CQC quality statement — Effective
Consent to care and treatment
"We tell people about their rights around consent and respect these when we deliver person-centred care and treatment." In MyCareCompliance, 9 mapped checks across 6 audit templates map to this quality statement.
Last reviewed: September 2026. This guidance reflects CQC information available at the date above — always refer to cqc.org.uk for current regulatory requirements.
How we check it
Each check below is a real question from a MyCareCompliance audit template. It names the regulation it evidences, describes what an auditor looks for in good and poor practice, and lists the evidence an inspector would expect you to produce.
- 9 mapped checks under the "Consent to care and treatment" quality statement
- Evidences 1 regulation: Regulation 11 — Need for consent
- Failed checks become tracked improvement actions with an owner, due date and evidence
The 9 checks
- Regulation 11 — Need for consentCare Plan Audit
Is there documented evidence of the person's consent to their care plan, or a mental capacity assessment and best interests decision if applicable?
What we look for: Look for a signature from the person or their legal representative (check LPA validity if family signs). Good looks like clear, consent-specific documentation. Fails if unsigned or if family signs without legal authority and no MCA/Best Interests process is followed.
Evidence: Signed consent forms, MCA forms, Best Interests decision records, LPA documentation
- Regulation 11 — Need for consentCompetency Audit
Are staff assessed on their practical understanding and application of the Mental Capacity Act (MCA) and consent during care delivery?
What we look for: Check if field supervisors observe staff gaining valid consent before tasks. Good looks like documentation showing staff asking permission and explaining tasks to clients, adjusting for cognitive impairments. A fail is observing staff performing tasks silently without checking client agreement.
Evidence: Spot check records, supervision notes, care plan review notes involving staff input
- Regulation 11 — Need for consentMCA / Consent / Best Interests
Is there documented evidence of signed, general consent to care and treatment from the person or their legal representative?
What we look for: Sample 5 care files. Check that a general consent form is completed and signed by the person. If signed by a relative, verify they have legal authority (LPA). Fails if consent is missing or signed by a relative without legal authority.
Evidence: Signed consent forms, Initial assessment records, Care plan signature pages
- Regulation 11 — Need for consentMCA / Consent / Best Interests
Are decision-specific Mental Capacity Assessments completed when there is doubt about a person's capacity to make a specific decision?
What we look for: Review files of people living with dementia or cognitive impairment. Ensure MCAs are decision-specific (e.g., capacity to consent to medication, care provision) and apply the two-stage test correctly. Fails if MCAs are generic or absent when capacity is clearly impaired.
Evidence: MCA forms (Stage 1 and 2), Decision-specific care plans, Care reviews
- Regulation 11 — Need for consentMCA / Consent / Best Interests
Are Best Interests decisions properly documented, involving relevant stakeholders such as family, professionals, or IMCAs?
What we look for: Check files where a person lacks capacity for a specific decision. Verify a clear best interests process was followed, documenting who was consulted and why the decision is the least restrictive option. Fails if care is provided against their will without a documented BI decision.
Evidence: Best Interests meeting minutes, Best Interests decision forms, IMCA reports, Care plans
- Regulation 11 — Need for consentMCA / Consent / Best Interests
Is legal authority verified and documented when family members or representatives make decisions on behalf of a person?
What we look for: Where a family member signs care plans or makes health decisions, check for a verified copy of an LPA (Health & Welfare) or Deputyship order on file. Fails if the service accepts family decisions overriding the person without verified legal authority.
Evidence: Copies of Lasting Power of Attorney (Health and Welfare), Court of Protection Deputyship orders
- Regulation 11 — Need for consentOnboarding New Service Users
Is there clearly documented, signed consent to care and data sharing obtained from the person or their legal representative prior to care delivery?
What we look for: Check the onboarding paperwork for explicit consent to receive care, share information, and (if applicable) manage keys/codes. If the person lacks capacity, look for an MCA assessment and evidence of who has the legal right to consent (e.g., LPA for Health and Welfare). Missing signatures or unverified LPAs are fails.
Evidence: Signed consent forms, Mental Capacity Act (MCA) specific assessments, Best Interests decision records, verified LPA documentation.
- Regulation 11 — Need for consentService User Experience
Are service users actively involved in giving informed consent for their risk management plans, especially regarding environmental or equipment risks?
What we look for: Review risk assessments for mobility, falls, and environment to ensure the service user's views and consent are documented. Good looks like client signatures or documented discussions about balancing risk with independence. A fail is risk mitigation strategies (e.g., removing rugs, hiding keys) implemented without the client's documented consent or a best interests decision.
Evidence: Risk assessments, Signed consent forms, Mental Capacity Act assessments, Care plan review records
- Regulation 11 — Need for consentService User Reviews Audit
Is consent to the revised care plan explicitly sought, recorded, and the Mental Capacity Act (MCA) applied if capacity is in doubt?
What we look for: Check that the person has signed to consent to any changes in care. If they lack capacity, ensure there is an MCA assessment and a best interests decision involving the right people. Fails if consent is presumed.
Evidence: Consent forms, Mental capacity assessments, Best interests decision records
Other Effective quality statements
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