End of Life Care and Advance Care Planning: What CQC Expects From Care Homes

End of life care is one of the most sensitive areas of care home practice, and also one of the most heavily scrutinised by the Care Quality Commission. There is no single "end of life regulation" that inspectors tick off. Instead, CQC builds its judgement from how well a home plans ahead with residents and families, how it makes and records decisions such as Do Not Attempt Cardiopulmonary Resuscitation (DNACPR), and how consistently that care is delivered when someone is dying. Getting this right protects a resident's dignity and rights at the most vulnerable point in their life, and it is also one of the clearest ways a home demonstrates person-centred, safe practice to an inspector.

Where end of life care sits in the CQC Single Assessment Framework

CQC's Single Assessment Framework does not have a standalone key question or quality statement labelled "end of life care". Instead, inspectors look for evidence of it woven through several quality statements, most heavily under Caring and Responsive. Under Caring, evidence sits within quality statements on compassionate care and treating people as individuals — for example, whether staff have the time, training and emotional support to sit with a dying resident and their family rather than treating the moment as purely clinical. Under Responsive, it sits within person-centred care and care provision, integration and continuity — whether a resident's wishes about where and how they want to die were captured early, reviewed as their condition changed, and actually followed by everyone involved in their care, including out-of-hours and agency staff.

Where a resident's care involves clinical decisions — pain relief, syringe drivers, DNACPR status — the Safe and Effective key questions come into play too, because inspectors want to see those decisions were made competently, recorded properly and reviewed. Understanding how the quality statements interlock across all five key questions is worth revisiting in detail — we've covered the framework structure fully in our guide to CQC's Single Assessment Framework quality statements.

Legally, the anchor points are Regulation 9 (person-centred care) and Regulation 12 (safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Regulation 9 requires that care and treatment reflects the resident's needs and preferences and involves them, or their representative, in decisions about it — exactly what advance care planning is meant to achieve. Regulation 12 requires that care and treatment is provided safely, which is where clinical decision-making around resuscitation and symptom management sits. There is no separate "dying well" clause. Inspectors read end of life practice as a test of whether a home applies its existing person-centred and safe-care obligations consistently at the end of someone's life, not only in the middle of it.

Advance care planning and the ReSPECT process

Advance care planning is the ongoing conversation with a resident — and, where appropriate, their family — about what matters to them as their health declines: where they want to be cared for, what treatments they would and would not want, and who should be involved in decisions if they lose capacity to make them. Good advance care planning starts well before someone is imminently dying, ideally as part of admission and care planning, and is revisited as circumstances change.

The nationally recognised tool for recording this in England is ReSPECT — the Recommended Summary Plan for Emergency Care and Treatment. Developed by the Resuscitation Council UK working with patients, carers and a range of health and care organisations, ReSPECT creates a single-page, portable summary of personalised recommendations for a person's clinical care in a future emergency, covering not just CPR but the full range of treatment and escalation decisions. It is built on a conversation between the resident (or their representative), their family and a health professional, and it travels with the person between care home, ambulance service and hospital, so their wishes stay visible to whoever is treating them. ReSPECT has progressively replaced older, narrower approaches that relied on a standalone DNACPR form completed in isolation, because a form on its own doesn't record the reasoning, the conversation, or the wider treatment wishes behind it.

For CQC, a home that can show a current, resident-specific ReSPECT plan (or equivalent local advance care planning document), reviewed regularly and referenced in day-to-day care planning, is demonstrating exactly the kind of person-centred, safe practice that Regulations 9 and 12 require. A home that only has an out-of-date DNACPR form in a file, disconnected from the resident's wider care plan, is a common inspection finding — and typically a sign of the same governance gaps that show up elsewhere in a service.

Getting DNACPR decisions right: no blanket policies

DNACPR decisions are the part of end of life care most likely to draw CQC scrutiny, and the part most likely to go wrong. Joint guidance from the Resuscitation Council UK, the British Medical Association and the Royal College of Nursing is unambiguous: a DNACPR decision must be made for an individual, based on clinical judgement about whether CPR would be successful and in that person's best interests, following discussion with the resident where they have capacity, or their family and representatives where they do not, wherever possible. A DNACPR decision must never be applied as a blanket policy to a group of people — by age, diagnosis, disability, or simply because they live in a particular care home.

This is not a theoretical risk. In March 2021, CQC published the findings of its review, Protect, respect, connect — decisions about living and dying well during COVID-19, commissioned after widespread concern that DNACPR decisions were being applied inappropriately during the pandemic. The review found worrying variation in practice, including evidence that DNACPR decisions had, in some cases, been applied to groups of people without the individual assessment and conversation that good practice requires, alongside poor record-keeping, inconsistent training and a lack of oversight of how decisions were reached. CQC described some of what it found as a potential breach of people's human rights and called for clearer national guidance and better local oversight — findings that fed directly into the wider push toward standardised tools like ReSPECT.

For a registered manager, the practical takeaway is that DNACPR decisions need a visible, individual paper trail: who was involved in the conversation, what was discussed, what the resident's own wishes were, or, if they lacked capacity, how a best-interests decision was reached under the Mental Capacity Act, and when the decision was last reviewed. Getting the decision-making process right matters as much to CQC as the decision itself — a point that overlaps closely with mental capacity and best-interests practice; see our guide to Mental Capacity Act and DoLS training requirements for how the two connect.

The Gold Standards Framework: a structured approach to palliative care

Many UK care homes use the Gold Standards Framework (GSF) to structure how they identify, plan for and deliver end of life care. GSF is a recognised training and accreditation programme, developed specifically for primary and community care settings including care homes, that gives staff a consistent method for identifying residents who may be approaching the end of their life, coordinating their care proactively rather than reactively, and communicating clearly with residents, families and external clinicians such as GPs and district nurses. Homes that complete GSF training and accreditation typically adopt tools such as a register of residents nearing end of life, regular multidisciplinary reviews, and structured advance care planning conversations built into the care planning cycle.

Adopting a recognised framework like GSF isn't a CQC requirement in itself, but it gives a home a defensible, evidenced structure for exactly the kind of person-centred and safe care inspectors are assessing — and it gives staff who might otherwise feel out of their depth a clear process to follow when a resident's health starts to decline.

What good evidence looks like at inspection

When CQC looks at end of life care, inspectors are rarely satisfied by a policy document alone. What tends to stand up well includes:

• Resident-specific advance care plans (ReSPECT or equivalent) that are dated, signed, and clearly the product of a real conversation rather than a box-ticking exercise;
• DNACPR decisions with a documented rationale, evidence of who was consulted, and a review date;
• Care plans updated as a resident's condition changes, not just at the standard review interval;
• Evidence that staff — including night and agency staff — know where to find a resident's current wishes and can describe them accurately;
• A clear record of how the home worked with GPs, district nurses and specialist palliative care teams, and how families were kept informed and supported.

This is, in effect, a documentation and governance exercise as much as a clinical one, and the same discipline that keeps a home's incident records inspection-ready applies here too — our piece on documentation standards for incident investigation covers record-keeping practices that transfer directly to end of life files.

Training staff with confidence, not just compliance

End of life conversations are difficult, and staff who haven't been trained to have them will understandably avoid or rush them — which is exactly when advance care planning becomes a paperwork exercise instead of a genuine reflection of what a resident wants. Structured CPD in end of life care, advance care planning, DNACPR decision-making and the Mental Capacity Act gives care staff the confidence and vocabulary to have these conversations well, and gives registered managers a documented training record to show CQC when asked how the home assures competence in this area. Learnsignal's CPD courses for health and social care cover end of life care alongside the wider regulatory and clinical topics CQC expects staff to be trained in.

End of life care will always be judged on how a resident's wishes were captured, communicated and honoured — not on whether a form exists. Building a home's practice around a recognised process like ReSPECT, following the individual, well-reasoned approach to DNACPR that national guidance requires, and structuring palliative care with a framework like the Gold Standards Framework gives a home a genuinely person-centred, defensible position at inspection — and, more importantly, gives residents and their families confidence that their wishes will be respected when it matters most.