners or electric elements, or use primary water/steam from a boiler to
heat the water via a heat exchanger. The equipment is available in a range of
storage capacities and recovery flow rates. This type of equipment is
particularly suitable where systems are being decentralised and water heaters
are required close to the point of use.

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Sizing of hot water storage vessels

9.20 Storage should be calculated on the requirements of peak demand and the rate
of heat input. There may be more than one peak period in each 24 hours. The
interval between peak periods is important, as it affects the recovery time.

9.21 The CIBSE Guide G: ‘Public health engineering’, gives guidance on sizing hot
water storage.

9.22 Since the original study set out in Appendix 1 a review of systems indicates that
the overall capacity and consumption predicted is excessive (see paragraphs
7.4–7.5).

9.23 Where storage calorifiers are used, the hot water storage capacity should be
sufficient to meet the consumption for up to two hours; this must include the
period of maximum draw-off. The installed hot water capacity should be sized
for current needs and should not be designed with built-in capacity for future
extensions.

9.24 Some devices are optimistically rated so that, at a continuous demand equal to
their design rating, the flow temperature can fall below 60°C. Semi-storage or
high-efficiency minimum storage calorifiers and instantaneous heaters are
especially prone to this if under-sized.

Connection arrangements for calorifiers and water heaters

9.25 Where more than one calorifier or heating device is used, they should be
connected in parallel, taking care to ensure that the flow can be balanced so
that the water temperature from all the calorifiers is not less than 60°C at all
times (see also paragraph 9.42).

9.26 Installations must not include for series operation of calorifiers.

Stratification in storage vessels

9.27 Stratification will occur in any storage calorifier or heater; the temperature
gradient will depend on the rate of draw-off and heat input. In some calorifier
designs, stratification is significantly more pronounced and is a feature of their
design. There will always be a volume of water in the temperature range that
encourages maximum growth of Legionella.

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Note 12: Water temperatures in the range 20°C–45°C favour growth of

Legionella. It is uncommon to find proliferation below 20°C, and Legionella does
not survive long above 60°C. The optimum laboratory temperature for the
growth of Legionella is 37°C, that is, body temperature. Legionella may,
however, remain dormant in cool water, multiplying only when the temperature
reaches a suitable level.

Note 13: Stratification: in a storage calorifier the upper level, above the heating
element, will be at operating temperature (60°C) during normal periods of
demand. Below this level will be a volume of water between the feed water
temperature and operating temperature. This level will vary as draw-off takes
place according to the thermal input and rate of demand.

9.28 Storage and semi-storage calorifiers should be provided with independently

pumped circulation from the top to the base of the calorifier; this is referred to as
a ‘shunt pump’. The pump should be run continuously for about an hour during
periods of minimum demand to raise the entire contents of the calorifier to 60°C.
During periods of low draw-off, the temperature will readily achieve 60°C to
effect disinfection. Control should be by a timing device that can be adjusted
when the profile of demand has been established.

9.29 Some semi-storage/high-efficiency calorifiers are supplied with an integral pump

that circulates water in the calorifier; in this case a second shunt pump is not
required.

Provisions for maintenance

9.30 There should be adequate access to calorifiers for inspection and cleaning,
removal and replacement of tube bundles and removal and replacement of the
entire calorifier.

9.31 All calorifiers and water heaters must be fitted with a drain valve located in an
accessible position at the lowest point on the vessel so that accumulated sludge
may be removed effectively from the lowest point. The drain should be of
sufficient size to empty the vessel in a reasonable time. A schedule of
approximate calorifier emptying times is given in Table 3.

9.32 Drain valves should be of the ball type to avoid clogging, and a drainage gully
should be provided of sufficient size to accommodate the flow from the calorifier
drain.

Unvented hot water systems

9.33 Hot water storage systems have traditionally been provided with an open vent
pipe that relieves any steam generated in the event of failure of temperature
controls. The open vent pipe also protects against rupture of the cylinder by
expansion of water.

9.34 The use of unvented hot water systems is now permitted in the UK and is
covered in Section 4: Safety section of Section 6 Energy in the Non-Domestic
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Scottish Technical Handbooks, 2007, which covers installation, specification

and discharge.

9.35 Where an unvented hot water system is connected directly to the water mains,
no back-up will exist in the event of a water supply failure. Such an arrangement
may also be unacceptable to the local water supply authority, since they will be
required to meet the maximum demand at any time over a 24-hour period.

Calorifier Diameter/ Capacity: Litres Drain valve sizes mm (inch)

type length ratio (Gallons) 25 (1.0) 38 (1.5) 50 (2.0)
Horizontal 1:2.5 13,500 (3,000) 3 hr 00 min 1hr 20 min 45 min
9,000 (2,000) 2 hr 10 min 1hr 00 min 30 min
4,500 (1,000) 1hr 10 min 30 min 20 min
2,250 (500) 39 min 17 min 10 min
1,800 (400) 32 min 14 min 8 min
1,400 (300) 25 min 11 min 6 min
Horizontal 1:1.5 13,500 (3,000) 3 hr 00 min 1 hr 20 min 45 min
9,000 (2,000) 2 hr 10 min 1 hr 00 min 30 min
4,500 (1,000) 1 hr 10 min 30 min 20 min
2,250 (500) 39 min 17 min 10 min
1,800 (400) 32 min 14 min 8 min
1,400 (300) 25 min 11 min 6 min
Vertical 1:1.5 13,500 (3,000) 2 hr 45 min 1 hr 15 min 40 min
9,000 (2,000) 2 hr 00 min 55 min 30 min
4,500 (1,000) 1 hr 10 min 30 min 20 min
2,250 (500) 38 min 17 min 9 min
1,800 (400) 31 min 14 min 8 min
1,400 (300) 25 min 11 min 6 min
Times assume no hose and simple ball-type valve
Table 3: Approximate emptying times for calorifiers
9.36 The design and installation of unvented hot water systems should comply fully
with the Non-Domestic Scottish Technical Notebooks, 2007 and the Scottish
Water Byelaws 2004.

9.37 The key requirements are that the temperature of stored water should be
prevented at any time from exceeding 100°C and that discharges from safety
devices should be conveyed to a safe and visible place and protected to
prevent blockages by the ingress of birds, rodents or insects etc.

9.38 A schematic layout of a typical directly heated unvented hot water system is
illustrated in Figure 4 along with a brief description of the main components.

9.39 The discharge pipes from the temperature relief valve and expansion valve
should be carefully located so that they are readily visible but do not present a
risk to people and protected to prevent blockage by the ingress of birds, rodents
or insects etc.

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9.40 Where the hot water is heated directly, for example by a steam or LTHW
primary coil, a non-self-resetting thermal cut-out wired to a motorised valve on
the primary coil must be provided for control of excessive temperature. This
should be further protected by a direct-acting protection device, particularly with
a plastic pipework installation.

Sealed expansion tanks for unvented hot water systems

9.41 These vessels are typically vertical in orientation and normally have a
diaphragm to separate the water from the gas space above. They introduce a
potential problem of colonisation by Legionella, as the plantroom space
temperature will exceed that of the incoming water. It is important that the
expansion vessel is located on the cold feed rather than on the hot water side of
the system and is fully insulated. All materials in contact with water should be
WRAS approved.

Hot water distribution system

9.42 To control the possible colonisation by Legionella, it is essential to maintain the
temperature within the hot water circulating system. To some extent, if properly
maintained, the calorifier/water heater will provide a form of barrier to Legionella
and other water-borne organisms. For premises with intermittent use, the
generation of domestic hot water must be continuous unless there is an
anticipated prolonged shut down, in which case systems should be drained dry,
as occurs between final commissioning and putting systems into use in a new
build situation.

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Figure 4: Directly heated unvented systems

9.43 The minimum flow temperature of water leaving the calorifier/water heater
should be 60°C at all times, and 55°C at the supply to the furthermost draw-off
point in the circulating system. The minimum water temperature of all return
legs to the calorifier/water heater should be 50°C.

Note 14: A minimum of 55°C may be required for the operation of suitable
mixing devices required to provide ‘safe’ hot water at the upper limit of the
recommended range.

9.44 To achieve the required circulating temperatures, it will be necessary to provide

some form of regulation to balance the flow to individual pipe branches serving
groups of draw-off points, for example each washroom/toilet and en-suite facility
etc.

9.45 The means of balancing the hot water circulation can be achieved by either
manual or thermostatic regulating valves installed in the return. There should be
means of isolation, both upstream and downstream. Adequate access for
servicing is also essential.

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9.46 In ward accommodation where en-suite facilities are provided, it is

recommended that the hot water circulation be extended to draw-off points in
series, for example the supply to a basin, bath and/or shower should be run as
one circuit (see Figure 3).

9.47 The operating pressures for both hot and cold water at draw-off points should
be the same.

9.48 The domestic hot water system must not be used for heating purposes. This
includes all radiators, towel rails, heated bedpan racks etc, whatever the
pipework configuration.

9.49 Particular attention should be given to ensuring that pipework containing

blended water is kept to the minimum. The same restriction applies to
“communal” blending, that is, where more than one outlet is served by one
device. Central blending systems should not be used, since the length of
distribution pipework containing water in the temperature range that supports
Legionella growth would be excessive. Generally, the complete length of spurs
without circulation should be as kept to a minimum with circulation pipework
taken right up to the point of use. Redundant branches and dead-legs within
existing installations should be removed, including replacing tee-pieces on the
circulating and main distribution pipework with straight couplings to avoid spurs
containing stagnant, non-circulating water. A typical configuration of pipework
to sanitary fittings is shown in Figure 3.

Water temperatures and delivery devices

9.50 The risk of scalding for patients (children and young people, older people, and
people with disabilities) and staff is a particular problem in healthcare premises
caring for such individuals, and therefore thermostatic mixing devices will be
needed for many hot water outlets, with different temperatures required for
differing toiletry needs. A risk assessment will be necessary to establish the
need and type of device to be installed.

9.51 Hand-washing is best performed under running water in basins/sinks without

plugs, as they easily become soiled especially where usage is high – this
necessitates the installation of a mixing device.

Note 15: The Scottish Water Byelaws 2004 place limits on the flow of water to
draw-offs where plugs are not provided. Spray-type mixer taps are not
recommended in healthcare premises; therefore, the type of tap should be
carefully selected to minimise the formation of aerosols. The water flow profile
must be compatible with the shape of the wash hand basin. Rosettes, flow
straighteners and aerators have been found to be heavily colonised with biofilm
but their removal can create turbulent flow at increased pressure resulting in
splashing of surrounding surfaces and flooring. Current advice is that they
should be removed but this should be subject to risk assessment. (With regard
to the requirement for plugs, see also the section on baths, sinks, showers and
taps in DEFRA’s (1999) guidance document to the Regulations.)

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9.52 Thermostatic mixing valves should comply with the standards of the MES D08:
‘Thermostatic mixing valves (healthcare premises)’. Thermostatic valves should
be tested and accepted by the BuildCert TMV Scheme
(http://www.buildcert.com/TMV).

9.53 The types of mixing device are specified in Table 4.

Showers

9.54 Showers with fixed heads are preferred for prevention of backflow. Where
flexible hoses and moveable shower outlets are provided, the outlet must not be
capable of being accidentally immersed into a drain, WC or other potential
source of contamination. Some shower heads are provided with a means for
adjusting the flow, for example fine spray, pulsating flow etc, selected by
utilising different sets of nozzles. As this will exacerbate possible stagnation
problems, they should not be installed in healthcare premises. Taps and
showers should be flushed every three days for 1 minute for hot and cold
supplies or the retained water flushed to waste immediately before use without
the generation of aerosols.

9.55 To facilitate the required regular removal of shower thermostatic mixing valves
for inspection, careful consideration will be required to ensure that these are not
recessed in such a way that access can damage thermal insulation on
connecting pipework or to the removable panels themselves in wet areas.
Surface mounted thermostatic mixing valves with smooth protective panels
concealing isolating valves, strainers and check valves will eliminate this
problem and avoid repetitive damage to waterproof membranes. Alternatively,
access for inspection and removal could be provided from the rear, off an
adjacent corridor (hotel-style).

Strainers

9.56 Strainers should be fitted within the water pipework system to protect expansion
vessels, mechanical backflow protection devices, thermostatic valves etc (see
also paragraph 5.4) against ingress of particulate matter, swarf, etc, that can be
in circulation during initial commissioning procedures. They should be provided
with means of upstream (and downstream where appropriate) isolation.
Strainers can be a source of Legionella and Pseudomonas bacteria and should
be removed after commissioning has been satisfactorily completed.

Cold feed cisterns and tanks

9.57 When separate cold feed cisterns are provided for hot water service
installations, they should comply with the requirements for cold water systems.

Note 16: Hot water cylinders with an integral feed and expansion tank are not
recommended.

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Service isolation valves

9.58 Service isolation valves should be fitted to all pipework preceding sanitary
tapware and WCs etc for servicing, repair and replacement. Drain-valve
provision may also be appropriate for certain installations, for example service
pipework to en-suite facilities etc.

Area/activity Recommended temperature Type of device (see MES

(°C) D08 for example
explanation of valve types)
Staff bases, ward and 41 Type 3 Thermostatic
consulting rooms etc basins
In-patient, out-patient hand-
wash basins
General areas to which staff 41 Type 2 Thermostatic
and visitors may have access
See note c below
Paediatric baths 40 - to allow for the cold Type 3 Thermostatic
paediatric bath/sink
NB: Paediatric nurses should
always use a thermometer
General baths 43 Type 3 Thermostatic
Showers 41 Type 3 Thermostatic
Assisted baths 46 - to allow for the cold mass Type 3 Thermostatic
of the bath
NB: Nurses should always
use a thermometer before
immersing patients
Hair-wash facilities 41 Type 3 Thermostatic
Bidets 38 Type 3 Thermostatic
All sinks, kitchens, pantries, 55 - minimum required for Separate hot and cold taps or
slop sinks etc food hygiene and combination tap assembly
decontamination purposes Type 1; no preceding
thermostatic device
Office, staff-only access 43 Type 1
areas hand-wash basins

Table 4: Safe water temperatures and delivery devices

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Note 17:

a. in all new installations thermostatic mixing devices shall be fitted directly to

the mixed temperature outlet or be integral with it, and be the method of
temperature and flow control, i.e. the mixing device should not be separate
and supply water via second tap or manual mixer since there will be many
cases where draw-off of cold water will not occur;

b. thermostatic mixing devices have complex internal structures that can

entrap waterborne bacteria and biofilm. Risk assessments should be
carried out to determine the potential to replace thermostatic mixing devices
with ordinary in augmented care accommodation where it is unlikely that
patients will use wash hand basins;

c. in the case of bidets with ascending sprays, or a handled douche, which

may be accidentally immersed in an adjacent WC, water taps must be
supplied via a suitable air gap, normally from a storage cistern;

d. automatic taps should be considered for general public access

washroom/toilets, surgical scrub sinks and hand-wash basins in main
kitchen/food preparation areas. Because the temperature is non-user
adjustable they should be supplied from a Type 2 TMV set to 41°C and they
are not recommended where the frequency of use of sanitary assemblies is
low. Part of the operational management will necessitate “flushing” of
outlets. Such flushing can be time-consuming and is not facilitated by
automatic taps that require a continual presence. These procedures must
be recorded in ICU accommodation and for seldom used taps, although
they are not recommended in low-use situations. Proximity detectors should
include a timer than can be adjusted to take account of the optimum
washing time: this is particularly important for scrub sinks;

e. non-touch / infrared / sensor taps also have a greater risk of their complex
internal surfaces becoming contaminated with micro-organisms and
biofilms. Sample water will require to be drawn off from sensor taps to
monitor the adequacy of maintenance.

f. automatic flushing WCs should be considered for similar areas. e.g. wards;

g. in the case of a dual function delivery device, i.e. shower/bath diverter, a

risk assessment will be necessary to establish what temperature setting is
required;

h. there has been much debate as to whether swan neck taps constitute any
additional risk associated with stagnant water remaining un-drained when
the tap is switched off. There is no evidence as yet to suggest that there is
any particular cause for concern given that the permitted lengths of dead-
legs are not compromised by their inclusion. There is therefore no need to
embark on unnecessary planned replacements for Swan Neck taps;

i. taps should be ideally removable and easily dismantled for cleaning and
disinfection.
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Accommodation periodically used

9.59 Departments within hospitals and healthcare premises closed at weekends,
overnight or similar (such as clinics and GP or Dental premises similarly
utilised) will require their stored water temperatures at all times to be maintained
within the same parameters as during normal usage. There is no practical
alternative to this if re-pasteurisation with hot water at 70ºC is to be avoided
every time prior to putting accommodation back into use. Ignoring this
requirement involves non-compliance with Workplace Regulations and the issue
affects all NHS contractors.

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10. Building and energy management systems

10.1 The continued safe operation of domestic hot and cold water systems requires
a number of routine checks to be made by physical means using separate
thermometric equipment. Consideration should be given to the incorporation of
intelligent water systems whereby a number of the control parameters can be
monitored by Building and Energy Management Systems (BEMS) continuously,
even though routine checks will still be required for “calibration purposes”.
Parameters that should be monitored are as follows:

 incoming mains temperature (at the water meter), inlet, outlet, and surface
water temperatures of cisterns and cold water feed tanks for hot water
calorifiers;
 calorifier flow and return temperatures;
 hot water service flow and circulation temperatures at the furthermost
outlets in individual wards;
 cold water service at the furthermost point from the pipeline entry to the
ward/department;
 consideration should be given to the frequency, timing and monitoring of
taps etc. with automatic flushing facilities.

Smaller premises without a Building and Energy Management System will

require the same routine checks and monitoring carried out manually with the
interval between checks determined by experience and risk assessments.

10.2 In addition to temperature, the BEMS should also monitor pressurisation and
circulating pumps, and water treatment systems for fault conditions or change of
status likely to result in a fault.

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11. Materials of construction

General
11.1 Any materials that come into contact with the water in a hot and cold water
installation must comply with the requirements of the Scottish Water Byelaws
2004. A list of products and materials that have been assessed for compliance
with the requirements of these Regulations is given in the current edition of
‘Water Fittings and Materials Directory’, which is updated every six months.
Further information on the selection of materials can be found in BS6700:2006,
BS EN 806-2: 2005, BS8558: 2011 and BS6920-1: 2000.

11.2 Materials of construction should be selected to take account of water quality

and its potential corrosive properties. The water supply authority should be
asked to provide details of any specific requirements and variability from
standard conditions.

11.3 Water supplied by the water supply authority, although remaining uniformly
wholesome, will nevertheless differ chemically. Some waters are slightly acidic
while others are slightly alkaline, and this affects the choice of materials for
pipes, fittings and cisterns. The water supply authority also blends water and
accordingly, the character of the water supply may vary from time to time. It will
therefore be necessary to consult the water supply authority for advice on what
materials should be avoided.

11.4 The choice of materials for buried piping and fittings should also take into
account the nature of the soil in which the piping is to be laid. The materials
selected should, where necessary, resist possible corrosion both inside and
outside. The extent, if any, of anti-corrosion treatment of the outside of the
piping will depend on the analysis of the soil. The advice of the water authority
(see Note 3); should be sought on the protective measures usually adopted in
the area.

11.5 Corrosion (or erosion) can be caused by the motion of water when it is in a
turbulent state and thus subject to rapid changes in pressure. Minute vapour or
gas bubbles may be released at instants of low pressure. The bubbles collapse
with implosive force the moment the pressure is increased. Their collapse upon
a metallic or concrete surface will quickly cause deep pitting or erosion of that
surface. The designer should therefore avoid high velocities, the sudden
increase of pressures or pulsating pressures.

11.6 Metallic piping should not be installed in contact with corrosive building products
and materials.

11.7 Corrosion may result from galvanic action where dissimilar metals are
connected. Dissimilar metals should be avoided as far as practicable, but if that
is not possible, it should be determined that deterioration through galvanic
action is unlikely to occur, or else effective measures should be taken to avoid
deterioration.

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11.8 The materials generally used for the conveyance of water in healthcare
premises are stainless steel or plastics. Copper is only used in exceptional
circumstances such as, an extension to existing premises with short life
expectancy, or very small stand alone premises. Where this is specified, only
lead-free solders should be used.

11.9 Substances leached from materials of construction of pipes, cisterns or other

water fittings in contact with water must not adversely affect the quality of water
stored or drawn for domestic or food production purposes (Scottish Water
Byelaws 2004).

11.10 Direct gas-fired water heaters are particularly prone to corrosion and scale
formation, and the inside of these heaters should be provided with suitable
linings to limit these effects.

Steel pipes and fittings

11.11 Where steel is used for bolts, nuts and slip-on couplings, adequate protection
from corrosion should be provided. This usually takes the form of bitumen
coating, but bitumen is not permitted in contact with water required to be
wholesome (that is, to be used for normal domestic or food production
purposes).

11.12 The character of water in Scotland is such that steel, whether galvanised or not,
should not be used at all for domestic hot and cold water installations. Any
existing premises with such pipework shall have this scheduled for early
replacement.

Stainless steel
11.13 Stainless steel has been increasingly used in hot and cold water service
systems. Reference should be made to Part E of this SHTM: ‘Alternative
materials and filtration’.

Copper pipes and copper/copper alloy fittings

11.14 As described previously, very careful consideration will be required if copper
pipework and fittings are to be specified for healthcare premises in Scotland.
Where this is considered to be acceptable either due to the size of the project or
the anticipated lifespan of the facility, the following will apply.

11.15 Copper in general has been resistant to corrosion. Unless resistant to

dezincification, brass fittings must not be used where water conveyed is
capable of dissolving undue amounts of zinc from the fitting. External protection
from corrosion for buried pipework may be obtained by using copper tube with a
factory-applied polythene sheath. Dezincification-resistant material must be
used for fittings that are concealed or inaccessible, for backflow prevention
devices, and for temperature and pressure-relief devices on heating systems.
Copper piping should conform to BS EN 1057: 1996 as appropriate for
underground or above - ground installations. When soldering copper tube and
fittings, refer to WRAS Information and Guidance Note 9-04-02: ‘Solder and
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fluxes’. If wax-based soldering fluxes must be used, they should be used

sparingly. They pose a risk of bacterial contamination to the system, which can
be difficult to eradicate.

11.16 Fittings should comply with the requirements of BS EN 1254-1−5:1998. Copper

piping may be jointed by means of compression joints or capillary joints.
Effective capillary joints in copper pipes can be achieved if care is taken in their
construction. Where compression joints are used with fully annealed copper
piping, these should be manipulative joints; that is, joints in which the tube ends
are flared or grooved.

11.17 Lead-free materials must be used in the formation of all potable water pipe
capillary joints.

Plastics
11.18 Most water systems operate at modest pressures and at a maximum
temperature of 70°C. Such operating conditions are within the specified
performance of plastics being produced in a range of sizes and costs suitable
for healthcare premises. Most ranges of plastic pipework are not suitable for
renal dialysis applications where water at a temperature of 95ºC is regularly
circulated for sanitisation and there is an incompatibility with reverse osmosis
treated water used in renal dialysis and in endoscope cleaning.

11.19 Advantages of plastic include corrosion resistance, lightness of weight and ease
of handling.

11.20 Disadvantages include poorer mechanical strengths than metals, greater

thermal expansion (about seven times that of metallic pipework), low
temperature (and possible long-term embrittlement [20–25 years]) and shorter
distances between pipe supports. The latter can be alleviated by employing the
manufacturer’s profiled longitudinal tray that snaps into place and extends the
distances between supports.

There have also been difficulties with ring seal failures that have required
wholesale replacements of all fittings. In the longer term (approx.20 years)
glues used for jointing have failed.

11.21 Materials in common use for plastic pipework are medium-density and high-
density polythene, the latter being stronger. Unplasticised polyvinyl chloride
(PVC-U) pipework has mainly been replaced by the stronger chlorinated
polyvinyl chloride (PVC-C) equivalent. All materials used for the transportation
of water can give rise to contamination by differing processes. It is therefore
important when introducing new materials that care is taken to ensure that
appropriate standards are maintained. In the case of plastic materials, this can
often be achieved by introducing a suitable ‘flushing’ routine during the
commissioning period.

11.22 PVC pipes to BS3505:1986, BS EN 1452: 2000 (parts 1−5) and BS3506:1969
are of a rigid material that has a greater tensile strength than polythene, but is
less resistant to fracture. These materials are less susceptible to frost damage

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than metal pipes. Although freezing is unlikely to damage the pipe, it will result
in interruption of supply, and subsequent leakage from joints may occur.

11.23 Polythene pipes are generally not susceptible to corrosion from either the water
or the ground in which they are laid. However, they are not recommended in
any soils contaminated with organic materials likely to permeate the plastics
and taint the water such as coal gas, methane, oils, petrol or other organic
solvents. Further advice is available in the WRAS Information and Guidance
Note 9-04-03: ‘The selection of materials for water supply pipes to be laid in
contaminated land’.

11.24 It is essential to consider the locality of exposed plastic pipes to ensure that
there is no likelihood of mechanical damage and effects of UV daylight;
otherwise suitable protection around the pipe will be necessary.

11.25 Further advice on flushing is given Part E of this SHTM: ‘Alternative materials
and filtration’.

11.26 Methods of jointing employed include compression joints with insert liners,
flanged, screwed and fusion-welded joints, as well as joints of the spigot and
socket type. The method of jointing employed is dependent on the bore of the
pipe and the applied internal pressure, and should be in accordance with the
manufacturer’s recommendations. A competent fitter who has been trained
under an approved scheme should make joints.

Composite materials
11.27 Less proven, but available on the market, are composite pipes, for example
aluminium pipe with an external and internal sheath of plastic. Little evidence on
the performance of such pipes is so far available, and questions remain over
earth bonding.

Iron pipes and fittings

11.28 Ductile iron is little used nowadays but it may be encountered in the course of a
refurbishment project or in areas with hostile soil conditions. Iron has good
resistance to corrosion, and this is further enhanced if the casting skin on the
metal is still intact. Although ductile iron pipes are thinner than grey iron pipes,
their resistance to corrosion is at least as good, and there is evidence that they
tend to be rather more resistant. In assessing the life expectancy of ductile iron
pipelines, account should be taken of any intended higher operating pressures
that may be used or permitted. Any iron pipework encountered should be risk
assessed with a view to early replacement, dependent upon the anticipated life
span of the accommodation served.

11.29 In made ground containing ashes and clinker, or in certain natural soils, such as
aggressive waterlogged clays, saline and peat marshes, additional external
protection may be required. This may be provided by the use of protective
coatings such as bitumen, by protective tapes, by loose polythene sleeving or,
in certain circumstances, by concrete. The water supply authority is using more
composite materials in pipework to overcome the risks.
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Lead
11.30 No new lead piping should be installed in any building. In the unlikely event of
any lead pipework being discovered in existing healthcare premises, it should
be removed as soon as practical.

Concrete
11.31 Protection of concrete pipes may be required against sulphate and acid attack.
The minimum size available in concrete pipework is 150mm diameter, and
therefore its practical use for healthcare premises is very limited.

11.32 Standard concrete pipes may be used when not subjected to internal pressure.
Pre-stressed concrete pipes are available as pressure pipes, but only in larger
sizes.

Asbestos cement pipes and fittings

11.33 Asbestos cement pipework should not be used and, if encountered in the
course of a refurbishment project, it should be stripped out and replaced as a
high priority with modern materials such as medium density polyethylene

11.34 Specialist advice should be obtained if stripping out materials containing, or

suspected of containing, asbestos is carried out.

Flexible water supply hoses

11.35 Flexible hoses (also known as “tails”) have become a convenient method of
connecting between hard pipework and sanitary fittings or equipment. They
typically comprise a steel braided outer sheath with a synthetic rubber inner
lining.

Reports have been received intimating that high levels of Pseudomonas and
Legionella bacteria have been found in water samples taken from outlets fed by
flexible hoses lined with ethylene propylene diene monomer (EPDM) due to
colonisation of the lining, although it is possible that other lining materials and
washers within couplings could be similarly affected.

New lining materials are now available such as polyethylene (PE), cross-linked
polyethylene (PEX), linear low-density polyethylene (LLDPE) and post
chlorinated PVC (PVC-C).

In view of this, it is recommended that the use of flexible hoses in potable water
supplies should be identified and risk assessed, taking account of areas of
highest risk involving persons vulnerable to infection. An action plan should be
developed for existing premises to address replacing flexible hoses by fixed
piping where they had been installed solely for speed or convenience. In new-
build projects flexible hoses should not be specified in such situations. Where
flexible hoses must be used for the likes of essential equipment subject to
vibration or articulation, such as hi-low baths, consideration would be given to
using the above listed alternative lining materials. Care would be required to
avoid kinking or distortion during installation. Reference should be made to
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paragraph 7.49 regarding disinfecting of hoses connected between shower

mixing valves and related shower heads. Such hoses are not presently covered
by the content of this paragraph.

Risk assessments should be reviewed regularly and whenever changes take

place to the patient user group or to the potable water system.

All flexible hoses must be WRAS approved.

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12. Pipework installations

General
12.1 All hot and cold water pipework should be designed and installed in full
accordance with the Scottish Water Byelaws 2004 and relevant parts of
BS6700:2006, BS EN 806-2: 2005 and BS8558: 2011.

12.2 It is essential to include within the system facilities for measuring, regulating,
isolating, venting, draining and controlling the flow of water. Regulating valves
with built-in pressure tappings or orifice plates with manometer tappings will be
required for the measurement of pressure drop, which enables the volume rates
of flow to be determined. Care must be taken to ensure that regulating valves or
orifice plates are sited well away from bends or fittings.

Sizing
12.3 Mains should be capable of a rate of flow to satisfy the combined maximum
demand of all the services to be supplied. All the maximum demands of the
separate services may not occur simultaneously, and the actual combined
maximum demand may be a proportion of the sum of the separate maximum
demands, which will be determined by the number and character of the
services.

12.4 Hot and cold water pipework should be sized using the procedure outlined in
CIBSE Guide G: ‘Public health engineering.

Routeing of pipework
12.5 Pipework in buildings should be designed and routed in a manner that will
promote good turnover of water particularly in cold water service systems (see
Figure 3). It should be installed so that it is accessible for inspection,
maintenance and repair as far as is practicable. Ducts, trenches and chases
containing pipework should be large enough to facilitate repairs.

12.6 Pipework distribution networks should be divided into sections by the provision
of isolating valves in accessible locations to facilitate isolation for repairs,
maintenance and flushing.

12.7 Underground mains need not be laid at unvarying gradients but may follow the
general contour of the ground. As far as possible, however, they should fall
continuously towards drain points and rise continuously towards the air vent.
They should not rise above the hydraulic gradient; that is, there should always
be a positive pressure, greater than atmospheric, at every point under working
conditions. The gradient between air release and drainage valves should be not
less than 1:500 rising in the direction of flow and not less than 1:200 falling in
the direction of flow.

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12.8 Underground pipes entering a building should do so with a cover of not less
than 0.75m below the external ground surface and should pass through the wall
within a watertight built-in sleeve. The sleeve should be filled in around the pipe
with a suitable material for a minimum length of 152mm at both ends to prevent
the ingress of water or vermin. External underground pipes should be at a
depth, or otherwise sufficiently protected, to prevent damage by traffic and any
consequent vibrations. A minimum depth under roadways of 1m measured from
the top of the pipe to the surface of the roadway is necessary. In other
underground locations the depth should not be less than 0.75m, subject to this
depth being sufficient protection against frost; frost penetration depends on the
nature of the subsoil and the ground surface. Freezing can occur at depths of
up to 1.1m. Local information on the prevalence of frost should be sought.

12.9 Marker tapes should be laid over the whole length of all underground water
services pipework. The tapes should be clearly marked with the description of
the service and should be coloured blue (red for fire mains). Tapes should be
spirally wound around pipes.

Vents and drains

12.10 Air-release valves should be provided at summits and drainage valves at low
points between summits, unless adequate provision is made for the discharge
of air and water by the presence of service connections. Large-orifice air valves
will discharge displaced air when mains are being charged with water. When air
is liable to collect at summits under ordinary conditions of flow, small orifice air
valves, which discharge air under pressure, may be required. “Double-acting”
air valves having both large and small orifices should be provided where
necessary. Air-valve chambers should be adequately drained to avoid the
possibility of contamination.

12.11 Automatic air-release valves should be installed where accessible for

maintenance. Installation in ceiling voids is not recommended.

12.12 Drain points should not discharge directly into a drain or sewer or into a
manhole or chamber connected thereto without a type ‘A’ air gap. Where a
washout discharges into a natural watercourse, the discharge should at all
times be well above the highest possible water level in the watercourse.
Consent for this discharge may be required from the Scottish Environment
Protection Agency. In some cases it may be necessary for the washout to
discharge into a watertight sump, which has to be emptied while in use by
portable pumping equipment.

12.13 In order to minimise quantities of water that may collect in stub pipes at drain
points, the length of such stub pipes should be kept to an absolute minimum.
This relates in particular to drains from hot water calorifiers, storage cisterns
and distribution pipework.

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Valves
12.14 A clear indication should be given on all valves of the direction of rotation
needed to close the valve. Normal practice is to have clockwise closing when
looking down on the valve.

12.15 Where blending valves have been installed at the end of a run of hot water
pipework, consideration should be given to the inclusion of a drain valve
adjacent to the mixer. This should be located upstream of the mixing valve so
as to facilitate flushing out and routine temperature testing of the hot water
without having to dismantle the blending valve.

Prevention of contamination
12.16 In all cold water installations it is important that adequate protection be provided
to all supplies against backflow. In healthcare facilities, there should be a high
degree of protection not only to the water in the water supply authority’s mains,
but also within the installations to protect the patients and staff. In addition to
backflow protection at all points of use, the whole installation protection should
be provided as required by the Scottish Water Byelaws 2004.

12.17 Healthcare buildings and medical premises have been identified as involving
Fluid Category 5 backflow risks (see Schedule 1 “Fluid Categories” from Byelaw
1 in the Scottish Water Byelaws 2004 which are defined as points of use or
delivery of water where backflow is likely to involve fluids contaminated with
human waste.) Within healthcare facilities, water usage covers a wide range of
applications, from domestic use by patients and staff to specialised use in
operating departments and pathology laboratories, and with equipment such as
bedpan washers and haemodialysis machines. In addition, many apparently
“commercial” usages may be classed as high-risk because they are for
healthcare purposes, such as centralised laundries.

12.18 The hot and cold water storage and distribution systems should be designed so
as to avoid the risk of contamination of the water supply. Such contamination
may be caused by backflow, interconnections between potable and non-potable
water supplies, stagnation, contact with unsuitable materials or substances,
Legionella growth etc. The Scottish Water Byelaws 2004 require the
identification, by colour-coding or labelling, of all pipework carrying fluids other
than wholesome water.

12.19 Comprehensive guidance on the measures required to prevent contamination of

the water supply is given in the WRAS ‘Water Regulations Guide’ and in
relevant parts of BS6700: 2006, BS EN 806-2: 2005 and BS8558: 2011.

12.20 Certain departments such as pathology laboratories present particular risks of

water contamination. Attention is drawn to section G15.24 in the WRAS ‘Water
Regulations Guide’ on supplementing point-of-use protection by zone
protection, where the pipes supplying a high-risk area can be given additional
protection by installation of a secondary backflow protection device.

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12.21 Instances of water use in hospitals where backflow is likely to be harmful to

health include bidets, bedpan washers, dental spittoons and equipment,
mortuary equipment, and water outlets located in laboratories.

12.22 Where any doubt exists with regard to the level of protection required against
water supply contamination, reference should be made to the Scottish Water
Byelaws 2004 and guidance contained in the WRAS ‘Water Regulations Guide’,
or water supply authority.

Frost protection
12.23 The Scottish Water Byelaws 2004 require that all cold water pipework and
fittings be adequately protected against damage from freezing.

12.24 In the case of external pipework that is run underground, the Regulations
require that consent be sought from the water supply authority if pipes are to be
run at depths of less than 750mm or greater than 1,350mm. Permission from
the water supply authority must be sought if any deviation is required.

12.25 Particular care is required when routeing pipework externally above ground or
through unheated areas within buildings. The WRAS ‘Water Regulations Guide’
gives guidance on the minimum thickness of thermal insulating materials that
should be applied in such cases.

12.26 Adequate provisions for isolating and draining sections of cold water distribution
pipework will ensure that disruption caused by frost damage can be minimised.

12.27 For further guidance on frost protection, refer to the WRAS ‘Water Regulations
Guide’.

Flushing
12.28 Prior to taking systems into use, they should be subject to a thorough regime of
flushing before disinfection (see paragraph 17.15).

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13. Noise and vibration

Pump noise
13.1 Noise generated by centrifugal pumps will not cause problems if water velocity
in the pipes and the speed of the pumps are low, for example about 1 m/s and
960 rpm respectively.

13.2 Care should be taken in locating water-boosting pumps within healthcare

buildings to ensure that they will not cause interference to wards and other quiet
zones.

13.3 Such interference may result from breakout noise from the boosting equipment,
or noise transmitted through the pipework system or through the building
structure. Pump noise may also result from cavitation caused by low suction
head.

13.4 Where pumps are located close to sensitive areas, provision for noise and
vibration reduction must be incorporated within the design. Such provision will
include selection of quiet-running motors, vibration isolation of boosting
equipment from pipework and structure and, if required, acoustic lining to the
booster plant enclosure.

13.5 Guidance on recommended noise levels for various locations is given in CIBSE
Guide A: ‘Environmental design’.

Other forms of system noise

13.6 Other forms of nuisance noise that may be generated by hot and cold water
distribution systems are listed below:

 noise from pipework due to excessive water velocity;

 water hammer caused by rapid closure of valves or taps;
 oscillation of the float of a float-operated valve;
 tap washer oscillation;
 noise caused by water discharging from float-operated valves into cisterns;
 noise caused by thermal movement of pipes;
 noise due to trapping of air within pipework, particularly on hot water
systems.

13.7 Further details on the above sources of noise, including guidance on avoiding
such noise problems, are given in the WRAS ‘Water Regulations Guide’.

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14. Water economy and energy conservation

Water
14.1 Hot and cold water distribution systems for healthcare buildings should be
designed so as to minimise the use of water. The cold water distribution
systems should incorporate an adequate number of water meters to allow for
close monitoring of water consumption. Where practicable, consideration should
be given to linking water meters to a building management system.

14.2 Measures to minimise water consumption that should be considered at design

stage include:

 provision of automatic systems to control flushing of urinals;

 use of showers rather than baths wherever practicable;
 WC pans and flushing cisterns that use more than 6 litres per flush are
prohibited by Scottish Water Byelaws 2004;
 control of water pressure to a level that is not excessive for the purpose
required;
 use of percussion taps in appropriate circumstances;
 locating warning pipes from cisterns and discharge pipes from relief valves
in such a way that any discharge can be readily observed, and/ or fitting
alarms on such pipes.

14.3 Further guidance on the prevention of wastage of water is given in the WRAS
‘Water Regulations Guide’. Reference should also be made to the Audit
Commission’s (1993) ‘Untapped savings: water services in the NHS’.

Energy
14.4 Energy used in the generation of hot water can be minimised by ensuring that
the hot water storage and distribution system is adequately insulated and that
thermostats controlling water temperature in hot water storage vessels are set
no higher than is necessary for the control of Legionella.

14.5 Hot and cold water systems should be designed to operate by gravity as far as
possible. Where water-boosting pumps are necessary, the pump motors should
be selected to operate at maximum efficiency at the required duty.

14.6 The practice of pre-heating of the cold feed to calorifiers should not be carried
out. The only time it is acceptable is when under all flow/demand conditions a
temperature greater than 45°C can be guaranteed at the entry to the calorifier.
Any pre-heater should have a low water capacity.

14.7 Further guidance on energy conservation in relation to hot and cold water
systems is given in Scottish Health Technical Memorandum 07-02: EnCO2de –

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making energy work in healthcare, environment and sustainability, 2006 (see

also the Carbon Trust’s website, http://www.carbontrust.co.uk).

BREEAM (Building Research Establishment Environmental

Assessment Method)
General Scope

14.8 BREEAM was established to set standards for best practice in sustainable
design and is used to describe a building’s environmental performance. The
concept has been through various stages of development. Most recently
“BREEAM New Construction 2011” has replaced “BREEAM Healthcare”. It
uses a scoring system to prove environmental credentials, setting and
maintaining robust technical standards, positively influencing design,
construction and management of buildings.

On 1st August 2008 its scope was extended to include

 a new 2-stage assessment process (Design Stage and Post Construction

Stage);
 introduction of mandatory credits.

“BREEAM Healthcare” replaced NEAT (NHS Environmental Assessment Tool)

after which all new healthcare buildings required to achieve an “excellent” rating
while refurbishment projects should be rated as “very good”.

External audits must be undertaken by BREEAM Healthcare-licensed

assessors with credits awarded for a whole range of environmental issues. The
various ratings comprise Pass, Good, Very Good, Excellent and Outstanding.

They are to apply to

 new buildings (whole buildings only);

 major refurbishments of existing buildings;
 new build extensions to existing buildings.

Among the environmental issues covered by BREEAM Healthcare are those

relevant to Scottish Health Technical Memorandum 04-01 regarding water
consumption and efficiency. Therefore the practicalities of the following should
be examined at the design stage of any project to verify their suitability given
the use of the premises, control of infection requirements and vulnerability of
patients concerned.

 use of water efficient appliances (low-flush toilets, P.I.R.-operated or

percussion taps);
 incorporation of leak detection systems;
 use of timed or PIR-instigated urinal flushing;
 provision of water metering.

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Many of these issues are routinely incorporated in new works and figure in this
Scottish Health Technical Memorandum but there are issues arising as set out
below that require further investigation and are not yet recommended for
automatic adoption in Scotland.

BREEAM email enquiries breeam@bre.co.uk

website http://www.breeam.org

Limitations of BREEAM

14.9 BREEAM Healthcare has been encouraging the incorporation of solar panels
for pre-heating of domestic hot water installations and adoption of rainwater
harvesting to promote energy efficiency and sustainability.

There is a temptation for those responsible for issuing design briefs to require
such installations to be incorporated into new and refurbishment projects and,
equally, for designers to offer them in order to achieve more easily the best
possible BREEAM rating. This ignores real issues that could be detrimental to
patients’ health and wellbeing. Several installations have been set up as pilot
projects and are, or will be, subject to monitoring.

Solar Panel Pre-heating

14.10 Paragraph 14.6 states that pre-heating of the cold feed to calorifiers should not
be carried out. Variable availability of solar power and its effect on
performance, together with the impact of intermittent usage would result in
situations whereby the stored temperatures of water would lie within the
Legionella breeding range. Further information will be found in SHTM 04-02
Part A “Solar Water Heating”.

Rainwater Harvesting

14.11 This relies on the ingathering of water from roofs and gutters where it would
have been contaminated by bird droppings and general unwanted detritus. The
volume of water would also require to be treated (decontaminated) by filtration
and either heating or chemical treatment, neither of which is conducive to
energy conservation. If this were not done, even when restricted to toilet
flushing, the dispersal of potentially contaminated aerosols into the patients’
breathing zone is not compatible with patient safety or control of infection. A
standard NHS-pattern risk assessment should be undertaken when users with
compromised immune systems were involved. Further information will be found
in SHTM 04-02 Part B “Rainwater Harvesting”.

Action required: Neither solar panel pre-heating nor rainwater harvesting

should be incorporated into new schemes as a matter of routine until further
research has been carried out into the practicalities and avoidance of risk.

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15. Water treatment

Introduction
15.1 The European Drinking Water Directive (98/83/EC), which is translated into the
Water Supply (Water Quality) (Scotland) Regulations 2001 & 2010, lay down
that Bodies must “…take measures to ensure that water intended for human
consumption is wholesome and clean…” and it further states that this
requirement is to be measured at the point of supply which, for the purposes of
this Guidance Document, is to be taken to mean the outlet of the tap.

The introduction of chemical treatment to the potable water supply is an

admission that the physical installation and/or the management process is
incapable of maintaining that water supply in a wholesome condition.

Before any water treatment regimes are considered, a risk assessment should
be carried out to verify that there are no other management processes or
mechanical steps that can be taken regarding pipework configuration, plant or
equipment that would avoid the need to introduce some form of treatment. For
the avoidance of doubt, this risk assessment must compare any risk to health
from contamination of the water supply as a result of the growth of bacteria or
other contaminants against the potential risk to health from the proposed
chemical additives.

15.2 Any decision to introduce water treatment should be externally validated by the
Authorising Engineer (or equivalent). Certain treatments are not suitable in all
circumstances.

Note 18: Further guidance on this particular matter can be found in Part “D” of
this SHTM.

15.3 Whichever treatment regime is adopted will have an impact on the discharge to
the foul sewer. Consequently, the Scottish Environment Protection Agency
(SEPA) must be informed and acceptance verified. Consideration could be
given to liaising with the water supply authority although their responsibility ends
with supplying wholesome water at the point of entry to the premises.

Treatment options
15.4 There are various forms of water treatment that may be considered. However,
continuous dosing of any disinfectant into potable water supplies cannot be
recommended as a first course of action although either “shock” or “campaign”
dosing may offer a short-term solution in a crisis situation.

15.5 If the disinfecting measures are related to the elimination of recurring Legionella
problems, they should be regarded as short-term solutions pending resolution of
issues relating to pipework configuration, dead-legs, etc. Attention is better
placed in the elimination of infrastructure contributory factors leading to
inadequate temperature control. If intractable problems remain in relation to
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this, trace heating of affected lengths of pipework may be considered. It should

be noted, however, that reliance on trace heating on its own cannot be
recommended and, should such a system be adopted, it must be supplemented
by a robust monitoring regime, including temperature measurement, to ensure
system operability within the design temperature parameters.

15.6 The following forms of treatment are available for consideration as listed below.
Each has its own range of concerns. Pending issue of the Addendum to this
Guidance Document referred to in paragraph 15.2, extreme care should be
exercised

Chlorine dioxide

15.7 Chlorine dioxide is an oxidising biocide that is capable of reacting with a wide
range of organic substances and has been shown to be effective in the control
of organisms in water systems. Use of chlorine dioxide as a chemical treatment
for drinking water treatment is now subject to a European Standard (BS EN
12671: 2009).

There are two aspects to be taken into consideration:

 in the cold water distribution system, chlorine dioxide may be injected into
the system upstream of all parts of the distribution, storage and boosting
equipment or at the break-tank serving the booster set. There must be close
monitoring and control of the dose, which must comply with the Water
Supply (Water Quality) Regulations 2001 and 2010 for the equivalent use of
chlorine dioxide in the treatment of water supplies by the water authority;
 in the case of hot water distribution systems with calorifiers/water heaters
operating conventionally, that is, at 60°C, there will be a tendency for
chlorine dioxide to be lost by ‘gassing off’, especially if the retention time in
a vented calorifier/water heater is long. In most cases, however, some total
oxidant should be found in the hot water, although at levels far less than the
minimum 0.5 ppm to be maintained at the taps.

Where copper supply pipes are used, chlorine dioxide can result in high
concentrations of copper being measurable in the water supplies.

Additional information on chlorine dioxide is given in Appendix 4 of this

document.

Silver/copper ionisation

15.8 Ionisation systems release copper and silver ions into the water stream by
means of electrolytic action. Ionisation as a water treatment method is covered
in BSRIA’s Technical Note TN 6/96 following a study in which it was shown that
copper and silver ion concentrations maintained at 400 µg/litre and 40 µg/litre
respectively can be effective against planktonic Legionella in hot water systems.
In soft waters a silver level as low as 20 µg/litre can be effective.

The use of ionisation as a control measure should only be considered

strategically on a complete site/campus basis to ensure continuity of control
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measures. This will depend on the water supply quality and on the design of
the systems in use and, in an existing system, their operational history.

The electrodes can be susceptible to accumulation of scale unless effective

anti-scaling electrode cells are fitted. The system should be designed to take
account of water quality; otherwise additional treatment may be necessary.
Copper and silver ion treatment is also sensitive to pH, and thus pH control may
be required.

In hard water areas there have been cases of staining of sanitaryware, but in a
properly controlled system where dosing levels of silver are not exceeded, this
should not be a major problem.

The opinion of the Committee on Products and Processes for Use in Public
Water Supply concerning the use of silver as a disinfectant in public water
supplies can be found on the Drinking Water Regulator website:
http://www.dwi.gov.uk/cpp/silver.htm.

Additional information on copper and silver ions is given in Appendix 5 and

attention is particularly drawn to Note 26 in the Appendix.

Ozone and ultraviolet treatment

15.9 Whereas the previous treatments are intended to be dispersive (that is, they
result in a residual agent within the system), ozone and ultraviolet are intended
to be effective close to the point of application. They are not, therefore,
necessarily effective in hot and cold water service systems.

Ultraviolet and ozone are methods that are suitable for water systems used for
dialysis equipment. However, allowance must be made for the aggressive
effects of ozone on materials exposed to it, particularly the degradation of
rubber compounds and the corrosion of metallic materials.

The systems should be fail-safe and have adequate instrumentation to monitor

operation. For example, UV systems should be preceded by particle filtration to
prevent microorganisms being shielded by particles, and incorporate a detector
so that any loss of transmission can be corrected immediately. They require
appropriate pre-filtration to remove particulate matter that may shield bacteria
from the UV rays.

Silver catalysed hydrogen peroxide

15.10 Silver catalysed hydrogen peroxide should not be dosed into the potable water
supplies on a continuous basis. Periodic dozes on a “shock” basis at varying
concentrations might be employed. A typical situation could arise from the
discovery of Legionella in a domestic water services system where
reconfiguration of the pipework installation proved to be prohibitively costly.
Paragraph 2.40 of Part D of this SHTM also refers. It also appears that this
form of treatment is effective in removing biofilm.

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Note 19: Whichever form of treatment is adopted, a change in potability will

occur and it will be necessary carry out a risk assessment and have proposals
audited by an independent authority.

Purging the systems

15.11 Immediately after initial dosing, checks should be made at various parts of the
system to ensure that satisfactory concentrations of treatment chemicals are
being achieved.

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16. Testing and commissioning

Introduction
16.1 While testing and commissioning is regarded as a discrete activity, continuous
monitoring is required throughout the installation to ensure that:

 materials and equipment installed comply with the Scottish Water Byelaws
2004 and other British Standards, and are not otherwise unsuitable.
Equipment that is listed in the latest edition of the ‘Water Fittings and
Materials Directory’ and installed in accordance with any of its relevant
conditions will comply;
 the work is done entirely within the specification for the scheme;
 all the requirements of current legislation are met, both during construction
of the installation and when it is completed, particularly with regard to the
Health and Safety at Work etc Act 1974.

The design and commissioning procedures should be signed off on behalf of

the client by a suitably experienced public health Engineer.

Installation checks
16.2 The system should be regularly checked during installation to ensure that open
pipes, valve ends, cylinder connections etc are sealed to prevent the ingress of
dust/debris that could cause problems during commissioning and subsequent
operation. Checks should also be made to ensure that fittings and materials
comply with the Regulations and are those listed in the ‘Water Fittings and
Materials Directory’, and that lead solders are not being used. Equipment that
requires to be maintained or which is likely to fail or be replaced during the life
of the system should be de-mounted and re-instated during the installation
process to ensure that it is maintainable and that appropriate isolation is
provided to ensure safety and continuity during operational use.

Inspection of joints
16.3 Before pressure testing, the site engineer should identify a number of fittings to
be cut out for examination to establish whether the quality of the finished joint
meets the specification. The exact number to be cut out will vary according to
the size of the installation, but as a guide, a ratio of one fitting per 400
installations should be cut out. In any event, a minimum of two, and not
normally more than five, fittings should be cut out for examination.

16.4 The fittings cut out should be cut open (quartered longitudinally) and examined.
If unacceptable joints are found, adjacent fittings should be cut out until the
extent of any faulty workmanship has been established.

16.5 The pipeline should be made good.

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16.6 The tube and fitting should be internally clean and free from particulate matter.
Some oxidation will be evident when hot ‘joints’ are made on copper piping.

16.7 When copper pipe and capillary fittings are used, because of the viscosity of the
brazing filler, full penetration may not be achieved.

16.8 The minimum penetration at any point must be three times the wall thickness of
the tube or 3mm, whichever is the greater.

Commissioning
16.9 Correct commissioning is vitally important for the satisfactory operation of the
hot and cold water systems. The designer should prepare a commissioning brief
for use by the contractor’s commissioning engineer. This brief should specify
fully and clearly the extent of the commissioning and maintenance and the
objectives which must be achieved, and should include:

 full design data on temperatures, water flow rates and pressures;

 plant and equipment data;
 number commissioning procedures for thermostatic mixing valves in
accordance with specification MES D08;
 drawings and schematics;
 a list of test certificates to be provided.

16.10 The designer’s attention is drawn to CIBSE Commissioning Code W: ‘Water

distribution’, which provides guidance on information that will be required by the
commissioning engineers.

16.11 In the preparation of commissioning instructions for domestic hot and cold water
services, designers should ensure that their work is in accordance with up-to-
date guidance from the Department of Health’s Estates & Facilities Division.

16.12 The designer should prepare for inclusion in the contract documents a list of
tests and measurements that are to be taken by the contractor and recorded by
him/her. These should be witnessed by the contract supervising officer or
project engineer on his/her behalf and he/she, if approved, will circulate the
results, in accordance with the client’s instructions.

16.13 The commissioning manual should be prepared by the contractor and submitted
to the client’s commissioning adviser for review before being issued in final
form.

16.14 Typical schedules of checks and performance tests should be included in the
commissioning manual together with record sheets. These should be amended
and supplemented as the designer/client advisor considers necessary.

16.15 The supervising officer or project engineer, who should countersign any
relevant test record documents, should witness commissioning and testing.

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16.16 ‘As installed’ record drawings, schematic diagrams, operating and maintenance
instructions must be supplied at the time of handover. Certified records of
pressure testing and disinfection should also be made available.

16.17 The whole commissioning procedure should be carried out under the guidance
of a single authority, although the involvement of specialists or manufacturers
may be required for specific items of plant.

16.18 Valid calibration certificates should be submitted and checked for all measuring
equipment to be used by the commissioning engineers prior to commencement
of commissioning.

16.19 The commissioning should be carried out in a logical and methodical manner.

16.20 The installation, on completion, should be operated by the contractor as a

whole, and subjected to specified functional or performance tests.

16.21 Once the system meets the design intent, the final completion record sheet(s)
should be completed. In the event of performance not being acceptable, the
matter should be dealt with in accordance with the contract requirements.

Commissioning and testing checklists

16.22 The following is a summary of the key activities associated with pre-
commissioning and commissioning of hot and cold water storage and
distribution systems. The list is not intended to be comprehensive.

Cold water installations

16.23 Pre-commissioning checks can be carried out on completion of the system
installation, filling and pressure testing.

16.24 Pre-commissioning checks and tests to be applied are as follows. Check that:

 systems have been provided and installed in accordance with specification

and drawings, and that the systems are charged with water, vented and free
from leaks;
 water storage cisterns are free from distortion and leaks, are properly
supported and secured, are provided with correctly fitting covers, and are in
accordance with the Scottish Water Byelaws 2004;
 distribution pipework is rigidly supported, insulated, and incorporates
adequate provisions for venting, draining, expansion, isolation and
measurement of flow, temperature and pressure;
 pipework systems have been pressure tested;
 pipework systems and storage cisterns have been flushed, disinfected,
appropriate certification received, and that specified residual chlorine levels
are attained;
 pipework systems and storage/break tanks are correctly identified and
marked;

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 regulating valves and flow control devices operate freely;

 water meter(s) is/are fitted correctly;
 electrical isolation, cross-bonding and wiring of system components are
installed in accordance with BS7671: 2008.

16.25 Upon satisfactory completion of the pre-commissioning tests, the

commissioning tests can commence.

16.26 Commissioning checks and tests to be applied are as follows. Check that:

 overflows run freely and discharged water does not cause flooding or
damage, and that drain-down points flow when released and are free from
leaks when shut;
 float-operated valves function satisfactorily and are adjusted to give the
correct water level;
 control valves operate correctly and shut-off valves close tightly;
 all electrical circuits are tested and the pump motor direction of rotation is
correct, and that electrical controls and alarms function correctly;
 operation of any safety or anti-flood device is satisfactory;
 circulating or lifting pumps are free from excessive noise, vibration and
leaks;
 remote control of pumps (if appropriate) is satisfactory;
 the installation is vented and regulated;
 the flow rate into, and out of, storage cisterns is recorded;
 all taps, mixers and outlets operate satisfactorily, and test and record mass
flow from outlets in positions shown on contract drawings. (TMVs require
hot and cold water for testing and commissioning. Type 3 TMVs are
commissioned in accordance with MES D08);
 temperature of water in storage cisterns and at taps is appropriate;
 full load current of components does not exceed the recommended values;
 the running current of components does not exceed the recommended
values;
 pump thermal overload trips are set;
 system schematic is displayed in a frame in the relevant plantroom,
complete with valve schedule.

Hot water installations

16.27 Pre-commissioning checks can be carried out upon completion of system
installation, filling and pressure testing.

16.28 Pre-commissioning checks and tests to be applied are as follows. Check that:

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 systems have been provided and installed in accordance with the

specification and drawings;
 the system is charged with cold water, vented, and free from leaks;
 hot water storage vessels are free from leaks and are properly supported
and secured;
 distribution pipework is rigidly supported, insulated, and incorporates
adequate provision for venting, drainage, expansion, isolation, and
measurement of flow, temperature and pressure;
 pipework systems, storage cylinders etc have been pressure tested, flushed
and disinfected, and appropriate certification has been received, and that
specified residual chlorine levels are attained;
 pipework systems, calorifiers and cisterns are correctly identified and
marked;
 regulating valves and flow control devices operate freely;
 all control and regulating valves are labelled or marked to correspond with
reference numbers on contract drawings;
 electrical isolation, cross-bonding and wiring of system components is
installed in accordance with BS7671: 2008;
 system schematic is displayed in a frame in the relevant plantroom.

16.29 Upon satisfactory completion of the pre-commissioning checks, the

commissioning checks and tests can then be started.

16.30 Commissioning checks and tests to be applied are as follows. Check that:

 drain down points flow when released and are free from leaks when shut,
and that air vents and release valves open correctly and are airtight when
shut off;
 all temperature and other controls are adjusted and calibrated to agreed
design limits of system performance;
 all electrical circuits are tested and the pump motor direction of rotation is
correct, and that electrical controls and alarms function correctly;
 control valves operate correctly and shut-off valves close tightly;
 heat exchangers operate satisfactorily;
 primary heating circuits are adjusted and regulated, and thermostatic
settings are correct; and that bypass circuits and automatic control valves
operate correctly;
 circulating pumps are free from excessive noise, vibration and leaks;
 remote and automatic control of pumps (if appropriate) is satisfactory, and
there are no leaks at joints under maximum flow conditions;
 secondary circuits are regulated and vented;

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 thermostatic mixing devices and regulating valves are adjusted and set to
desired values (TMVs require hot and cold water for testing and
commissioning, and should be commissioned in accordance with MES
D08);
 all taps, mixers and outlets operate satisfactorily;
 water flow quantities at all plant items, regulating valves and flow-measuring
valves are recorded;
 mass flow from taps, main and other outlets in positions shown on contract
drawings is satisfactory;
 pressure drop at heat exchangers at full design demand flow is tested and
recorded;
 hydraulic balancing of hot water secondary circulation system is carried out
to ensure that minimum temperatures are achieved in all parts of the circuit;
 full load current of components does not exceed the recommended values;
 the running current of components does not exceed the recommended
values;
 pump thermal overload trips are set.

Pressure testing
16.31 Pressure testing must be carried out before disinfection. Except where
otherwise specified, testing of underground pipelines should be carried out in
accordance with the requirements of the Scottish Water Byelaws 2004.

16.32 Open pipes should be capped and valves closed to avoid contamination.

Temperature testing
16.33 These tests should be performed prior to contractual handover and bringing the
system into use. Separate thermostatic measuring and recording equipment
should be used, that is, independent of any building management system. It will
be necessary to have systems fully operational and to simulate typical draw-off
of water.

16.34 Tests should include:

 measuring the incoming water temperature at the main water meter;

 testing the inlet, outlet and surface water temperatures of cisterns and cold
water feed/ header tanks for the hot water calorifiers. The temperature
should not be greater than 2°C above that measured at the main water
meter;
 testing the flow and return temperatures at connections to calorifiers and
water heaters. These should not be less than 60°C and 50°C respectively;
 testing the temperature in branches of hot water circulating systems
installed in all departments to ensure that the system has been balanced,

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and that under “no draw-off” conditions 55°C is achieved in the circulating
system at outlets furthermost from the calorifier/heater;
 testing single hot water outlets and inlets to mixing valves to ensure that a
minimum of 55°C is achieved within 1 minute;

Note 20: The Health and Safety Commission’s (2000) Approved Code of
Practice L8 permits a period of 1 minute to achieve an equilibrium temperature
of 50°C. A minimum of 55°C may be required for the operation of suitable
mixing devices required to provide ‘safe’ hot water at the upper limit of the
recommended range. Hot water at 55°C is required in many cases for reasons
of food hygiene or decontamination requirements, for example in kitchens and
sluice rooms. In a properly balanced hot water circulating system, with the
circulation taken close to the draw-off point, achieving temperature should be
virtually instantaneous. (At a typical flow to a wash-hand basin of 4.5 litres/m, 1
min to achieve temperature would indicate a 25m dead-leg of 15mm pipe or that
the system is out of balance.)

 testing single cold water outlets and inlets to mixing valves to ensure that
temperature equilibrium below 20°C is achieved within 2 min;

Note 21: The Health and Safety Commission’s (2000) Approved Code of
Practice L8 permits a period of 2 min to achieve an equilibrium temperature
below 20°C. Achieving this minimum requirement would be indicative of an
exceptionally under-utilised water system in an unoccupied building. During
commissioning, therefore, it is essential to encourage draw-off to simulate
normal usage. (At a typical flow to a hand-wash basin of 4.5 litres/m, 2 min to
achieve temperature would indicate a 50m dead-leg of 15mm pipe or that
stagnation is occurring.)

 Testing the temperature at hot water draw-off points to ensure that they
comply with the recommended temperatures in Table 4. (NB: the maximum
temperatures should not exceed those shown in Table 4 by more than
2°C.).

Note 22: Further information on commissioning procedures can be found in

Part E of this SHTM: Alternative materials and filtration.

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17. Disinfection

17.1 Guidance on disinfection is given in BSRIA’s (2004) Application Guide 1/2001.1:

‘Pre-commission cleaning of pipework systems’, which contains
recommendations for the design, installation, system-flushing and chemical
cleaning of pipework systems. Disinfection should be applied to the complete
hot and cold water service systems. When considering a contractor to carry out
the work, preference should be given to companies/individuals who are
members of the Legionella Control Association (formerly, the Code of Conduct
Association for the Control of Legionellosis).

17.2 Alternative disinfectants may be used, provided satisfactory disinfection is

achieved. The infection control team should be consulted, and advice should
also be sought from the Drinking Water Quality Regulator.

Note 23: Disinfection is a requirement of the Water Regulations. Additional

advice on the use of alternative disinfectants can be found in Part “D” of this
SHTM which covers continuous dosing of installations in use.

17.3 Proprietary solutions of disinfectant should be used in accordance with the

manufacturers’ instructions. The COSHH Regulations require that the risks from
using the disinfectant for each task be assessed to ensure that the control
procedures adopted are suitable for the particular application.

17.4 Disinfection should not be undertaken before materials, for example linings in
cisterns, have fully cured. Advice should be sought from equipment
manufacturers to ensure that proposed disinfection chemicals will not adversely
affect performance. No heat source should be applied during the disinfection
procedure, including final flushing.

17.5 Pipework under pressure from the mains should be disinfected through an
injection point and the disinfectant residual measured at the end of the pipeline.
BS6700: 2006, BS EN 806-1-5: 2000-2012 and also BS8558: 2012 and the
Approved Code of Practice L8 advise 50 mg/litre (ppm) for one hour or 20
mg/litre (ppm) for two hours; it is usual practice to leave the chlorine solution in
the pipes for 24 hours before thoroughly flushing out with fresh water. Junctions
that are to be inserted into existing pipelines should be disinfected prior to
installation.

17.6 All disinfection of pipework under pressure from the mains must be carried out
in accordance with the requirements of the water supply authority. Failure to
ensure close liaison between the contractor and the water authority during
design, construction, pressure testing or commissioning could present a
potential risk of back-flow of contaminated materials or chemicals into the public
water supply. Site supervision to ensure compliance with any requirements
specified by the local water supply authority is recommended.

17.7 All cisterns should be internally cleaned to remove all visible dirt and debris.
Cisterns and distributing pipework should be drained, filled with fresh water and
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then drained completely. The cisterns should then be refilled and the supply
servicing valves closed. On re-fitting it is normal practice to add high doses of
sodium hypochlorite to the water in the cisterns, for example, to give a
calculated chlorine concentration of 50 ± 10 mg/litre (ppm) in the water, and
leave the water to stand for one hour. Whatever disinfection method is used, the
concentration should be adjusted if necessary. The use of a high dose ensures
an adequate residual concentration to allow proper disinfection of the
downstream services. Each tap or fitting should then be opened, progressively
away from the cisterns, and water discharged until the disinfectant is detected.
Each tap or fitting should then be closed, and the cistern and pipes left charged
for a further hour. The tap(s) furthermost from the cisterns should be opened,
and the level of disinfectant in the water discharged from the taps measured. If
the levels set are not achieved, the disinfection process should be repeated.

17.8 As soon as possible after disinfection, the distribution pipework should be

drained and thoroughly flushed through with fresh water and refilled (see
paragraphs 17.14 and 17.15). Appropriate hazard warnings should be placed
on all taps throughout the building during disinfection procedures.

17.9 After disinfection, microbiological tests for bacteria colony counts at 37°C and
coliform bacteria, including Escherichia coli, should be carried out under the
supervision of the infection prevention control team to establish that the work
has been satisfactorily completed. Water samples should be taken from
selected areas within the distribution system. The system should not be brought
into service until the infection control team certifies that the water is of potable
quality.

Discharge of waste water used during disinfection procedures

within buildings
17.10 Contaminated water should not be run to drain without discussion and approval
of the water or environmental authority.

Thermal disinfection (of hot water service systems)

17.11 The process introduces a serious scalding risk, and it is essential that steps are
taken to ensure that access is limited to authorised personnel only until such
time that the system has returned to normal operating temperature: it is unlikely
to be a practicable alternative for a large system. It also requires the removal of
thermostatic elements, thus introducing additional practical difficulties.

17.12 This process can be performed by raising the temperature of the entire contents
of the calorifier, or hot water heater, followed by circulating the water throughout
the system for at least an hour. The calorifier/heater temperature must be
sufficiently high to ensure that the temperature in all parts of the circulating
system, and at the return connection, does not fall below 60°C. After this period,
each tap or draw-off-point should be run sequentially from the nearest point to
the furthermost outlet. At branches it will be necessary to draw-off water to at
least one outlet, the nearest, to ensure adequate purging. The draw-off at the
tap or outlet should be for a period of at least five minutes at full temperature.

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Maintaining control of systems

17.13 Once disinfection has taken place, it is essential to put in place measures to
ensure that hot and cold water temperatures are maintained. This will require
regular flushing, at least weekly, and possibly more frequently during periods of
hot weather.

17.14 Once filled, systems should not be drained unless full disinfection is to be
carried out prior to building occupancy and use. However, allowing water in
newly installed capillary-jointed copper plumbing to stagnate can result in
serious corrosion of the copper. To reduce the risk of this, it is recommended
that flushing should take place on a weekly basis to introduce fresh water
throughout the system.

17.15 To prevent the accumulation of biofilm during construction and testing,

continuous dosing of water systems with appropriate biocides should be
considered. Such treated systems should be regularly flushed to ensure that the
biocide reaches all parts of the systems, and particularly outlets. Dosing with an
appropriate level of biocide as soon as water hits a pipe or storage vessel,
along with regular flushing, can control the accumulation of biofilm more
effectively.

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18. Documentation

General
18.1 It is essential that a full report of all commissioning and testing activities is
compiled and handed over to be incorporated within the operation and
maintenance manuals.

18.2 These commissioning and testing records will be required so that subsequent
maintenance and periodic checks can be made to ensure that the installation
continues to operate as intended. Such information will include results of
temperature checks on the cold water supply and hot water circulating systems
and commissioning and in-service test data for Type 3 TMVs. The information
should also include identification of, and test results for, sentinel taps.

18.3 Where continuous water treatment is installed, the commissioning records

should include details of settings of the equipment, dosing rates and
requirements for testing.

18.4 Operation and maintenance manuals should be in accordance with BSRIA’s

(1990) Application Guide 1/87: ‘Operation and maintenance manuals for
building services installations’.

18.5 As a minimum, for new installations or major refurbishment, the contract should
require the following documents and drawings to be supplied:

 full manufacturing details, including batch numbers of all pipes and fittings;
 full records and certificates of pressure tests for all sections of pipework;
 settings of all balancing valves, with readings of flow rates where
applicable;
 full details of each item of plant, including arrangement drawings and
appropriate test certificates;
 as-fitted drawings showing clearly the location of balancing valves, flows
and settings, isolation valves, drain valves;
 schematic drawings for installation in plantrooms showing all valves and
items of plant;
 full details of water treatment parameters and operating modes and
settings;
 full details of maintenance requirements;
 detailed confirmation of disinfection procedures to BS6700: 2006, BS EN
806-1-5: 2000-2012 and BS 8558: 2011, and results of post-disinfection
microbiological analysis;
 full records confirming that all materials and fittings hold WRAS or
equivalent accreditation.

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Appendix 1: Water consumption

Ward unit
1 For the purposes of this study, a ward unit is defined as a combination of all the
rooms which make up the working area for patient care, that is, patients’
bedrooms, day spaces, treatment, utility and test rooms, bathrooms, showers,
WCs, pantry, staff rooms, cleaners’ room etc and circulation spaces. Figure A1
shows the average daily consumption of stored water and Figure A2 shows the
rate of supply of mains water to cistern.

Designers should consider the impact on water consumption of such specialist

departments such as Renal Dialysis and the dumping of water as part of the
filtration processes.

Figure A1: Average daily consumption of total stored water

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Figure A2: Rate of supply of mains water to cistern

Average water consumption by type and size of hospital

2 Table A1 (the results of a survey of NHS hospitals by the Department of Health
and Social Security in 1974) provides basic data for design guidance on the
estimation of water storage and consumption for whole hospitals.

The definitions that have been used for the classification of hospitals are shown
in Table A2. ‘Excluded departments’ are those for psychiatry (mental illness),
psychiatry (mental handicap), diseases of the chest, chronic sick, geriatrics and
convalescence (including rehabilitation, but not pre-convalescence).

Relative intensity of water consumption

3 Whilst water consumption per bed content is a convenient estimating and
planning yardstick, it does not show the widely differing floor areas which are
provided per bed in hospitals of different sizes and type.

To illustrate the relative rates of consumption as seen against a basis of

comparable patient density and showing the amount of water consumed − not
only directly by the patient but also in the supporting treatment departments − a
graphical presentation of the figures given in Table A1 is presented on a per
bed and per floor area basis in Figures A3 and A4.

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Sire band No of Total no of Average Total Average

(no of beds) hospitals in beds in size of consumption consumption
sample sample hospital (no m³ per annum litres/bed/day
of beds)
Acute (Types 1, 2, 3 and 17)
0-50 150 4,208 28 458,900 299
51-100 58 4,151 72 602,909 398
101-200 70 9,946 142 1,780,700 490
201-400 62 18,167 293 3,914,351 590
401-600 23 10,741 467 2,348,682 599
Over 600 3 2,023 674 721,887 978
Specialist acute (Types 11, 14, 15, 16 and 18)
0-25 53 931 18 108,336 319
26-50 18 651 36 82,455 347
51-100 38 2,664 70 352,133 362
101-200 16 1,952 122 341,004 479
Over 200 7 1,633 233 316,874 531
Long stay (Types 4 and 5)
0-50 30 1,126 38 74,009 180
51-100 45 3,463 77 339,791 569
101-200 44 6,222 141 560,731 247
201-300 10 2,300 230 182,617 217
Over 300 3 1,121 374 25,247 306
Recovery and convalescent
0-25 6 126 21 9,965 216
26-50 35 1,339 38 100,721 206
51-100 19 1,357 71 91,947 185
Over 100 3 449 150 29,663 181
Geriatric and chronic sick (Type 19)
0-50 18 573 32 51,520 246
51-100 20 1,460 73 108,163 203
101-200 6 788 131 46,987 164
Over 200 2 512 256 23,748 127
Psychiatric (Types 12 and 13)
0-100 46 2,186 48 166,588 209
101-200 12 1,773 148 156,814 242
201-400 13 3,782 291 976,559 273
401-600 10 4,884 488 443,662 249
Table A1: Average water consumption by type and size of hospital

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Sire band No of Total no of Average Total Average

(no of beds) hospitals in beds in size of consumption consumption
sample sample hospital (no m³ per annum litres/bed/day
of beds)
601-1,000 7 5,112 730 654,024 350
Over 1,000 5 6,098 1,220 747,676 336
London teaching (all types)
0-100 20 1,161 58 789,422 680
101-200 15 1,896 126 1,642,106 866
201-300 10 2,580 258 2,141,166 830
301-500 8 3,161 395 2,859,434 904
Over 500 4 2,611 652 3,207,658 1,228
Table A1 continued: Average water consumption by type and size of hospital

Type of hospital Type number Definition

Acute 1 Hospitals with not more than 15 per cent of their
beds allocated to the “excluded departments”
Mainly Acute 2 Hospitals with more than 15 per cent and up to
40 per cent of their beds allocated to the
“excluded departments”
Partly Acute 3 Hospitals with more than 40 per cent and up to
60 per cent of their beds allocated to the
“excluded departments”
Mainly Long-stay 4 Hospitals with more than 60 per cent and up to
85 per cent of their beds allocated to the
“excluded departments”
Long-stay 5 Hospitals with more than 85 per cent of their
beds allocated to the “excluded departments”
Pre-convalescent 7 Hospitals with 90 per cent or more of their beds
allocated to patients who have already received
elsewhere the most intensive part of their
treatment, but who still require active nursing
care and medical oversight
Convalescent 8 Hospitals with 90 per cent or more of their beds
allocated to patients recovering from a disability
who no longer require active medical supervision
or nursing care in bed though they may need
such simple nursing procedures as renewal of
dressings or the administration of medicines

Table A2: Definition of types of hospital

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Type of hospital Type number Definition

Rehabilitation 9 Hospitals with 90 per cent or more of their beds
allocated to patients who no longer require
nursing care in bed and who, with or without the
aid of appliances, can get about and attend to
their own needs with occasional assistance but
who require remedial and re-educative treatment
with a view to attaining the maximum degree of
use of functions
Maternity 11 Hospitals (including General practice maternity
Hospitals) with 90 per cent or more of their beds
allocated to obstetrics
Psychiatric (Mental 12 Hospitals with 90 per cent or more of their beds
Illness) allocated to mental disorder and 50 per cent or
more of the psychiatric beds allocated to metal
illness
Psychiatric (Mental 13 Hospitals with 90 per cent or more of their beds
Handicap) allocated to mental disorder and more than 50
per cent of psychiatric beds allocated to
handicapped and/or severely handicapped
patients
Orthopaedic 14 Hospitals with 90 per cent or more of their beds
allocated to traumatic and orthopaedic surgery,
including bone and joint tuberculosis
Tuberculosis and Chest 15 Hospitals with 90 per cent or more of their beds
allocated to tuberculosis (both respiratory and
non-respiratory) or diseases of the chest
(including thoracic surgery) or both
Tuberculosis and Chest 16 Hospitals with 90 per cent or more of their beds
Isolation allocated to tuberculosis (both respiratory and
non-respiratory) or diseases of the chest
(including thoracic surgery) or both, and
infectious diseases
Children’s (Acute) 17 Hospitals with 90 per cent or more of their beds
allocated as in Type 1 but for children only
Eye 18 Hospitals with 90 per cent or more of their beds
allocated to that one function
Other hospitals 19 These include Dental and ENT hospitals and
also:
All hospitals with 90 per cent or more of their
beds allocated to a single department not
specifically named above unless that department
is “General Medicine”, “General Surgery” or
“General Practice (Medical)”, in which event the
hospital would be classified as “Acute” (Type 1)
Type 19 will include Geriatric and Chronic Sick
Hospitals
Table A2 continued: Definition of types of hospital

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Figure A3: Average water consumption by type and size of hospital (litres per bed)

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Figure A4: Average water consumption by type and size of hospital (litres per floor area)

Table A3 and Figure A5 provide a worked example of water consumption by

nursing staff in residential accommodation.

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Residential accommodation for nursing staff

1. Data
Type of Number of residents Allocation of fittings Total fittings
accommodation
A 150 1 LB per person 150 LBs
Student nurses 1 Bath per 5 persons 30 Baths
1 WC per 5 persons 30 WCs
1 Sink per 5 persons 30 Sinks
1 Laundry per 50 3 Laundries
persons
B 50 1 LB per person 50 LBs
Staff nurses 1 Bath per 4 person 12 Baths
1 WC per 4 persons 12 WCs
1 Sink per 4 persons 12 Sinks
C-F 50 1LB per flat 50 LBs
Deputy matrons plus 1 Bath per flat 50 Baths
MOs etc 50 family residents 1 WC per flat 50 WCs
1 Sink per flat 50 Sinks
Totals 300 - 250 LBs
92 Baths
92 WCs
92 Sinks
3 laundries
2. Daily usage per fitting
Type of fitting Accommodation A Accommodation B Accommodation C
LB 3 3 6
Bath 2.5 2 1
WC 20 16 8
Sink 5 4 6
Washing machine 8 - -
3. Consumption per use
LB 4.5 litres
Bath 72 litres
WC 6 litres
Sink 6 litres
Washing machine 114 litres
4. Estimated daily consumption - 34,090 litres
Daily consumption per person - 114 litres
5. Peak demands
If two-thirds of resident staff work three shifts commencing at 06.00, 14.00 and 22.00 hours,
peak demands will occur from 05.00 to 07.00, 13.00 to 15.00 and 21.00 to 23.00 hors. Peak
demand may reach 1.5 litres per sec, with an average demand of 1.06 litres per sec over three
periods.

Table A3: Example of water consumption by nursing staff in residential accommodation

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Figure A5: Water consumption profile for residential accommodation of nursing staff

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Appendix 2: Water treatment

General
1 All water supplied to healthcare premises must comply with current legislation
on water quality.

The following sections on water treatment are intended to provide a brief

overview only. Further details can be found in BSRIA Application Guide 2/93:
‘Water treatment for building services systems’. Some of the more common
water treatment processes are mentioned below. The extent of treatment will
vary for each application depending on water quality, intended usage etc, and
specialist advice should be obtained when considering the adoption of any
water treatment processes.

The needs for water treatment, and the treatment processes used, depend on
the purposes for which the water is to be used and the quantity required for
each purpose. While potability is not normally affected by such characteristics
as hardness, colour, and (within limits) smell and/or taste, a measure of
treatment may be necessary to provide a more acceptable supply.

A supply from a water supply authority should not normally require any further
treatment when used for hospital purposes other than laundries, domestic hot
water systems, humidification plant and steam boiler feed water. Private
supplies, however, will require some measure of treatment, and in many cases
the installation of pumping and treatment plant needs to be extensive to ensure
a constant acceptable quality.

Water is not naturally found in a state of chemical purity. Surface waters in

upland reservoirs, rivers and lakes often contain organic matter including algae,
tree foliage and silt. River water may also be polluted by sewage and industrial
effluents and chemicals leached from agricultural land etc. Groundwaters in
springs, wells and boreholes collect impurities from the surrounding strata;
shallow wells collect impurities from surrounding soil.

The impurities that must therefore be removed include tree foliage and matter in
suspension consisting of mineral particles, algae, organic matter and various
kinds of living organisms and bacteria. Other dissolved chemicals may also
require removal.

Suspended matter in water covers a wide range of particle size varying from the
large organic particles and silt found in fast-flowing rivers, to colloidal matter
with a size of 1 micron or less. Natural filtration takes place as water percolates
through the permeable strata and generally reduces suspended solids.

Water treatment processes

2 For high quality groundwater sources, the only treatment that may be required
is disinfection, which is covered in Section 17. However, for other water sources

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such as grey water, further treatment will be required, and this may be
extensive, depending on intended use.

There is a wide range of treatment options available, but the most relevant to
health establishments are:

 coagulation and flocculation;

 settlement;
 dissolved air flotation;
 filtration;
 iron and manganese removal;
 pH adjustment;
 solids treatment and disposal.

Coagulation and flocculation

3 This is the addition of a coagulant (often aluminium sulphate or an organic
polymer) followed by gentle agitation. The process is used to destabilise fine
particles in the water so that they agglomerate together such that they will settle
out more easily in the settlement process or that they can be removed more
easily by filtration.

Settlement
4 In this process, water is passed through tanks in which solid particles settle out.
Settlement covers a range of designs from simple horizontal flow tanks to
complex upflow sludge blanket clarifiers and lamella flow separators. Settlement
is basically a gravity process, although the sludge blanket used in some designs
of tank is part of a flocculation process.

Dissolved air flotation

5 Dissolved air flotation uses fine bubbles of air to lift particles present in water to
the surface of a tank, from where they are removed by a skimming system.
Water to be treated passes through a rectangular tank. High-pressure water,
saturated with air, is introduced into the bottom of the tank. The air in this water
comes out of solution because of the pressure drop, and forms fine air bubbles
on solids within the water; these solids then rise. The process is particularly
suitable for the removal of low-density solids such as algae. It is a sophisticated
process and is unlikely to be used except in special circumstances.

Filtration
6 Filtration is a solids removal process that involves passing water through a
filtering medium, which is normally sand. The most likely form of sand filter to be
found in a modern small treatment plant is a pressure filter; these are normally
vertical cylindrical steel or GRP pressure vessels.

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Water enters at the top of the vessel and passes down through 500mm of sand.
The sand rests on gravel which, in turn, is supported on a perforated floor. After
passing through the sand and gravel, the filtered water leaves through the
bottom of the vessel.

As the water passes through the vessel, the sand becomes increasingly
clogged with dirt and the pressure drop across the filter increases. Once the
pressure drop becomes excessive, the filter is cleaned. This is done by flow
reversal with water, and sometimes air, flowing up through the sand to waste.
This expands the bed and frees the dirt from the sand.

The need to clean filters involves a fairly complex system of pipes and valves.
On modern filters, cleaning is normally done automatically, with electrically
operated valves.

Filtration removes solids, and for relatively clean waters it may be the only
treatment process needed apart from disinfection. For dirtier waters, pre-
treatment by settlement or dissolved air flotation is required in order to prevent
too great a frequency of backwashing. For sources liable to pollution from
animal waste, filtration is essential for the removal of cryptosporidium and/or
giardia cysts. The filtering medium may be sand but may also be granular
activated carbon, to remove tastes and odours, or a catalytic medium (for
example manganese dioxide) to oxidise and remove iron and manganese.

Modern packaged plants may also use other sorts of filtration system.

Iron and manganese removal

7 A common problem, particularly with ground water, is excessive iron and
manganese levels. This problem is often solved by oxidising the iron and
manganese to an insoluble form by chlorination, pH adjustment and filtration to
remove the iron and manganese. Filtration is often done in pressure filters with
a catalytic medium.

pH adjustment
8 This is often needed either to oxidise iron and manganese or to render water
less corrosive to the distribution system.

Solids treatment and disposal

9 It should always be borne in mind that a water treatment plant will produce
wastes from settlement tanks and filters. These wastes will need to be disposed
of, probably to the site foul sewerage system.

Contaminated water that is run to waste into a natural watercourse or a drain

leading to it should be treated in accordance with the requirements of the
authority responsible for land drainage and pollution control. The authority
responsible for that sewer should be informed. Dechlorination can be achieved
using either sulphur dioxide or sodium thiosulphate. 20g of sodium thiosulphate
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crystals are required to dechlorinate 500 litres of water containing 20 mg/litre

free chlorine. For water requiring dechlorination, an automated system dosing
bisulphite solution or similar solutions can be linked to the BEMS.

Further advice on filtration methods and standards can be found in Part E of this
SHTM: Alternative materials and filtration.

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Appendix 3:Chloramine (and chlorine) in public water

supplies

1 The Water Authority in Scotland has been introducing chloramine as a

disinfecting agent in water supplies as an alternative to free chlorine.
Chloramines tend to be more stable and provide better residual antibacterial
activity with lower total chlorine levels. The protection lasts longer and avoids or
reduces the need for additional disinfectant dosing stations along the network
between water treatment plant and the end–user to ensure that the strict
microbiological standards set within the Regulations are met. This explains why
chloraminated supplies have been introduced in rural areas.

In Scotland, the drinking water standards are identified in the water Supply
(Water Quality) (Scotland) Regulations 2001 and 2010, in line with all European
community (EC) requirements. This is a legal document with which the Water
Authority is required to comply. The Drinking Water Quality Regulators (DWQR)
monitor the Water Authority to ensure that the Regulations are complied with
and the 2001 Regulations detail the acceptable levels of certain characteristics,
elements and substances allowed in drinking water for which these permissible
levels are known as Prescribed Concentration of Value (PCV).

It has been recognised by Scottish Water that the secondary disinfection of

water supplies with chloramine offers a number of benefits, mainly comprising:

 a longer lasting treatment process within the distribution network than would
apply if chlorine was used on its own;
 the process helps prevent the formation of trichloramine compounds that
are formed with traditional chlorination;
 it removes the need to add further chlorine further along the pipework
distribution network;
 there is the benefit of having no significant taste or odour when correct
dosing rations are applied.

There is evidence that the use of free chlorine as a disinfecting agent in surface
water supplies containing natural organic residues can combine to form
trihalomethanes (THMs), for example chloroform (CHCl3),
bromodichloromethane (CHCl2Br) and other compounds that are carcinogenic.
(Free chlorine is still preferred for disinfecting borehole waters.)

The local water supply authority carries out chloramination at the water works
by introducing both chlorine (Cl2) and ammonia (NH3), which combine in
aqueous solution to form monochloramine (NH2Cl), dichloramine (NHCl2) and a
small quantity of trichloramine (NCl3).

The quantities of these depend upon the ratio of chlorine and ammonia and the
acidity of the water; it is important to achieve the correct balance, as
dichloramine and trichloramine can lead to problems of taste and odour and
their formation needs to be minimised.
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In the UK there is no standard for chloramines in water. The World Health

Organisation (WHO) recommends a maximum concentration of 3 mg/litre. This
is based on a tolerable daily intake that is derived from the ‘no observable
adverse effect level’ (NOAEL) to which a safety factor of 100 is applied. The
levels of chloramine that the UK will use (and dialysis treatments units should
be designed to handle) is likely to be in the order of 1 mg/litre total chlorine,
most of which is present as monochloramine.

Problems associated with aquaria have been reported in the USA, where much
higher levels of chemicals are used than is proposed in the UK.

Chloramine is also extensively used in Europe for disinfection of public water

supplies.

Implications for healthcare

2 In systems where free chlorine is rapidly lost, such as typical hot and cold water
service systems, chloramines can remain for much longer, posing particular
problems for dialysis patients. The effect of chloramine-induced acute
haemolytic anaemia and methaemoglobinaemia has been well reported. Little
other information is available on chloramine.

Chloramines, and to a lesser extent chlorine, in dialysis water can cause

haemolysis – a condition whereby red blood cells are ruptured. In addition, all
renal patients suffer from anaemia to some extent because they are lacking in
erythropoietin (EPO). This natural hormone, which stimulates bone marrow to
produce red blood cells, is not available in sufficient quantities in patients with
damaged or diseased kidneys. Synthetic EPO is administered to dialysis
patients but, apart from its high cost, can have unpleasant side effects. Where
chlorine or chloramines are present, the need for EPO escalates, and therefore
it is imperative to eliminate chlorine and chloramines from water supplies to
dialysis equipment to minimise the dosage of EPO.

Dialysis requires a water supply that has the minimum of chemical and bacterial
impurities. This requires water treatment – typically reverse osmosis and
softening; neither process removes chloramines or chlorine.

Some reduction of chloramine occurs in deionisation equipment because of

adsorption onto ion-exchange resin molecules, but performance of the
ionisation process is unpredictable in this respect and cannot be relied upon.
The Renal Association sets limits of 0.1 mg/litre and 0.5 mg/litre respectively for
chloramines and total chlorine in water for dialysis. (The European
Pharmacopoeia specifies a maximum limit of 0.1 mg/litre for chloramine: studies
have shown, however, that levels as low as 0.25 mg/litre can cause
haemolysis.) Therefore, it can be seen that the margin for error is low. (See also
Health Building Note 53: ‘Facilities for renal services’, Volumes 1 and 2 which
have not been adapted for Scotland but may be used with general caution.)

There remain some concerns about chloramine, but in the main, these are
about high concentrations for bathing water disinfection. Further studies are
taking place.
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Removal of chloramines
3 The use of granular-activated carbon (GAC) filtration upstream of the reverse
osmosis (RO) equipment) is recognised as an effective means of dealing with
chloramine. (In hard water areas, water softening will also be required.)

Chemical reduction by use of ascorbic acid (vitamin C), which is capable of

neutralising many oxidising agents, is also an effective method. There is some
concern about the use of ascorbic acid because of its toxicity for dialysis
patients. Management of vitamin C intake has to be carefully monitored in
dialysis patients; therefore chemical reduction, particularly for domiciliary
patients, is undesirable.

GAC is manufactured from a variety of products, but mostly bituminous coal.

The charcoal derived is pulverised and “activated” by exposure to superheated
steam. This increases the total surface area for adsorption, which can be as
high as 1500 m2/g. This highly porous substance is formed into disposable
cartridges, or used in rechargeable tanks.

The critical factor in the selection of the carbon filter is the empty bed contact
time (EBCT), which can be calculated as follows:

volume(GAC(litres))
EBCT = x 50
flow(water(litre/m))

The aim should be an EBCT of about 6 min.

As a yardstick, the Drinking Water Quality Regulator has advised the Renal
Association to design water treatment systems, whether domiciliary or hospital-
based, to remove up to 1 mg/litre total chlorine.

Summarising
4 The following facilities require special attention

Renal Departments

 the Renal association identifies that dialysis water purification plant should
be capable of accepting 1mg/Iitre total chlorine, while setting limits of 0.1
mg/Iitre and 0.5 mg/Iitre, respectively, for chloramines and total chlorine in
water for dialysis. Dialysis requires a water supply that has the minimum of
chemical and bacterial impurities and to achieve this, further water
purification is required, typically reverse osmosis and softening, neither of
which is an effective means of removing chloramines and chlorine;
 the use of Granular Activated Carbon Filtration (GAC – filtration) upstream
of the Reverse Osmosis (RO) equipment is recognised as an effective
means of chloramines and chlorine and the impact of dealing with
chloramines is limited only to the increased contact time within the activated
carbon filters associated with the renal water purification plant because
chloramines take longer to be absorbed than free chlorine. It has been
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estimated that an increase in contact time of around 6 to 10 minutes will be

required, increasing the total surface are for absorption. The assessment
would normally be calculated by the specialist water treatment company
specialising in renal water supply and plant selection.

Pharmacy Departments

 the residual levels of chloramines within a water supply can affect the
manufacturing of pharmaceuticals and therefore pharmacy departments
within healthcare premises may be more effected by a chloraminated water
supply. For this reason, monitoring of the water supply is required and any
subsequent review of any existing purification processes and procedures
currently operating may have to be enhanced, upgraded or renewed.

Laboratories

 areas within healthcare facilities that require specialised water, such as

science laboratories, would also require their water treatment and
purification to be reviewed and, where necessary, enhanced, upgraded or
renewed.

Hydrotherapy Departments

 water treatment processes and procedures to hydrotherapy pools, etc., may

also require their water treatment processes to be reviewed as the
introduction of additional chlorine may induce the production of
dichloramine and trichloramine. The water treatment and procedures to
these areas may require to be enhanced, upgraded or renewed where
necessary;
 there have been instances in which chloraminated water supplies have
been introduced in Scotland by the Water Authority without advance
warning or consultation. To avoid this, the maintenance of close liaison with
the Water Authority is essential and that the quality of incoming supplies is
monitored at all times to avoid adverse effects, principally on vulnerable
patients.

Chloramines and the effect on pipework materials

5 There is no test data available identifying that a chloraminated water supply
affects pipework or pipework components, neither within the various UK water
authorities’ nor undertakings’ infrastructure, nor within industrial, commercial or
domestic premises. The Water Research Council (WRc) advises that no recent
product testing had been carried out on any plumbing components or material
to assess the long-term affects that chloramine may bring.

However, the fact that such supplies have been delivered in the Thames Water,
Northumbrian and Anglian Water areas for so many years without any reported
detrimental affects leads to the confidence that traditional and contemporary
plumbing materials and components are unaffected as a result of handling
chloraminated water supplies.

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6 Further guidance on chloraminated water supplies can be found in Part F of this

SHTM.

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Appendix 4: Chlorine dioxide

Chlorine dioxide is an oxidising biocide that is capable of reacting with a wide

range of organic substances. Its effectiveness in the control of organisms in
water systems has been demonstrated in a study carried out by BSRIA (see
BSRIA’s (1998) TN 2/98: ‘Chlorine dioxide water treatment − for hot and cold
water services’).

For hot and cold water services, chlorine dioxide is usually generated by sodium
chlorite reacting with gaseous chlorine or hydrochloric acid:

5NaClO2 + 4HCl 4ClO2 + 5NaCl +

2H2O.

Alternatively, a number of systems use proprietary solutions that release

chlorine dioxide on acidification.

Use of chlorine dioxide as a chemical for drinking water treatment is now

subject to a European Standard (BS EN 12671: 2000). National conditions of
use require that the combined concentration of chlorine dioxide, chlorite and
chlorate do not exceed 0.5 mg/litre as chlorine dioxide. Chlorine dioxide
dissolves unchanged in water, but is very slowly hydrolysed to chloric and
chlorous acids. In alkali, chlorate and chlorite are formed:

2ClO2 + 2OH− ClO3− ClO2− + 2H2O.

It is essential that the maximum amount of chlorine dioxide is available for

reaction with organic molecules and not total chlorite or chlorate.

In water, the oxidising properties of chlorine dioxide result from two reactions.
Chlorine dioxide gains one electron to form chlorite:

ClO2 + 1e− ClO2−.

If available, the chlorite gains four electrons to form chloride:

ClO2− + 2H2O + 4e− Cl− + 4OH−1.

The first of these reactions proceeds readily in the range of pH found in potable
water.

The latter reaction, to complete the five-electron transfer, does not always
occur.

In the inactivation of microorganisms, the chlorine dioxide molecule acts as a

free radical (oxidising biocide) that readily bonds with the amino acids − the
basic building blocks of proteins − which form the living cells. This results in
their destruction.

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Note 24: The difference between the chlorine dioxide injected into the system
and the levels at the furthermost parts of the system, where its presence can be
measured, is an indication of the bio-burden oxidised.

Chlorine dioxide is also effective in the destruction and removal of biofilms,

which contribute to the nutrients within the systems and provide protection for
bacteria against the effects of heat and chlorine.

Note 25: Further information on disinfection can be found in Part D of this

SHTM.

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Appendix 5: Copper and silver ionisation

Ionisation as a water treatment method has been shown to be effective against

planktonic Legionella in hot and cold water systems at 400 µg/litre and 40
µg/litre respectively. In soft waters a silver level as low as 20 µg/litre can be
effective. Ionisation systems release copper and silver ions into the water
stream by means of electrolyte action. Copper and silver ionisation involves the
release of copper and silver ions by electrolytic generation for use as a water
treatment.

Copper and silver ionisation is concerned with releasing silver and copper ions
into water by passing an electrical current between two copper electrodes and
between two silver electrodes placed in running water.

The copper and silver ions attach, through electrostatic bonds, to negatively
charged sites on bacterial cell walls. This distorts and weakens the cell wall,
allowing penetration of the silver ions. The silver ions attack the cell by binding
at specific sites to DNA, RNA, cellular protein and respiratory enzymes, denying
all life support systems to the cell, causing paralysis and death. The copper and
silver ions act synergistically to kill bacteria.

Silver/copper ionisation’s effectiveness in the control of Legionella bacteria in

water systems has been demonstrated in a study carried out by BSRIA (1996;
TN 6/96: ’Ionisation water treatment for hot and cold water services’). Results
show that where silver and copper ion concentrations could be maintained at
0.04 ppm and 0.4 ppm respectively, copper and silver ionisation was effective
against Legionella bacteria in both cold and hot water systems with reduced
water temperatures as low as 35°C. pH levels above 7.6 may affect the efficacy
of this technology.

Water analysis certificates-of-analysis results from samples collected from

outlets at sites that operate silver/copper ionisation systems in the UK show that
where silver and copper ion concentrations are maintained at outlets at between
0.01 and 0.08 ppm and at between 0.2 and 0.8 ppm respectively, Legionella
contamination is avoided and controlled.

The study carried out by BSRIA also showed that the copper and silver ions not
only reduce the biofilm coverage in cisterns and within pipework circuits, they
also reduce the number of Legionella bacteria present within the biofilm.

Further studies by Walker et al (1997) showed that when copper and silver
ionisation was operated at concentrations of 0.04 ppm of silver and 0.4 ppm of
copper, it is an effective non-chemical disinfectant for the control of bio-fouling.

However, attention is drawn to Note 26 overleaf.

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Note 26: From February 2013 copper ionisation was banned and it become
illegal to sell or use water treatment products that added copper into the water
as a biocide under an EU ruling. At the time or preparing this text (January
2013) it was understood that HSE would pursue an “Essential use derogation”.
This involves relaxations or appeals for use of copper for Legionella control in
the UK. The outcome of this was unknown and the decision for special use was
unlikely to be known before the ban was enforced. Water treatment regimes
should therefore be reviewed. Silver ionisation systems will still be allowed
together with silver hydrogen peroxide provided systems are flushed to ensure
that silver levels are less than 0.1mg/litre.

Note 27: Further information on disinfection can be found in Part D of this

SHTM.

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Appendix 6: Temperature settings

Building Management Systems

Domestic hot & cold water systems should be temperature monitored by the
Building Management Systems performing to SHTM 08-05 to ensure
compliance with the temperature standards specified in the relevant regulations
and guidance. System parameters must be detailed in the Written Scheme for
the Water system.

The minimum Building Management System performance of the water system

must be to ensure:

 Domestic Hot Water is continuously monitored and records the parameters

highlighted above i.e. 60°C flow (minimum) from the water heating device to
ensure 55°C at the supply to the farthest draw-off (sentinel) point in the
circulating system under normal use and no less than 50°C return (lowest
limit) to the water heating device;
 Cold Water is continuously monitored and records from the point where it
enters a building as described above, i.e. no more than 20°C (highest limit);
 failures outwith the parameters are subject to alarms and service response
messages;
 performance data require to be secured and retained for at least 5 years, but
must be easily available to the Authorised Person (Water), the other
independent professional advisors, assessors and others with an interest in
system performance.

Definition of Sentinel Point

 Sentinel Point is the first and last outlet point on any hot water or any cold
water recirculating system;
 Sentinel Point is the nearest and furthest from storage tanks on a non-
recirculating cold water system;
 Sentinel Point is the nearest and furthest from the hot water source on a
non-recirculating hot water system;
 Sentinel Point would also include any other outlet points considered to
represent a particular risk in the Written Scheme.

TMV settings
The safe outlet temperatures (as also shown in other SHTMs, SHPNs, HBNs
still applicable in Scotland and ADB Room Data Sheets) are

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Application Temperature Setting

°C
Staff bases & consulting rooms etc., basins, inpatient & outpatient 41
hand wash basins
Paediatric baths 40
General baths 43
Showers 41
Assisted baths Not more than 46
Hair-wash facilities 41
Bidets 38

Other hot water settings

Where no thermostatic mixing valve (TMV) outlet is provided, each outlet should
be provided with a “Caution – Very Hot Water” notice.

Application Temperature Setting

°C
Sinks: kitchens, pantries 55
Slop sinks, etc 55
Offices, staff-only access wash hand basins 43

Other water system settings

Application Temperature
Setting °C
Hot water flow from heat source 60 (minimum adjusted
to ensure minimum of
55°C at sentinel point)
Hot water return to heat source 50 (minimum)
Minimum hot water temperature reaching most distant outlets 55 (minimum at sentinel
point)
Hot water pre-pasteurisation temperature 70
Cold water temperature in high-risk departments 20 (maximum)
Cold water temperature at sentinel outlets 20 (maximum)
Manual re-set high limit thermostat setting at heat source 75

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References

Acts and regulations

NB: Access to information related to the following Acts and Regulations can be
gained via www.legislation.gov.uk.

The Scottish Technical Handbooks, Non-Domestic, 2007

Control of Substances Hazardous to Health Regulations 2002, SI 2002 No

2677. HMSO, 2002.

Food Safety (General Food Hygiene) Regulations 1995, SI 1995 No 1763.

HMSO, 1995.

Food Safety (Temperature Control) Regulations 1995, SI 1995 No 2200.

HMSO, 1995.

The Health and Safety at Work etc Act 1974. HMSO, 1974.

Private Water Supplies (Scotland) Regulations 1992, S75 (s.64) HMSO,

1991.

The Water Act 1989. HMSO, 1989.

The Water Services Etc (Scotland) Act 2005. SI 2005 No 3172 HMSO, 2005
www.legislation.gov.uk/asp

Water Resources Act 1991. HMSO, 1991.

Scottish Water Byelaws 2004 refer to: (The) Water Supply (Water Fittings)
Regulations 1999, SI 1999 No 1148. HMSO, 1999.

The Water Supply (Water Quality)(Scotland) Regulations 2010. SI 2010 No

95. HMSO, 2010.

Scottish Health Planning Notes

Scottish Health Planning Note 13: Decontamination (in preparation).

Scottish Health Technical Memoranda

Scottish Health Technical Memorandum 06-01: ‘Electrical services supply
and distribution’. 2011. http://www.hfs.scot.nhs.uk

Scottish Health Technical Memorandum 07-02: EnCO2de – making energy

work in healthcare, Environment and sustainability, 2006.

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Model Engineering Specifications

MES C07 – Heating, hot and cold water systems. HMSO, 1997.

MES D08 – Thermostatic mixing valves (healthcare premises). HMSO, 1997.

Other Government publications

Department for Environment, Food & Rural Affairs (DEFRA) (1999). Water
Byelaws (Scotland) 2000 guidance document relating to Schedule 1: Fluid
Categories and Schedule 2: Requirements for Water Fittings [See Regulation
4(3)].
http://www.defra.gov.uk/environment/water/industry/wsregs99/guide/index.htm

British Standards
BS2486: 1997 Recommendations for treatment of water for steam boilers and
water heaters. British Standards Institution, 1997.

BS3505: 1986 Specification for unplasticised polyvinyl chloride (PVC-U)

pressure pipes for cold potable water. British Standards Institution, 1986.

BS3506: 1969 Specification for unplasticised PVC pipe for industrial uses.
British Standards Institution, 1969.

BS6100: 1984−2000 Glossary of building and civil engineering terms. British

Standards Institution, 1984−2000.

BS6700: 2006+A1: 2009 Specification for design, installation, testing and

maintenance of services supplying water for domestic use within buildings and
their curtilages. British Standards Institution, 2006. Commencing June 2012
this will co-exist with successor BS EN 806 1-5: 2000-2012 and BS8558:
2011during a transitional period.

BS6920-2.1: 2000 Suitability of non-metallic products for use in contact with

water intended for human consumption with regard to their effect on the quality
of the water. Specification. British Standards Institution, 2000.

BS7671: 2008 Requirements for electrical installations. IEE Wiring Regulations.

Seventeenth edition. British Standards Institution, 2008.

BS8007: 1987 Code of practice for design of concrete structures for retaining
aqueous liquids. British Standards Institution, 1987.

BS8558: 2011: Guide to the design, installation, testing and maintenance of

services supplying water for domestic use within buildings and their curtilages –
complementary guidance to BS EN 806.

BS EN 806-1-5: 2000-2012 Specifications for installations inside buildings

conveying water for human consumption. Design. British Standards Institution,
2000-2012.

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BS EN 1057: 1996 Copper and copper alloys. Seamless, round copper tubes
for water and gas in sanitary and heating applications. British Standards
Institution, 1996.

BS EN 1254-1: 1998 Copper and copper alloys. Plumbing fittings. Fittings with
ends for capillary soldering or capillary brazing to copper tubes. British
Standards Institution, 1998.

BS EN 1254-2: 1998 Copper and copper alloys. Plumbing fittings. Fittings with
compression ends for use with copper tubes. British Standards Institution, 1998.

BS EN 1254-3: 1998 Copper and copper alloys. Plumbing fittings. Fittings with
compression ends for use with plastics pipes. British Standards Institution,
1998.

BS EN 1254-4: 1998 Copper and copper alloys. Plumbing fittings. Fittings

combining other end connections with capillary or compression ends. British
Standards Institution, 1998.

BS EN 1254-5: 1998 Copper and copper alloys. Plumbing fittings. Fittings with
short ends for capillary brazing to copper tubes. British Standards Institution,
1998.

BS EN 1452-1: 2000 Plastics piping systems for water supply. Unplasticised

polyvinyl chloride) (PVC-U). General. British Standards Institution, 2000.

BS EN 1452-2: 2000 Plastics piping systems for water supply. Unplasticised

polyvinyl chloride) (PVC-U). Pipes. British Standards Institution, 2000.

BS EN 1452-3: 2000 Plastics piping systems for water supply. Unplasticised

poly vinyl chloride) (PVC-U). Fittings. British Standards Institution, 2000.

BS EN 1452-4: 2000 Plastics piping systems for water supply. Unplasticised

polyvinyl chloride) (PVC-U). Valves and ancillary equipment. British Standards
Institution, 2000.

BS EN 1452-5: 2000 Plastics piping systems for water supply. Unplasticised

polyvinyl chloride) (PVC-U). Fitness for purpose of the system. British
Standards Institution, 2000.

BS EN 12671: 2009 Chemicals used for treatment of water intended for human
consumption. Chlorine dioxide. British Standards Institution, 2009.

BS EN 13280: 2001 Specification for glass fibre reinforced cisterns of one-piece

and sectional construction, for the storage, above ground, of cold water. British
Standards Institution, 2001.

Other publications
Audit Commission (1993). Untapped savings: water services in the NHS. NHS
Occasional Papers.

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BSRIA (1996). TN 6/96: Ionisation water treatment for hot and cold water
services. BSRIA, 1996.

BSRIA (1998). TN 2/98: Chlorine dioxide water treatment − for hot and cold
water services. BSRIA, 1998.

BSRIA (1990). Application Guide 1/87: Operation and maintenance manuals for
building services installations. BSRIA, 1990.

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

BSRIA (2004). Application Guide 1/2001.1: Pre- commission cleaning of

pipework systems. BSRIA, 2004.

CIBSE (2003). Commissioning Code W: Water distribution. CIBSE, 2003.

CIBSE (1999). Guide A: Environmental design. CIBSE, 1999.

CIBSE (2004). Guide G: Public health engineering. CIBSE, 2004.

European Pharmacopoeia 3rd Edition 1997 (Supplement) (2000). Water for

diluting concentrated haemodialysis solutions. European Directorate for the
Quality of Medicines, Council of Europe, Strasbourg, France.

Health and Safety Commission (2000). Approved Code of Practice,

Legionnaires’ disease: the control of Legionella bacteria in water systems (L8).
Health and Safety Executive, 2000.

Maver, TWA (1964). Study of water consumption in ward units. Hospital

Engineering Research Unit, University of Glasgow, Glasgow, 1964.

Public Health Laboratory Service (1994). Hygiene for spa pools: guidelines
for their safe operation. The report of a PHLS spa pools working party. PHLS,
1994. http://www.hpa.org.uk

Public Health Laboratory Service (1999). Hygiene for hydrotherapy pools.

PHLS, 1999.http://www.hpa.org.uk The Renal Association (2002). Treatment of
adults and children with renal failure: standards and audit measures. The Renal
Association and the Royal College of Physicians, London.
http://www.renal.org/Standards/RenalStandards_2002b. PDF

Standing Committee of Analysts (2002). The Microbiology of Drinking Water.

Environment Agency, 2002.

Walker JT, Ives S, Morales M, West AA and Pavey N (1997), ‘Control and
monitoring of Legionella pneumophila biofouling in a water system treated with
silver and copper ions’, Biofilms in the Aquatic Environment, pp 131–138.

Water Regulations Advisory Scheme (WRAS) (1992). Information and

Guidance Note 9-04-02: Solder and fluxes. WRAS, 1992.

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Water Regulations Advisory Scheme (WRAS) (1993). WRAS Information and

Guidance Note 9-04-03: The selection of materials for water supply pipes to be
laid in contaminated land. WRAS, 1993.

Water Regulations Advisory Scheme (WRAS) (1994). Information and

Guidance Note 9-04-04: Cold water storage systems – design recommendation
for mains supply inlets. WRAS, 1994.
http://www.wras.co.uk/PDF_Files/IGN%209-04- 04%20Cisterns.pdf

Water Regulations Advisory Scheme (WRAS) (2004). Water Regulations

Guide. WRAS, 2004. http://www.wras.co.uk

Water Regulations Advisory Scheme (WRAS) (2005). Water Fittings and

Materials Directory. WRAS, 2005. http://www.wras.co.uk

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