Getting It Right for Residents, Staff and CQC
Oxygen can be a genuine lifeline for residents with COPD and other long‑term respiratory conditions. But in a care home or home‑care setting, it’s also a high‑risk medicine – with implications for fire safety, record‑keeping, staff training and CQC compliance.
NICE, the Royal Pharmaceutical Society and oxygen suppliers such as BOC all make one thing very clear: oxygen must be handled with the same discipline as any other prescription medicine, and often with more caution because of the fire risk and potential for serious harm if doses are wrong.
In this blog we’ll look at:
- How oxygen should be handled in care homes
- Key tips for safe use in day‑to‑day practice
- What CQC inspectors may look for on inspection
- Where oxygen for residents with COPD is usually supplied from
- Storage, signage and practical safety essentials
- A real‑world example of what happens when oxygen isn’t managed safely
1. How should we be handling oxygen in care homes?
Oxygen is a prescribed medication, not a comfort measure you can “turn up a bit” when a resident is breathless.
NICE guidance on home oxygen and medicines in care homes emphasises that oxygen use must be based on a clear clinical indication and prescription, usually following specialist assessment through the Home Oxygen Service (HOS) [NICE]. The Royal Pharmaceutical Society’s guidance on medicines in care homes adds that all medicines (including gases) must be handled in line with written policies, risk assessments and good record‑keeping.
In practical terms, that means:
a) Prescription and documentation
- Every resident on oxygen should have:
- A clear prescription showing flow rate (L/min), device (e.g. nasal cannula), and when it should be used (continuous, nocturnal, PRN etc).
- A care plan describing target oxygen saturations, when to escalate concerns, and any specific risks (e.g. CO₂ retention in COPD).
- Oxygen recorded on the MAR chart like any other medicine – including PRN rationale and outcome.
- You should never see:
- “Oxygen 24/7” written with no flow rate.
- Flow rates changed by staff without a written order.
- Oxygen being used for “shortness of breath” with no documented review.
b) Treat it as a high‑risk medicine
The RPS and CQC both expect homes to identify and manage high‑risk medicines – usually including anticoagulants, insulin, controlled drugs and oxygen. Under CQC’s “safe” key question, inspectors will look for robust processes around these medicines, and how risks are assessed, recorded and reviewed [CQC].
For oxygen this usually includes:
- A specific oxygen risk assessment for each resident.
- A fire risk assessment that explicitly includes oxygen, smoking, and use of flammable creams.
- Staff training and competencies on oxygen use, maintenance checks, and emergency procedures.
2. Where is oxygen supplied from for residents with COPD?
Residents with COPD usually receive oxygen through the NHS Home Oxygen Service following specialist assessment (often via a respiratory clinic or community respiratory team).
Typically:
- A clinician completes a Home Oxygen Order Form (HOOF), which goes to the contracted supplier in your region (often BOC or another medical gas company).
- Common equipment:
- Oxygen concentrator in the resident’s room for long‑term therapy.
- Portable cylinders for mobility or as a back‑up if power fails.
- Sometimes liquid oxygen systems, though these are less common in standard care homes.
The care home or home‑care provider is then responsible for:
- Day‑to‑day operation, checks and basic maintenance (filter/water checks, visible damage, trip hazards from tubing).
- Ensuring delivery access and cylinder rotation (oldest stock used first, empty cylinders removed).
Having a business continuity plan for power cuts and equipment breakdown.
3. Key storage and use information: getting the basics right
Most enforcement action around oxygen doesn’t come from obscure technical issues – it comes from failing to control very basic, well‑known risks.
a) Storage of cylinders
Using BOC and RPS guidance as a benchmark:
- Store cylinders:
- Upright, on appropriate stands, or properly secured to prevent them falling.
- In a well‑ventilated area, away from direct sunlight, heaters, or other sources of heat.
- Away from oil, grease, aerosols, cleaning fluids, paper and other combustibles.
- You should have:
- A clearly labelled area for “Full” and “Empty” cylinders to avoid confusion.
- Stock checks with dates and batch / cylinder numbers logged where appropriate.
- A log of delivery and collection from the oxygen supplier.
b) Use in bedrooms and communal areas
During use:
- Ensure good ventilation – windows or vents open if safe to do so.
- Display “Oxygen in Use – No Smoking / No Naked Flames” signage on the resident’s door and at main entrances.
- Keep all electrical items, candles, lighters and matches well away from the oxygen source.
- Tubing:
- Arrange tubing to avoid trip hazards across doorways or communal walkways.
- Replace tubing according to manufacturer/supplier recommendations and if visibly discoloured, cracked or kinked.
c) Emollients and fire risk
A common CQC concern is the combination of:
- Oxygen therapy,
- Paraffin‑based emollients, and
- A smoking or ignition source.
Fabrics and hair that are repeatedly exposed to paraffin‑based products can catch fire very suddenly in an oxygen‑enriched atmosphere.
Safe practice includes:
- Avoiding paraffin‑based products for residents on oxygen where possible – use water‑based alternatives.
- Documenting this in the care plan and risk assessment.
- Making sure staff, residents and families understand why these products are restricted.
4. What CQC inspectors are likely to look for
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CQC’s fundamental standards and the 5 key questions (Safe, Effective, Caring, Responsive, Well‑Led) frame how inspectors look at oxygen practice [CQC inspector guidance].
For oxygen specifically, they may:
Under “Safe”
- Check care plans and MAR charts for residents on oxygen:
- Is the prescription clear and current?
- Is actual use recorded?
- Are there documented risk assessments around fire, smoking and emollients?
- Look at equipment in situ:
- Are concentrators serviced according to the schedule?
- Are cylinders stored correctly, labelled and secured?
- Ask staff:
- “What would you do if this concentrator alarmed?”
- “What would you do if you found a resident on oxygen smoking in their room?”
Under “Effective”
- Is oxygen being used in line with clinical guidance (e.g. for COPD, often 88–92% target sats rather than pushing to 100%)?
- Are staff trained and competent in:
- Using pulse oximeters correctly.
- Recognising early deterioration and when to call 999 or NHS 111.
- Is there regular review by appropriate clinicians – respiratory team, GP or community nurse?
Under “Well‑Led”
- Are there clear, up‑to‑date policies on:
- Medicines management (including medical gases).
- Fire safety that explicitly references oxygen.
- Is there incident reporting and learning if there is:
- Incorrect oxygen use (wrong flow, left off when prescribed).
- An oxygen‑related near‑miss or fire incident?
- Can leaders describe:
- How many residents currently use oxygen.
- Where the oxygen is stored.
- When the last audit of oxygen practice was done and what changed as a result.
External tools and checklists used by providers echo this, such as CQC‑aligned inspection templates that routinely ask about gas cylinders, oxygen signage and staff training as part of medicines and safety checks [SafetyCulture CQC checklist].
- Check care plans and MAR charts for residents on oxygen:
5. Key tips for safe oxygen use in everyday practice
You don’t need complicated systems – you need consistent basics done well:
- Know your oxygen users.
Maintain a simple up‑to‑date list of residents using oxygen (care homes and home‑care caseloads). Include equipment type, usual flow rate and who to contact in an emergency. - Build oxygen into your medicines policy.
Clearly set out:
- Who can adjust flow rates (usually only on written clinical instruction, not by care staff independently).
- How oxygen is recorded on MARs, including refusals and PRN use.
- What staff must check at the start and end of each shift.
- Make fire safety real, not theoretical.
- Explicitly link oxygen to your fire risk assessments and drills.
- Practice evacuation of a room where a concentrator is in use.
- Ensure fire risk signage is current and not hidden behind furniture or decorations.
- Train for the worst day, not the best day.
Short, repeated training sessions work better than a one‑off induction. Include:
- How to safely isolate or remove oxygen in a fire, without putting staff at risk.
- What to do if there is a suspected oxygen‑fuelled fire (e.g. on bedding or clothing).
- When to escalate to emergency services.
- Audit little and often.
Simple monthly checks:
- Are all cylinders stored and labelled correctly?
- Are flow rates and usage consistent with prescriptions and care plans?
- Are residents who shouldn’t be on oxygen accidentally using someone else’s equipment?
6. A example using themes from CQC: when oxygen goes wrong
To illustrate how this plays out in practice, let’s look at a composite example drawn from recurring themes in CQC reports and enforcement bulletins. Details are anonymised, but the scenario reflects the kind of issues the regulator has highlighted in recent years in its State of Care and themed publications [CQC publications].
“Rosewood Lodge” – a cautionary tale
Rosewood Lodge was a medium‑sized care home for older people, several of whom had advanced COPD and required long‑term oxygen therapy. The home had a mixture of concentrators and portable cylinders.
A CQC inspection, triggered by concerns from a relative and the local fire service, found:
- No individual oxygen risk assessments.
Residents on oxygen had generic care plans that mentioned “shortness of breath” but did not outline:
- Prescribed flow rates
- Target oxygen saturations
- Fire risks or emergency actions
- Unsafe storage of cylinders.
Inspectors found:
- Multiple cylinders lying on the floor of a cluttered laundry room.
- No clear separation of full and empty cylinders.
- No evidence of regular stock checks or rotation.
- Smoking and oxygen in the same room.
One resident, Mr A, was known to be a smoker and was using a paraffin‑based emollient for dry skin. He had a concentrator in his bedroom and a portable cylinder under his chair. Staff described him as “non‑compliant” but there was no documented plan around smoking safety, alternative arrangements, or emollient choice. - Inconsistent MAR and care plan entries.
Oxygen appeared on some MAR charts as “Oxygen PRN for breathlessness”, with no flow rate; on others it wasn’t listed at all, despite obvious use of equipment. - Poor staff understanding.
When inspectors asked staff about oxygen:
- Some believed oxygen was “not really a drug, just air”.
- Few knew who was responsible for equipment checks or when concentrators were last serviced.
What would CQC’s response be?
CQC would rate the service “Inadequate” for Safe and Well‑Led, citing breaches of the Health and Social Care Act regulations around:
- Safe care and treatment (unsafe medicines and equipment management).
- Good governance (lack of effective risk assessment, audit and learning).
The regulator used its enforcement powers to:
- Issue a Warning Notice, requiring immediate action on:
- Oxygen risk assessments
- Cylinder storage and signage
- MAR documentation for oxygen
- Staff training and competency records
- Impose conditions on the home’s registration, including:
- Regular reporting on fire safety improvements.
- An external medicines management review by a pharmacist with experience in care homes and high‑risk medicines.
Failure to comply would have led to suspension or cancellation of the home’s registration.
What changed – and what others can learn
With support from the local pharmacy team and fire service, Rosewood Lodge:
- Introduced robust oxygen care plans and risk assessments for each resident.
- Reconfigured cylinder storage into a dedicated, ventilated, secure area with clear signage.
- Switched residents on oxygen to safer, non‑paraffin emollients where clinically appropriate.
- Implemented staff training and competency checks, focusing on:
- Oxygen as a high‑risk medicine
- Fire risks and emergency actions
- Correct documentation on MARs
- Built oxygen safety into regular clinical audits and governance meetings.
At re‑inspection, CQC noted significant improvement in the “Safe” domain and removed some of the enforcement conditions, though the home remained under close monitoring until it could sustain those improvements over time.
7. Bringing it all together
If you support residents using oxygen – whether in a care home or through a home‑care service – ask yourself:
- Can every nurse and senior carer confidently explain how oxygen is prescribed, documented, stored and monitored in your service?
- If a CQC inspector walked in today and chose any resident on oxygen, would they find:
- A clear prescription and MAR entry?
- A personalised care plan and risk assessment?
- Safe storage of cylinders and appropriate signage?
- Evidence of staff training and recent audits?
If the honest answer is “not quite”, now is the right time to strengthen your systems. CQC’s own publications and State of Care reports show a recurring pattern: where oxygen is handled casually, residents are put at risk and providers do face enforcement action [CQC publications].
Oxygen saves lives – but only when it’s prescribed, stored, administered and reviewed with respect, precision and healthy caution. Getting this right protects your residents, supports your staff, and means that when CQC visit, you can confidently show that oxygen in your service is managed safely and well.
