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Registration Number: {{org_field_registration_no}}

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Oxygen Storage, Use, and Safety Policy

1. Purpose

This policy sets out the arrangements for the safe prescribing, receipt, storage, handling, administration, monitoring and return of medical oxygen within {{org_field_name}}. Medical oxygen is a medicine and must be managed safely and administered only in accordance with the individual person’s current prescription or other lawful written direction from an appropriately authorised prescriber.

The purpose of this policy is to ensure that people receiving oxygen therapy are protected from avoidable harm and that risks associated with oxygen, including incorrect administration, interruption of prescribed therapy, fire, oxygen enrichment, cylinder damage and unsafe storage or handling, are identified, assessed and controlled.

{{org_field_name}} will manage oxygen in accordance with applicable legal and regulatory requirements, including:

• the Health and Social Care Act 2008;
• the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including Regulation 11: Need for consent, Regulation 12: Safe care and treatment, Regulation 15: Premises and equipment, Regulation 17: Good governance and Regulation 18: Staffing;
• the Health and Safety at Work etc. Act 1974;
• the Management of Health and Safety at Work Regulations 1999;
• the Dangerous Substances and Explosive Atmospheres Regulations 2002, where applicable;
• the Regulatory Reform (Fire Safety) Order 2005, as amended; and
• current guidance issued by the Care Quality Commission, Health and Safety Executive, medicines regulators, the oxygen supplier and other relevant national bodies.

The policy is intended to ensure that oxygen therapy is person-centred, clinically authorised, properly recorded and delivered only by staff who have been assessed as competent to undertake the task.

2. Scope

This policy applies to:

• All staff involved in the storage, handling, or administration of oxygen.
• Healthcare professionals and care staff responsible for supporting people using oxygen therapy.
• Maintenance staff managing oxygen storage facilities.
• Visitors and external contractors present in areas where oxygen is used or stored.

3. Related Policies

This policy should be read alongside:

• CH11 – Safe Care and Treatment Policy
• CH16 – Health and Safety at Work Policy
• CH17 – Infection Prevention and Control Policy
• CH20 – Fire Safety and Evacuation Procedures
• CH42 – Communication and Engagement with Service Users and Families Policy

4. Safe Storage of Oxygen

Medical oxygen must be stored safely and in accordance with the oxygen supplier’s instructions, the manufacturer’s instructions where applicable, the home’s fire risk assessment and any individual oxygen risk assessment.

The following requirements apply:

• Secure and ventilated storage: Oxygen cylinders that are not in immediate use must be stored in a clean, dry, secure and adequately ventilated location designated as suitable for medical gas cylinders.
• Protection from combustible and flammable materials: Oxygen cylinders must be kept away from combustible materials, flammable liquids, flammable gases and other sources of fuel or ignition. Separation arrangements must reflect the fire risk assessment, supplier instructions and applicable fire-safety guidance rather than relying on a fixed generic distance.
• Separation from flammable gas cylinders: Oxygen cylinders must be appropriately separated from cylinders containing flammable gases.
• Protection against heat and ignition: Cylinders and oxygen equipment must not be stored next to naked flames, smoking materials, heaters or other inappropriate sources of heat or ignition. Storage must comply with the temperature limits specified by the supplier or manufacturer.
• Cylinder security: Cylinders must be secured by suitable restraints or stored in an appropriate rack or other purpose-designed storage arrangement so that they cannot fall, roll or be damaged.
• Quantity: Only quantities reasonably required for the needs of people using the service and for appropriate contingency arrangements should be stored.
• Full, empty and defective cylinders: Full cylinders and cylinders awaiting collection or return must be clearly identifiable and managed in accordance with the supplier’s instructions. Empty cylinders must be treated with the same safety precautions as full cylinders. Damaged, leaking or suspect cylinders must be isolated only where it is safe to do so and dealt with in accordance with the supplier’s emergency instructions.
• Signage: Appropriate warning signs must be displayed where oxygen is stored or used, as identified through the fire risk assessment and supplier guidance. These must include prohibition of smoking and naked flames where required.
• Access: Oxygen storage areas must be protected from unauthorised access while remaining accessible to authorised staff and, where necessary, emergency responders.
• Housekeeping: The oxygen storage area must not be used for the storage of combustible materials, oils, grease or unrelated equipment that could increase fire risk.
• Checks: The condition and security of the storage arrangements and cylinders must be checked at appropriate intervals. Any leak, damage, contamination, missing restraint, inappropriate storage or other safety concern must be acted upon promptly.

The location and quantity of oxygen stored within the home must be considered within the home’s current fire risk assessment and emergency arrangements.

5. Safe Handling and Use of Oxygen

Medical oxygen is a medicine. It must only be administered to a person where there is a current prescription or other lawful written direction from an appropriately authorised prescriber and where staff have access to sufficient information to administer the oxygen safely.

5.1 Individual Assessment, Prescription and Care Plan

Before staff administer or assist with oxygen therapy, the person’s records must clearly identify:

• the person’s identity;
• the reason for the oxygen therapy, where this information has been provided by the responsible clinician;
• the prescribed oxygen delivery method;
• the prescribed flow rate or other prescribed setting;
• the prescribed frequency and duration of treatment, including whether oxygen is continuous or to be used at specified times or in specified circumstances;
• any clinically specified target oxygen saturation range or monitoring requirements, where applicable;
• the equipment to be used;
• relevant precautions and known risks;
• what staff must monitor;
• what staff must do if the person’s condition deteriorates, prescribed oxygen cannot be administered, oxygen equipment fails or the available oxygen supply is insufficient; and
• contact and escalation arrangements for the relevant healthcare professional or emergency services.

The person’s oxygen requirements must be incorporated into their care plan and must be reviewed when their needs, prescription, equipment or circumstances change.

An individual risk assessment must be completed where oxygen therapy creates risks that require specific controls. The assessment must consider the person’s needs and abilities, the environment in which oxygen is used, fire and smoking risks, safe positioning of equipment, tubing hazards, storage arrangements and any other reasonably foreseeable risk.

5.2 Consent and Mental Capacity

Oxygen therapy must be provided with the consent of the relevant person in accordance with Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Where a person aged 16 or over lacks capacity to make the relevant decision, staff must act in accordance with the Mental Capacity Act 2005, including its principles and best-interests requirements, and must record the relevant decision-making process.

A person’s refusal of oxygen must not be ignored. Staff must follow the person’s care plan, assess the immediate risk, seek appropriate clinical advice and escalate urgently where the person’s condition presents a medical emergency.

5.3 Administration of Oxygen

Staff administering or assisting with oxygen must:

• confirm the identity of the person before administration;
• check the current prescription or lawful written direction and the person’s care plan;
• use the correct oxygen delivery equipment;
• set the oxygen at the prescribed flow rate or setting;
• administer it for the prescribed period or in accordance with the prescribed instructions;
• check that tubing, masks, nasal cannulae, regulators, concentrators and other relevant equipment appear safe, correctly connected and suitable for use;
• ensure that tubing is positioned so far as reasonably practicable to minimise avoidable trip, entanglement or obstruction risks;
• monitor the person in accordance with their care plan and clinical instructions;
• record administration promptly and accurately in the appropriate medicines administration record and/or care record; and
• report and escalate any concern about the person’s response to therapy, equipment, oxygen supply or prescribed instructions.

Staff must not independently increase, decrease, stop or otherwise alter a prescribed oxygen flow rate, concentration, duration or treatment regime unless they are themselves appropriately authorised to make that clinical decision. Any change made by an authorised prescriber or other appropriately authorised healthcare professional must be documented promptly and the person’s care plan and administration records updated.

5.4 Safe Handling of Cylinders and Equipment

Oxygen cylinders must be handled carefully and protected from impact or damage.

Where cylinders need to be moved, staff must use an appropriate purpose-designed trolley or other handling method specified by the supplier and must not drag, roll or otherwise handle cylinders in a manner that could damage them.

Cylinder valves must be operated in accordance with the manufacturer’s or supplier’s instructions. Valves must be opened carefully and oxygen equipment must not be forced, modified or used with incompatible fittings.

Only equipment intended and approved for use with medical oxygen must be connected to the oxygen supply.

5.5 Oils, Grease, Smoking and Sources of Ignition

Oxygen does not itself burn, but it supports combustion and can cause materials to ignite more easily and burn more intensely.

Staff, people using the service and visitors must comply with the home’s oxygen fire-safety precautions.

Oils, grease and other incompatible substances must never be applied to oxygen cylinders, valves, regulators, connections or other oxygen equipment.

Smoking, vaping, naked flames and other prohibited ignition sources must not be permitted in an oxygen-use or oxygen-storage area where this would create a fire risk.

Any emollient, cream or other product used by a person receiving oxygen must be considered as part of their individual care and fire-risk arrangements where it may increase combustibility or otherwise affect oxygen safety.

5.6 Self-Administration

Where a person wishes to manage or administer their own oxygen, their ability to do so safely must be assessed and recorded.

The assessment must consider the person’s understanding of their prescribed treatment, ability to operate the equipment safely, ability to recognise problems and seek assistance, storage arrangements and risks to themselves or others.

The arrangements must be reviewed when the person’s needs, abilities, prescription, equipment or circumstances change.

6. Fire Safety and Emergency Procedures

Oxygen supports combustion and can cause combustible materials to ignite more readily and burn more intensely. The presence, storage and use of medical oxygen must therefore be specifically considered within the home’s fire-safety arrangements.

6.1 Fire Risk Assessment

The Responsible Person must ensure that the home’s fire risk assessment is suitable and sufficient, recorded and kept under review in accordance with the Regulatory Reform (Fire Safety) Order 2005, as amended.

Where oxygen is stored or used, the fire risk assessment must consider the additional risks created by oxygen, including:

• the location in which oxygen is stored and used;
• the quantity and type of oxygen equipment present;
• oxygen enrichment arising from a leak or inappropriate use;
• combustible materials;
• smoking, vaping, naked flames and other ignition sources;
• the mobility and evacuation needs of people receiving oxygen;
• emergency isolation or management of oxygen equipment where this can be undertaken safely;
• the information required by staff and emergency responders; and
• appropriate fire-detection, warning, evacuation and fire-fighting arrangements.

The assessment must be reviewed when there is reason to suspect it is no longer valid or where there has been a significant change affecting fire risk, including significant changes to oxygen use, storage arrangements or a person’s evacuation requirements.

6.2 Smoking and Ignition Sources

Smoking, vaping, naked flames and any other ignition source identified as unsafe by the fire risk assessment must be prohibited in relevant oxygen storage and use areas.

Appropriate warning signage must be displayed.

6.3 Emergency and Evacuation Arrangements

The home’s emergency arrangements must take account of people receiving oxygen therapy.

Where a person requires oxygen during an evacuation or would be placed at clinical risk if oxygen therapy were interrupted, this must be addressed within the person’s care planning and emergency evacuation arrangements, with appropriate clinical and fire-safety advice obtained where necessary.

Staff must know:

• how to raise the alarm;
• how to summon the emergency services;
• the home’s evacuation procedure;
• how people who use oxygen will be supported during an emergency;
• the location of oxygen cylinders, concentrators and storage areas relevant to their duties; and
• what action they may safely take in relation to oxygen equipment without placing themselves or others at additional risk.

Staff must not place themselves at risk by attempting to retrieve, isolate or move oxygen cylinders during a fire unless this forms part of an assessed safe procedure and it is safe to do so.

6.4 Suspected Oxygen Leak or Equipment Failure

Where an oxygen leak is suspected, staff must:

• keep people away from the immediate hazard where necessary;
• eliminate ignition sources where this can be done safely;
• follow the oxygen supplier’s emergency instructions;
• increase ventilation where appropriate and where this can be done safely;
• not use equipment that is suspected to be defective;
• arrange urgent replacement or technical assistance as required; and
• contact the emergency services where the leak creates an immediate danger or cannot be safely controlled.

Any leak, equipment failure or associated incident must be reported and recorded in accordance with the home’s incident-reporting procedures.

6.5 Fire-Fighting Equipment

The type, number and location of fire extinguishers and other fire-fighting equipment must be determined through the home’s fire risk assessment and maintained in accordance with applicable fire-safety requirements.

Oxygen must not be described as having a specific type of “oxygen fire extinguisher”. Staff must use fire-fighting equipment only where they have been instructed or trained to do so and where doing so does not expose them to unacceptable risk.

6.6 Fire Drills and Training

Fire drills, fire-safety instruction and training must be undertaken at a frequency appropriate to the home’s fire risk assessment, emergency plan, staff roles and the needs of people using the service.

Where oxygen is used or stored, relevant staff must understand the additional fire hazards associated with oxygen and the precautions and emergency arrangements that apply.

7. Maintenance and Equipment Checks

Oxygen equipment must be suitable for its intended purpose, safe to use, maintained in accordance with the manufacturer’s and supplier’s requirements and available in sufficient quantity to meet the assessed needs of people using the service.

7.1 Pre-Use Checks

Before oxygen equipment is used, relevant staff must carry out appropriate checks within the limits of their role and training.

These checks must include, where relevant:

• the general condition of the cylinder or concentrator;
• the regulator, flow meter and connections;
• tubing, masks and nasal cannulae;
• evidence of damage, contamination or leakage;
• availability of sufficient oxygen for the intended treatment;
• correct connection and set-up of the equipment; and
• any warning indicator, alarm or fault shown by the equipment.

Equipment that appears damaged, defective, contaminated or otherwise unsafe must not be used and must be reported promptly.

7.2 Maintenance and Servicing

Oxygen concentrators, regulators and other reusable oxygen equipment must be maintained and serviced at the intervals and in the manner required by the manufacturer, supplier or other competent responsible body.

Staff must not undertake repairs, modifications or maintenance beyond the duties for which they have been trained and authorised.

Records of servicing, maintenance, identified defects and corrective action must be retained where the home is responsible for those records.

7.3 Cylinders Requiring Return

Empty, expired, damaged, defective or unwanted cylinders must be identified, kept safely pending collection and returned or otherwise dealt with in accordance with the oxygen supplier’s instructions.

Staff must not dispose of medical oxygen cylinders through normal, clinical or household waste streams.

Empty cylinders must continue to be handled and stored with appropriate safety precautions because they may contain residual pressurised oxygen.

7.4 Continuity and Contingency Arrangements

{{org_field_name}} must have arrangements to ensure that a person’s prescribed oxygen therapy can be maintained in accordance with their assessed clinical needs.

Where interruption of oxygen therapy would present a foreseeable risk to the person, an appropriate contingency plan must be documented. Depending on the person’s prescription, equipment and clinical needs, this may include a suitable backup supply, alternative equipment, urgent supplier arrangements and/or instructions for seeking clinical or emergency assistance.

The amount and type of backup oxygen must be determined by the person’s needs, the prescriber’s or oxygen service’s instructions and the reliability and response arrangements of the oxygen supply system. A generic reserve quantity must not be substituted for an individual assessment.

8. Training and Staff Competency

Only staff who have received appropriate training and have been assessed as competent for the oxygen-related tasks they are expected to perform may undertake those tasks without appropriate supervision.

The level and content of training must reflect the staff member’s role and responsibilities.

Where relevant to the person’s duties, training must include:

• the purpose and basic principles of prescribed oxygen therapy;
• recognition that medical oxygen is a medicine;
• the requirement to follow the person’s prescription or other lawful written direction and care plan;
• checking the correct person, equipment, prescribed flow rate or setting, timing and duration;
• recording administration;
• actions to take where oxygen is refused, omitted or unavailable;
• safe cylinder storage and handling;
• safe operation of oxygen equipment relevant to the staff member’s role;
• use of cylinder trolleys or other approved handling arrangements;
• oxygen fire hazards and prevention of oxygen enrichment;
• smoking, vaping, naked-flame and ignition-source precautions;
• safe management of tubing and other equipment;
• recognition of damaged, leaking or defective equipment;
• emergency procedures and escalation;
• incident and medicines-error reporting; and
• the limits of the staff member’s role and when clinical or technical advice must be sought.

Staff who administer or assist with oxygen must demonstrate competence before undertaking the task independently.

Competence must be reviewed at appropriate intervals and whenever there is reason to believe that additional training, supervision or reassessment is required, including following:

• a change in equipment or procedures;
• a change in the staff member’s duties;
• an oxygen-related incident, error or near miss;
• an identified gap in knowledge or practice; or
• a significant period during which the staff member has not undertaken the task.

Refresher training must be provided at intervals necessary to maintain safe practice and competence.

Records of required training, competency assessment, refresher training and any remedial action must be maintained.

Staff must not administer oxygen where they do not have the necessary competence for the task and must seek assistance from an appropriately competent person.

9. Responsibilities

9.1 Responsibilities of the Registered Manager

The Registered Manager must ensure that:

• this policy is implemented and kept consistent with current legal, regulatory and nationally recognised guidance;
• people receiving oxygen have appropriate individual care planning and risk assessment;
• oxygen is administered only in accordance with a current prescription or other lawful written direction;
• appropriate arrangements exist for obtaining, receiving, storing, administering, recording and returning medical oxygen;
• fire-risk assessments and emergency arrangements take account of oxygen stored or used within the home;
• sufficient oxygen and equipment are available to meet people’s assessed needs and appropriate contingency arrangements are established where interruption of oxygen would place a person at risk;
• staff undertaking oxygen-related duties receive appropriate training, supervision and competency assessment;
• staff do not undertake duties beyond their competence;
• oxygen equipment is appropriately maintained and defects are acted upon;
• relevant prescription, care, medicines-administration, risk-assessment, training, maintenance and incident records are accurate and appropriately retained;
• oxygen-related incidents, medicines errors, near misses and equipment failures are reviewed and appropriate action is taken to reduce the risk of recurrence; and
• relevant external reporting, notification and duty of candour requirements are followed where the circumstances meet the applicable thresholds.

9.2 Responsibilities of Care Staff

Care staff must:

• follow the person’s current oxygen prescription or other lawful written direction, care plan and risk assessment;
• obtain appropriate consent and follow applicable Mental Capacity Act requirements;
• administer or assist with oxygen only when trained and competent to do so;
• check the person’s identity, oxygen equipment and prescribed setting before administration;
• not alter the prescribed oxygen regime unless appropriately authorised to make that clinical decision;
• record oxygen administration accurately and promptly;
• monitor and respond to the person in accordance with the care plan and clinical instructions;
• follow oxygen-storage, handling and fire-safety procedures;
• immediately report concerns about oxygen supply, cylinders, equipment, prescriptions, records or a person’s condition; and
• report oxygen-related incidents, errors and near misses in accordance with the home’s procedures.

9.3 Responsibilities of Maintenance and Fire-Safety Personnel

Staff or contractors with responsibilities for premises, equipment or fire safety must, within the limits of their role:

• ensure that oxygen-storage arrangements are included within relevant premises and fire-safety assessments;
• ensure appropriate signage and physical storage controls are maintained;
• ensure that maintenance for which the home is responsible is completed by competent persons;
• ensure identified defects and hazards are promptly escalated and addressed;
• ensure emergency and evacuation arrangements appropriately take account of oxygen; and
• maintain relevant servicing, maintenance and fire-safety records.

The involvement of contractors, oxygen suppliers or external healthcare professionals does not remove the registered provider’s responsibility to ensure that care and treatment delivered by the service meets applicable CQC requirements.

10. Legal and Regulatory Compliance

This policy supports compliance with the following legal and regulatory requirements relevant to the safe management and administration of medical oxygen.

10.1 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

Regulation 11 – Need for consent

Care and treatment, including oxygen therapy, must only be provided with appropriate consent. Where a person aged 16 or over lacks capacity to consent, the requirements of the Mental Capacity Act 2005 must be followed.

Regulation 12 – Safe care and treatment

{{org_field_name}} must ensure that oxygen therapy is provided safely. This includes:

• assessing risks to people’s health and safety;
• doing all that is reasonably practicable to mitigate identified risks;
• ensuring staff have the qualifications, competence, skills and experience necessary to provide care safely;
• ensuring premises and oxygen equipment are safe and used safely;
• ensuring sufficient quantities of medicines and equipment are available where these are supplied by the provider;
• ensuring the proper and safe management of medicines; and
• working appropriately with other healthcare professionals and providers where responsibility for care is shared or transferred.

Regulation 15 – Premises and equipment

Premises and equipment used by the service must be appropriately maintained, secure, suitable for their purpose and used properly. Oxygen storage and equipment arrangements must therefore form part of the home’s systems for maintaining safe premises and equipment.

Regulation 17 – Good governance

{{org_field_name}} must operate effective systems to assess, monitor and mitigate risks and to maintain accurate, complete and contemporaneous records concerning people’s care and treatment and the management of the regulated activity.

For oxygen therapy this includes, as applicable, prescriptions or lawful written directions, care plans, risk assessments, medicines-administration records, incident records, training and competency records and relevant maintenance and servicing records.

Regulation 18 – Staffing

Staff must receive the training, support, supervision and development necessary to enable them to perform their duties. Staff undertaking oxygen-related tasks must therefore be appropriately trained and competent for those tasks.

10.2 Health and Safety Requirements

{{org_field_name}} must comply with its duties under the Health and Safety at Work etc. Act 1974 and the Management of Health and Safety at Work Regulations 1999, including the assessment and control of reasonably foreseeable risks to employees and other people who may be affected by the home’s activities.

The Dangerous Substances and Explosive Atmospheres Regulations 2002 must be applied where they are relevant to risks arising from dangerous substances, including applicable risks associated with gases under pressure.

10.3 Fire Safety

The Regulatory Reform (Fire Safety) Order 2005, as amended, applies to the home’s fire-safety arrangements.

The Responsible Person must ensure that a suitable and sufficient fire risk assessment is completed, recorded and kept under review and that appropriate preventative and protective measures, emergency arrangements, information, instruction and training are provided.

The storage and use of medical oxygen must be specifically considered where it affects the home’s fire risks or evacuation arrangements.

10.4 Medicines Management

Medical oxygen must be managed as a medicine.

{{org_field_name}} must have arrangements to ensure that oxygen is:

• prescribed or otherwise lawfully authorised for the individual;
• available in sufficient quantity to meet the person’s assessed needs;
• stored safely;
• administered correctly by competent staff;
• recorded accurately;
• monitored in accordance with the person’s care plan and clinical instructions; and
• returned to or otherwise managed through the appropriate supplier arrangements when no longer required.

Relevant current CQC guidance and nationally recognised medicines guidance, including NICE guidance on managing medicines in care homes, must be taken into account when the home’s procedures are reviewed.

10.5 Monitoring Compliance

Compliance with this policy will be monitored through appropriate governance and quality-assurance arrangements. These must include review, as relevant, of:

• individual oxygen prescriptions and care plans;
• oxygen risk assessments;
• medicines-administration records;
• oxygen storage and cylinder checks;
• fire-risk controls;
• equipment servicing and maintenance;
• staff training and competency records;
• incidents, errors and near misses; and
• actions identified through audits or safety reviews.

Any identified shortfall must be assessed, acted upon and followed through to completion.

11. Policy Review

This policy will be reviewed annually or sooner if legislation changes or business needs evolve. Updates will be communicated to all staff, and additional training will be provided if necessary.

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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}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.