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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 provide clear guidance on the safe use, storage, and management of emollients to minimise fire risks in {{org_field_name}}’s supported living services. Emollients, while essential for skincare and treating conditions such as eczema and psoriasis, can increase fire hazards due to the build-up of residue on clothing, bedding, and upholstery.

This policy ensures that people we support receive safe and effective care, and that staff are aware of the fire risks associated with emollient use while adhering to CQC, Health and Safety Executive (HSE), and Fire Safety Regulations.

2. Scope

This policy applies to:

• All staff who support people with the use, application, storage, recording or disposal of emollients as part of a regulated activity provided by {{org_field_name}}.
• All people we support who use emollients and for whom {{org_field_name}} provides care or support relevant to their use of those products.
• Staff who complete or contribute to individual risk assessments, care plans, medicines records or fire-safety arrangements relating to a person who uses emollients.
• Visitors, relatives, contractors and healthcare professionals where information about an identified emollient-related fire risk needs to be communicated to them in order to protect the person or others from harm.
• Premises, equipment and areas for which {{org_field_name}} has responsibility or control in connection with the regulated activity.

In supported living, a person’s accommodation is normally their own home. Nothing in this policy gives {{org_field_name}} authority or control over a person’s home, possessions or lifestyle beyond that provided by law, the person’s valid consent, the terms of any applicable tenancy or occupancy arrangement, or the responsibilities of {{org_field_name}} in carrying on the regulated activity.

Where the accommodation, building, common parts or fire-safety arrangements are controlled by a landlord, housing provider or another Responsible Person, {{org_field_name}} will identify relevant risks arising from the care and support it provides, communicate those risks to the appropriate person or organisation where necessary, and co-operate with those who hold the relevant fire-safety responsibilities.

3. Legal and Regulatory Compliance

This policy will be implemented in accordance with applicable legislation and regulatory requirements, including:

• Health and Social Care Act 2008.
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as amended, including:
  • Regulation 9 – Person-centred care;
  • Regulation 11 – Need for consent;
  • Regulation 12 – Safe care and treatment;
  • Regulation 15 – Premises and equipment, where applicable;
  • Regulation 17 – Good governance; and
  • Regulation 18 – Staffing.
• Care Quality Commission (Registration) Regulations 2009, as amended, including Regulation 18 – Notification of other incidents.
• Regulatory Reform (Fire Safety) Order 2005, as amended, where it applies to the premises or parts of premises concerned.
• Fire Safety Act 2021, where applicable.
• Fire Safety (England) Regulations 2022, where applicable.
• Health and Safety at Work etc. Act 1974.
• Control of Substances Hazardous to Health Regulations 2002, where applicable.
• Current Care Quality Commission guidance relating to safe care and treatment, medicines management, external medicines and fire risk.
• Current Medicines and Healthcare products Regulatory Agency guidance on the safe use of emollients and associated fire risks.
• Current National Fire Chiefs Council guidance relevant to emollient use and fire safety.

Where legislation or national guidance changes, the most recent applicable legal or regulatory requirement will take precedence over this policy and the policy will be reviewed accordingly.

4. Responsibilities

Registered Manager

The Registered Manager is responsible for ensuring that:

• Staff involved in supporting people who use emollients receive information, instruction and training appropriate to their role concerning emollient fire risks, safe medicines practice and relevant emergency procedures.
• Staff who apply or otherwise support the use of emollients are competent to carry out the tasks expected of them and their competence is reviewed when necessary.
• Individual risks associated with emollient use are assessed, recorded, monitored and reviewed as part of the person’s care planning and risk-management arrangements.
• Risk assessments consider the person’s individual circumstances, including their use of emollients, frequency and extent of application, smoking, cooking, use of candles or naked flames, exposure to heaters or other ignition sources, contamination of clothing, bedding, dressings and soft furnishings, and their ability to understand and act on fire-safety advice.
• Relevant information about emollient-related risks and agreed control measures is clearly recorded in the person’s care plan, risk assessment and medicines documentation where applicable.
• Significant changes in risk, incidents, near misses or concerns are reviewed promptly and appropriate action is taken.
• CQC is notified without delay when an incident meets the statutory notification criteria under the Care Quality Commission (Registration) Regulations 2009. An emollient-related incident must not be treated as automatically notifiable solely because emollient was involved.
• Incidents are also reported to the police, fire and rescue service, safeguarding authority, health and safety enforcing authority or any other external body where reporting is required by law or is necessary because of the circumstances of the incident.
• Where responsibility for the building or fire precautions rests with a landlord, housing provider or other Responsible Person, relevant concerns are communicated promptly and appropriate co-operation takes place.

Staff Members

Staff members are responsible for:

• Following the person’s current care plan, risk assessment, medicines instructions and this policy.
• Supporting emollients to be used in accordance with the prescription, product directions or instructions provided by an appropriate healthcare professional.
• Understanding that all emollients can increase the flammability of fabric when residue accumulates on clothing, bedding, dressings or soft furnishings, including products described as paraffin-free.
• Explaining identified fire risks and agreed precautions to the person in a way that they can understand.
• Respecting the person’s rights, choices and control over their own home while taking reasonable action to identify, communicate and reduce risks arising from the care and support being provided.
• Recording the application of an emollient when staff are responsible for applying it, in accordance with the person’s medicines-management arrangements.
• Reporting changes in the person’s circumstances, increased fire risks, unsafe practices, incidents, near misses or concerns promptly to the appropriate manager.
• Taking appropriate emergency action in accordance with the person’s emergency arrangements and the organisation’s emergency procedures.

People We Support

People who use emollients will:

• Be given clear and accessible information about the fire risk associated with emollient residue on clothing, bedding, dressings and soft furnishings.
• Be supported to understand how smoking, naked flames, cooking, candles, open fires, heaters and other heat or ignition sources may increase the risk.
• Be involved, wherever possible, in decisions about the precautions required to manage their individual risk.
• Be encouraged to tell staff or an appropriate healthcare professional about changes to their emollient use, skin treatment, smoking habits or other circumstances that may affect their level of fire risk.
• Retain the right to make decisions about their care and lifestyle where they have capacity to do so, subject to applicable law and the rights and safety of others.

Where there is reason to doubt a person’s capacity to make a particular relevant decision, staff must follow the Mental Capacity Act 2005 and any associated organisational policy before restrictive measures are considered.

5. Safe Use of Emollients

5.1 Emollient Selection and Risk Assessment

Emollients must be used in accordance with the person’s prescription, healthcare professional’s instructions, product directions and agreed care plan, as applicable.

Staff must not assume that a particular emollient is free from fire risk because it contains little or no paraffin. The fire risk applies to all emollients, including paraffin-free products, because residue transferred to fabric can increase the speed and intensity with which that fabric burns.

Where {{org_field_name}} supports a person with emollient use, an individual risk assessment must be completed where there is a reasonably foreseeable fire risk. The assessment must take account of relevant factors, including:

• the type of emollient and how it is used;
• the quantity used;
• the frequency of application;
• the area of the body to which it is applied;
• the likelihood of residue transferring to clothing, bedding, bandages, dressings, cushions, chairs or other soft furnishings;
• whether the person smokes;
• whether other people smoke in the person’s immediate environment;
• use of candles, lighters, matches, open fires or other naked flames;
• cooking arrangements, particularly the use of gas hobs or other exposed heat sources;
• use of open fires, electric bar heaters, gas heaters, halogen heaters or other significant sources of heat;
• the person’s mobility, dexterity, cognition and ability to recognise and respond to fire;
• the person’s ability to understand and follow fire-safety information;
• previous fire incidents, near misses or evidence of unsafe smoking or cooking practices; and
• any relevant risks identified by a healthcare professional, landlord, Responsible Person, fire and rescue service or other competent person.

The findings and agreed control measures must be clearly recorded in the person’s care plan and risk assessment and must be reviewed following any significant change, incident or increase in risk.

5.2 Application and Safe Use of Emollients

Emollients must be applied in accordance with the prescription, dispensing label, manufacturer’s directions or instructions provided by the relevant healthcare professional. Staff must not independently alter the prescribed or recommended quantity, frequency or method of application for the purpose of reducing fire risk.

Where staff apply an emollient, they must:

• confirm the correct person, product, instructions, application site and frequency before application;
• apply the product in accordance with the person’s medicines and care instructions;
• record administration or application in the appropriate record where this forms part of the person’s medicines support;
• take reasonable steps to prevent unnecessary transfer of the product onto furniture and other fabrics; and
• follow appropriate hand-hygiene requirements after application.

People using emollients must be informed that clothing, bedding, bandages, dressings and soft furnishings that have been in contact with an emollient or emollient-treated skin can catch fire more readily and burn more rapidly.

People must be advised not to smoke, use naked flames or go close to significant heat or ignition sources while wearing clothing or dressings that have been contaminated with emollient residue.

Where a person chooses to continue smoking, cooking or undertaking another activity involving a foreseeable ignition source, an individual risk assessment must be completed and proportionate risk-reduction measures agreed with the person. Where necessary, advice should be sought from an appropriate healthcare professional or the local fire and rescue service.

Clothing and bedding contaminated by emollient residue must be changed and washed regularly. Items must be washed at the highest temperature permitted by the manufacturer’s care label. Staff and people we support must understand that washing, including washing at high temperatures, may reduce emollient residue but does not reliably remove it completely and therefore does not eliminate the fire risk.

5.3 Education and Awareness

People who use emollients must receive information appropriate to their identified level of risk. Information must explain, as applicable:

• that emollient residue can transfer from the skin onto clothing, bedding, dressings and soft furnishings;
• that contaminated fabric can ignite more easily and burn more rapidly and intensely;
• that the risk applies to paraffin-containing and paraffin-free emollients;
• the need to avoid cigarettes, naked flames and significant heat sources where fabric may be contaminated;
• the importance of changing and washing contaminated clothing and bedding regularly;
• that laundering can reduce but does not completely remove the residue or fire risk; and
• the individual precautions identified in the person’s risk assessment.

Information must be provided in a format that the person can understand. Reasonable adjustments must be made where required.

Relevant relatives, carers and others may be provided with appropriate safety information where this is necessary to manage the identified risk and is consistent with the person’s consent, confidentiality requirements and applicable law.

6. Fire Risk Management

6.1 Fire Safety Precautions

Where {{org_field_name}} has responsibility for premises under applicable fire-safety legislation, fire risks associated with emollient use must be considered as part of the relevant fire risk assessment where such use creates a reasonably foreseeable risk.

Where another organisation or person, such as a landlord or housing provider, is responsible for the building’s fire precautions, {{org_field_name}} must communicate any significant emollient-related fire risk that is relevant to those responsibilities and co-operate with the Responsible Person as necessary.

For each person identified as being at increased fire risk because of emollient use:

• individual fire risks must be assessed and documented;
• identified precautions must be proportionate to the risk and the person’s circumstances;
• the person must be involved in decisions about how risks will be reduced wherever possible;
• smoking, cooking, naked flames, heaters and other ignition sources must be specifically considered where relevant;
• staff must not impose blanket restrictions on smoking, matches, lighters, candles or other personal possessions solely because a person uses an emollient; and
• any restriction upon a person’s choices, possessions or movement must have a lawful basis and must be necessary and proportionate.

Where a person lacks capacity to make a particular decision about an identified risk, staff must follow the Mental Capacity Act 2005, including the requirement to act in the person’s best interests and to consider the least restrictive available option.

6.2 Handling and Storage of Emollients

Emollients must be:

• stored in accordance with the manufacturer’s instructions, dispensing label and any relevant pharmacy or healthcare professional advice;
• kept in their original container or packaging unless an alternative arrangement has been specifically authorised and is safe;
• kept away from avoidable sources of excessive heat or ignition where required by the product instructions or individual risk assessment;
• stored in a way that supports the person’s safety while respecting their rights and independence;
• kept secure where a medicines risk assessment identifies that secure storage is necessary; and
• disposed of in accordance with the manufacturer’s instructions and the organisation’s medicines-disposal procedures.

There is no automatic requirement for all emollients or large quantities of emollients to be stored in a fire-resistant cabinet. Any specialist storage provision must be based on the product information, relevant fire risk assessment or competent professional advice.

Staff must not obscure, remove or alter manufacturer or pharmacy labels, warnings, expiry information or directions for use.

6.3 Fire Prevention Measures

The provision of fire extinguishers, fire blankets or other firefighting equipment must be determined by the applicable fire risk assessment and the responsibilities of the Responsible Person for the premises. Such equipment must not be introduced solely because a person uses an emollient unless the risk assessment identifies that it is required.

Where {{org_field_name}} is responsible for firefighting or other fire-safety equipment, it must be:

• suitable for the identified risks;
• appropriately located;
• maintained in accordance with legal requirements and manufacturer instructions; and
• supported by appropriate staff information, instruction and training.

Clothing, bedding and other washable fabrics affected by emollient residue must be changed and washed regularly at the highest temperature permitted by the item’s care label. Staff must recognise that laundering reduces but does not completely remove emollient residue or the associated fire risk.

Fire-safety training provided to staff must include awareness of emollient-related fire risks where relevant to the people they support.

6.4 Emergency Procedures

In the event of a fire, staff must follow the applicable emergency and evacuation arrangements, raise the alarm and contact the fire and rescue service as required.

The emergency arrangements for a person who uses emollients must take account of any additional risks or support needs identified through their individual assessment, including:

• mobility or evacuation support;
• cognitive or communication needs;
• sensory impairments;
• the person’s ability to recognise and respond to a fire alarm or emergency instruction;
• smoking-related risks;
• increased flammability of contaminated clothing, bedding or dressings; and
• any specific advice received from the fire and rescue service or another competent person.

Staff must know what assistance they are expected to provide in an emergency and must not put themselves or others at unreasonable risk.

Where the person lives in premises for which another organisation or person controls the building fire-safety arrangements, {{org_field_name}} must co-operate with that person or organisation so that relevant individual support needs are taken into account.

7. Incident Reporting and Risk Management

Recording and Reporting

All fires, burns, near misses and other significant incidents in which emollient use was or may have been a contributing factor must be recorded promptly in accordance with {{org_field_name}}’s incident-reporting procedures.

The Registered Manager must review the circumstances of the incident and determine whether any external notification or report is legally required.

CQC must be notified without delay where the incident falls within the statutory notification requirements of the Care Quality Commission (Registration) Regulations 2009. This may include, depending on the circumstances:

• a qualifying serious injury to a person using the service;
• an incident reported to or investigated by the police; or
• an event that prevents, or is likely to threaten to prevent, the registered provider from carrying on the regulated activity safely or in accordance with registration requirements.

The fact that an emollient was involved does not, by itself, make an incident automatically notifiable to CQC.

Other organisations, including the police, fire and rescue service, local safeguarding authority or relevant enforcing authority, must be informed where required by law or where the circumstances of the incident require their involvement.

Immediate Action Following a Fire or Burn

If a person’s clothing, bedding or dressings catch fire:

• staff must raise the alarm and follow the emergency fire procedure;
• the source of burning must be stopped where this can be done safely;
• emergency medical assistance must be requested where required;
• burns must be treated in accordance with current first-aid guidance and staff training;
• burns should be cooled promptly with cool running water in accordance with current NHS guidance;
• clothing or jewellery near the affected area may be removed where safe to do so, but staff must not pull away clothing, dressings or other material that is stuck to burnt skin; and
• appropriate medical assessment must be obtained according to the nature and severity of the injury.

Staff must not apply emollients, creams, oils or other greasy substances to a fresh burn unless instructed to do so by an appropriate healthcare professional.

Investigation and Learning

Following an emollient-related fire, burn or significant near miss, the Registered Manager must ensure that:

• the incident is reviewed to establish what happened and whether existing controls were adequate;
• the person’s emollient and fire risk assessments are reviewed without unnecessary delay;
• the person’s care plan and risk controls are updated where required;
• relevant healthcare professionals, the fire and rescue service, landlord, housing provider or Responsible Person are involved where necessary;
• lessons from the incident are shared with relevant staff;
• identified deficiencies in staff knowledge or competence are addressed;
• any required safeguarding or regulatory action is completed; and
• actions arising from the investigation are recorded, allocated and monitored to completion.

8. Training and Competency of Staff

Staff whose role involves supporting people who use emollients must receive information, instruction and training sufficient for them to perform their duties safely.

Relevant training must include:

• the fire risk created when emollient residue accumulates on clothing, bedding, bandages, dressings and soft furnishings;
• the fact that the risk applies to paraffin-containing and paraffin-free emollients;
• recognising individual factors that increase fire risk;
• safe application and recording of emollients where staff provide medicines support;
• smoking, cooking, naked-flame and heater risks;
• appropriate laundering advice and the fact that washing does not completely remove emollient residue;
• individual risk assessment and care-plan requirements;
• emergency and evacuation procedures relevant to the service;
• immediate action following a fire or burn;
• incident reporting and escalation; and
• the circumstances in which management must consider CQC or other statutory notifications.

Training must be provided:

• during induction before staff undertake relevant duties without appropriate supervision;
• when staff take on new responsibilities;
• when a person’s needs or identified risks require additional knowledge;
• following a significant incident, near miss or identified competency concern;
• following material changes to legislation, national guidance or organisational procedures; and
• at suitable refresher intervals determined by the organisation’s training-needs assessment and identified risks.

An annual refresher may be used where {{org_field_name}} determines that this is appropriate, but the organisation must not rely solely on the passage of a fixed period where earlier retraining is necessary.

Staff competence must be assessed where their role requires them to apply, administer, record or otherwise provide direct support with emollients. Competency assessments and any required remedial action must be documented.

Staff must not undertake tasks for which they have not received appropriate information, instruction, training or assessment of competence.

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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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