Rationale
The single care plan should be based on the multi-agency and multidisciplinary assessment of needs. To co-ordinate services and ensure continuity of care, roles and responsibilities should be agreed. For the service user, this should include discussion of service user role and responsibilities in promoting their own wellbeing. Information should also be provided to the informal carer to support them to care.

The service user should be involved in the nomination of a care plan co-ordinator, who has responsibility for planning, managing and reviewing the plan at an agreed frequency (at least annually). The service user should also be invited to give consent for a copy of the care plan to be held by their informal carer.

Crisis intervention plans should be developed with service users who are experiencing a crisis of such severity that without professional intervention the person would require a hospital stay (National Standards for Crisis Services, Scottish Executive 2006).

Examples of evidence required to meet standard 17:
- The local policy or agreement with partner agencies on how a single care plan for an individual will operate across all service care providers
- A blank template care plan containing sections confirming that it:
- names a nominated care plan co-ordinator
- 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
- records unmet needs since the last assessment
- includes a record of the service user's named person, where applicable
- includes the offer of an advance statement
- includes a crisis plan drawn up by the service user and care team
- includes a staying-well plan
- contains a date of the next review