Advance Care Planning Policy Suite (CQC Regulation 9 | MCA 2005 ADRT | DNACPR | ReSPECT | 13 Operational Forms)

Complete CQC-compliant Advance Care Planning documentation suite, built by a practising Registered Manager operating a CQC Good-rated community care service with ISO 9001 and ISO 45001 certification.

What’s included — 4 documents, 13 forms

✔ Policy Template (ACP1) — comprehensive advance care planning policy covering person-centred planning for future health, welfare, and end-of-life care; Mental Capacity Act 2005 sections 24–26 Advance Decisions to Refuse Treatment (ADRTs); Mental Capacity Act 2005 section 4 best interests decision-making; DNACPR decision-making protocols post-Tracey and post-Winspear case law; ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) process framework; End of Life (EOL) wishes documentation; bereavement and post-death support pathways; capacity assessment for ACP decisions under Mental Capacity Act 2005 sections 2 and 3; Lasting Power of Attorney recognition; Court of Protection deputy engagement; cultural and religious sensitivity at end of life; and quarterly governance oversight. Fully white-label and editable. Version 3.0.

✔ Excel Forms Workbook (ACP2) — 13 operational forms across 14 tabs (1 Contents index + 13 forms), each in a dedicated worksheet, cross-referenced within the policy body:

1. ACP Register and Tracker (Form 1) — organisation-wide register of service users offered advance care planning with progress status tracking
2. Individual ACP Record (Form 2) — a comprehensive person-centred record of the advance care plan for each consenting service user
3. ACP Review Record (Form 3) — annual and significant-change review documentation with DNACPR and ReSPECT integration
4. Advance Decision to Refuse Treatment (ADRT) Record (Form 4) — legally-binding ADRT documentation compliant with MCA 2005 sections 24–26, including witness requirements and validity criteria
5. Statement of Wishes and Preferences (Form 5) — non-binding but regulatorily material statement of preferences for end-of-life care
6. Capacity Assessment for ACP (Form 6) — decision-specific, time-specific capacity assessment under Mental Capacity Act 2005 sections 2 and 3 with diagnostic and functional tests
7. ACP Communication and Handover Record (Form 7) — ensures ACP wishes reach all providers across care transitions
8. Best Interests Decision Record (Form 8) — MCA 2005 section 4 checklist-compliant best interests framework for service users lacking capacity
9. ACP Audit and Compliance Checklist (Form 9) — quarterly audit of ACP programme compliance under CQC Regulation 17
10. Bereavement and Post-Death Support Record (Form 10) — records whether ACP's wishes were honoured; feedback from family members; supports continuous improvement
11. Quality Improvement Action Plan (Form 11) — structured QIAP framework for all AMBER and RED audit findings, incidents, and complaints
12. Mock CQC Inspection — Advance Care Planning (Form 12) — pre-inspection simulation replicating CQC questioning methodology
13. Annual Governance Report — Advance Care Planning (Form 13) — comprehensive annual ACP review for Board presentation under CQC Regulation 17

✔ Individual Word Forms (ACP3) — all 13 forms above as standalone, print-ready Word documents in fill-in format. Each form is self-contained with instructions and clearly labelled for day-one deployment.

✔ Master Implementation Checklist (ACP5) — comprehensive 5-phase implementation checklist covering policy tailoring, forms deployment, MCA framework and ACP conversations, staff training and competency, and governance and audit framework. RAG-rated priority coding throughout (MUST / SHOULD / GOOD PRACTICE) with task ownership, evidence requirements, and completion tracking. Designed to be completed before going live and retained as CQC inspection evidence. Estimated customisation time: 5–6 hours.

Regulatory coverage

• CQC Regulation 9 — Person-centred care (individualised advance care planning, wishes and preferences, ACP conversations) — primary regulation, inspected at every CQC visit under the Caring domain
• CQC Regulation 12 — Safe Treatment (ADRT compliance, DNACPR decision-making, emergency care wishes, clinical deterioration planning) — life-safety critical where end-of-life decisions are concerned
• CQC Regulation 13 — Safeguarding service users from abuse and treatment (undue influence on ACP decisions, financial abuse protection, capacity-based safeguarding)
• CQC Regulation 17 — Good governance (quarterly audit cycle, QIAP tracking, annual governance reporting, 3-year retention)
• CQC Regulation 20 — Duty of Candour (openness and transparency where ACP wishes have not been honoured, apology, investigation, systemic learning)
• Mental Capacity Act 2005 sections 24–26 — Advance Decisions to Treatment, statutory validity requirements, formalities for life-sustaining treatment refusals
• Mental Capacity Act 2005 sections 2 and 3 — Diagnostic and functional tests of capacity; decision-specific, time-specific capacity assessment
• Mental Capacity Act 2005 section 4 — Best interests checklist for decisions made on behalf of persons lacking capacity
• Mental Capacity Act 2005 Code of Practice — statutory guidance integrated throughout forms and decision-making frameworks
• Lasting Powers of Attorney — recognition of Health and Welfare LPAs, Property and Financial Affairs LPAs, Court of Protection deputy engagement
• Care Act 2014 — Wellbeing principle, continuity of care in planning, safeguarding under Section 42
• Human Rights Act 1998 Articles 2 and 8 — Right to life (life-sustaining treatment decisions); right to respect for private and family life (autonomy in end-of-life decisions)
• Equality Act 2010 — protected characteristics in ACP conversations, reasonable adjustments for accessible communication
• UK GDPR and Data Protection Act 2018 — lawful basis for processing ACP information, consent to share, special category data handling
• DNACPR legal framework — R (Tracey) v Cambridge University Hospitals (2014); Winspear v City Hospitals Sunderland (2015); statutory duty of consultation
• ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) — national emergency care planning framework integration
• General Medical Council and Nursing and Midwifery Council professional standards — Treatment and care towards the end of life: good practice in decision making
• CQC Single Assessment Framework — aligned to Responsive (R1 Person-centred care, R4 Listening to and involving people), Caring (C1 Kindness, compassion and dignity, C3 Independence, choice and control), Safe (S1 Learning culture, S2 Safeguarding), and Well-Led (W5 Governance, management and sustainability) quality statements

For all community services

Domiciliary care · Live-in care · Extra care housing · Supported living · Outreach · Day services · Reablement

Buy once — yours permanently

£84.99 one-time purchase. No subscription required. No renewal fees. Purchase once and deploy across your organisation.

Licence scope

This suite is licensed for use by the purchasing legal entity and any subsidiary undertakings registered under the same parent company at Companies House. The suite may be white-labelled with your organisational branding, customised to reflect your operational context, and deployed across your registered service types. The suite may not be resold, sublicensed, published to third-party platforms, or shared with providers outside your organisational group.

Why this suite

• Written by a practising Registered Manager operating a CQC Good-rated community care service with ISO 9001 and ISO 45001 certification
• Advance Care Planning is life-safety critical — an Advance Decision to Refuse Treatment (ADRT) that is not honoured results in unwanted life-sustaining treatment in contravention of the service user’s legally-binding refusal; an ADRT that is wrongly enforced (for example, because its validity is not assessed at the point of decision) can result in premature death. This suite provides the complete evidence trail for CQC Regulation 12 compliance at the end of life.
• Mental Capacity Act 2005 sections 24–26 fully operationalised in Form 4 ADRT Record — statutory validity requirements including age 18+, capacity at the time of making, specificity, Treatment being refused, in writing where life-sustaining treatment is concerned, signed and witnessed, and the statement “even if my life is at risk” for life-sustaining treatment refusals.
• DNACPR decision-making protocols post-Tracey (2014) and post-Winspear (2015) — R (Tracey) v Cambridge University Hospitals established the duty to consult with the patient before a DNACPR decision is made; Winspear v City Hospitals Sunderland extended this to incapacitated patients via consultation with those close to the patient. This suite operationalises both judgments into the Form 3 ACP Review Record.
• ReSPECT process integration — the national emergency care planning framework now adopted by many NHS Trusts; Form 3 ACP Review Record maps to the ReSPECT recommendation format for seamless hospital-community integration
• Best Interests Decision-Making framework under MCA 2005 section 4 — Form 8 operationalises the full statutory checklist (consider all relevant circumstances, consider whether capacity may return, permit and encourage participation, consider past and present wishes and feelings, consider beliefs and values, consult carers and relatives)
• Capacity Assessment (Form 6) is decision-specific and time-specific under MCA 2005 sections 2–3 — the functional test (understand, retain, use and weigh, communicate) is applied to each specific ACP decision rather than globally, and is aligned with the Mental Capacity Act 2005 Code of Practice.
• Bereavement and Post-Death Support Record (Form 10) — captures whether ACP wishes were honoured, feedback from family members, and systemic learning feeding back into the Annual Governance Report; this completes the governance loop from individual care through organisational quality improvement
• Quarterly audit cycle with QIAP (Form 11), 6-monthly Mock CQC Inspection (Form 12), and Annual Governance Report (Form 13) — the full three-tier governance architecture for sustained CQC Regulation 17 compliance and continuous improvement
• RAG-coded 5-phase implementation checklist with MUST, SHOULD, and GOOD PRACTICE priority coding — you know exactly what is mandatory for CQC compliance and what is quality enhancement.
• Cultural and religious sensitivity at the end of life, accessible formats and Easy Read, and professional standards (GMC and NMC guidelines), all embedded within the operational framework

File formats: 3 × Word (.docx) · 1 × Excel (.xlsx)

Delivered by: Care Franchising Compliance, a trading style of Care Franchising Limited (registered in England and Wales, Company No. 16271445).