Legionella Management Policy, Equality Screening | Causeway Coast & Glens Borough Council

S75 Equality And Good Relations Screening Form

This is a new policy / procedure.

Operational Area: Council Wide.

Title: Legionella Management Policy.

Brief Summary:

This Policy sets out the Council’s framework for preventing and controlling risks from legionella bacteria. It ensures compliance with health and safety requirements through risk assessment, control measures, defined responsibilities, training, and effective communication. The policy reflects the Council’s duty to protect health and provide safe environments across its services and facilities.

What is it trying to achieve? (intended aims and outcomes)

Aims
The policy aims to prevent and control the risks associated with legionella bacteria in Council facilities.

Outcomes
To safeguard the health of staff, service users, and the public; ensure compliance with health and safety legislation; provide clear lines of responsibility and accountability; equip staff with appropriate training; and maintain safe, well-managed water systems through effective monitoring and communication.

Who owns and who implements each element of the function, service, policy, procedure, project, strategy, plan or guidance?

Overall Responsibility: Chief Executive / Council leadership.

Responsible Person: day-to-day management of Legionella risks.

Premises Managers: oversee local implementation, ensure flushing, monitoring, and maintenance are undertaken, maintain logbooks.

Contractors: implement control measures, maintain schematics and logbooks, carry out inspections, and escalate unresolved issues.

Project Managers: ensure building works comply with CDM 2007, notify Premises Managers of underused outlets, and provide updated system information.

Corporate Health and Safety Team: provide guidance, monitoring, training, and outbreak response.

Other policies etc. which have a bearing on this function, service, policy, procedure, project, strategy, plan or guidance?

Other internal policies / strategies with a bearing on this policy:

CC&G Health & Safety Policy.
Procurement Policy.
Environmental Services Enforcement Policy.
Risk Management Policy and Strategy.
Cemetery and Old Burial Grounds Rules and Regulations.
Issue of Formal Cautions Policy.
Every Customer Counts Policy.
Procurement Policy.
Customer Services Charter.
Disability Action Plan.
Equality Scheme.
Health and Wellbeing.
Safeguarding Policy.

External legislation and guidance:

Health and Safety at Work, etc Act 1974.
Management of Health and Safety at Work Regulations 1999.
Construction (Design and Management) Regulations 2007.
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995.
Public Health Act (Northern Ireland) 1967.
Control of Substances Hazardous to Health.
Control of Legionella bacteria in water systems Approved Code of Practice (L8).
Legionnaires’ Disease a brief guide for duty holders.
Legionnaires’ Disease HPA and HSE Guidance: Management of Spa Pools (part1).
Legionnaires’ Disease HPA and HSE Guidance: Management of Spa Pools (part2).
The control of legionellosis: A recommended code of conduct for service providers.
Barbour Guide to Legionella.

Available Evidence

What evidence/information (both qualitative and quantitative have you gathered to inform this function, service, policy, procedure, project, strategy, plan or guidance? Specify details for relevant Section 75 categories.

It is proposed that all Section 75 categories will be considered via:

Quantitative evidence has been sourced via the NI Census in 2021 and the Northern Ireland Life and Times Survey 2024.
Public Health Agency, Legionellosis: Northern Ireland, Surveillance Report 2014 to 2024. During the period 2014 to 2024 there were 68 confirmed cases of Legionnaires disease.
Within Causeway Coast and Glens Borough Council facilities there have been no legionella cases.
Legionella Records within each facility.

Section 75 Category Details of Evidence/Information:

The Census statistics in 2021 collated by NISRA statistics detailed the usual resident population of Causeway Coast & Glens Local Government District to be 141,746 accounting for 7.45% of the N.I. total. Statistical information with regards to the Districts makeup and individuals therein was also reviewed.

Religious Beliefs

According to the 2021 Census, residents of Causeway Coast and Glens Borough Council broadly reflect the religious profile of Northern Ireland, with 40.1% Roman Catholic (45.7% regionally) and 51.2% Protestant and Other Christian (43.5% regionally). A further 0.8% in the borough (1.5% regionally) identified with other religions, while 7.9% locally (9.3% regionally) reported no religion or chose not to state one.

As of 6 June 2024, Council employed 682 staff, comprising 39% Roman Catholic, 55% Protestant, and 5% Non-Determined, reflecting representation from across the main community backgrounds.

No equality issues have been identified in relation to this category, and the policy content does not conflict with any recognised religious practices.

Political Opinion

The 2024 Northern Ireland Life and Times Survey shows that the Alliance Party (24%) is the party people feel closest to, followed by Sinn Féin (20%), with unionist parties at 22% and nationalist parties at 30%; 17% chose none or didn’t know, highlighting both Alliance’s growth and a notable proportion of the population remaining disengaged from or undecided about party politics. (this information is not available at local government level).

No staff information is held regarding this category.

No equality issues have been identified specific to this category.

Racial Group

According to the 2021 Census, while the local population is becoming more diverse, 97.8% still speak English as their main language, with Polish, Irish, Portuguese, Arabic, Bulgarian, Chinese, and Cantonese also spoken locally.

As of 6 June 2024, 92% of Council staff identified as White/White European, 0.3% as Other, and 7.6% were Unknown. To support inclusion and understanding, staff, agency workers and contractors are advised that the policy and related materials can be translated into alternative languages, and pictorial or multilingual guides on water flushing and safety procedures can be provided.

Current Public Health Authority data does not explore racial links to Legionella cases so the Head of Estates will monitor any future research in this area.

No equality issues have been identified specific to this category.

Age

According to the 2021 Census, the Causeway Coast and Glens Borough has a population of 141,745, with a slightly higher proportion of residents aged 50 and over, indicating an ageing population. NISRA’s 2020-based projections show this trend continuing, with people aged 65+ expected to outnumber children by 2027.

As of 6 June 2024, the Council employed 682 staff, with the majority aged 40 and over. To ensure inclusion, staff information can be provided in large print or Easy Read, and communication during implementation will support equal access for all age groups.

Public Health Authority data (2014-2024) indicates that older adults, particularly those aged 50-69, represent the majority of confirmed Legionnaires’ disease cases, highlighting age as a vulnerability factor. In response, the Council will use plain language, large text, clear visuals, in signage and relevant documents. Training will include the option of practical demonstrations, mentoring, and refresher training, while offering e-learning options for younger staff, agency workers and contractors. OD/HR will commission occupational health to identify any reasonable adjustments for staff or agency workers undertaking the role of Responsible Person.

The outbreak team will prioritise older people (staff and service users) when developing their response actions, and the Head of Estates will continue to monitor emerging research on age-related risk.

Marital Status

According to Census 2021, Causeway Coast and Glens reflects Northern Ireland trends, with the highest proportion of residents married (47.8%), slightly above the NI average of 45.6%. All other marital status categories are broadly in line with regional figures, except for civil partnerships (0.14%), which are slightly lower than the NI average of 0.18%. Same-sex marriage has been legal in Northern Ireland since 13 January 2020.

As of 6 June 2024, Council staff (n=682) are 57% married, 25% single, and the remainder divided across divorced, separated, widowed, civil partnership, or other, with 8% unknown.

No equality issues have been identified in relation to marital status. The Head of Estates will continue to monitor research for any emerging implications related to Legionella.

Sexual Orientation

The 2021 Census included a question on sexual orientation for the first time. In Causeway Coast and Glens, 91.3% of residents aged 16+ identified as straight or heterosexual, 1.4% as gay, lesbian, bisexual, or another orientation, and 7.3% preferred not to say or did not state. Patterns were broadly similar to Northern Ireland overall, with younger age groups more likely to identify as LGBT+, reflecting generational differences.

The Council currently has no workforce data on this Section 75 category. No equality issues have been identified, and inclusive communication of processes will support staff, contractors, and all Section 75 groups to have equal access to opportunities and assistance.

Men and Women Generally

According to Census 2021, the population of Causeway Coast and Glens Borough is evenly split by gender, with 49.3% male and 50.7% female, similar to Northern Ireland overall. As of 6 June 2024, Council staff (n=682) are 59.5% male and 40.5% female.

Public Health Authority data from 2014-2024 shows that 61.8% of confirmed Legionnaires’ disease cases were male, reflecting male sex as a known risk factor, with the highest proportion of cases for both sexes occurring in the 60-69 age group. Inclusive communication of processes will continue to support staff, contractors, and service users within all Section 75 groups to have equal access to opportunities, training for safe testing and assistance.

Dependants

In Causeway Coast and Glens, 28% of households include dependent children, slightly below the NI average of 29.2%, and 9.6% are lone-parent households, compared with 10.6% regionally. The borough has fewer single-person households under 66 but a higher proportion of older households, reflecting an ageing population. Around 12.3% of residents provide unpaid care, broadly in line with Northern Ireland overall, with those aged 40–64 most likely to be carers.

As of 6 June 2024, Council staff (n=682) include 31.5% with children, 1.5% adults only, 28.9% with no dependents, and 38.1% unknown. No equality issues have been identified, and inclusive communication of processes will support staff, contractors, and service users within all Section 75 groups to have equal access to opportunities and assistance.

Disability

According to Census 2021, 36% of residents in Causeway Coast and Glens have a long-term health condition or illness that limits daily activities, slightly above the NI average of 34.7%. Common conditions include long-term pain, mobility or dexterity limitations, breathing difficulties, and mental health issues.

As of 6 June 2024, Council staff (n=682) include 12 employees (1.8%) with a disability and 670 (98.2%) without. Public Health Agency data identifies underlying medical conditions including immunosuppression, chronic respiratory diseases, liver or kidney disease, and smoking as risk factors for Legionnaires’ disease. Between 2014 and 2024, 66.2% of confirmed cases had at least one risk factor, with hypertension and smoking most prevalent in 2024.

Inclusive communication and accessible processes support staff, contractors, and all Section 75 groups to have equal access to opportunities and assistance. Guidance will be provided in Easy Read, large print, and other accessible formats as needed, with visual symbols, pictograms, verbal briefings, face-to-face explanations, or captioned training videos. Taps and lever controls on fixtures will aid ease of use. OD/HR will commission occupational health to identify any reasonable adjustments for staff or agency workers undertaking the role of Responsible Person. Estates make every effort to improve accessibility when replacing current fixtures and fittings.

Screening Questions 1

1. What is the likely impact on equality of opportunity for those affected by this function, service, policy, procedure, project, strategy, plan or guidance?

Section 75 Category - Positive impact (it could benefit), Neutral or Negative impact (it could disadvantage).

Gender
Women, Men, Transgender men/women, Other: Potential positive - neutral (women) impact on this section. This section 75 group can benefit from consistent policies and procedures across the organisation, with mitigation measures and training to reduce the risk of exposure and/or infection for both staff and service users.

Race
The categories used in the Race section are those used in the 2011 census. Consideration should be given to the needs of specific communities within the broad categories.

Asian, Black, Chinese, Mixed race, Other: Potential positive impact.
Minority ethnic staff, service users, agency workers and contractors from other underrepresented groups can benefit from accessible policies and procedures across the organisation, with mitigation measures and training to reduce the risk of exposure and/or infection.

Disability
Long term health impairment could include mental health problems, asthma, heart conditions, chronic fatigue etc.

Potential positive impact on this section. Disabled staff, service users, agency workers and contractors can benefit from accessible policies, reasonable adjustments and procedures across the organisation, with mitigation measures and training to reduce the risk of exposure and/or infection.

Sexual orientation Heterosexual, lesbian, gay men, bisexual, others.

Potential neutral impact. The guidance has no adverse impact on sexual orientation and ensures that all staff and service users, including those who are LGBT+ or prefer not to disclose, have equal access to information, opportunities, and safe working practices.

Age Older People / Younger people and children

Potential positive impact. Both older and younger staff, service users, agency workers and contractors can benefit from accessible policies, reasonable adjustments and procedures across the organisation, with mitigation measures and training to reduce the risk of exposure and/or infection.

Political Opinion

Potential neutral impact. The guidance has no adverse impact on political opinion and ensures that all staff and service users, regardless of their political opinion have equal access to information, opportunities, and safe working practices.

Religious Belief

Potential neutral impact. The guidance has no adverse impact on people with religious or no religious belief and ensures that all staff and service users, have equal access to information, opportunities, and safe working practices.

Martial Status

Potential neutral impact. The guidance has no adverse impact on marital status and ensures that all staff and service users, have equal access to information, opportunities, and safe working practices.

Dependants

Potential neutral impact. The guidance has no adverse impact on those with or without dependants and ensures that all staff and service users, have equal access to information, opportunities, and safe working practices.

Screening Questions 2

2. Are there opportunities to better promote equality of opportunity for people within any of the Section 75 categories?

Gender (Women, Men, Transgender men/women, Other please specify).

Yes. Opportunities exist to better promote equality of opportunity by ensuring that all communications, guidance, and training materials are fully inclusive and accessible for all Section 75 groups. This includes:

Providing multilingual, Easy Read, large print, or captioned formats for staff and service users where required.

Incorporating inclusive training imagery, examples, and scenarios that reflect diversity across age, disability, gender, sexual orientation, and other protected characteristics.

Offering targeted support, mentoring, or practical demonstrations for staff or service users who may face barriers due to age, disability, or other factors.

Regularly reviewing policies and procedures to identify emerging equality needs or gaps.

These measures would strengthen accessibility, understanding, and participation, ensuring that everyone has equal opportunity to engage safely and effectively.

Race The categories used in the Race section are those used in the 2011 census. Consideration should be given to the needs of specific communities within the broad categories.
(Asian, Black, Chinese, Mixed race, White, Other please specify).

Disability Long term health impairment could include mental health problems, asthma, heart conditions, chronic fatigue etc.

Sexual orientation Heterosexual, lesbian, gay men, bisexual, others.

Age Older People, Younger people and children.

Political Opinion.

Religious Belief.

Marital Status.

Dependants.

Screening Questions 3

3. To what extent is the policy likely to impact on good relations between people of different religious belief, political opinion or racial group?

Section 75 Category: Religious Belief.
Level of impact: The policy is unlikely to have an impact on good relations between people of different religious beliefs, political opinions, or racial groups. It is designed to be inclusive, neutral, and fair, applying equally to all staff, contractors, and service users regardless of background. By promoting accessible communication, safe working practices, and equal opportunities, the policy supports understanding and cooperation across diverse groups.

Where possible, ensuring that materials reflect diverse communities and that any consultation or training engages a representative range of people can further strengthen good relations. Overall, the policy is expected to maintain or enhance positive relationships across these groups.

Section 75 Category: Political Opinion.
Level of impact: The policy is unlikely to have an impact on good relations between people of different religious beliefs, political opinions, or racial groups. It is designed to be inclusive, neutral, and fair, applying equally to all staff, contractors, and service users regardless of background. By promoting accessible communication, safe working practices, and equal opportunities, the policy supports understanding and cooperation across diverse groups.

Where possible, ensuring that materials reflect diverse communities and that any consultation or training engages a representative range of people can further strengthen good relations. Overall, the policy is expected to maintain or enhance positive relationships across these groups.

Section 75 Category: Racial Group.
Level of impact: The policy is unlikely to have an impact on good relations between people of different religious beliefs, political opinions, or racial groups. It is designed to be inclusive, neutral, and fair, applying equally to all staff, contractors, and service users regardless of background. By promoting accessible communication, safe working practices, and equal opportunities, the policy supports understanding and cooperation across diverse groups.

Where possible, ensuring that materials reflect diverse communities and that any consultation or training engages a representative range of people can further strengthen good relations. Overall, the policy is expected to maintain or enhance positive relationships across these groups.

Screening Questions 4

4. Are there opportunities to better promote good relations between people of different religious belief, political opinion or racial group?

Religious Belief: Yes. Opportunities exist to better promote good relations by ensuring that communications, guidance, and training reflect and respect the diversity of religious beliefs, political opinions, and racial backgrounds. This could include:

Using inclusive language and imagery in materials.

Consulting and engaging with representative groups from different communities when developing or delivering training and guidance.

Highlighting examples that show collaboration and understanding across diverse groups.

Ensuring that all staff and service users feel respected, included, and heard, which can strengthen trust and cooperation.

These measures can help foster positive interactions and mutual understanding across all community backgrounds.

Political Opinion: Yes. Opportunities exist to better promote good relations by ensuring that communications, guidance, and training reflect and respect the diversity of religious beliefs, political opinions, and racial backgrounds. This could include:

Using inclusive language and imagery in materials.

Consulting and engaging with representative groups from different communities when developing or delivering training and guidance.

Highlighting examples that show collaboration and understanding across diverse groups.

Ensuring that all staff and service users feel respected, included, and heard, which can strengthen trust and cooperation.

These measures can help foster positive interactions and mutual understanding across all community backgrounds.

Racial Group: Yes. Opportunities exist to better promote good relations by ensuring that communications, guidance, and training reflect and respect the diversity of religious beliefs, political opinions, and racial backgrounds. This could include:

Using inclusive language and imagery in materials.

Consulting and engaging with representative groups from different communities when developing or delivering training and guidance.

Highlighting examples that show collaboration and understanding across diverse groups.

Ensuring that all staff and service users feel respected, included, and heard, which can strengthen trust and cooperation.

These measures can help foster positive interactions and mutual understanding across all community backgrounds.

Additional Considerations.

Yes. Some individuals may belong to more than one Section 75 category, and this intersectionality can create unique needs or vulnerabilities. For example, a disabled minority ethnic person or a young LGBT+ staff member may face additional barriers to accessing information, training, or safe working practices.

The policy/ guidance seeks to minimise these potential impacts by:

Providing accessible information and materials (Easy Read, large print, multilingual, pictorial guides, captions).

Offering flexible training and support, including mentoring or practical demonstrations where needed.

Ensuring inclusive consultation and communication, so all staff and service users, including those with multiple protected characteristics, can fully participate.

These measures help ensure that people with multiple identities have equal opportunities, safety, and access, reducing the risk of exclusion or disadvantage.

Provide details of data on the impact of the function, service, policy, procedure, project, strategy, plan or guidance on people with multiple identities.

Currently, Council data does not capture detailed intersectional information on staff or service users with multiple Section 75 characteristics. However, relevant Section 75 categories that could overlap and create combined impacts include:

Disability and Age – e.g., older staff or service users with long-term health conditions may have additional vulnerabilities, particularly in relation to Legionella risk.

Disability and Gender – e.g., male staff with disabilities may require specific support or adjustments for safe testing.

Sexual Orientation and Age – younger LGBT+ staff or service users may have different communication preferences or engagement needs.

Race/Ethnicity and Disability – minority ethnic staff or service users with disabilities may face combined barriers in accessing information or participating in training.

While specific quantitative data is not available, the policy and associated guidance have been designed to address potential compounded impacts by providing accessible information, inclusive communication, reasonable adjustments, and flexible support, ensuring equality of opportunity for people with multiple protected characteristics.

Disability Considerations.

Is there an opportunity to better promote positive attitudes towards disabled people by altering this function, service, policy, procedure, project, strategy, plan or guidance?

Yes. There is an opportunity to promote positive attitudes towards disabled people by ensuring the policy and associated guidance:

Use inclusive language, imagery, and examples that reflect the contributions and capabilities of disabled staff and service users.

Highlight the importance of reasonable adjustments, accessibility measures, and supportive practices as a standard part of health and safety procedures.

Provide training and awareness sessions that emphasise equality, inclusion, and respect for people with disabilities.

The Estates team where possible are upgrading facilities to meet the needs of disabled people when practicable.

These measures can help challenge stereotypes, increase understanding, and foster a culture of respect and inclusion across the organisation.

Is there an opportunity to encourage participation by disabled people in public life by altering this function, service, policy, procedure, project, strategy, plan or guidance?

Yes.

Please give further information and examples:
Yes. The policy and associated guidance provide an opportunity to encourage participation by disabled people in public life by ensuring that all processes, training, and roles are accessible, inclusive, and supported. Measures could include:

Providing accessible materials (Easy Read, large print, pictorial guides, captioned videos) to enable full understanding.

Offering reasonable adjustments and practical support for disabled staff or service users to undertake roles safely and confidently.

Promoting awareness of inclusive opportunities within the organisation, including participation in training, consultation, or decision-making roles.

Ensuring mentoring, shadowing, or coaching is available to support engagement and confidence.

These steps help disabled people fully participate in organisational activities and access opportunities on an equal basis.

Screening Decision.

Likely Impact: Minor.

If the decision is to subject the policy to an equality impact assessment (i.e. likely impact – Major), please provide details of the reasons for this:
N/A.

If the decision is not to conduct an equality impact assessment (i.e. likely impact = Minor) the Council should consider if the policy should be mitigated or an alternative policy be introduced:

Mitigation measures can be applied to further reduce any potential adverse effects on Section 75 groups.

Ongoing monitoring and review will identify any emerging issues or unintended impacts.

Communications, training, and guidance will be reviewed periodically to ensure they are inclusive, accessible, and responsive to the needs of all staff and service users.

If the decision is not to conduct an equality impact assessment (i.e. likely impact = None), please provide details of the reasons for this:
N/A.

Mitigation.

When the Council concludes that the likely impact is ‘Minor’ and an equality impact assessment is not to be conducted, the Council may consider mitigation to lessen the severity of any equality impact, or the introduction of an alternative policy to better promote equality of opportunity or good relations.

Can the policy/decision be amended or changed or an alternative policy introduced to better promote equality of opportunity and/or good relations?

Yes.

If YES, give the reasons to support your decision, together with the proposed changes/amendments or alternative policy:

Timetabling And Prioritising.

If the policy/decision has been ‘screened in’ for equality impact assessment, then please answer the following questions to determine its priority for timetabling the equality impact assessment.
On a scale of 1 to 3, with 1 being the lowest priority and 3 the highest, assess the policy in terms of its priority for equality impact assessment.

Priority Criterion Rating (1 to 3).
Effect on equality of opportunity and good relations N/A.
Social Need N/A.
Effect on people’s daily lives N/A.
Relevance to the Council’s functions N/A.

Monitoring.

Please outline proposals for future monitoring of the policy/decision:

Regular Review of Workforce Data – Collect and analyse staff data across all Section 75 categories, including any emerging trends in multiple identities, to identify potential barriers or disparities.

Feedback Mechanisms – Establish channels for staff, contractors, and service users to provide comments, concerns, or suggestions about accessibility, inclusion, or safety.

Incident and Risk Tracking – Monitor health and safety incidents, including Legionella-related issues, with attention to the impact on vulnerable groups.

Evaluation of Accessibility Measures – Regularly assess whether training, guidance, and communications are accessible (e.g., Easy Read, large print, pictorial guides, captioned videos, multilingual resources).

Policy Updates – Review the policy annually or in line with new legislation, research findings, or emerging risks, ensuring it continues to meet equality and inclusion obligations.

Reporting and Accountability – Provide periodic reports to senior management and relevant committees on monitoring outcomes, adjustments made, and lessons learned.

Approval And Authorisation

Screened By: Assets Officer, 10.11.2025.

Approved By: Director of Environmental Services, 12.11.2025.