Sample policy · Adult social care

End-of-life care policy (adult social care)

Statutory anchor: Regulation 9 (person-centred care), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 20 (duty of candour) and the Mental Capacity Act 2005. · primary source

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

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:

The Service does not replace GP, community nursing or specialist palliative-care clinical responsibility.

6. Roles and responsibilities

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:

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:

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:

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:

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:

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:

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:

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:

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:

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.

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

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.

Note on the Mental Capacity Act: the Supreme Court's judgment of 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 confirms that the judgment has immediate effect and that the Mental Capacity Act 2005 and Regulation 11 consent requirements are unchanged. Providers should use DHSC's guidance published on 15 June 2026 and seek legal advice where the position remains uncertain. The republished DoLS Code of Practice does not fully reflect the 2026 judgment.

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
v1.2 2026-07-21 Verivius (sample) Replaced the pending-guidance wording with current DHSC guidance on the 2026 Supreme Court judgment.
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.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

End-of-life records have to work at emergency speed and then outlive the person who made them. If someone in the last days of life deteriorates overnight, an ambulance crew acts on what staff can put in their hands, so a ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) recommendation or a DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) decision that is filed correctly but cannot be produced in minutes has the same effect as no record at all, and the person receives the attempted resuscitation their recorded plan was written to prevent. The risk runs the other way too. A plan written once on admission drifts quietly while the person's condition and wishes move on, so the care given in the final week matches a conversation from months earlier rather than the one nobody got round to having. After the death the person cannot correct the account. What the family understands about whether their relative was comfortable, whether anyone came and whether their wishes were honoured rests on what staff wrote at the time, which is why reviewing each death earns its place as learning for the next person approaching the end of life.

  1. Staff can locate and present the current ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) and DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) documents in an emergency, not just confirm that a form exists somewhere in the file. Where the emergency recommendation is inaccessible or out of date, the ambulance crew or clinician at the person's side acts without knowing what was agreed for them.

    Strong evidence: The ReSPECT record covering whether a form exists, where it is kept, its date, who completed it and whether staff know how to access it in an emergency (Section 9), and the DNACPR record held separately, covering whether a decision or form exists, where it is kept, the date and authorising clinician, and how staff will present the document in an emergency (Section 10). The quarterly audit sample explicitly checks ReSPECT or DNACPR access (Section 17).

    Weak evidence: The form exists but lives in a paper folder in the office while care is delivered from a phone at the person's side, or it is a photocopy carrying no date and no authorising clinician. A night worker asked for the current emergency recommendation says it will be in the file somewhere, and nobody has checked whether it still stands after the last hospital admission.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  2. In the last days of life, an appropriate healthcare professional reviews the person's condition and individualised care plan, and change is recorded at each visit or shift, not only when the person deteriorates. Otherwise a dying person goes without clinical review while their plan drifts out of step with what they need.

    Strong evidence: Records of change at every visit or shift, and evidence that the appropriate healthcare professional reviewed the person's condition and individualised care plan at least every 24 hours, or more often where the clinical plan requires it (Section 7). The quarterly audit checks the 24-hour review in the last days of life (Section 17).

    Weak evidence: Shift notes reading "no change" or "settled overnight" for several days running, with no named GP, community nurse or palliative-care professional recorded as having reviewed the person's condition and their individualised care plan within the interval the care plan sets. A visit is logged with a time but nothing about what was reviewed or what changed in the plan, and the fullest entry in the whole record is the one written on the day the person died.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  3. The advance care plan reflects a live conversation, kept current and travelling with the person, not a form completed once on admission. When it is only a form, care stops matching the person's recorded wishes, or the plan never reaches the hospital on transfer.

    Strong evidence: Advance care planning conversations recorded in the care plan and reviewed when the person's condition, wishes or circumstances change, a current copy available where the person lives and accompanying them on admission or transfer, and a record of who received updated information and when (Section 8). The death review asks whether care matched recorded wishes (Section 15).

    Weak evidence: An advance care planning form completed once on admission and never revisited, carrying an entry that says "wishes discussed" with no record of what the person actually said. Preferred place of care is written down but nothing shows who was told, and the plan sits only in the service's own system with no copy that travelled with the person when they were admitted to hospital.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  4. Each death review stays open until its linked actions close, rather than being signed off while an incident, a safeguarding concern, a complaint, the Regulation 20 duty of candour owed to the person, or a statutory notification to CQC is still outstanding. The local authority, CQC and the person are three separate audiences, and meeting one duty does not discharge another. A review closed on paper while a cross-referenced action sits overdue means the next family meets the same failure.

    Strong evidence: The Registered Manager's review of each death, with any related incident, safeguarding concern, complaint, Regulation 20 duty of candour process or statutory notification to CQC entered in the appropriate register and cross-referenced, each tracked as a duty in its own right rather than treated as covered by one of the others, improvement actions carrying an owner, due date and closure evidence, and the review not closed while a linked action remains overdue without a recorded escalation decision (Section 15).

    Weak evidence: A death review signed off as "no concerns" while the cross-reference field is blank and the linked incident or safeguarding entry is still open on its own register. Actions carry wording like "ongoing" or "continue to monitor" instead of an owner, a due date and the evidence that will close them, and no escalation decision is recorded to explain why the review was closed with an action still outstanding.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  5. Symptoms are escalated promptly to the right clinical route and the response is written down, not just kept in mind as comfort. Where distress or a change in symptoms is logged but the advice sought and action taken are not, the colleague on the next shift cannot tell whether the person's pain was treated.

    Strong evidence: The symptom record showing symptoms, advice sought, medicines administered, comfort measures and family contact (Section 11), with the death review and quarterly audit both checking whether symptoms were escalated promptly (Sections 15 and 17).

    Weak evidence: Charting that says "settled" with no record of the symptom that prompted a dose of anticipatory medicine, and calls to the out-of-hours service logged as "advice sought" with nothing about what advice was given or who gave it. A family member raises concern about pain and the record captures the concern but not the response, so nobody can tell afterwards whether the person's pain was actually treated.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

Related

Last verified 20 July 2026

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Last reviewed 21 July 2026