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Venepuncture with RRI for people who lack capacity to consent SOP

Contents

1 Aim

This standard operating procedure (SOP) will guide and support the Rotherham, Doncaster, and South Humber NHS Foundation Trust (RDASH) staff in applying the correct procedure for taking bloods (venepuncture) for patients who lack capacity to consent to the procedure.

This SOP outlines the key responsibilities and expectations of the trust in respect of the process which needs to be followed in order for RDASH to meet its legal obligations. This is to ensure that any decisions made on behalf of people who lack capacity in relation to consenting to the taking of bloods are carried out lawfully in the person’s best interests and are the least restrictive of their rights and freedoms.

The content of this SOP applies to all staff working within the adult learning disability service in the trust where required.

2 Scope

This SOP applies to staff providing care and treatment to any patient who meets the eligibility criteria to receive input from the adult learning disability service who are referred for the taking of blood. The rationale for taking the bloods is for the monitoring of prescribed medication or other physical health reasons, for people who may lack capacity to make an informed decision about the procedure.

3 Link to overarching policy, and or procedure

This SOP is overarched by the Mental Capacity Act 2005 policy. and is to be read in conjunction with the following trust polices:

Section 5 of the Mental Capacity Act 2005 (MCA) allows staff to carry out certain tasks without fear of liability. The aim is to provide a legal framework for tasks that need to be carried out in the best interests of the patient who lacks capacity to consent, and this includes the use of restraint.

However, section 6 of the MCA Code of Practice imposes some important limitations on acts that can be carried out with protection from liability under section 5.

The key areas where acts might not be protected from liability are where there is inappropriate use of restraint or, where a patient who lacks capacity is deprived of their liberty.

Section 6.40 of the MCA Code of Practice states that someone is using restraint if they:

  • “use force or threaten to use force to make someone do something that they are resisting or restrict a person’s freedom of movement whether they are resisting or not.”

It states that any action intended to restrain a person who lacks capacity will not attract protection from liability unless the following two conditions are met:

  • the person taking the action must reasonably believe that restraint is necessary to prevent harm to the person who lacks capacity
  • the amount or type of restraint used and the amount of time it lasts must be a proportionate response to the likelihood and seriousness of harm

4 Criteria for referral to venepuncture or phlebotomy service

Blood sample request form received from medical staff.

Request screened to make sure it meets the criteria, for example, the request is made by a consultant psychiatrist from the learning disability service and, or it relates to someone who is unable to have their bloods taken at their GP surgery.

Referrals from other appropriate health professionals also accepted, for example the patient’s GP or nurse practitioner.

A variety of methods will be explored as part of the screening process to ensure that the least restrictive intervention and techniques are used.

Accessible information provided to the patient on the process in the form of photos easy read leaflet, orientation to the clinical area, desensitisation.

The use of the restrictive intervention is the last resort and will only be carried out after the care and support plan is fully agreed. The care plan is to be formulated with input from people involved in the care and support of the individual.

5 Procedure or implementation

5.1 Step 1, capacity to consent to the procedure

Staff should ensure that they have taken all practicable steps to provide information in a way the person may be able to understand, to enable them to make their own decision around giving consent to the procedure of taking blood.

This should include appropriate accessible information about the procedure, why it is necessary, what it will involve, and the risks involved in not carrying it out.

Where there is doubt about a patient`s capacity to give informed consent to the procedure of taking bloods staff should ensure that:

A formal assessment of capacity has been undertaken and documented on Form MCA1 record of assessment of Mental Capacity as detailed in the trust MCA Mental Capacity Act 2005 policy.

5.2 Step 2, best interests decision made

Where the decision is made for the patient or resident to receive care and treatment it is made in their best interests.

Ensure that all appropriate people are involved in the decision-making process.

This to include the person requesting the bloods to be taken.

Check if the person has a Lasting Power of Attorney for Health and Welfare.

The decision is to be documented on the MCA2 best interest form in the patient record.

Where the person or their family is strongly objecting it may be necessary to hold a ‘best interests meeting’ and record on the best interest meeting template attached to the MCA2 form.

Outcome of the decision to be communicated to all involved.

Copies of the MCA1 and MCA2 can be found on the patient’s system one record in the questionnaires section.

5.3 Step 3, care and support plan

The plan should include:

  • use of restrictive interventions, which could be physical and, or chemical
  • least restrictive options explored initially in all cases

Restrictions should only be used when deemed absolutely necessary. When they are applied it must be conducted in a safe and effective manner by trained professionals. A care and support plan must be completed in order to ensure personalised care is delivered and alternatives to restriction have been implemented. When restrictions are necessary, they should be used for the shortest possible time, be recorded, monitored, and reviewed in line with reducing restrictive interventions (RRI) policy (formerly PMVA policy) and procedure.

Least restrictive ‘will depend on the likelihood of harm occurring, the severity of the harm and how proportionate the restriction is to the level of likely harm’.

Any physical intervention planned should be:

  • reasonable, justifiable, and proportionate to the risk posed by the patient
  • used for only as long as is absolutely necessary
  • involve a recognised technique
  • be carried out by staff who have received specific clinical holds training from the PMVA team which is recognised by the trust

The care and support plan should also include:

  • agreement of least restrictive intervention and techniques required, look at previous evaluations of intervention if available, discuss with care staff
  • agreement of which staff need to be involved in the procedure and holds.
  • agree date and time procedure will be carried out
  • agree appropriate environment where the procedure will be carried out
  • agree appropriate equipment required, high back chair, bed, settee, wheelchair, cushion, safety pod etc.
  • carry out environmental risk assessment
  • agree any involvement of carers or family
  • consult with medical staff regarding any pre-procedure medication required and, or the use of topical anaesthesia
  • agree who will administer any prescribed medication
  • consult with reducing restrictive interventions team for any specialist advice
  • agree aftercare
  • in advance of procedure or visit agree communication of care and support plan

People who use services, families and carers must be involved in planning, reviewing, and evaluating all aspects of their care and support.

After care information for carers and family to be shared prior to the procedure.

5.4 Step 4, venepuncture procedure carried out, recognised techniques

Staff should read the care and support plan before the procedure and feel confident in carrying out the venepuncture. Access the PMVA zone on the intranet or speak to members of the PMVA team for advice on a case-by-case basis.

Staff team supporting can at any time halt the procedure by saying Stop if they feel the situation has become unsafe for the patient. However, consideration must be given to the effect stopping may have on the patient if the procedure has to be repeated.

Should an incident occur which results in harm to patient or a member staff the incident should be reported via the completion of a Ulysses safeguard IR1 form which can be found on the trust intranet page. Should any bruising be evident, a body map to be completed in the patient’s electronic record.

Any required medication to reduce anxiety or sedate the person should be given by care staff prior to the intervention as agreed in the care and support plan.

Staff should work through the various safe holding positions identified in care and support plan depending on which is least restrictive for the patient.

5.5 Step 5, aftercare

As detailed in the care and support plan staff will discuss and agree with carers or family where restraint has been utilised to enable venepuncture to be carried out, the attending clinical team will leave the room after the intervention and carers or family will support the patient. This is to alleviate any additional distress caused by the presence of the clinical team.

The patient`s carers will be responsible for providing aftercare as detailed in the care and support plan and accompanying leaflet.

The health team will remain available to the carers for an agreed period of time to ensure the patient recovers appropriately and any concerns can be raised and addressed.

5.6 Step 6, recording of actions

It is the responsibility of all staff to be aware of and adhere to the record keeping standards as set in the RDASH Healthcare record keeping policy.

  • Debriefing with patient Evaluation and reflection, what went well, what could be improved on. Families or carers views
  • Completion of Ulysses safeguard IR1 form as detailed above in 5.4 if the patient develops bruising as a result of the clinical holds techniques utilised.

All the above will be recorded in the patient’s electronic clinical record.

6 Appendices

6.1 Appendix A Care and support plan

6.2 Appendix B Leaflet 1, taking blood for people who lack capacity to consent

6.3 Appendix C Leaflet 2, aftercare information for blood taking procedures


Document control

  • Version: 2.1.
  • Unique reference number: 628 (formally 472).
  • Approved by: Clinical policy review and approval group.
  • Date approved: 08 November.
  • Name of originator or author: Community learning disability team manager, Rotherham or Mental Capacity Act lead.
  • Name of responsible individual: Clinical policy review and approval group.
  • Date issued: 20 June 2022 (minor amendment to unique ref no).
  • Review date: November 2024.
  • Target audience: All clinicians working within the adult learning disability service.

Page last reviewed: March 18, 2024
Next review due: March 18, 2025

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