The care plan

The care plan must always be recorded in writing. All service users, including those on standard CPA must have an opportunity to sign the agreed care plan and then receive a copy.

What should a care plan include?

Care plans for all service users should include:

• How the services will intervene and what should be expected of them
• Details of what the services should do to reach agreed goals
• Give a time scale for action
• Details of which agency does what
• Have a date of the next planned review
• Include a plan of what should happen in a crisis
• Include arrangements for mental health care including medication and other care.

For people on enhanced CPA the care plan should include:

• Arrangements for management of risk to the service user and to others, carers, and the wider public including circumstances when action should be taken.
• A crisis plan which should include - who the user is most responsive to; how to contact that person; previous arrangements to prevent crisis developing at short notice, either if the care co-ordinator is not available or if part of the care plan cannot be provided.
• Arrangements for physical health care
• Action needed to secure accommodation
• Arrangements to provide domestic support
• Action needed for employment, education and training
• Arrangements for adequate income
• Action to provide for cultural and faith needs
• Arrangements to promote independence and sustain social contact.

For service users with severe mental illness who are at risk of suicide the care plan should include:

• More intensive provision for the first three months after discharge from in-patient care
• Specific follow-up in the first week after discharge.