Transition from Children’s to Adults Services · 2015-04-02 · pre-publication draft - content...

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Transition from Children’s to Adults Services

P46 – PROCEDURE V1.1 2015-04-01

WARNING! PLEASE NOTE IF THE REVIEW DATE SHOWN BELOW HAS PASSED THIS PROCEDURE MAY NO LONGER BE CURRENT AND YOU SHOULD CHECK THE

E-LIBRARY FOR THE MOST UP TO DATE VERSION

THIS PROCEDURE APPLIES IN THE FOLLOWING DIRECTORATE(S)/ UNIT(S) (please delete as appropriate)

Adult Social Care, including Cumbria Care

Children’s Services

CONTENTS

1. INTRODUCTION / BACKGROUND ................................................................... 3

Carers ................................................................................................................ 3

Young carers ...................................................................................................... 4

Disability ............................................................................................................. 4

The Care Act: Transition .................................................................................... 6

Assessment and Eligibility .................................................................................. 6

Safeguarding ...................................................................................................... 7

Health and Mental Health ................................................................................... 7

2. GUIDING PRINCIPLES FOR TRANSITION PLANNING FOR YOUNG PEOPLE

WITH DISABILITIES AND ADDITIONAL NEEDS IN CUMBRIA .............................. 8

Values: ............................................................................................................... 8

Partnership: ........................................................................................................ 8

Person-centred approach: .................................................................................. 8

Lead professional and the Team around the Young Person: .............................. 8

Working with the family: ..................................................................................... 9

Information sharing:............................................................................................ 9

Information, advice and guidance: ...................................................................... 9

Additions to Options after Leaving School: ......................................................... 9

Programmes and grants & specialist support: .................................................. 10

Guidance for Year 8 (summer term) 12-13 years ............................................. 11

Guidance for Year 9 13 -14 years (Preparation) ............................................... 12

Guidance for Year 9 (Preparation cont.) ........................................................... 13

Guidance for Year 9 (Transition Review) .......................................................... 14

http://inetweb1/socsarchive/user/archive.asp


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Guidance for Year 10 14 – 15 years (Preparation) ........................................... 14

Guidance for Year 11 15 -16 years (Preparation) ............................................. 15

Guidance for Year 11 (Annual Review) ............................................................ 16

Guidance for Year 12 16 – 17 years (preparation) ............................................ 17

Guidance for Year 12 (Annual Review) ............................................................ 19

Guidance for Year 12 (Annual Review cont) ..................................................... 20

Guidance for Year 13/14 17 – 19 years (preparation) ....................................... 20

Guidance for Year 13/14 (Annual Review) ....................................................... 20

3. OPTIONS AFTER LEAVING SCHOOL ........................................................... 21

Programmes and grants & specialist support ................................................... 21

Continued education options ............................................................................ 22

Cost of college ................................................................................................. 22

Adult Social Care ............................................................................................. 23

Health Support ................................................................................................. 24

TRANSITION PROCESS FLOWCHART .......................................................... 25

DOCUMENT HISTORY ........................................................................................... 26


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1. INTRODUCTION / BACKGROUND This document seeks to set out the processes and responsibilities for managing the transition of young people with care care needs, their Carers and young Carers to ensure that there is no gap in services upon reaching the age of 18 – it is aimed at all staff and other stakeholders who may be involved in the Transition process. It should be read in conjunction with the following legal and policy documentation and key resources:

The Care Act 2014 - Part 1 Section 58 to 66 The Care and Support (Children’s Carers) Regulations 2014

Chapter 16 of the Care and Support Statutory Guidance

Carers and Disabled Children Act 2000 – Section 2

Children and Families Act 2014 – Part 3

Children Act 1989 – Section 17

Children Act 2004 - Sections 10 and 11

Children (Leaving Care) Act 2000

Chronically Sick and Disabled Persons Act (CSDPA) 1970 – Section 2

Education Act 1996 - Section 323

NHS Act 2006 – Section 82

SEND code of practice: 0 to 25:

All-Party Parliamentary Group on Autism (2009) Transition to adulthood: Inquiry into transition to adulthood for young people with autism

Care Quality Commission (2014) From the pond into the sea: Children’s transition to adult health services

Department for Education (2010) The Children Act 1989. Guidance and Regulations Volume 3: Planning Transition to Adulthood for Care Leavers

Department for Education (2012) Care leavers in England: data pack

Department for Education (2013) Care leaver strategy: a cross-departmental strategy for young people leaving care

Department of Health (2013) Code of Practice for Children with Special Educations Needs

Department of Health (2014) Transition to adult care and support

Getting a Life The Getting a Life programme ran from 2008 to 2011, as part of the Valuing People Now strategy. It was set up to drive the changes needed to ensure young people with severe learning disabilities achieve paid employment and full lives when they leave education.

HM Government (2014) Disabled Students’ Allowances (DSAs)

HM Government (2013) Staying put: arrangements for care leavers aged 18 years and above

Preparing for adulthood A programme funded by the Department for Education as part of the delivery support for the SEN and disability reforms.

Health and Care Services internal procedures and guidance Carers

Carers Support Centre Bristol and Gloucestershire Transition National Carers’ Strategy

Carers’ Trust Carers’ stories

Examples of practice in supporting young carers including Tiered support for young carers

Matter for Young Adult Carers Matter gives young adult carers in the UK a space to connect, share advice and access trusted support.

NIACE (2010) We are carers and we want to learn! Easy Read

NHS Parent caring


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Young Minds (2011) Guide to transition for parents and carers Young carers

ADAS, ADCS, Children’s Society (2012) Working together to support young carers and their families

Channel 4 (2014) Britain’s youngest carers

Young carers tell their story.

Carer’s Trust (2014) Time to be heard

Children’s Society (2013) Hidden from view: the experiences of young carers in England

Children’s Society (2008) Young carers, parents and their families: key principles of practice. Supportive practice guidance for those who work directly with, or commission services for, young carers and their families

Children’s Society (2014) Include Programme: supporting young carers and their families

NHS (2014) Young carers hub

NIACE (2014) The really useful book of learning and earning (RUBLE) for young adult carers

SCIE (2005) Research Briefing 11: The health & wellbeing of young carers

SCIE (2008) Research briefing 24: Experiences of children and young people caring for a parent with a mental health problem

SCIE (2010) Recognising young carers: See me, hear me, talk to me

SCIE Young Carers Assessment Protocol

The Site (2014) Support for young carers Disability

Action for Children (2009) The transition to adulthood: keeping disabled young people at the centre

Association for Real Change (2011) ARC guide for services: supporting disabled young people from black and minority ethnic communities through the transition to adulthood

Association for Real Change Scotland (2014) Principles of Transition 2

Cerebra (2013) Transition to adulthood: a guide for practitioners working with disabled young people and their families

Transition to adulthood: a guide for parents

Change Making transition work: Supporting young people with learning disabilities to get on the ladder of work

Contact a family (2014) Preparing for adult life and transition: information for families

Council for Disabled Children Disabled children: a legal handbook (Chapter 10: ‘Transition to adulthood’)

Croydon Borough Council A guide to transition planning: transition guide for parents/carers of disabled young people

DH (2007) archived Good practice guidance on working with parents with a learning disability

Dimensions Transition: How to find your way through

Disability Talk: a website for disabled people offering help, guidance and advice

foundation for people with learning disabilities (2009) Prepared for the future? Information to prepare families when a young person with a learning disability is leaving school or college

foundation for people with learning disabilities (2013) Thinking ahead: a planning guide for families

foundation for people with learning disabilities (2005) We are the strongest link


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Gloucestershire Youth Support Team (2013) Forward: information for parents and carers on opportunities for young people with learning difficulties and disabilities

Hampshire County Council (2011) The Hampshire transition handbook for families and carers

Hertfordshire County Council, Ideas 4 Life and Youth Connexions (2013) Thinking about the future: a transition guide for parents and carers of young people with additional needs

IRISS (2010) Transition to adulthood for young people with autistic spectrum disorder (ASD)

Mencap (2009) Your guide to transition

Moving on up (2007) Moving on up: a guide for professionals about transition for people with learning disabilities from ethnic minorities

National Autistic Society Parents of adults with autism: your rights

National Autistic Society Transition to adulthood

National Deaf Children’s Society (2011) Transition from paediatric to adult audiology services: guidelines for professionals working with deaf children and young people

NHS East Midlands (2010) Principles for transition: guidance materials to improve transition into adult life for young people with additional needs Based upon a Young People’s Charter

NHS Kensington and Chelsea, Royal Borough of Kensington and Chelsea (2006) In transition to adult life: information for parents and carers of young people with a learning disability

National Transition Support Team (2011) Person-centred approaches in transition planning

Next Steps Next steps: a guide to transition planning

Preparing for adulthood A programme funded by the Department for Education as part of the delivery support for the SEN and disability reforms.

Preparing for Adulthood (sample transition plan) My transition plan: achieving a successful move into adulthood

Delivering Support and Aspiration for disabled young people

Factsheet: The Links between the Children and Families Act and the Car Act.

Revolving Doors Agency Aiming higher – Transition to adulthood: a good practice guide

RNIB (2013) Your future, your choice: bridging the gap. Supporting your transition from school to college, university or work

SCIE (2004) The road ahead: information for young people with learning difficulties, their families and supporters at transition

SCIE (2007) Community-based day activities and supports for people with learning disabilities- transition planning

SCIE (2009) Making choice a reality: the impact of the mental Capacity Act on Young People in Transition to Adulthood

SCIE (2011) Guide 43: Improving access to social care for adults with autism

Sense Getting a result! Information and ideas to help young people who are multi-sensory-impaired and their families understand and participate more fully in the transition planning process

Transition Information Network (2009) TransMap: from theory to practice: the underlying principles in supporting disabled young people in transition to adulthood

About Transition Information Network

Transition Pathways (2005) The big picture: your guide to transition. For young people aged 13–25

TTRB3 Transition pathway: guidance and tools to support person-centred planning for young disabled people aged 13–25


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Wandsworth Borough Council (2011) Moving on: a guide to transition in Wandsworth for young people with disabilities and special needs

Warwickshire County Council Transition information pack for parents and carers

Working Families (2011) From child to adult: a guide to disability, transition and family finance

Young People's Support Services (2013) Transition planning information for young people from year 9

The Care Act: Transition

Transition to adult care and support comes at a time when a lot of change can take place in a young person’s life. Effective person-centred transition planning is essential to support the young person and their family during this time of change. Some of the life outcomes that matter for young people approaching adulthood and their families, may include (but are not limited to):

Paid employment;

Good health;

Completing exams or moving to further education;

Independent living (choice and control over one’s life and good housing options);

Social inclusion (friends, relationships and community). The wellbeing of each young person or carer must be taken into account so that

assessment and planning is based around the individual needs, wishes, and outcomes which matter to that person. Early conversations provide an opportunity for young people and their families to reflect on their strengths, needs and desired outcomes, and to plan ahead for how they will achieve their goals. Professionals from different agencies, families, friends and the wider community should work together in a coordinated manner around each young person or carer to help raise their aspirations and achieve the outcomes that matter to them. The purpose of carrying out transition assessments is to provide young people and their families with information so that they know what to expect in the future and can prepare for adulthood. Assessment and Eligibility

The same standard and approaches apply to the assessment of young people in transition as to adults and as such staff should refer to internal procedures and guidance:

ASC-P35 Procedure Assessment

Guidance – Assessment

ASC-P36 Procedure Eligibility

Guidance – Eligibility

Protocol For The Transition Of Young People From Child And Adolescent Mental Health Services To Adult Mental Health Services


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Safeguarding

The same standard and approaches apply to safeguarding of young people in transition as to adults and as such staff should refer to internal procedures and guidance:

ASC-P9 Safeguarding Health and Mental Health The National Service Framework for Children, Young People and Maternity Services sets standards for health and social services for children and young people with a view to ensuring fair, high quality and integrated care from pregnancy through to adulthood. Standard 4 is that: “All young people have access to age-appropriate services which are responsive to their specific needs as they grow into adulthood”. This includes ensuring that “All transition processes are planned in partnership and focussed around the preparation of the young person. PCTs, local authorities a commissioned Careers Information Advice and Guidance Services have agreed protocols detailing roles and responsibilities for co-ordinating transition process, including schools, children and adults social services and health teams. ...” Standard 8 covers disabled children and young people and those with complex health needs: “Children and young people who are disabled or who have complex health needs receive co-ordinated, high quality child and family-centred services which are based on assessed needs, which promote social inclusion and, where possible, which enable them and their families to live ordinary lives.” It is essential that there is a smooth transition of care and transfer of responsibility from Child and Adolescent Mental Health Services (CAMHS) to secondary care Adult Mental Health Psychosis and Non Psychosis Services or Early Intervention in Psychosis Service (EIP) when a Service User reaches 18 years of age. Agreeing the point at which Service Users move from CAMHS to Adult Mental Health Services is one aspect of ensuring a seamless service for the Trust and Adult Social Care, whilst encouraging collaborative working practices. The Mental Health Policy Implementation Guide (2002) suggests that there should be flexibility in the way care is determined, in line with locally agreed protocols, concerning transitions from CAMHS to Adult Mental Health Services. The National Service Framework for Children (Standard 9 for CAMHS) clearly states that the age range for the service is extended to 18 years, which is reflected within the protocol. There are also some circumstances where Children’s Services may retain responsibility for young people until the age of 21. The development of Early Intervention Services in first onset psychosis demands a clear framework for Service Users between the ages of 14-35. The Mental Health Policy Implementation Guide (2002) identifies a need to provide a young person-centred, seamless service that effectively integrates CAMHS and Adult Mental Health Services, which works in partnership with Primary Care, Education, Social Services, Youth and other related services. The detail of the Protocol For The Transition Of Young People From Child And Adolescent Mental Health Services To Adult Mental Health Services


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can be found on Cumbria Partnership NHS Trust website or via this link https://www.cumbriapartnership.nhs.uk/health-professionals/policy-documents/category/clinical 2. GUIDING PRINCIPLES FOR TRANSITION PLANNING FOR YOUNG PEOPLE WITH DISABILITIES AND ADDITIONAL NEEDS IN CUMBRIA

Above all, our aim for transition planning is to achieve the best possible outcome for each young person and to maximise their independence, choice and control, equitably within available resources. We are committed to working together to overcome obstacles and joining up services in order to achieve this aim Values:

We will ensure that every young person has the opportunity to make informed choices and exercise control over their life.

All those working with young people in transition will promote independence, rights, choice and inclusion for the young person.

Partnership:

Everyone involved in transition planning will work in partnership to ensure positive outcomes for each young person.

Partner organisations have a joint responsibility to ensure an appropriate co-ordinated response to the needs of the young person, whether through provision of direct support or of advice and guidance.

Professionals should understand their role and those of others involved.

Good communication is vital to ensure an open and balanced approach. Person-centred approach:

Transition planning is for the young person and is about what is important to them.

All young people should be involved in drawing up their Transition Plan in partnership with the key people in their life to ensure their plan is meaningful to them.

Young people will always be given the opportunity to be present at their Transition Review.

Young people with significant communication difficulties will be supported to express their own views and to participate as fully as possible in the transition planning process.

The aim of transition planning is to achieve the best possible outcomes for young people.

We will monitor our success in improving outcomes defined in EHCPs and Quality of Life Outcomes for young people in transition and share results.

We will listen to people to learn from the experiences of young people, their families and professionals.

Lead professional and the Team around the Young Person:

An identified person will act as the main point of contact or lead professional for young people and their families.

The lead professional is responsible for:

o Keeping the young person and their family informed o Ensuring good communication between professionals. o Ensuring that this Transition Protocol is followed. o Ensuring delivery of the outcomes in the Plan.

https://www.cumbriapartnership.nhs.uk/health-professionals/policy-documents/category/clinical

https://www.cumbriapartnership.nhs.uk/health-professionals/policy-documents/category/clinical


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All practitioners offering support to a young person and their family are part of the Team around the young person. Each member of the Team will take responsibility for:

o accepting the lead role if appropriate o keeping the lead professional up to date with developments o remaining accessible and involved until no further action is needed. o taking responsibility for elements of the Plan.

Working with the family:

The focus of the Transition Plan is on the young person’s needs and desired outcomes.

It is important that those involved in transition planning work in partnership with families and carers.

The needs of family members and carers should be acknowledged and parents and carers offered a carer’s assessment to identify and address their own needs.

Information sharing:

Young people and their families will always be asked for their consent to the sharing of information.

Wherever possible, we will not require young people and their families to provide the same basic information more than once for assessment and monitoring purposes.

Services and professionals will have arrangements in place to facilitate sharing of information.

Information sharing arrangements will take full account of data protection requirements and respect the individual’s right to confidentiality, but will facilitate provision of a co-ordinated, multi-agency service to the young person and their family.

It is important that all relevant information is shared appropriately to inform transition planning.

Information, advice and guidance:

We will provide accessible information to young people and their families, including information on:

o The role of different agencies o Team members and their contact details o How to access advocacy services o How to make a complaint

Additions to Options after Leaving School:

A Disability Employment Adviser (DEA) at your local Jobcentre can help you find a job or gain new skills and tell you about disability friendly employers in your area. They can also advise you about claiming DWP benefits such as Universal Credit; Jobseekers Allowance; Employment Support Allowance and Personal Independent Payment. Services include:

Employment Assessment to identify skills and experience;

Referral to a Work Psychologist for specialist assessment;

Practical advice regarding adjustments or support at work;

Advice regarding employers’ obligations under the Equality Act 2010


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Programmes and grants & specialist support:

Your DEA can tell you about programmes and grants to help you back into work. These include:

Work Choice – a specialist employment programme for disabled people that helps you find a job, and get support when you start work;

Residential Training – provided by specialist colleges that offer a wide range of vocational training to improve your skills and employment prospects;

Access to Work – a programme that provides practical and financial support to help you and employers’ overcome barriers to starting or keeping a job.

DEA’s usually have links with local Careers Services such as Inspira. Ask your Inspira Personal Adviser about referral arrangements in your area or call in to your local Jobcentre and ask to make an appointment to speak to a DEA.


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Guidance for Year 8 (summer term) 12-13 years

What should happen? Who should do it? Guidance

Identify the young people who have Education Health and Care Plans (EHCP). Senco and Assessment Officers will identify any young person who needs more support during their Transition Reviews.

School – Special Educational Needs Co-ordinator.

Assessment Officers.

As above

Start to work with the young person to explain the Transition process.

School – Special Educational Needs Co-ordinator

Refer to this procedure

Advice and information sent to the young person and parent/carer(s).

School – Special Educational Needs Co-ordinator.

Young person’s involvement and communication needs to be identified.

School Link with Tutors, Parents/carers, Speech and Language Specialists and other relevant professionals.

These identified needs should be taken into consideration throughout the Transition process e.g. written report formats to inform Preparing for Adulthood outcomes within the EHCP.

Two weeks before the start of the academic year (Year 9) notification of all young people with EHCP ‘s who will require a Transition Review to be sent to Assessment Officer and Transition Workers.

Inclusive Learning – Special Educational Needs and Disabilities (SEND) Team

Transition Worker to consider timing of the assessment based upon when it is of “significant benefit” to the young person.

Transition Worker


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Guidance for Year 9 13 -14 years (Preparation)


EHC plan review at Year 9 must include a focus on preparing for adulthood.

School

The Head Teacher or Special Educational Needs Co-ordinator will start the process by contacting parent/carer(s)

Transition Workers

Assessment Officers

Ensure young people and families receive information on how to request a Child’s Needs Assessment (CNA) as part of the Care Act 2014.

Planning should include support to prepare for higher education (HE), general further education (GFE) and/or employment with appropriate pathways identified.

Should also include support to prepare for independent living where appropriate.

Should include support for maintaining good health in adult life.

Should include support in participating in society – including understanding mobility and transport support, social & community activities and developing and maintaining friendships and relationships.

Date of annual EHC plan review arranged.

School to liaise with Inspira Professional Adviser and young person / parent/carer(s)/transition worker/Assessment Officer and other relevant professionals including health.

Young person with disabilities and parent/carers to be consulted about other professionals involved.

School

EHC plan review dates to be sent to SEND Statement Officers, Locality LD & D team, Transition Workers, Children’s Community Nurses and other relevant agencies and key service providers as detailed in step above, to ensure representation. This will help to ensure that everyone attends the review.

School Where relevant effective planning with health services of the transition from specialist paediatric services to adult health care.


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Guidance for Year 9 (Preparation cont.)


Invitations to EHC Plan review and request for written reports to be sent. Young person and their parents/carers to be at the centre of the process.

School / young person. Minimum 2 months notice as part of annual planning.

Organisation of EHC Plan review meeting and the bringing together of the responses from agencies and parents.

School – Special Educational Needs Coordinator.

Assessment Officer

Transition Worker

Working in partnership

Pre-review meeting – To explain review process to young person and parent/carer(s)

School (Special Educational Needs Coordinator) – unless agreed another lead professional to do this.

There should be sufficient preparation time to enable young person and parent/carer(s) to understand purpose of review and its outcomes and to be prepared for EHC Plan review.

Preparation by everyone involved for Year 9 EHC Plan review (as defined by Special Educational Needs Code of Practice and other statutory guidance).

Copies of all reports to be sent to parent/carer(s) minimum of 2 weeks before review date.

Set up a session as part of the tutorial time to discuss Transition process.

Gathering information- e.g. about the young person’s needs, Health Action Plan, Care Plan, Inspira Action Plan and identify if Common Assessment Framework has been completed.

School

School

School

School

Representatives could be from:

- School - Assessment Officers - Inspira Professional Adviser - Services for Children, Young

People and Families - Health - LD&D team - Existing Key Worker - Youth Service - Youth Offending Team - Transition Workers

Personal, Social and Health Education timetable could include preparation for Transition planning.


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Guidance for Year 9 (Transition Review)

What should happen? Who should do it? Guidance All options for over 16s

discussed.

Actions agreed by all parties – integrated EHC Plan.

CIAG Professional Adviser.

Health and Care representative (where appropriate)Assessment Officer

Head teacher (or delegated person) in consultation with Assessment Officer.

Referring to Pathways guidance within this protocol.

School - Special Educational Needs Coordinator to ensure schools use recommended format. (Need to make sure young people with learning difficulties are able to understand Transition Plan e.g. symbols or images rather than print).

Copy of updated EHC Plan including preparing for adulthood outcomes to be given to the young person, parent/carer(s) and appropriate partners.

School

Managing how the EHC Plan works.

Nominated person agreed at EHC Plan review.

Nominated person would normally be the person who is best placed to co-ordinate delivery of the EHC Plan. They would have experience in the critical points; they would act as main point of contact for young people and family in relation to delivering the plan. Parents and young people must also be included when deciding who the nominated person should be.

Guidance for Year 10 14 – 15 years (Preparation)


Preparation the same as for Year 9

At age 14 Childrens services should identify young people with likely needs for NHS continuing healthcare (NHS CHC) and relevant Clinical Commissioning Group informed. (Best practice point)


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Guidance for Year 10 (Annual Review)


Review the same as for Year 9 except for the following:

Year 9 updated EHC Plan to be reviewed and actions agreed by all parties. EHC Plan revised and adjusted where relevant.


Provide opportunities for young person to visit potential future educational provisions so that the young person can make informed decisions and choices.

School Local Offer

Availability of local provision to be kept updated.

Copy of Year 10 EHC Plan update to be given to young person, parent/carer(s) and relevant partners

School

Managing delivery of EHC Plan.

Nominated person agreed at EHC Plan review.

Nominated person would normally be the person who is best placed to co-ordinate delivery of the EHC Plan. They would have experience in the critical points; they would act as main point of contact for the plan. Parents and young people must also be included when deciding who the nominated person should be.

Guidance for Year 11 15 -16 years (Preparation)


Review to take place in Autumn term of Year 11

Allow maximum planning and preparation for the young person, family and professionals

Preparation the same as for Year 9 except for the following

EHC Plan review dates to be sent to Post 16 provider if already identified in addition to those as per Year 9

School Availability of local provision to be kept updated.

Local Offer

There should be a formal referral for adult NHS CHC screening at age 16 for those young people that may meet NHS CC criteria.(Best practice point)

Transition Worker

All

NHS CC guidance


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Year 10 updated EHC Plan reviewed and actions agreed by all parties. Revision to EHC Plan drawn up.

Agree who coordinates next review.


Post 16 provider (if young person is leaving school) in consultation with young person/parent/carer(s).

Health and Care representative (as appropriate)

There should be increasing involvement from adult services – Health, Social Care and Education.

Copy of Year 11 updated EHC Plan to be distributed to young person, parent/carer(s) and relevant partners.

School

EHC Plan to be passed by end of Spring term to Post 16 provider, LD&D Teams, Adult Social Care and other relevant agencies. EHC Plan must identify support needs within Further Education or Training and provision required to meet them.

Assessment Officer

Young person/ parent/carer(s)

School

This would not be required if the young person is moving into 6th form.

Over-seeing delivery of EHC Plan (Preparing for Adulthood).

Assessment Officer

Nominated Person agreed at Transition Review

Post 16 Provider

Nominated person would normally be the person who is best placed to co-ordinate delivery of the EHC Plan and have experience in the critical points; they would act as a main point of contact for young people and family in relation to delivering the plan. Parents and young people must also be included in deciding who the nominated person should be.


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Guidance for Year 12 16 – 17 years (preparation)


In principle decision re NHS CHC referral should be in place at 17 years old so that package of care can be in place once young person turns 18. (Best practice point)

Health Continuing Care Panel

Identify other young people who are likely to have care or support needs after turning 18, their carers and young carers?

Refer Carers to relevant pathway for assessment

Refer other young people for Transition assessment – assessment should be completed within 28 days of agreed start date and determination of eligibility communicated in writing

All

All

All – Transition Worker/Social Work Practitioner completes assessment

The Care Act

Date of annual EHC Plan review to be agreed.

School or other Post 16 provider to liaise with young person/parent/carer(s) and Assessment Officer.

Health and care lead for young people planning to leave education at 18.

EHC Plan review dates to be sent to Assessment Officers, Locality CWD Manager. Community Child Health (designated Medical Officer), other relevant agencies and key service providers including Education Psychologist (if appropriate) to ensure representation.

School or other Post 16 provider.

Proforma for letter for Post 16 provider

Young person /parent /carer(s) to be consulted about other professionals involved.

School or other Post 16 provider

Allocation of an Adult Services social worker for a CLA with disabilities at age 16 - 17 to attend the review so that an adult placement can be identified in preparation for the young person turning 18.

At 18 yrs old, Children’s

Adult Services / Children Looked After Team


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Services will work alongside Adult Services and withdraw gradually

Allocation of Adult Services social worker for young people with complex disabilities at 16 – 17, where considered appropriate.

Adult Services

Invitation to annual EHC Plan Review and requests for written reports to be sent. Involve the young person in this process. Minimum 2 months notice as part of annual planning.

School or other Post 16 provider/young person.

GP and Adult consultant as appropriate to be made aware of the needs of young person.

Paediatric Consultant/School Doctor

Organisation of review meeting and collation of the responses from agencies and parents.

School or other Post 16 provider.

Pre-review meeting to explain review process to young person with disabilities and parent/carer(s).

School or other Post 16 Provider - unless agreed another lead professional to do this.

Refer to this guide

Preparation by everyone involved for Year 12 EHC Plan review.

- copies of all reports to be sent

to parent/carer(s) minimum of 2 weeks before review date

- Set up a session as part of the

tutorial time to discuss Transition process.

- Gathering all relevant

information.

Representatives appropriate to young person/family to contribute by personal attendance or information provided in a way which is accessible to young person.

School or Post 16 provider.

School – Special Educational Needs Coordinator – or Post 16 Provider.


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Transition Screening to be completed which should be sent to the Local LDD teams and Adult Social Care pre-empting future needs

Year 11 EHC Plan reviewed and actions agreed by all parties. Revision to the EHC Plan drawn up.

Agree who coordinates next review

Assessment Officers.

Health and Care Services representative = lead for young people planning to leave education at 19.

Lead person identified for young person who is planning to leave education at 19


School or Post 16 provider (if young person is leaving school) in consultation with young person/parent/carer (s).

Transition Screening is a mechanism:

- to identify young people with very complex needs at an appropriate time in order to assist effective multi-agency working.

- to monitor the numbers of young people in specific categories of high need.

- to monitor the effectiveness of the referral, assessment and planning process.

There should be increasing involvement from adult services – Health, Social Care and Education

Copy of Year 12 Transition Plan to be distributed to young person, parent/carer and relevant partners

School

Over-seeing delivery of Transition Plan

Assessment Officer.

Nominated Person agreed at Transition Review.

Nominated person would normally be the person who is best placed to co-ordinate delivery of the EHC Plan. They would have experience in the critical points; they would act as a main point of contact for young people and family in relation to delivering the plan. Parents and young people must also be included when deciding who the nominated person is.


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Guidance for Year 12 (Annual Review cont)


If young person leaving School updated EHC Plan to be sent to the new Post 16 provider if appropriate and agreed

Assessment Officer

Young Person parent/carer(s)

Guidance for Year 13/14 17 – 19 years (preparation)


Identify other young people who are likely to have care or support needs after turning 18, their carers and young carers?

Refer Carers to relevant pathway for assessment

Refer young people for Transition assessment – assessment should be completed within 28 days of agreed start date and determination of eligibility communicated in writing

All

All

All - Transition Worker/Social Work Practitioner completes assessment

Preparation the same as for Year 12

Guidance for Year 13/14 (Annual Review)


Review the same as for Year 12 plus the following:

Agreement as to how and when further reviews (as necessary) will be conducted

All parties


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3. OPTIONS AFTER LEAVING SCHOOL

This section will look at the services available in Adult Services, which can be accessed by young people when they reach 18 i.e. options after the student leaves school. There are four main options for a student supported by an Education Health Care Plan / Statement of SEN to consider when they are looking at the opportunities available after they leave school:

continued education

community options

volunteering

employment Inspira is the main source of information about these options. Inspira helps young people (from the age of 13 up to 24) to prepare for their transition to adult life. Depending on the young person’s needs, an Inspira personal adviser can offer information, advice and guidance on many areas including education, benefits, training and employment. In addition young people should be encouraged to consider their aspirations for their living arrangements in the longer term. A Disability Employment Adviser (DEA) at your local Jobcentre can help you find a job or gain new skills and tell you about disability friendly employers in your area. They can also advise you about claiming DWP benefits such as Universal Credit; Jobseekers Allowance; Employment Support Allowance and Personal Independent Payment. Services include:

Employment Assessment to identify skills and experience;

Referral to a Work Psychologist for specialist assessment;

Practical advice regarding adjustments or support at work;

Advice regarding employers’ obligations under the Equality Act 2010 Programmes and grants & specialist support

Your DEA can tell you about programmes and grants to help you back into work. These include:

Work Choice – a specialist employment programme for disabled people that helps you find a job, and get support when you start work;

Residential Training – provided by specialist colleges that offer a wide range of vocational training to improve your skills and employment prospects;

Access to Work – a programme that provides practical and financial support to help you and employers’ overcome barriers to starting or keeping a job.

DEA’s usually have links with local Careers Services such as Inspira. Ask your Inspira Personal Adviser about referral arrangements in your area or call in to your local Jobcentre and ask to make an appointment to speak to a DEA.


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Continued education options

There are many things you will need to consider doing if you/your child wants to go to college when they leave school. The Government has increased the age to which all young people in England are required to continue in education or training - pupils who leave year 11 in summer 2014 or later will have to continue until at least their 18th birthday. This does not mean young people must stay in school. They will able to choose from:

full-time education (eg at a school or college) an apprenticeship or traineeship part-time education or training combined with one of the following:

o employment or self-employment for 20 hours or more a week o volunteering for 20 hours or more a week

Areas to consider:

Talk to the teachers at school who know you/your child and their skills and seek their advice.

Talk to the Inspira personal adviser at their school about general options.

When your child is 16, make an appointment to see the Inspira adviser to discuss your teenager’s particular needs and local options.

Visit the local colleges which are listed below to decide which college may be suitable.

If your child is interested in a college, tell the college of your interest and ask what their procedures are for putting your child’s name down for a placement.

If on assessment the local colleges cannot meet your needs you can look at specialist options.

Cost of college Local college There is no charge for local college courses which are full-time. You will need to pay for all the food and drink needs during the day. There are additional costs such as a contribution to the cost of cooking ingredients when there is a cooking session. Young people could get a bursary to help with education-related costs if they are aged 16 to 19 and:

studying at school or college (not university) in England on a training course, including unpaid apprenticeships

A bursary is money that the young person, or their education or training provider, can use to pay for things like:

clothing, books and other equipment for their course transport and lunch on days they study or train

There are 2 types of 16 to 19 bursary:

Vulnerable student bursary – a bursary worth up to £1,200, depending on circumstances.

Discretionary bursary - a discretionary bursary may be available if the young person needs financial help but doesn’t qualify for a vulnerable student bursary. The education or training provider decides how much you get and what it’s used for.


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The provider will decide how the bursary is paid. It might be:

paid in full or in instalments paid in cash, by cheque or through a bank account given a travel pass, free meals, books etc instead of money

Some providers also offer one-off payments to cover study trips or travel for university interviews. A young person must be:

under 19 at the start of the academic year they want a bursary for studying at school or college, or on an unpaid training course

Vulnerable student bursary Up to £1,200 could be available if at least 1 of the following applies:

the young person is in or recently left local authority care gets Income Support or Universal Credit in their own name is disabled and gets both Employment and Support Allowance (ESA), and

either Disability Living Allowance (DLA) or Personal Independence Payment (PIP) in their own name

The young person may get the full amount if they have expenses and study full-time on a course of at least 30 weeks. They will usually get less or no bursary, if their course is shorter, or they study part time or have few expenses. The provider will inform you of what evidence will be needed, e.g. benefit letters.

Discretionary bursary Education and training providers set their own criteria for discretionary bursaries, e.g. they might look at family income. Applications are made to the school, college or training provider and should be made as soon as the young person knows where they will study or train. Residential college If the LA pays for the entire placement, there will be no charge to you. However, if Adult Social Care pays a contribution towards the residential care then the student may be asked to help towards the costs from their benefits. They will still receive Disability Living Allowance (DLA) Mobility Allowance. The DLA care component will go towards the student’s care. Carers’ Allowance will only be paid in the holidays. You will need to provide spending money when they go to college. Preparing to go to college Some schools provide a ‘link’ course to a local college in the student’s last year in school to enable them to get used to college life. Adult Social Care

If the young person is in receipt of children’s services the Transition Worker will have completed an assessment as they approach adulthood to identify their needs and provide information about what they can expect when they become an adult. A social worker will have been allocated in order to arrange the support and services identified from the assessment and provide ongoing advice, information and guidance.


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Upon leaving school the Adult Social Care social worker/Transition Worker will continue to work with all parties, including Children’s Services potentially up to age 25, to ensure that care and support needs are met appropriately. If the young person is not in receipt of children’s services the Transition Worker will have completed an assessment as they approach adulthood to identify their needs and provide information about what they can expect when they become an adult. A social worker will have been allocated in order to arrange the support and services identified from the assessment and provide ongoing advice, information and guidance. If the young person remains in education, College, the Transition Worker may work alongside the social worker and continue to provide support, information and guidance and attend reviews and contribute to the Education Health & Care Plan, as long as the individual remains in education. Transition Worker input will diminish over time, in agreement with the social worker. The Transition Worker will work closely with Inspira to support young people and identify opportunities for education, training, volunteering, apprenticeships and employment. Once the adult social care social worker has taken over the case Health and Care Services procedures in relation to, for example: assessment, eligibility, care and support planning and review will apply. Health Support

Cumbria Partnership Foundation Trust recognises that transition is a purposeful, planned process that addresses the medical, psychosocial and educational/vocational needs of adolescents and young adults with long term physical and medical conditions as they move from child-centred to adult orientated health care systems. It should not be confused with “transfer” which is a single event whereby the young person’s care is transferred from one service to another. The transition process for Cumbria Partnership Foundation Trust utilises the Ready Steady Go programme as its preferred model. This consists of a series of questionnaires which address the medical, psychosocial and educational/vocational needs of young people in order to prepare them for accepting ownership of their ongoing needs. On completion, the questionnaires provide information to enable the completion of a transition plan which is held by the young person and can be used to inform any future health, education or social care professionals of the young person’s level of need and ability to take ownership for their own care. It is essential that the transition process is tailored for each young person’s individual need and is introduced appropriately and in a timely manner. The transition process is centred on the voice of the young person and clearly state their opinions and views. In instances where the Ready Steady Go programme is not considered to be

appropriate, an alternative method will be sought which meets the needs of the young person more closely. It is recognised that children’s and adult health care professionals need to provide developmentally appropriate health care for adolescents and young adults with chronic physical and medical conditions addressing medical, psychosocial and educational/vocational needs working together when necessary to support continuity. For this reason, transitional arrangements for health needs should be considered alongside social and educational/vocational needs with particular reference to the Special Educational Needs and Disability reforms (SEND reforms).


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Depending on the young person’s personal circumstances, the ideal age for commencing the transition process in health services is at age 11 years. This is a time of change for young people as they are moving from junior to secondary school, and are taking on more responsibility in all aspects of their lives. However, as some young people do not access health services until later in their teenage years, a flexible approach needs to be adopted and each young person’s situation needs to be assessed to ensure that needs are met appropriately. This is particularly poignant for young people whose presenting condition may not persist into adulthood. (e.g. young people who access CAMHS). TRANSITION PROCESS FLOWCHART


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DOCUMENT HISTORY

RELATED DOCUMENTS

OTHER RELATED DOCUMENTS

ASC-P35 Procedure Assessment

Guidance Assessment

ASC-P36 Procedure Eligibility

Guidance Eligibility

IAS Guidance

LEGISLATION OR OTHER STATUTORY REGULATIONS

See section in main document above

DOCUMENTS SUPERSEDED BY THIS PROCEDURE

N/A

APPROVAL AND REVIEW

Original Author: Gary Wilson

Current Author: (If different to original author)

Authorising Assistant Director:

Amanda Evans

Approved By: (Insert groups/ bodies and dates)

Legal Services – 31/03/2015

Consultation: (Insert details of who has been consulted on this procedure)

Date Originally Published:

01/04/2015

Date of Next Review:

DOCUMENT CHANGE HISTORY

Version No

Date Issued by Reason for change

V1.1 02/04/2015 Louise Johnstone

Addition of Mental Health and Adult Social information

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