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Medical Gases Safe Use in Care Homes Policy

It is {{org_field_name}}’s policy to provide a safe, secure and reliable medical gas service to people who use services and staff. The aim of the policy is to ensure the health, safety and wellbeing of staff and people who use services by maintaining the safe use, handling, storage and maintenance of medical gas systems within {{org_field_name}} premises.

Medical oxygen is the most commonly used medical gas. {{org_field_name}} will ensure that oxygen use will be undertaken and according to CQC guidance, the oxygen care plan for the person will include the normal oxygen saturations, both on air and on their usual oxygen therapy, which will be monitored daily as part of the person’s care.

This policy applies to all persons who have access to, use of or responsibility for the supply of medical gas services in {{org_field_name}}. It applies to the supply, delivery, installation and maintenance of the medical gas service from the point of supply, up to and including any terminal outlets.

The policy is written to be in line with all statutory care and treatment and health and safety requirements for care services to maintain high standards in the safe use of all medical devices, equipment and facilities.


  1. Medical gas therapy or application will only be administered or supplied on prescription.
  2. Medical gas therapy or application should be administered only by suitably qualified and trained care staff and full details recorded in the plan of care and the individual’s notes.
  3. Staff involved in using or handling medical gases must:
    a. be familiar with the medical gases policy
    b. undertake training as required to ensure safe use/handling
    c. report any concerns to their line manager
    d. be aware of the procedures specific to their location which detail safe systems of work.
  4. Records will be kept of all medical gas supplies received, administered and leaving the home.
  5. All staff handling medical gas cylinders will ensure that all health and safety requirements are complied with at all times, including manual handling requirements.
  6. All persons handling or responsible for medical gas cylinders and associated equipment should ensure they are familiar with the operating and safety procedures laid down in the manufacturer’s user manual and only persons who have received instruction or authorisation from the estates manager to handle or change cylinder manifolds will be allowed access into the manifold area.
  7. Staff involved in handling medical gas cylinders should:
    a. wear safety shoes and gloves
    b. only move cylinders with a trolley designed for appropriately sized loads
    c. never roll cylinders along the ground as this may cause the valve to open accidentally and damage the label and paintwork
    d. always handle cylinders with care, never knocking them violently or allowing them to fall over
    e. never paint or obscure any markings or labels on cylinders
    f. where possible, place cylinders near to an exit so that they can be moved quickly in an emergency.
  8. Medical gas cylinders will be stored in a purpose-built, covered location that is:
    a. secured against the treats of unauthorised entry or trespass
    b. not subject to extremes of heat
    c. kept dry, clean and well ventilated at top and bottom
    d. accessible for delivery vehicles and tail lift operation
    e. large enough to allow for segregation of full and empty cylinders and permits separation of different gases within the store
    f. large enough to allow for strict stock rotation of full cylinders so that the oldest are used first
    g. sited away from storage areas containing highly flammable liquids or other combustible materials
    h. sited away from any sources of heat or ignition.
  9. Highly visible warning notices will be posted in and around the medical gases storage area prohibiting smoking and naked lights within the vicinity of the store.
  10. The estates manager will be responsible for maintaining schematic diagrams of the medical gases system, indicating pipe runs, isolating valves and terminal outlets, including a site plan showing sources of supply and distribution.
  11. The estates and facilities manager will be responsible for appointing competent persons to maintenance tasks on the medical gases system, including the appointment of competent specialist contractors.
  12. Before any routine maintenance or other planned work is carried out on the medical gas system, the authorised person must advise the head of care, the estates and facilities manager and the competent person. Notice of planned work should be made well in advance. Where urgent work is required the head of care and the estates and facilities manager will work together to put contingency plans in place.
  13. In the event of a fire, the safety of staff and people who use services is the first priority and staff should follow their building fire evacuation arrangements.
  14. In the event of a medical gas incident or a fire it is the responsibility of the person in charge of any clinical area with medical gas outlets to ensure the system is turned off at the local isolating valve.
  15. All incidents or near-misses involving medical gases should be recorded and reported to the estates manager without delay and appropriate investigatory action taken.


All staff are responsible for the implementation of this policy. Overall responsibility for ensuring the policy is implemented, monitored and reviewed rests with the estates and facilities manager.

An Authorised Person will be made responsible for the maintenance and management of medical gases and the medical gases system.

The Competent Person is the person who carries out work on the system under the guidance and control of the authorised person.

Information on the policy will be:


All new staff should read this policy as part of their induction. Those with specific duties and responsibilities under the policy will be offered additional training.

Nursing or care staff who use medical gases must be trained in the use of the system, and in particular how to isolate the supply locally, and how to implement the emergency procedures.

All authorised and competent persons must have had suitable training and should be sufficiently experienced and familiar with their particular installation. They should also be reassessed every three years.

Staff who carry out bottle changing operations need to be trained in bottle changing and the operation of the manifold so as to be able to carry out the procedure safely and properly.

Staff will be able to monitor and respond to a person’s oxygen saturations in line with their care plan, and record their findings.

Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}

Reviewed on: {{last_update_date}}

Copyright ©2024 {{org_field_name}}. All rights reserved

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