Login

SL85-Oxygen Storage and Safety Policy

{{org_field_logo}}

{{org_field_name}}

Registration Number: {{org_field_registration_no}}

Oxygen Storage and Safety Policy

1. Purpose

The purpose of this policy is to ensure the safe prescribing, planning, storage, handling, use and monitoring of medical oxygen within services provided by {{org_field_name}}. The policy is intended to minimise foreseeable risks to people we support, staff, visitors, contractors and others who may be affected by oxygen use.

Medical oxygen is a medicinal gas and must be treated as a medicine. Oxygen is not itself flammable; however, it is an oxidising gas that supports combustion. An oxygen-enriched atmosphere can cause materials to ignite more readily and burn more rapidly and intensely. Oil, grease, petroleum-based products, smoking materials, naked flames, sparks and other ignition sources can therefore create a serious fire or explosion risk when oxygen is present.

This policy ensures that people we support receive safe and appropriate oxygen therapy when needed, without compromising the safety of the living environment.

This policy does not authorise staff to commence oxygen, alter a prescribed oxygen flow rate, use one person’s oxygen for another person, refill equipment, repair equipment or improvise connections. Oxygen must only be used in accordance with a valid prescription or other lawful clinical direction and the instructions supplied with the equipment.

2. Scope

This policy applies to:

This policy covers:

This policy does not permit staff to provide emergency oxygen from general stock unless {{org_field_name}} has separately established a lawful and clinically governed emergency-oxygen arrangement, including suitable equipment, prescribing or medicines authority, training, competency assessment, maintenance and emergency protocols.

3. Legal and regulatory framework

This policy has been prepared with reference to the following legislation, regulations and guidance, as applicable:

COSHH assessments may be required for substances used in association with oxygen care, including cleaning agents. The principal risk from oxygen as an oxidising gas must, however, be assessed and controlled under applicable general health and safety, fire-safety and dangerous-substances requirements.

BS EN ISO 7396-1 should only be referenced where the service operates or controls a fixed medical-gas pipeline system. It is not normally applicable to ordinary portable cylinders or home oxygen concentrators in supported living.

4. Responsibilities

Registered Manager

The Registered Manager must:

Nominated Oxygen Lead

Where one or more people regularly use oxygen, the Registered Manager should nominate a competent person to coordinate oxygen-safety arrangements. The nominated person must:

Staff Members

Staff must:

People We Support

People who use oxygen will be:

Where a person chooses not to follow safety advice, staff must not use coercion. Staff must assess the immediate risk, discuss the concern with the person, record the decision, notify the manager and seek advice from the prescriber, respiratory team, oxygen supplier or other relevant professional. Any decision involving a person who may lack capacity must be managed in accordance with the Mental Capacity Act 2005.

Prescriber, Oxygen Supplier and Landlord

The service must establish and record:

Delegating work or relying on an external supplier does not remove the provider’s responsibility to take reasonable steps to ensure that care is delivered safely. CQC states that providers remain responsible when arrangements are delegated to third parties and should make every effort to ensure that person-owned equipment is safe and suitable.

5. Assessment before oxygen support begins

Before staff support a person with oxygen, the Registered Manager or delegated competent person must confirm and document:

The assessment must be completed in partnership with the person and, where appropriate, their representative, prescriber, respiratory team, oxygen supplier, landlord and relevant fire-safety professionals.

6. Safe Storage of Oxygen

Oxygen equipment must be stored in accordance with the person’s individual risk assessment, the oxygen supplier’s instructions, the manufacturer’s instructions and the applicable fire-risk assessment. Storage arrangements must be proportionate to the type and quantity of equipment and must respect that supported living accommodation is ordinarily the person’s own home.

7. Handling and Use of Oxygen

8. Medicines management and recording

Medical oxygen must be managed as a medicine. The person’s records must clearly state whether staff are administering oxygen, assisting the person to use it, prompting independent use or providing general safety support.

The care plan and medicines records must include, where applicable:

Each episode of staff administration or assistance must be recorded on the medicines administration record or other approved oxygen record. The record must include the date, time, flow rate, duration, relevant observations, outcome and staff signature or electronic identifier.

Refusal, omission, equipment failure, interruption of supply, use outside the expected plan or inability to obtain an oxygen-saturation reading must be documented and escalated in accordance with the care plan.

Oxygen prescriptions and care plans must be reviewed following hospital discharge, a change in health, a change in equipment, a change in smoking behaviour, an incident, a new prescription or a change in flow rate.

9. Fire Safety Precautions

10. Smoking, vaping and high-risk behaviour

Smoking or vaping in the presence of oxygen creates a serious risk of fatal fire. Where smoking or vaping is known or suspected:

Where the person has capacity and continues to make a high-risk choice, the discussion, advice, professional input and agreed risk-management plan must be recorded. Where capacity is in doubt, a decision-specific capacity assessment and, where necessary, best-interests process must be completed.

11. Transportation and travel

Oxygen should normally be transported only where this is necessary for the person’s prescribed use and in accordance with the oxygen supplier’s transport instructions.

Before a journey, staff must:

Oxygen equipment must not be transported loose in a vehicle, placed where luggage can damage it or left in direct sunlight.

Staff must not assume that an “Oxygen in Use” vehicle sign is always legally required. Any signage, documentation, quantity limits or dangerous-goods requirements must be determined from the oxygen supplier’s instructions, the nature and quantity of oxygen and the applicable transport legislation.

The service must document who is authorised and competent to transport or accompany the person’s oxygen. Commercial transportation or transport of substantial oxygen quantities must not take place without specialist advice.

12. Oxygen Therapy for People We Support

13. Oxygen concentrators and power failure

Where a person uses an electrically powered oxygen concentrator:

Planned power interruptions, maintenance works or relocation must be assessed in advance. The person must not be left without a safe oxygen supply.

14. Incident Reporting and Risk Management

15. Equipment maintenance, servicing and safety alerts

Oxygen cylinders, concentrators, regulators, flow meters and associated equipment must only be serviced, repaired, tested or altered by the authorised supplier or another suitably qualified and authorised organisation.

{{org_field_name}} must:

Staff must not:

16. Training, competency and supervision

Staff must not prompt, assist with, administer, monitor, move or transport oxygen until they have completed role-appropriate training and have been assessed as competent.

Training must cover, as relevant:

Competency must be assessed through observation and practical demonstration using the equipment the staff member will encounter. Completion of an online course alone is not sufficient evidence of practical competence.

Competency must be reassessed:

Agency and temporary staff must receive suitable information and must demonstrate competence before undertaking oxygen-related duties. Staff who are not competent may only take basic emergency action within their general training, such as raising the alarm, calling 999 and supporting evacuation.

17. Consent, capacity and restrictive practice

Oxygen support must be provided with the person’s consent in accordance with Regulation 11.

Where there is reason to doubt the person’s capacity to make a specific decision about oxygen use or a proposed safety measure, a decision-specific capacity assessment must be completed. A general diagnosis, learning disability, mental illness or apparently unwise decision must not be treated as proof of incapacity.

Any best-interests decision must:

Locking oxygen equipment away, restricting access to a person’s room, removing lighters, imposing continuous observation or preventing the person from leaving their home may amount to restrictive practice. Such measures must not be used routinely and require lawful, proportionate and individually assessed justification.

18. Infection prevention and single-person use

Masks, nasal cannulae, tubing and other person-contact components are for single-person use unless the manufacturer expressly states otherwise.

Staff must:

Cleaning agents must be compatible with oxygen equipment and must not introduce flammable residues. Alcohol-based products must be allowed to dry completely and must not be used on equipment unless specifically approved by the manufacturer or supplier.

19. Business continuity and emergency supply

The service must maintain person-specific contingency arrangements for:

The contingency plan must identify:

Staff must not wait until a cylinder is empty or a concentrator has completely failed before escalating a foreseeable supply problem.

20. Supported living tenancy and shared responsibilities

In supported living, the person’s home and care arrangements must remain distinct. The provider must not treat the property as if it were a care home merely because staff attend or provide 24-hour support.

For each person using oxygen, the service must document:

Staff must not make alterations to the property, install signs, drill cylinder brackets into walls, move fixed electrical equipment or change fire doors without the person’s agreement and any required landlord or competent-person authorisation.

Where the provider identifies an accommodation risk outside its direct control, it must record the concern, take reasonable immediate precautions, inform the responsible party and escalate unresolved risks through appropriate contractual, safeguarding, commissioning, environmental health or fire-safety routes.

21. Audit and governance

The Registered Manager must ensure that oxygen safety is audited at a frequency proportionate to the risks and at least annually.

Audits must examine:

Audit findings must identify responsible persons, completion dates and evidence that actions have been completed. Significant findings and trends must be reported through the organisation’s governance arrangements.

22. Related Policies

23. Policy review

This policy will be formally reviewed at least annually and sooner where:

The Registered Manager must ensure that revised requirements are communicated to affected people and staff in an accessible format. Training, competency assessments, care plans, risk assessments and operational procedures must be updated where necessary.

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.

Leave a Reply

Your email address will not be published. Required fields are marked *