Single care plan
Standard 17: There is a single care plan that operates across all
service care providers.
17a The single care plan records a nominated co-ordinator who has
been identified and agreed with the involvement of the service
17b The single care plan operates across all service care providers
• is based on the assessment of needs, strengths and past
• identifies goals and aspirations
• specifies tasks, treatment and interventions (including risk
• records roles and responsibilities of all individuals and
• includes a record of service user desired outcome (self-directed
• includes a system to record disagreement
• records that service users are invited to hold a copy of the care
• 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
• the offer of an advance statement
• a crisis plan drawn up by the service user and care team,
• a staying-well plan.