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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Gas Safety and Compliance Policy

1. Purpose

The purpose of this policy is to set out how {{org_field_name}} ensures full compliance with legal, regulatory, and health and safety obligations in relation to gas safety. The safe management, installation, inspection, and maintenance of all gas appliances, fittings, pipework, and flues is essential to safeguard the lives of residents, staff, and visitors within our care home environment. This policy is informed by the Regulation and Inspection of Social Care (Wales) Act 2016, Health and Safety at Work Act 1974, Gas Safety (Installation and Use) Regulations 1998, and current CIW guidance, with the aim of preventing gas-related hazards, including fire, explosion, and carbon monoxide poisoning.

2. Scope

This policy applies to all staff, contractors, and maintenance personnel involved in the management, maintenance, or use of gas appliances and installations within {{org_field_name}}. It encompasses the full lifecycle of gas equipment—from installation and routine servicing to emergency procedures and record-keeping. It applies to all areas of the premises where gas is present or in use, including kitchens, laundry facilities, plant rooms, and any accommodation areas with gas-fired appliances.

3. Related Policies

This policy should be read alongside the following:

• CHW11 – Safe Care and Treatment Policy
• CHW16 – Health and Safety at Work Policy
• CHW17 – Infection Prevention and Control Policy
• CHW18 – Risk Management and Assessment Policy
• CHW19 – Emergency and Business Continuity Plan
• CHW20 – Fire Safety and Evacuation Procedures
• CHW24 – Management of Accidents, Incidents, and Near Misses Policy
• CHW25 – Notification of Other Incidents Policy

4. Policy Statement and Implementation

4.1 Legal Compliance and Responsibility

{{org_field_name}} will ensure that gas systems, appliances, fittings, installation pipework, flues and associated ventilation arrangements are managed in accordance with the Gas Safety (Installation and Use) Regulations 1998, as amended, the Health and Safety at Work etc. Act 1974, the Management of Health and Safety at Work Regulations 1999 and other applicable health and safety legislation.

As a registered care home service in Wales, {{org_field_name}} will also comply with the Regulation and Inspection of Social Care (Wales) Act 2016 and the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended. In particular, the service will ensure that the premises and equipment are properly maintained and, so far as is reasonably practicable, free from hazards to the health and safety of individuals, and that risks to the health and safety of individuals are identified and reduced so far as is reasonably practicable.

Gas work, including installation, alteration, servicing, maintenance, repair and safety checking where it constitutes gas work, will only be undertaken by a person who is competent and appropriately registered with the Gas Safe Register for the category of gas and type of appliance or work concerned.

Responsibility for operational oversight of gas safety arrangements rests with the Registered Manager and the appointed Health and Safety Lead. The Responsible Individual will maintain oversight of the service provider’s compliance with regulatory requirements in accordance with their statutory responsibilities. The Fire Safety Lead, {{org_field_the_fire_safety_lead_name}}, will support the management of any fire or evacuation risks associated with gas installations and appliances.

The Registered Manager will ensure that statutory inspections, safety checks, maintenance, repairs, risk assessments and identified remedial actions are completed within the required timescales and that evidence of compliance is available for regulatory inspection.

4.2 Gas Safety Checks, Inspection, Servicing and Maintenance

{{org_field_name}} will ensure that all gas fittings, appliances, installation pipework and flues for which it has responsibility are maintained in a safe condition.

Gas appliances and flues to which the annual gas safety checking requirements of the Gas Safety (Installation and Use) Regulations 1998 apply will be checked for safety at intervals of no more than 12 months by a suitably qualified Gas Safe registered engineer who is competent and registered for the category of work concerned.

Where permitted by regulation 36A of the Gas Safety (Installation and Use) Regulations 1998, an annual safety check may be completed during the permitted period before the existing deadline while retaining the original annual deadline date.

Gas appliances and associated equipment will also be serviced and maintained in accordance with the manufacturer’s instructions. Where manufacturer’s instructions are unavailable, the frequency of servicing and maintenance will be determined on the advice of a suitably qualified Gas Safe registered engineer and having regard to the equipment, its condition, its use and the associated risks.

Gas appliances or installations used exclusively within non-residential or workplace areas of the care home will be inspected and maintained at a frequency appropriate to the equipment and its use and in accordance with applicable statutory requirements, manufacturer’s instructions and competent engineering advice. Where such appliances also serve residential accommodation, the applicable annual gas safety check requirements will be followed.

A Landlord Gas Safety Record, or equivalent gas safety check record containing all information required by the Gas Safety (Installation and Use) Regulations 1998, will be obtained following each statutory gas safety check.

Where the statutory requirements concerning provision or display of gas safety records apply, {{org_field_name}} will ensure that the current gas safety record is provided to the relevant occupant within the required timescale, provided before a new occupancy begins where applicable, or displayed prominently where the Regulations permit the display of the record as an alternative.

The Registered Manager will ensure that checks are scheduled sufficiently in advance to prevent statutory deadlines being missed.

Any gas appliance, fitting, flue or installation identified as unsafe, or reasonably suspected of being unsafe, must not be used. Any warning notice, isolation, disconnection or other safety measure imposed by a Gas Safe registered engineer must remain in place until the defect has been satisfactorily rectified by a suitably qualified Gas Safe registered engineer and the equipment has been confirmed as safe for use.

4.3 Gas Safety Records and Evidence of Compliance

{{org_field_name}} will maintain accurate, complete and up-to-date records demonstrating the safe management, inspection, servicing, maintenance and repair of all gas systems and equipment for which the service is responsible.

For every statutory gas safety check, the gas safety check record must contain, as a minimum:

• a description and location of each appliance or flue checked;
• the address of the premises at which the appliance or flue is installed;
• the date on which the safety check was completed;
• the name and address of the landlord, service provider or agent, as applicable;
• the name of the individual engineer who carried out the check;
• the engineer’s Gas Safe registration number;
• the engineer’s signature or an acceptable secure electronic equivalent;
• details of any safety-related defect identified;
• details of any remedial action taken; and
• confirmation that the safety check included the examinations required by the Gas Safety (Installation and Use) Regulations 1998.

The Gas Safety Log will additionally contain, where applicable:

• servicing and planned preventive maintenance records;
• reports relating to installation pipework, flues and ventilation systems;
• records of gas leaks, suspected gas leaks and carbon monoxide incidents;
• records of appliance isolation, disconnection and recommissioning;
• records of repairs and remedial works;
• Gas Safe registration and competency verification for engineers undertaking gas work;
• equipment commissioning and installation documentation;
• manufacturers’ operating and maintenance information;
• records showing completion of defects and corrective actions;
• relevant gas safety risk assessments; and
• records of any associated notifications or reports made to statutory or regulatory bodies.

Statutory gas safety check records will be retained for the period required by the Gas Safety (Installation and Use) Regulations 1998. Where the provisions allowing an annual safety check to be carried out before the existing deadline while retaining the original deadline are used, the relevant records will be retained until two further gas safety checks have been completed. Where an appliance or flue has been removed from the premises, the applicable record will be retained for at least two years from the date of the last check.

Records may be maintained electronically or in paper form. Electronic records must be secure against loss or unauthorised alteration, must identify the engineer who carried out the check and must be capable of being reproduced in legible paper form when required.

All gas safety records and evidence of corrective action will be readily retrievable for inspection by Care Inspectorate Wales, the Health and Safety Executive or another authorised body where legally entitled to request them.

4.4 Installation and Use of Gas Appliances

All new gas installations, alterations and replacements will be carried out only by a competent Gas Safe registered engineer who is appropriately registered for the category of work concerned.

Gas appliances must be suitable for their intended purpose and for use within the care home environment. They must be installed, commissioned, operated and maintained in accordance with applicable statutory requirements and manufacturer’s instructions.

Before any newly installed or replacement gas appliance is brought into use, {{org_field_name}} will ensure that all required commissioning and safety checks have been completed and that appropriate documentation has been received and retained.

Staff must not install, alter, disconnect, reconnect, repair, interfere with or attempt to move any gas appliance, fitting, pipework, flue or safety device unless they are legally competent and authorised to undertake the work.

Gas appliances will only be used for their intended purpose and in accordance with manufacturer’s operating instructions.

Any defects, damage, unusual operation, discolouration, soot deposits, pilot-light problems, unexplained extinguishing of flames, unusual smells or other concerns relating to gas equipment must be reported immediately to the Registered Manager or person in charge.

Any appliance suspected of being unsafe must be taken out of use and must not be returned to service until it has been examined and confirmed as safe by a suitably qualified Gas Safe registered engineer.

4.5 Carbon Monoxide Detection and Alarm Systems

Carbon monoxide detectors will be provided in areas where the service’s risk assessment identifies that carbon monoxide detection is required, including areas containing relevant fuel-burning appliances.

Carbon monoxide detectors will be suitable for their intended location and use and will comply with the applicable British Standard or other recognised safety standard.

Detectors will be installed and positioned in accordance with the manufacturer’s instructions and any applicable competent professional guidance.

The designated maintenance officer or other suitably authorised person will test carbon monoxide alarms at the frequency specified by the manufacturer and in accordance with the home’s planned maintenance arrangements.

A record will be maintained of:

• routine alarm tests;
• battery replacement where applicable;
• detector replacement;
• faults;
• maintenance; and
• any alarm activation.

Any carbon monoxide detector that is defective, damaged, beyond its manufacturer’s recommended service life or otherwise unreliable must be replaced without delay.

Where a carbon monoxide alarm activates, staff must treat the activation as a potential emergency and follow the procedure in section 4.7.

4.6 Staff Training and Awareness

Staff will receive gas safety awareness information and training appropriate to their role and responsibilities.

Training and instruction will include, where relevant:

• recognising signs that may indicate a gas escape;
• recognising possible symptoms of carbon monoxide exposure, including headache, dizziness, nausea, breathlessness, confusion, collapse or loss of consciousness;
• recognising signs of unsafe combustion, including soot, staining or unusual flame appearance;
• knowing how to raise the alarm;
• knowing when and how to evacuate the affected area;
• the location of relevant emergency contact information;
• actions that must not be taken where a gas leak is suspected, including operating electrical switches or introducing sources of ignition;
• how to respond to activation of a carbon monoxide alarm;
• reporting defects and concerns;
• incident reporting requirements; and
• their individual responsibilities under this policy.

Staff will not be trained or authorised to undertake gas work unless they hold the legally required competence and Gas Safe registration for the work concerned.

Gas safety awareness will be included within relevant staff induction arrangements and refreshed at intervals determined by the service’s training needs analysis, changes in legislation or guidance, changes to equipment or premises, or following an incident, near miss or identified gap in staff knowledge.

The Registered Manager will ensure that training and competency records are maintained and reviewed.

4.7 Emergency Procedures for Gas Leaks, Carbon Monoxide and Other Gas Incidents

If a gas leak, unsafe gas appliance or carbon monoxide incident is known or suspected, staff must act immediately to protect residents, staff and visitors.

Staff must:

• raise the alarm and move individuals away from the affected area, evacuating the affected area or premises where this is necessary for safety;
• call the National Gas Emergency Service on 0800 111 999 for a suspected natural gas leak and call 999 where there is an immediate danger to life, fire, explosion, collapse or a person requires emergency medical assistance;
• extinguish naked flames where this can be done safely;
• avoid smoking or introducing any other source of ignition;
• not operate electrical switches, plugs, doorbells or other electrical equipment within the affected area where a gas leak is suspected;
• open doors and windows to ventilate the affected area where this can be done safely and without delaying evacuation;
• turn off the gas supply at the emergency control valve where staff have been instructed how to do so and it is safe to approach and operate it;
• ensure that any person who may have been exposed to carbon monoxide or who displays symptoms consistent with carbon monoxide exposure receives urgent medical assessment;
• immediately notify the Registered Manager or the senior person in charge;
• notify the Fire Safety Lead where fire or evacuation arrangements are affected;
• prevent re-entry to an evacuated area until the emergency service, gas transporter or suitably qualified Gas Safe registered engineer confirms that it is safe;
• prevent the use of any appliance or installation that has been classified as unsafe until the defect has been rectified and the appliance or installation has been confirmed as safe by a suitably qualified Gas Safe registered engineer; and
• make a complete record of the incident, actions taken, advice received and any remedial work required.

Following a gas-related incident, the Registered Manager and Responsible Individual must determine without delay whether a statutory notification is required.

Where the event falls within a notification category under the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, including where the event prevents or could prevent the continued safe delivery of the service, results in a notifiable serious accident, injury, illness or death, or otherwise meets a statutory notification threshold, the appropriate notification must be submitted to Care Inspectorate Wales through CIW Online without delay and in accordance with the applicable regulatory requirements.

The Registered Manager must also ensure that any report required under other applicable health and safety legislation, including the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 where applicable, is made to the relevant enforcing authority.

All gas incidents and near misses will be reviewed to establish their cause, whether existing risk-control measures were adequate and whether changes to risk assessments, maintenance arrangements, emergency procedures, staff training or the Business Continuity Plan are required.

The emergency arrangements will be reflected in CHW19 – Emergency and Business Continuity Plan and CHW24 – Management of Accidents, Incidents and Near Misses Policy.

4.8 Risk Assessment and Environmental Monitoring

Gas safety will form part of the service’s overall health and safety risk-management arrangements.

{{org_field_name}} will ensure that risks associated with gas appliances, gas installations, pipework, flues, ventilation, gas cylinders where applicable, combustion products and carbon monoxide are identified, assessed and controlled so far as is reasonably practicable.

Gas safety risk assessments will take account of:

• the type, location and condition of gas appliances and installations;
• the needs, mobility and vulnerability of individuals using the service;
• the potential consequences of loss of heating, hot water or cooking facilities;
• access to gas appliances and controls;
• risks associated with plant rooms, kitchens, laundries and other service areas;
• ventilation requirements;
• flue arrangements;
• the location and protection of pipework;
• carbon monoxide risks;
• storage and use of gas cylinders where applicable;
• emergency isolation arrangements;
• maintenance and inspection findings;
• previous defects, incidents or near misses; and
• any proposed structural alteration, refurbishment, change of use or installation of new equipment.

Identified control measures and remedial actions will be prioritised according to risk and completed within appropriate timescales.

Where an immediate or serious risk is identified, the affected appliance, installation or area will be taken out of use or otherwise made safe without delay.

Gas safety risks will be reassessed where:

• there is a significant change to the premises;
• new gas appliances or equipment are installed;
• existing installations are altered;
• there is a change in the needs of individuals using the service that affects the risk;
• a gas incident or near miss occurs;
• defects or deterioration are identified; or
• there is reason to believe that an existing risk assessment is no longer valid.

Findings from gas safety assessments, inspections, maintenance and incidents will inform the service’s wider health and safety, fire safety and business-continuity arrangements.

4.9 Contractor and Gas Engineer Compliance

All gas work undertaken on behalf of {{org_field_name}} must be carried out by a competent Gas Safe registered engineer who is appropriately registered for the category of gas, appliance and type of work being undertaken.

Before gas work begins, the person responsible for authorising the work must:

• verify the identity of the engineer carrying out the work;
• verify the engineer’s current Gas Safe registration;
• confirm that the engineer’s Gas Safe registration includes the categories of work required for the appliance or installation concerned;
• retain appropriate evidence that these checks have been completed;
• ensure that the contractor has been informed of relevant site risks, emergency arrangements, safeguarding requirements and areas to which access is restricted; and
• ensure that the planned work does not expose individuals, staff or visitors to avoidable risk.

Where work may affect residents, consideration must be given to the impact on:

• heating;
• hot water;
• catering facilities;
• ventilation;
• fire precautions;
• access and evacuation routes; and
• the continued safe delivery of the care home service.

Appropriate temporary risk-control and business-continuity arrangements must be implemented where required.

Contractors working within the care home must comply with the service’s applicable health and safety, safeguarding, infection prevention and control, visitor, security and emergency procedures.

Following completion of gas work, {{org_field_name}} will obtain the documentation appropriate to the work undertaken, which may include:

• servicing records;
• gas safety records;
• commissioning documentation;
• warning notices;
• defect reports;
• repair documentation; and
• evidence that identified remedial actions have been completed.

Where an engineer identifies an appliance or installation as unsafe, any warning notice, isolation, disconnection or other safety measure must be respected.

No member of staff, contractor or other person acting on behalf of the service may reconnect, reactivate or knowingly use equipment that has been isolated or classified as unsafe unless the defect has been properly remedied and the equipment has been confirmed as safe by an appropriately qualified Gas Safe registered engineer.

The Registered Manager or delegated Health and Safety Lead will ensure that outstanding gas safety defects and remedial actions are monitored through to completion and that evidence of completion is retained.

A contractor compliance record or checklist will be maintained for gas-related work to demonstrate that appropriate pre-work checks, safety arrangements and post-work documentation have been completed.

5. Policy Review

This policy will be reviewed at least annually, or sooner where there is a change in legislation, CIW guidance, or following a gas-related incident or near miss. The review will be carried out by the Health and Safety Lead in consultation with the Registered Manager and updated copies will be made available to all staff and relevant stakeholders.

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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.