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Registration Number: {{org_field_registration_no}}

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Oxygen Storage, Use, and Safety Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} safely supports individuals who have been prescribed oxygen therapy, and safely stores, handles and manages oxygen equipment within the service, in line with regulatory, medicines governance and health & safety requirements. Oxygen therapy is essential for individuals with respiratory conditions, but it presents fire and health risks if not handled correctly. This policy outlines safe storage, handling, and risk management practices to protect service users, staff, and visitors.

This policy supports compliance with the following (as amended from time to time):

• Regulation and Inspection of Social Care (Wales) Act 2016 and associated requirements for regulated services.
• Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 (as amended) and the Welsh Ministers’ Statutory Guidance for Care Home and Domiciliary Support Service Providers and Responsible Individuals (last updated 27 March 2024) – providers and responsible individuals must have regard to this guidance.
• Health and Safety at Work etc. Act 1974 and the Management of Health and Safety at Work Regulations 1999 (risk assessment and safe systems of work).
• COSHH Regulations 2002 (oxygen presents a hazardous oxidising/enrichment risk and must be risk assessed and controlled).
• RIDDOR 2013 (reporting certain workplace incidents/dangerous occurrences).
• Regulatory Reform (Fire Safety) Order 2005 (as amended/clarified, including by the Fire Safety Act 2021) where it applies to any non-domestic premises/work activities.
• Manual Handling Operations Regulations 1992 (safe moving/handling of cylinders).
• Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2009 where staff transport oxygen cylinders for work purposes.
• CIW notification and record keeping requirements under the 2017 Regulations, including Schedule 2 (records) and Schedule 3 (notifications).

2. Scope

This policy applies to:

• All employees, including care workers, managers, and healthcare staff handling oxygen.
• Service users receiving oxygen therapy at home.
• Visitors, family members, and external healthcare professionals involved in the care of service users using oxygen.

It covers:

• Assessment and prescription of oxygen.
• Safe storage and handling of oxygen cylinders.
• Fire safety and risk management.
• Staff training and emergency procedures.

2.1 Roles and accountability (Regulated Service Governance)

• The Registered Manager is responsible for day-to-day implementation of this policy, staff competency, incident management and ensuring risk assessments are completed, reviewed and acted upon.
• The Responsible Individual is accountable for ensuring suitable arrangements are in place for up-to-date policies, recording incidents and notifiable matters, and effective oversight of quality and safety. (This includes ensuring systems exist to record incidents/complaints/notifiable matters and to keep policies up to date.)

3. Prescription and Assessment for Oxygen Use

3.1 Who Can Prescribe Oxygen?

• Oxygen must only be prescribed by a qualified healthcare professional (GP, respiratory specialist, or consultant).
• Care staff must not administer oxygen unless explicitly trained and authorised.

• Care staff must never change prescribed oxygen flow rates, device settings, or mask/cannula type.
• Where care staff support oxygen use, this must be in accordance with the prescription, the individual’s personal plan, and documented competency for any delegated healthcare task.

3.2 Oxygen Needs Assessment

Before oxygen support begins (and at review), a documented risk assessment must consider:

• Fire/ignition risks (smoking, vaping/e-cigarettes, candles, gas cooking, open fires, heaters, charging batteries/e-scooters/e-bikes near oxygen).
• Whether the individual smokes/vapes or allows others to do so; and the escalation pathway to the prescriber/oxygen supplier/fire service where risk is high. (Home oxygen + smoking significantly increases risk of severe burns/fatal fire.)
• Presence/working order of smoke alarms and whether a Fire & Rescue home safety check has been offered.
• Use of flammable products (aerosols, paint thinner/solvents, and oil-based emollients such as petroleum-based creams) and safer alternatives.
• Location of oxygen equipment and cylinder storage suitability (ventilation, stability, trip hazards from tubing).
• Mobility/transfer risks (tubing trip risk, falls risk), cognition, ability to follow safety advice, and supervision needs.
• Electrical safety (distance from appliances/heat sources), and safe charging locations away from oxygen equipment.
• Emergency plan: how oxygen will be turned off, evacuation support, and who to contact.

4. Safe Storage and Handling of Oxygen Cylinders

4.1 Oxygen Storage Requirements

• Cylinders must be stored upright and secured to prevent falling.
• Keep oxygen equipment at least 3 metres away from any appliance with an open flame (e.g., gas cooker/fire), and at least 1.5 metres away from electrical devices/heat sources (e.g., TV, hair dryer, radiators/heaters).
• Ensure adequate ventilation in the storage area.
• Service users and staff must never store oxygen in confined spaces (e.g., cupboards, under beds).

• When oxygen is not in use (where clinically appropriate), ensure equipment is turned off and cylinder valves are closed in line with the supplier’s instructions.
• Keep oxygen equipment away from oils/grease; do not use petroleum-based creams near oxygen equipment due to increased fire risk.

4.2 Handling and Transportation

• Staff should avoid manual handling of heavy cylinders unless trained.
• Use oxygen cylinder trolleys or holders to move equipment safely.
• Do not drop, roll, or drag oxygen cylinders.
• Where staff transport oxygen cylinders for work purposes, cylinders must be transported upright and secured to prevent movement, with valves closed and protective fittings in place where applicable. Cylinders should be carried in a well-ventilated area (preferably not the passenger compartment), must be kept away from heat/direct sunlight, and smoking/vaping is prohibited in or near the vehicle at all times. Oxygen equipment must not be used while refuelling.

5. Fire Safety and Risk Management

5.1 Fire Prevention Measures

• Strict no-smoking policy in areas where oxygen is stored or used.
• Keep oxygen away from open flames, stoves, and electrical devices that could cause sparks.
• Display “Oxygen in Use” warning signs in homes where service users receive oxygen therapy.

Where oxygen is used in the home, staff must reinforce that oxygen is not flammable but greatly increases how fast materials burn. Staff must advise that nobody smokes or vapes in the home when oxygen is present, and that oil-based products/aerosols must not be used near oxygen equipment. Staff should also encourage the individual/family to inform their local Fire & Rescue Service that oxygen is in use at the address (or confirm the supplier has done so) and to ensure working smoke alarms are in place.

5.2 Fire Risk Assessments

• A fire risk assessment must be completed before a service user starts oxygen therapy.
• The Registered Manager must ensure compliance with fire safety standards.
• The Fire Safety Lead: {{org_field_the_fire_safety_lead_name}} ({{org_field_the_fire_safety_lead_role}}) oversees fire risk management.

5.3 Emergency Procedures in Case of Fire

• Turn off the oxygen supply immediately if safe to do so.
• Evacuate the service user and others from the area.
• Call 999 and inform the fire service that oxygen is present.
• Do not attempt to move oxygen cylinders during a fire.

6. Staff Training and Competency Requirements

6.1 Training for Oxygen Handling

All staff handling oxygen must receive mandatory training on:

• Safe storage and transportation of oxygen.
• Recognising and managing fire hazards.
• Emergency response procedures for oxygen leaks or fires.
• Proper use of PPE when handling oxygen.

6.2 Competency Assessments

• Staff must complete a practical assessment before handling oxygen independently.
• Annual refresher training ensures staff remain competent.

7. Emergency Procedures for Oxygen Leaks

7.1 Identifying an Oxygen Leak

• Hissing sounds, unusual smells, or difficulty turning off the valve may indicate a leak.
• A leak can increase the risk of fire, so immediate action is required.

7.2 Steps to Take in Case of a Leak

1. Turn off the oxygen cylinder if safe to do so.
2. Ensure proper ventilation (open windows and doors).
3. Do not use electrical switches, matches, or flames.
4. Move away from the area and notify the supplier immediately.
5. Report the incident to the Registered Manager.
6. If the leak cannot be stopped safely, or there is immediate danger (e.g., strong oxygen enrichment, fire/ignition risk), evacuate the area and call 999, stating that oxygen cylinders/oxygen equipment are present.

8. Maintenance and Equipment Checks

• Oxygen cylinders and equipment must be inspected regularly for damage or leaks.
• Any faulty equipment must be reported to the supplier and replaced immediately.
• Service users must be trained in basic maintenance and safety procedures.

9. Incident reporting, CIW notifications and record keeping

9.1 Immediate internal reporting

Staff must report any oxygen-related incident or near miss to the Registered Manager without delay, including (but not limited to): burns, smoke/fire, equipment failure, suspected oxygen enrichment, unsafe smoking/vaping behaviour, or emergency service attendance.

9.2 CIW notifications (Regulation 60 / Schedule 3)

The service must notify CIW (via CIW Online) without delay and in writing where a notifiable event occurs. This includes:

• Serious accident or injury to an individual (including oxygen-related burns or injuries requiring healthcare professional treatment).
• Any incident reported to the police.
• Any event that prevents, or could prevent, the provider from continuing to provide the service safely, including significant safety system failures and incidents affecting safe provision.
  CIW’s published process requires providers to submit notifications using CIW Online and allows Responsible Individuals to delegate online assistants for notifications.

9.3 Duty of candour (Responsible Individual)

Where something goes wrong, the Responsible Individual must ensure the service acts in an open and transparent way with the individual and/or their representatives, and keeps appropriate records of actions taken.

9.4 Required records

Oxygen-related incidents must be recorded in line with the regulated service record keeping requirements, including keeping a record of serious accidents/injuries and relevant safety events as required.

9.5 Learning and review

Oxygen incidents and near misses must be included in quality and safety monitoring and used to improve training, risk assessment controls and practice.

10. Monitoring and Compliance

The Registered Manager and Responsible Individual must ensure systems are in place to record, review and learn from oxygen-related incidents/near misses (including fire risks, smoking non-compliance, equipment failures and injuries). Trends and patterns must be analysed and used to improve risk assessments, staff training and the safety of care delivery.

Arrangements must also ensure the service’s policies and procedures remain up to date and accessible to staff, with understanding checked through induction, supervision and performance review.

11. Related Policies

This policy should be read in conjunction with:

• Fire Safety and Evacuation Procedures Policy (DCW20).
• Health and Safety at Work Policy (DCW16).
• Infection Prevention and Control Policy (DCW17).
• Risk Management and Assessment Policy (DCW18).
• Emergency and Business Continuity Plan (DCW19).

12. Policy Review

This policy will be reviewed at least annually and sooner if required by:

• changes to relevant legislation
• updates to Welsh Government statutory guidance (currently last updated 27 March 2024)
• learning from incidents, audits or CIW inspection findings

The Responsible Individual must ensure suitable arrangements are in place to keep policies and procedures up to date.

Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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