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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}} maintains safe and effective procedures for the storage, handling, and use of oxygen in compliance with Care Inspectorate Wales (CIW) regulations and national health and safety legislation. Oxygen therapy is essential for certain service users, and its storage and use must be carefully managed to prevent risks such as fire hazards, leaks, and improper administration.

This policy ensures:

• Safe storage, handling, and administration of oxygen.
• Compliance with regulatory and legal requirements.
• Risk management to prevent fire hazards and oxygen leaks.
• Proper staff training in the use of oxygen therapy and emergency response.

This policy aligns with:

• The Health and Safety at Work Act 1974, requiring employers to ensure a safe working environment.

• The Dangerous Substances and Explosive Atmospheres Regulations 2002 (DSEAR), as amended, requiring risks arising from dangerous substances, including gases under pressure, and associated fire, explosion and similar safety risks to be assessed, eliminated or reduced so far as is reasonably practicable.
• The Management of Health and Safety at Work Regulations 1999, requiring suitable and sufficient assessment and management of risks to employees and other persons affected by the service’s activities, including risks arising from the storage and use of medical oxygen.

• The Regulatory Reform (Fire Safety) Order 2005, which requires measures to reduce the risk of fire associated with oxygen use.
• The Human Medicines Regulations 2012, as amended, which provide the legal framework for medicinal products, including medicinal oxygen. Medical oxygen must therefore be managed as a medicine as well as being subject to the specific health, safety and fire precautions associated with oxygen.
• The Medical Device Regulations 2002, which cover the use and maintenance of oxygen equipment.
• The Regulation and Inspection of Social Care (Wales) Act 2016 and the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, including requirements relating to safe care and support, suitable premises and equipment, health and safety, medicines management, staff competence and record keeping.
• Care Inspectorate Wales (CIW) guidance, ensuring the safe handling of medical gases​.

2. Scope

This policy applies to:

• All employees, including care staff, nurses, and maintenance personnel.
• Service users who require oxygen therapy, ensuring their safety and dignity.
• Visitors and contractors, ensuring they follow oxygen safety protocols.
• Suppliers and external medical professionals, ensuring compliance with safe oxygen delivery and maintenance.

The policy covers:

• Oxygen storage requirements.
• Safe administration and handling procedures.
• Emergency procedures in case of oxygen leaks or fire.
• Staff training and competency requirements.

3. Safe Storage of Oxygen

3.1. General Storage Guidelines

To minimise risks, all oxygen cylinders and equipment must be stored:

• In a designated oxygen storage area, which is well-ventilated and free from ignition sources.
• Upright and secured, preventing cylinders from falling or being knocked over.
• Away from combustible materials, such as paper, fabric, or cleaning products.
• In a dry, cool location, away from direct sunlight and heat sources.
• With clear warning signs, indicating the presence of oxygen and fire risks.

A monthly safety inspection of the oxygen storage area is conducted to ensure compliance.

3.2. Storage of Oxygen Cylinders in Service User Rooms

If service users require oxygen cylinders in their rooms, we ensure:

• Cylinders are placed on a stable stand or trolley to prevent tipping.
• Rooms are well-ventilated to prevent oxygen build-up.
• Smoking and open flames are strictly prohibited in the vicinity.
• Staff regularly check oxygen levels and replace cylinders when necessary.

Staff must not move or adjust oxygen cylinders without appropriate training.

3.3. Oxygen Risk Assessment

• A suitable and sufficient documented risk assessment must be completed before oxygen is stored or used within the care home or introduced into a service user’s bedroom or other routinely occupied area.
• The assessment must consider the individual receiving oxygen, other service users, staff, visitors and any other person who may be affected.
• The assessment must consider, as applicable:
  • the type and quantity of oxygen supplied;
  • the location and security of cylinders, concentrators and associated equipment;
  • ventilation and the potential for oxygen enrichment;
  • ignition sources and combustible materials;
  • smoking, vaping and naked flames;
  • the use of emollients, oils, grease or other materials which may increase fire risk;
  • safe movement and handling of cylinders;
  • electrical equipment and electrical safety;
  • the individual’s ability to understand and follow oxygen safety precautions;
  • risks associated with visitors or other occupants;
  • emergency arrangements, including fire and evacuation arrangements; and
  • the safe location of oxygen during evacuation.
• The risk assessment must be reviewed whenever circumstances change, following an oxygen-related incident or near miss, where there is reason to believe the assessment is no longer valid, and as part of the service’s normal review arrangements. Identified control measures must be implemented without delay according to the level of risk.

4. Safe Handling and Administration of Oxygen

4.1. Staff Responsibilities

• Only trained and authorised staff are permitted to handle and administer oxygen.
• Staff must always check prescription details before administering oxygen therapy.

• Medical oxygen must only be administered in accordance with a current prescription or other lawful clinical direction applicable to the individual. Staff must not independently commence oxygen, alter the prescribed flow rate, change the prescribed delivery method or discontinue prescribed oxygen unless authorised to do so by an appropriately qualified healthcare professional or where emergency clinical arrangements lawfully provide otherwise.
• The individual’s current oxygen requirements must be clearly reflected in their personal plan and associated clinical records. Staff must check these records before providing oxygen support.
• Oxygen equipment must be inspected before each use to ensure it is functioning correctly.

4.2. Personal Plan and Individual Risk Assessment

Where a service user receives oxygen therapy, the service user’s provider assessment, personal plan and relevant risk assessments must contain sufficient information to enable staff to provide that support safely. As applicable, this must include:

• the reason oxygen is required;
• the prescribed flow rate or other prescribed dosage instructions;
• the prescribed delivery device;
• when oxygen is to be used, including whether it is continuous, intermittent or prescribed for specified circumstances;
• any monitoring specified by the prescribing or treating healthcare professional;
• actions staff must take if the service user’s condition deteriorates or the oxygen equipment fails;
• relevant individual fire and safety risks and the control measures required;
• the location of the oxygen equipment and any backup supply; and
• the healthcare professional or service to be contacted where clarification or clinical advice is required.

The personal plan and associated risk assessments must be reviewed and revised when the service user’s oxygen requirements change, following a significant change in their health or circumstances, following an oxygen-related incident, or following new instructions from the prescribing or treating healthcare professional.

4.3. Safe Administration Procedures

When administering oxygen therapy:

1. Verify the prescription – Ensure the correct flow rate and delivery method are used.
2. Check the equipment – Inspect for leaks, damage, or incorrect fittings.
3. Ensure proper positioning – Masks or nasal cannulas must be applied securely and comfortably.
4. Monitor service users – Regularly check for shortness of breath, dizziness, or irritation.
5. Record administration – Each administration of medical oxygen must be recorded in the service user’s medication administration record or other medicines record approved by the service, as applicable. The record must include the date and time of administration, the prescribed flow rate or dosage, the delivery method where relevant, and the identity of the staff member administering or supporting administration. Relevant observations, monitoring and the service user’s response must also be recorded in the appropriate care or clinical record.

If a service user experiences discomfort or adverse reactions, staff must seek medical advice immediately.

4.4. Medicines Management of Medical Oxygen

Medical oxygen must be managed within the service’s medicines-management system. The service must have arrangements to ensure:

• a sufficient prescribed supply is available to meet the individual’s assessed needs;
• oxygen is ordered and re-ordered through the appropriate authorised supplier or healthcare service;
• receipt and supply are recorded appropriately;
• oxygen is stored and handled safely;
• administration is recorded accurately;
• empty, expired, damaged or no longer required cylinders are returned to the authorised supplier or otherwise dealt with in accordance with authorised arrangements; and
• oxygen medicines-management arrangements are included within the service’s medicines audits.

This section must be read alongside CHW45 – Assisting Service Users with Medication Policy and any other applicable medicines-management procedure.

4.5. Use of Oxygen Concentrators

Oxygen concentrators are used for long-term oxygen therapy and must:

• Be placed at least 3 feet away from walls and furniture to allow proper ventilation.
• Be connected to an uninterrupted power source, with backup arrangements in case of power failure.
• Have filters cleaned and maintained regularly by trained staff.

5. Fire Safety Precautions and Emergency Response

5.1. Fire Safety Measures

Oxygen-enriched environments can increase the risk of fire. To prevent this:

• Smoking is strictly prohibited in all areas where oxygen is stored or used.
• All electrical equipment near oxygen must be properly maintained to prevent sparks.
• Oxygen storage areas must have fire-resistant signage and accessible fire extinguishers.
• The fire risk assessment must specifically consider the storage and use of oxygen and the increased consequences of fire in an oxygen-enriched environment. The assessment must be kept under review and reviewed regularly, including whenever there is reason to suspect that it is no longer valid and whenever there is a significant change affecting oxygen storage, oxygen use, the premises, equipment or the individuals receiving the service. Any scheduled annual review does not replace the requirement for an earlier review when circumstances change.

Relevant staff must receive instruction on oxygen-related fire risks and the home’s emergency arrangements. Oxygen supplies may only be isolated during an emergency where this forms part of the service’s approved fire and emergency procedure and it is safe to do so. Staff must not delay evacuation or place themselves or others at risk in order to isolate oxygen equipment.

5.2. Emergency Procedures for Oxygen Leaks

If an oxygen leak is detected:

1. Turn off the oxygen supply, if safe to do so.
2. Evacuate the area and ensure good ventilation.
3. Remove any ignition sources from the affected area.
4. Inform the Fire Safety Lead: {{org_field_the_fire_safety_lead_name}}.
5. Call emergency services if necessary.

If a fire occurs, staff must follow the Fire Safety and Evacuation Procedures policy.

6. Staff Training and Competency

6.1. Mandatory Oxygen Safety Training

All staff whose duties involve the storage, handling, administration, monitoring or emergency management of oxygen must receive training appropriate to their role before undertaking those duties. Training must include, as applicable:

• the nature and fire risks of oxygen;
• safe storage and handling of cylinders and concentrators;
• the safe use of the oxygen equipment used within the service;
• medicines-management requirements relating to medical oxygen;
• checking and following the individual’s prescription or lawful clinical direction and personal plan;
• safe administration within the limits of the staff member’s role and competence;
• recognising equipment faults, leaks and other hazards;
• individual and environmental fire precautions;
• actions to take in the event of equipment failure, oxygen leakage, fire or other emergency; and
• the limits of the staff member’s role and when clinical advice or emergency assistance must be obtained.

Training must be refreshed at appropriate intervals and when there are changes to equipment, procedures, legislation, guidance or an individual’s needs. Where the service specifies annual refresher training, this must be completed in addition to any earlier training required following such changes.

6.2. Competency Assessments

• Staff administering oxygen must complete a competency assessment before independently managing oxygen therapy.
• Supervisors regularly observe and review staff competency in handling and storing oxygen.

• Competence must be demonstrated for the specific oxygen equipment and duties the member of staff is expected to undertake before they work without appropriate supervision. Where equipment, procedures or the individual’s oxygen requirements change, competence must be reassessed where necessary before the staff member undertakes the changed activity independently.
• A written record of oxygen-related training and competency assessment must be maintained.

7. Monitoring and Compliance

7.1. Leadership and Accountability

• The Registered Manager oversees compliance with oxygen safety regulations.
• The Fire Safety Lead: {{org_field_the_fire_safety_lead_name}} ensures fire risks are assessed and mitigated.
• The Health and Safety Team conducts regular audits and inspections of oxygen storage and use.

7.2. Audits and Inspections

• Audits of oxygen arrangements must include safe storage and handling and, where medical oxygen is administered by or with the support of staff, the medicines-management arrangements for supply, administration, recording and disposal. Oxygen must be included within the service’s regular medicines-management audit arrangements. Any identified shortfall must be acted upon according to the level of risk.
• Incident reports are reviewed to identify areas for improvement.
• CIW inspections ensure compliance with legal and regulatory requirements.

7.3. Incident Reporting and Regulatory Notification

Any oxygen-related accident, equipment failure, leak, fire, near miss, administration error or other safety incident must be reported immediately in accordance with the service’s incident-reporting procedure and recorded appropriately. The Registered Manager must ensure that the individual’s safety and clinical needs are addressed without delay and that relevant risk assessments and personal plans are reviewed following the incident.

The Registered Manager and Responsible Individual must ensure that any oxygen-related incident which meets a statutory notification threshold is notified without delay to Care Inspectorate Wales and/or any other relevant authority in accordance with the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

8. Related Policies

This policy works alongside:

• 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
• CHW20 – Fire Safety and Evacuation Procedures

9. Policy Review

This policy is reviewed annually, or sooner if required due to regulatory updates, CIW guidance, or safety concerns.

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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}}
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