1. What the regulation says
The care and treatment of service users must be appropriate, meet their needs, and reflect their preferences. (Reg 9(1): the headline duty)
carrying out, collaboratively with the relevant person, an assessment of the needs and preferences for care and treatment of the service user (Reg 9(3)(a): collaborative assessment)
This policy also engages the duty of candour where something goes wrong:
Registered persons must act in an open and transparent way with relevant persons in relation to care and treatment provided to service users in carrying on a regulated activity. (Reg 20(1): the headline duty)
The full text of Regulation 9 is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/9 and Regulation 20 is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/20. Where this policy and the regulation diverge, the regulation wins.
2. Plain-English summary
Care and treatment must be appropriate, meet the service user's needs, and reflect their preferences. The regulation lists nine specific things you have to do to deliver person-centred care, including: assessment with the service user, designing care to meet their preferences, involving them and the people supporting them in decisions, providing information, making reasonable adjustments, and considering well-being when meeting nutritional and hydration needs. For people approaching the end of life, this means recording their wishes, involving the people they want involved, and working with their clinical team so that care matches what matters to the person.
3. Purpose
This policy sets out how the Service supports people approaching the end of life, records their wishes, works with healthcare professionals, supports families and learns from deaths.
The Service must verify this policy against current NICE end-of-life guidance, local palliative-care pathways, ReSPECT source material, DNACPR guidance and CQC source material before adoption.
4. Sources to verify before adoption
- NICE QS13, End of life care for adults: https://www.nice.org.uk/guidance/qs13
- NICE NG31, Care of dying adults in the last days of life: https://www.nice.org.uk/guidance/ng31
- NICE NG31 recommendations: https://www.nice.org.uk/guidance/ng31/chapter/recommendations
- ReSPECT, Resuscitation Council UK: https://www.resus.org.uk/respect
- ReSPECT for healthcare professionals: https://www.resus.org.uk/respect/respect-healthcare-professionals
- Mental Capacity Act 2005: https://www.legislation.gov.uk/ukpga/2005/9/contents
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 9: https://www.legislation.gov.uk/uksi/2014/2936/regulation/9
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20: https://www.legislation.gov.uk/uksi/2014/2936/regulation/20
5. Scope
This policy applies to people using the Service who may be approaching the end of life, are in the last days of life, or have died while receiving support from the Service.
It applies to:
- care homes
- supported living or home-care services where the Service supports end-of-life care
- family and carer communication
- advance care planning records
- ReSPECT and DNACPR recording
- after-death care and body release process
- learning from each death
The Service does not replace GP, community nursing or specialist palliative-care clinical responsibility.
6. Roles and responsibilities
- Registered Manager: owns the service pathway, ensures out-of-hours and local clinical contacts are current and makes sure mortality-review actions are completed.
- Clinical lead or named senior practitioner: coordinates with the GP, community nursing and palliative-care teams, checks clinical instructions are current and reviews concerns about deterioration or symptom control.
- Key worker or named care coordinator: keeps the person's wishes, contacts and advance care plan current and makes sure relevant information follows the person between settings.
- Medicines lead: checks access to prescribed anticipatory medicines and equipment, storage and administration records, and escalates any gap to the prescriber or pharmacy.
- Care staff: recognise and record change, provide care within their competence, follow the current plan and seek clinical advice promptly.
- All staff: respect the person's wishes and dignity, communicate concerns without delay and record what they observed, did and were advised.
7. Identifying the end-of-life phase
Staff remain alert to signs that a person may be approaching the end of life.
Triggers for senior review may include:
- advanced progressive illness
- repeated hospital admissions
- increasing frailty or weight loss
- reduced intake
- increasing sleepiness or withdrawal
- deterioration after infection or acute illness
- clinician advice that the person may be approaching the end of life
- family, carer or staff concern
The Registered Manager or clinical lead seeks GP, community nursing or specialist palliative-care advice when staff identify deterioration.
Staff verify clinical indicators against current NICE NG31, local palliative-care pathway and the person's clinical team before adopting local wording.
Where the person may be in the last days of life, the Service records changes at every visit or shift and makes sure the appropriate healthcare professional reviews the person's condition and individualised care plan at least every 24 hours, or more often where the clinical plan requires it. Improvement, stabilisation and uncertainty are escalated as well as deterioration.
8. Advance care planning
Advance care planning is a conversation process, not just a form.
Where the person wishes to take part, staff support discussions about:
- what matters to the person
- preferred place of care
- people the person wants involved
- spiritual, cultural or personal wishes
- care and treatment preferences
- hospital transfer preferences
- comfort, privacy and dignity
- who should be contacted if the person deteriorates
The Service records advance care planning conversations in the care plan and reviews them when the person's condition, wishes or circumstances change. A current copy is available where the person lives and accompanies them on an admission or transfer where this is lawful and practicable. Staff record who received updated information and when.
Where the person may lack capacity, staff follow the Mental Capacity Act 2005 and involve lawful decision-makers or people interested in the person's welfare as appropriate.
9. ReSPECT-form recording
Where a ReSPECT process is used locally, the Service records:
- whether a ReSPECT form exists
- where the form is kept
- date of the current form
- who completed it
- whether staff know how to access it in an emergency
- whether the GP, community team or ambulance service need updated information
Staff do not complete or alter ReSPECT clinical recommendations unless their role and local process authorise them to do so.
The Service verifies ReSPECT procedure against current Resuscitation Council UK source material and local NHS process before adoption.
10. DNACPR conversations and decisions
DNACPR is not the same as advance care planning.
The Service records DNACPR information separately from broader preferences about care and treatment.
Records include:
- whether a DNACPR decision or form exists
- where the form is kept
- date and authorising clinician where recorded
- whether the person, family or representative has been involved according to the clinical process
- any review date or review trigger recorded by the clinical team
- how staff will present the document in an emergency
Staff do not make DNACPR clinical decisions. If staff identify uncertainty, distress or disagreement, they escalate to the GP, clinical lead or relevant healthcare professional.
11. Symptom management referral pathways
The Service escalates symptoms promptly to the appropriate clinical route.
The local pathway includes:
- GP
- community nursing team
- specialist palliative-care team
- out-of-hours GP or urgent community response
- pharmacy
- hospice advice line where available
- emergency services where immediate emergency care is needed
Staff record symptoms, advice sought, medicines administered, comfort measures and family contact.
The Service verifies symptom-management escalation against NICE NG31 and local palliative-care guidance before adoption.
12. Family support and bereavement
The Service supports family, carers and people important to the person.
Support includes:
- identifying who the person wants involved
- offering private space for conversations where possible
- explaining what staff can and cannot do
- keeping communication factual and compassionate
- supporting cultural, spiritual and religious needs
- signposting bereavement support
- recording concerns, complaints or compliments
Staff respect confidentiality and the person's wishes when sharing information.
13. After-death care
After a person dies, staff follow the local after-death procedure.
The procedure covers:
- who confirms or verifies death according to local arrangements
- who informs family or representatives
- personal care after death
- cultural, religious or personal wishes
- care of property and valuables
- medicines and controlled-drug handling
- infection prevention requirements
- records to complete
- staff support
Staff do not release the body until the required local process has been completed.
14. Body release procedure
The Service keeps a local body release procedure that reflects the service type and local arrangements.
The record includes:
- name and date of birth
- date and time of death where known
- person authorising release
- funeral director or authorised collection details
- property and valuables record
- forms sent with the person
- staff member completing release
- witness where local procedure requires one
Where death is unexpected, suspicious or subject to coroner involvement, staff follow police, coroner, GP and local procedure before any release.
15. Learning from each death
The Registered Manager reviews each death.
The review considers:
- whether the person was expected to be approaching end of life
- whether care matched recorded wishes
- whether ReSPECT and DNACPR records were accessible where relevant
- whether symptoms were escalated promptly
- whether family communication was appropriate
- whether medicines and equipment were available
- whether staff need support
- whether any incident, safeguarding concern, complaint, notification or duty of candour issue needs action
Learning is recorded without blame and converted into improvement actions where needed.
Any related incident, safeguarding concern, complaint, duty of candour process or statutory notification is entered in the appropriate register and cross-referenced to the death review. Improvement actions have an owner, due date and evidence required for closure. The mortality review is not closed while a linked action remains overdue without a recorded escalation decision.
16. Staff training
The Service maps end-of-life training to role.
- All staff receive induction on dignity, comfort, escalation and family communication.
- Care staff receive training on recognising deterioration, care after death and recording.
- Senior staff receive training on advance care planning records, ReSPECT access, DNACPR documentation, medicines escalation and family liaison.
- Managers receive training on governance, notifications, mortality review, complaints and staff support.
The Service verifies training expectations against current NICE guidance, local NHS pathway and CQC source material before adoption.
Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.
17. Audit and monitoring
The Registered Manager reviews every death within 10 working days, or sooner where the death was unexpected or a concern has been raised. Open end-of-life risks, unavailable plans, medicines or equipment gaps and overdue clinical follow-up are reviewed through monthly governance.
Each quarter, the Service audits 10 current or recently closed end-of-life records, or all records if fewer than 10 are available. The sample checks advance care planning, plan availability, 24-hour review in the last days of life, ReSPECT or DNACPR access, symptom escalation, family communication and transfer information.
Actions are entered in the improvement action plan with an owner, due date and closure evidence. A repeated gap, unexpected death, inaccessible emergency recommendation or unresolved symptom-control concern is escalated immediately. Closure requires a later record sample or other evidence showing the change worked.
18. Related policies
- Mental Capacity Act policy
- Notification of death policy
- Medicines management policy
- Duty of candour policy
- Incident reporting, investigation and learning policy
- Record keeping and documentation standards policy
19. Sources and further reading
This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.
- CQC Regulation 9: Person-centred care
- CQC Regulation 20: Duty of candour
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/9)
- NICE end-of-life care guidance (including NICE QS13 and NICE NG31)
- CQC end-of-life key lines and CQC assessment framework and sector-specific guidance, as updated by CQC from time to time
- Mental Capacity Act 2005; MCA Code of Practice (2007, update in consultation)
- Human Rights Act 1998, especially Article 2 and Article 8 where end-of-life decisions, DNACPR, communication with families or serious treatment decisions are involved. Article 5 / AGNI is relevant only where restrictive arrangements may amount to deprivation of liberty
- DNACPR and ReSPECT guidance (Resuscitation Council UK)
- Local palliative-care pathways and local NHS process
Note on the Mental Capacity Act: the Supreme Court's AGNI judgment (2 June 2026) overruled Cheshire West and there is no longer an "acid test"; deprivation of liberty is now determined by a multifactorial assessment. CQC's statement (8 June 2026) confirms the judgment has immediate effect, that providers may need legal advice, and that the Mental Capacity Act 2005 and Regulation 11 consent requirements are unchanged. DHSC guidance on the Deprivation of Liberty Safeguards and Court of Protection cases is awaited.
20. When to seek further advice
Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.
21. Document control
| Version | Date | Author | Changes |
|---|---|---|---|
| v1.1 | 2026-07-19 | Verivius (sample) | Added named roles, plan-availability controls, register links, mortality-review timing and audit sampling. |
| v1 | 2026-06-10 | Verivius (sample) | Conformed existing template to the Verivius policy standard: added statutory anchor, verbatim regulation text, plain-English summary, sources and further reading, and document control. All original operational sections preserved. |
This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the provider's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.