Standard 17: There is a single care plan that operates across all service care providers.

Criteria
17a The single care plan records a nominated co-ordinator who has been identified and agreed with the involvement of the service user.

17b The single care plan operates across all service care providers and:
• is based on the assessment of needs, strengths and past experience
• identifies goals and aspirations
• specifies tasks, treatment and interventions (including risk management)
• records roles and responsibilities of all individuals and agencies involved
• includes a record of service user desired outcome (self-directed outcome)
• includes a system to record disagreement
• records that service users are invited to hold a copy of the care plan, and
• records unmet needs since the last assessment.

17c The single care plan is reviewed regularly (at least annually and for dementia at least every 6 months).

17d The single care plan includes:
• a record of the service user’s named person, where applicable
• the offer of an advance statement
• a crisis plan drawn up by the service user and care team, and
• a staying-well plan.