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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Safe Use of Emollients and Fire Risk Management Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} manages the safe use of emollients and takes appropriate measures to identify, assess and reduce the associated fire risks. Emollients are widely used for the treatment and management of dry and other skin conditions. Although emollients themselves are not necessarily flammable, residue can transfer from the skin onto clothing, bedding, dressings and other fabrics and can build up over time. Fabrics contaminated with emollient residue may ignite more readily and burn more rapidly and intensely when exposed to an ignition source.

{{org_field_name}} will ensure that risks associated with emollient use are identified and reduced so far as reasonably practicable and that medicines are managed safely, in accordance with the Regulation and Inspection of Social Care (Wales) Act 2016, the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, in particular Regulations 57 and 58, and relevant statutory guidance issued by the Welsh Ministers.

Fire safety arrangements will be managed in accordance with the Regulatory Reform (Fire Safety) Order 2005, as amended, including relevant amendments made by the Building Safety Act 2022, and any other fire-safety legislation applicable to the premises.

The service will have regard to current medicines safety information and national guidance, including advice issued by the Medicines and Healthcare products Regulatory Agency (MHRA), when assessing and managing fire risks associated with emollient products.

2. Scope

This policy applies to all staff members, including care workers, nurses, cleaning and laundry staff, and external healthcare professionals involved in administering, storing, and managing emollients within {{org_field_name}}. It also applies to residents and their families, ensuring that all individuals understand the fire risks associated with emollient use and how to mitigate them effectively.

3. Principles of Safe Emollient Use and Fire Risk Management

Safe Application of Emollients

• Emollients must be used and applied in accordance with the individual’s prescription, medication directions, personal plan and/or instructions provided by an appropriate healthcare professional.
• Staff must not reduce the prescribed amount or frequency of application, discontinue an emollient or substitute one emollient for another solely because of fire risk without appropriate clinical advice.
• Staff must recognise that a fire risk may arise from all types of emollients, including creams, ointments, lotions, gels, sprays and soap substitutes. The risk applies to products containing paraffin and to paraffin-free products.
• No emollient must be regarded as being free from fire risk solely because it is described as water-based, contains a low concentration of paraffin or is paraffin-free.
• Staff must understand that the principal fire hazard arises when emollient residue transfers onto clothing, bedding, dressings or other fabrics. Residue can accumulate within the fabric and cause it to ignite more readily and burn more rapidly and intensely when exposed to an ignition source.
• Individuals receiving emollient treatment must continue to receive the treatment as directed. Fire risk must be managed through appropriate risk assessment, control of ignition sources, laundering arrangements, information, supervision where required and other proportionate risk-reduction measures rather than through unauthorised alteration of treatment.
• Where an emollient is administered or supported by staff as a medicine, administration must be recorded in accordance with the service’s Medication Management and Administration Policy and the individual’s medication administration arrangements.
• Any concerns about the suitability, quantity, frequency or method of application of an emollient must be referred to an appropriate healthcare professional, such as the individual’s GP, pharmacist, nurse or other prescriber.

Storage and Handling of Emollients

• Emollients should be clearly labelled and stored safely, away from naked flames, heat sources, or potential ignition points.
• Care staff should check expiry dates and product integrity to ensure safe usage.
• Emollient containers must be kept sealed when not in use to prevent accidental spills and contamination.
• Staff must document all emollient applications in residents’ medication records, ensuring accurate tracking and monitoring.

Fire Risk Management and Mitigation Strategies

• The fire risk associated with emollient use must be considered as part of the individual’s risk assessment where an individual uses an emollient and there is a reasonably foreseeable risk of contact with an ignition source.
• The assessment must be proportionate to the individual circumstances and must consider, where relevant:
  • the type, quantity and frequency of emollient use;
  • the area of the body to which the emollient is applied;
  • the likelihood of emollient residue accumulating on clothing, bedding, dressings, upholstery or other fabrics;
  • whether the individual smokes or has access to cigarettes, smoking materials, matches or lighters;
  • access to candles, open fires, gas fires or other naked flames;
  • proximity to electric bar, gas, halogen or other high-temperature heaters;
  • cooking activities and exposure to naked flames or hot surfaces;
  • the individual’s cognition, capacity, mobility, dexterity, behaviour and ability to recognise and respond to fire risk;
  • the level of supervision or assistance required;
  • previous fire-related incidents, near misses or unsafe behaviours; and
  • any additional measures required to reduce the identified risk.
• Individuals who use emollients, and their representatives where appropriate, must be informed that clothing, bedding, dressings and other fabrics contaminated with emollient residue can ignite more readily and burn more rapidly and intensely.
• Individuals must be advised not to smoke or go near naked flames or other ignition sources while wearing clothing or dressings that have been in contact with emollients or emollient-treated skin.
• Where an individual cannot independently follow this safety advice, proportionate controls must be identified within the person’s risk assessment and personal plan. These may include appropriate supervision, management of ignition sources and advice from relevant healthcare or fire-safety professionals.
• Emollient-contaminated clothing, bedding and other washable fabrics must be laundered regularly in accordance with the manufacturer’s care instructions and the service’s laundry procedures.
• Staff and individuals must understand that laundering may reduce the build-up of emollient residue but does not completely remove the fire risk. Fire-safety precautions must therefore continue to be followed after clothing, bedding or other fabrics have been washed.
• Emollient-related fire risks and the control measures required must be reflected, where relevant, in the individual’s personal plan and Personal Emergency Evacuation Plan (PEEP).
• Where an individual presents a significant or complex emollient-related fire risk, the service must seek appropriate specialist advice, which may include advice from the relevant Fire and Rescue Service and healthcare professionals.
• Risk assessments and associated control measures must be reviewed following a relevant incident or near miss, where the individual’s circumstances or emollient treatment change, or where there is reason to believe that the existing assessment is no longer valid or sufficient.

Staff Training and Awareness

• Staff whose roles involve the care or support of individuals using emollients must receive appropriate information, instruction and training concerning the safe use of emollients and associated fire risks.
• Training must ensure that staff understand that the fire risk applies to all types of emollients, including paraffin-containing and paraffin-free products, because residue can transfer to clothing, bedding, dressings and other fabrics.
• Staff must understand that contaminated fabrics may ignite more readily and burn more rapidly and intensely when exposed to a naked flame, cigarette, heater or other ignition source.
• Staff must understand that laundering can reduce emollient residue but does not necessarily remove it completely and therefore does not eliminate the need for other fire-safety precautions.
• Training must include:
  • recognising individuals and situations where the risk may be increased;
  • safe administration and application in accordance with prescribed or professional instructions;
  • identification and control of potential ignition sources;
  • appropriate laundering arrangements;
  • the importance of individual risk assessment and Personal Emergency Evacuation Plans where applicable;
  • actions to take where circumstances or risks change;
  • incident and near-miss reporting; and
  • the service’s fire emergency and evacuation procedures.
• Housekeeping and laundry staff must receive information and instruction appropriate to their role concerning the handling and laundering of fabrics contaminated or potentially contaminated with emollient residue.
• Staff competence and understanding must be monitored and refreshed where required, including following changes to relevant legislation, national safety guidance, service procedures or identified learning from incidents.

Emergency Response Procedures

• In the event of a fire or suspected fire, staff must immediately follow the service’s Fire Safety and Emergency Evacuation Policy, the premises fire emergency plan and the individual’s Personal Emergency Evacuation Plan (PEEP), where applicable.
• The fire alarm must be raised and the emergency services contacted in accordance with the service’s established emergency procedures.
• The immediate priority must be the protection and evacuation of individuals from danger in accordance with the fire emergency plan. Staff must not place themselves or other individuals at unnecessary risk by attempting to fight a fire.
• Any attempt to extinguish a fire must only be undertaken where it is safe to do so, is consistent with the service’s fire procedures and the member of staff has received appropriate instruction or training.
• Where a person’s clothing catches fire, staff must follow their emergency fire-safety training and take immediate action appropriate to the circumstances to stop the person moving or running, extinguish the flames where this can be done safely and summon emergency assistance.
• Following a burn injury, appropriate first aid must be provided immediately in accordance with current first-aid guidance and emergency medical assistance must be obtained where required.
• Staff must inform responding emergency services, where known or suspected, that emollient-contaminated clothing, bedding, dressings or other materials may be involved.
• Every fire involving or suspected of involving an emollient must be recorded in accordance with the service’s incident-recording arrangements and statutory record-keeping requirements.
• Following any fire or relevant near miss involving an emollient, the service must review the individual’s risk assessment, personal plan and PEEP, where applicable, together with the relevant fire risk controls and organisational procedures. Required improvements must be implemented without unnecessary delay.
• The manager must ensure that any notification to Care Inspectorate Wales, the Fire and Rescue Service, Health and Safety Executive, local authority, safeguarding authority or any other relevant body is made where the circumstances meet the applicable statutory notification or reporting requirements.

4. Related Policies

• 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
• CHW27 – Fire Safety and Emergency Evacuation Policy
• CHW21 – Medication Management and Administration Policy

5. Monitoring and Review

This policy will be reviewed at least annually and sooner where required because of changes to legislation, statutory guidance, national medicines safety guidance, Care Inspectorate Wales requirements, identified fire risks, incidents, near misses or changes in the needs of individuals using the service.

The service provider and manager will ensure that compliance with this policy is monitored through appropriate governance, risk-management and audit arrangements.

Monitoring will include, where applicable:

• review of individual emollient-related fire risk assessments and associated control measures;
• review of relevant Personal Emergency Evacuation Plans;
• review of medicines administration and recording arrangements;
• review of staff training and competency;
• monitoring of laundry arrangements and other relevant risk-control measures;
• review of fires, fire-related incidents and near misses involving or potentially involving emollients;
• consideration of relevant safety alerts or guidance issued by the Medicines and Healthcare products Regulatory Agency, Welsh Government, Care Inspectorate Wales, the Fire and Rescue Service or other relevant statutory bodies; and
• confirmation that actions identified through assessments, audits, incidents or external advice have been completed according to the level of risk.

The Responsible Person for fire safety must ensure that the premises fire risk assessment and fire-safety arrangements are recorded and maintained in accordance with the Regulatory Reform (Fire Safety) Order 2005, as amended.

The service must maintain the records required under the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, including applicable records of fires, fire practices and drills and tests of fire equipment.

Where monitoring, audit, an incident, a near miss or external professional advice identifies an increased or uncontrolled risk, appropriate action must be taken without unnecessary delay.

Learning arising from incidents, near misses, audits and reviews must be communicated to relevant staff and incorporated into risk assessments, personal plans, training and working practices as appropriate.

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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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