Transition to Adulthood Multi Agency Protocol · Transition to Adulthood Multi Agency Protocol ......

Transition to Adulthood

Multi Agency Protocol DRAFT Version 11

June 2017

For Children and Young People with Complex Needs in Greenwich

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Section Page

1. Foreword and Vision 3

2. Introduction 4

3. Aims and Outcomes 5

4. Principles 6

5. Governance 7

6. Transition Process 9

7. Transition Pathway 13

8. Roles and responsibilities 23

Appendices:

Appendix A: Further Information and Guidance 26

Appendix B: Role Description for the Joint

Directorate Management Team (JDMT) 27

Appendix C: Role Description Multi-Agency Transition Panel Terms of Reference

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Contents

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1. Foreword and Vision

Drawing on the key messages from a multi-agency transition away day in July 2016, the

following organizations (below) are committed to the vision (above) and principles outlined in

this protocol

Our Vision:

We will work together to enable our young people to fulfil their potential and achieve

their dreams

Preparing for adulthood can be an exciting time for young people and their families. Plans are made

for their future and young people should enjoy increasing levels of independence and choice in their

lives. This can also be an anxious and confusing time when serious challenges may emerge,

especially for young people with complex needs. Getting the transition process right will provide

young people with positive goals and plans as they move into adult life. If it goes wrong there can be

confusion, anxiety and disappointment leading to poor outcomes in later years.

A key factor in determining whether the preparation process is successful is how well agencies can

work together and with young people and their families to create effective transition plans. Research

suggests that services designed with young people in mind and delivered by friendly, approachable

professionals can help them find the right support and advice at the right time and help them become

independent (NICE 2016).

It is essential that there are in place the right local arrangements to meet the aspirations of our young

people. These arrangements are not the responsibility of any one service but cover all of the

agencies who deliver education, health and social care services for these youngsters. This protocol

describes the transition pathway and aims to ensure that everyone understands the specific roles and

responsibilities of each agency at different stages in the process. This will lead to more effective

multiagency working and better outcomes for our young people.

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2. Introduction

The purpose of this protocol is to make clear the planning and review processes that support the move from adolescence to adulthood for young people from their 14th to their 18th birthday and their move in to Adult services. The protocol recognises that the SEND reforms mean that a young person’s Education Health and Care Plan may continue to their 25th birthday, as appropriate. Whilst all young people go through transition to adulthood, this protocol focuses on young people with disabilities and complex needs. All partners should ensure that the transition process for this group is timely and planned. This applies to those in receipt of assessed services

as well as those receiving other forms of support.

These transitions might include moving from one education setting to another, the transfer from Children’ Services to Adult Services or accessing new social or housing opportunities in the community. The protocol is relevant to all the professionals and agencies in the Borough of Greenwich that have a responsibility for ensuring that disabled young people make a successful transition to adulthood. These include professionals involved in planning and commissioning services as well as those who actually deliver them. The protocol does not replace internal processes within individual agencies but is intended to support and guide multi-agency planning.

This protocol applies to young people that:

Have a Statement of Special Educational Needs (SEN) or EHC plan or have specialist educational provision

May meet the eligibility criteria of under the Care Act 2014

Receive a service from the Children with Disabilities Team

Have continuing health/social care needs requiring referral onto adult services

Have complex needs (a combination of multiple and profound impairments, challenging behavior and learning disabilities and acute and chronic medical conditions)

Are not assessed as having special educational needs but who may need some support in planning for and adapting to adult life because of their disability

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Why does transition matter? The aim of this protocol is to ensure young people and their parents or carers have a positive experience when preparing for adulthood. Outlined below is what this should look like:

3. Aims and Outcomes

Young People

• Will have meaningful life choices

• Will be supported to make plans to achieve their desired outcomes

• Will be able to access the same opportunities as other young people

• Will have support to enable them to travel independently and access services.

• Will be able to try things out beforehand

• Will be able to change their mind

• Will have access to a range of accommodation opportunities

Young People and their Parents or Carers

• Will be listened to and fully involved in decision making as far as they are able

• Will have one point of contact to link with

• Will feel supported

• Will receive consistent messages

• Will have easy access to understandable information

• Will see agencies stick to agreed plans unless they need to be flexible to accommodate changes

• Will feel safe and experience safeguarding services that are seamless and vigilant as they move in to adulthood

In order to achieve the above this protocol seeks to ensure that:

Young people and their families are well supported and placed at the centre of all planning

Young people are encouraged to develop the skills and understanding they need to make informed choices

The transition process is coordinated, systematic and consistent

Post-16 services and opportunities are commissioned effectively, based on early identification of likely need for support

Planning should start early

We will measure these outcomes by:

How far the plans agreed with the young person have been achieved

Improved monitoring through the transition register and transition panel

Setting key performance targets e.g. for the percentage of young people with a learning difficulty or complex needs that are Not in Education, Training or Employment (NETE).

Using feedback from young people, their families and other stakeholders to monitor our progress over time.

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Drawing on the key messages from the multi-agency transition away day in July 2016 and from the work of the Preparing for Adulthood Programme in 2014 (http://www.preparingforadulthood.org.uk) all agencies involved in this protocol are committed to the following principles:

Person-centered transition planning: The young person should be at the centre of the transition planning process, giving them choice and control over their own future and ensuring the focus is on their needs, hopes and aspirations. Person-centered planning and reviews that support young people to express their views, should inform support planning and ensure positive outcomes for them.

Involvement and consultation of parents and carers: The parents and carers of our young people should be recognized as partners in the process and be actively involved in planning their future. The experience of young people and their families should also inform strategic planning and commissioning.

Partnership working across agencies: A shared vision, which places young people and their families at the centre and focuses on improving life chances, should be developed and owned across all partners. Key agencies must be committed to working together and have a clear understanding of the specific roles and responsibilities of each service.

Provision of accessible and clear information: Clear information should be shared with young people to help raise aspirations by illustrating what is available and what has already worked for others. Information should be developed with young people and their families to ensure it is relevant, accessible and understandable.

Working towards positive outcomes: Transition planning should be focused on achieving life outcomes, promoting independence and supporting young people to lead meaningful and enjoyable adult lives. This may involve consideration of personal budgets or other forms of allocating resources. The key measure of success will be how far the transition arrangements have allowed the young person to achieve their desired outcomes.

Early assessment and transition planning: Early assessment and transition planning facilitates more responsive and flexible forward planning. Timely assessments and transition plans are essential for commissioners to plan services to meet the projected support needs of young people moving into adulthood. Agencies should share relevant information with each other and with commissioners to ensure that the transition process is smooth and that services will be developed to meet the needs of young people as they move into adulthood Information must be accurate and timely and shared in adherence to data sharing principles

Quality and monitoring: Accurate monitoring ensures that the progress of all of our young people is tracked and none “fall through the net”. Mechanisms need to be built in to ensure the quality of provision meets appropriate standards and that the transition process is as effective as possible.

Safeguarding: It is a fundamental principle that children with complex needs have the same right as non-disabled children to be protected from harm and abuse. The relevant agencies need to ensure the seamless transfer of safeguarding arrangements as the young person approaches adulthood.

4. Principles

http://www.preparingforadulthood.org.uk/

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5. Governance

Joint Directorate Management Team (JDMT) JDMT oversees monitors and reviews the effectiveness of procedures, policies and protocols for transition to adult services across the Royal Borough of Greenwich. JDMT meets quarterly and is co-chaired by the Director of Adult and Older People Services and the Director of Children Services for the Borough. The JDMT ensures that agencies work together with young people and their families towards maximising their independence, supporting and raising young people’s own aspirations for social inclusion, education, employment and quality of life. The JDMT will:

Provide critical challenge to proposals where appropriate, to balance the needs, aspirations, wishes and resources available across the transition landscape

Consider proposals on strategic issues and emerging themes from the Transition’s Team that require a more strategic response and resolution, formulating proposals to the appropriate governance board.

Monitoring and Annually reviewing the effectiveness of this protocol

Resolving strategic issues with the aim of improving the transition process by identifying trends and gaps in service possess or practice.

Multi-Agency Transition to Adulthood Panel

The operation of the transition process is overseen by the Greenwich Transition Panel and coordinated by the Greenwich Transitions Team. Panel has operational responsibility for driving transition processes forward in the Royal Borough of Greenwich. A senior officer from Adult/Children’s Services chairs the Panel and attendees include officers from all agencies that have a role or responsibility for planning transition. The panel will;

Meet monthly to monitor and challenge the transition plans proposed for each young person as they prepare for adulthood.

Ensure adherence to the transition pathway, ensuring that proposals are person-centred and meet assessed, and where appropriate, eligible need.

Ensure that young people’s needs and aspirations are matched to the right resources available across the transition landscape

Track the progress of all children and young people in the transition process via the maintenance of a Transition Register

Capture feedback from young people, their families and other stakeholders.

(Role descriptions for both the JDMT and the Transition Panel can be found in appendix Band C)

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SEND Transformation Group

This is a multi-agency group including parent representatives, health and Local Authority Commissioners and Providers, and the voluntary sector. Working across the whole system, this group is overseeing the SEND reforms and is developing a SEND strategy and improvement plan. The group is linked to the Children’s Services Strategic Partnership and is responsible for delivering Priority 4 of the Greenwich Children and Young People Plan ‘we will pay particular attention to the experiences and needs of children with SEND as they often face barriers to reaching their full potential’ The SEND Transformation Group will:

Ensure that the voice, needs and experiences of parents, children and young people inform priorities and developments

Ensure that the organisations and services are actively part of preparation for Adulthood element of SEND reforms

Take a whole systems approach to improving outcomes for children with SEND and make or recommend changes to multi agency services, pathways, policies and procedures

SEND Joint Commissioning Group (JCG)

This is a strategic group of health and local authority commissioners with responsibility for commissioning services for children with SEND. The group is responsible for leading joint commissioning and ensuring joint and single agency commissioning contributes to a whole systems approach. The SEND JCG will:

Identify opportunities for joint commissioning

Oversee strategic commissioning decisions

Monitor and challenge performance across commissioned services

Ensure commissioned services are embedded within the children’s services system and are contributing to the delivery of the Greenwich Children and Young People Plan and SEND strategy

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6. Transition Process

Who can request an assessment? A young person or carer, or someone acting on their behalf has the right to request a transition

assessment. On receipt of a request Greenwich Transitions Panel will consider whether the “likely

need” and “significant benefit” conditions apply. If they do, then a transition assessment will be

carried out. If the Panel decides that the conditions do not apply, then the reasons for the refusal will

be sent in writing to the referrer in a timely manner. If the Transitions Panel judges that the young

person or carer is likely to have needs for care and support after turning 18, but that it is not yet of

significant benefit to carry out a transition assessment the Transitions Panel will indicate when it

believes the assessment will be of significant benefit. In these circumstances the Panel will agree the

timing of the assessment rather than leaving the young person or carer with uncertainty or having to

make repeated requests for assessment. Where a young person or carer has been refused an

assessment but later makes a further request the Panel will reconsider whether an assessment

should take place.

When should transition assessment be offered?

A transition assessment will be offered to a young person or carer who is likely to have needs when

they, or the child they care for, turn 18. Most young people who receive transition assessment will be

‘Children in Need’ as defined under the Children Act 1989 and will already be known to The Royal

Borough of Greenwich. However, there may also be some young people who are not receiving

children’s services but are likely to have care and support needs as an adult including young people

who needs have been largely met by their educational institute but who once they leave, will require

their needs met in some other way.

The assessment will be carried out early enough to ensure the right care and support is in place

when the young person moves to adult services. It will generally be undertaken at the point when the

young person’s needs for care and support as an adult can be predicted reasonably confidently. The

‘Special Educational Needs and Disability Code of Practice (Department of Education /Department of

Health 2015): 0 to 25 years’ states that Local Authorities should minimise disruption to young people

and their families and should endeavour to combine assessments and planning where this is

appropriate.

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Transition Assessment

Assessment for transition to adult care and support will involve the young person and can include

another person that they choose to involve in the assessment. The Care Act (2014) places a duty on

Local Authorities to provide an independent advocate to facilitate involvement in assessment where

an individual would experience substantial difficulty in understanding the necessary information or in

communicating their views, wishes and feelings and if there is nobody else appropriate to act on their

behalf. This duty applies to young people or carers who meet the criteria, regardless of whether they

lack mental capacity as defined under the Mental Capacity Act (2005). Assessment for adult care or

support will be proportionate to the complexity of the person’s needs and it will consider current

needs and how these impact on wellbeing. A transition assessment can be carried out alongside the

process for completing a young person’s Education, Health and Care (EHC) Plan. All EHC plans will

include the provision to assist in preparing for adulthood from school year 9 (age 13 to 14 years).

Having carried out a transition assessment, the Transition Team will give an indication of which

needs are likely to be regarded as eligible needs so that the young person understands the care and

support they are likely to receive once children’s services cease. Where a young person’s needs are

not eligible for adult services, the Transition Team will provide information and advice about how

those needs may be met and the provision and support that the young person can access locally.

Safeguarding

For all practitioners and agencies, ensuring young people are safeguarded is integral to everything

they do. Practitioners will make certain that any young person subject to a protection plan is

supported to remain safe as they move into adulthood. Practitioners from all services will be clear

about their respective policies and procedures and be equipped to deal with issues relating to

safeguarding and risk management. All agencies will also ensure that staff working with vulnerable

young people and adults have the appropriate training and supervision in order to minimise risks and

provide effective protection for these young people and adults.

Information sharing

Information sharing is vital to support effective assessment and planning in transition. In most cases

the young person will already have support plans and other information held by the key agencies.

The transition assessment will draw on the information held by others, for example the EHCP and

pathway plans will be used to clarify the young person’s aspirations and to understand their history.

Wherever possible practitioners will ensure that young people and their families will only need to tell

their story once during the assessment and planning process. All agencies will follow the

requirements of the Data Protection Act 1998 and the practice guidance laid out in the Caldecott

Principles.

Looked After Children

The Care Act 2014 states that for young people who are Looked After, the statutory ‘Pathway

Planning Process’ will be used to plan and monitor transition arrangements, where this is

appropriate.

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Carers

The Royal Borough of Greenwich will assess the needs of an adult carer where there is a likely need

for support after a young person turns 18 and it is of significant benefit to the carer to do so. There

are also a small number of situations where a young person aged 14 to 17 may find themselves in a

caring role for a family member who needs support due to illness or disability. Where the

professionals are satisfied that the child's welfare can be promoted and safeguarded as they take on

this substantial caring role they could decide that it would be helpful for the young person to be

assessed and receive services. The Care Act 2014 states that these young people will also need to

be offered a transition assessment. Young carers will be identified by relevant services and

information shared where appropriate.

Continuity of Support

All agencies will work hard to ensure a smooth transfer of support and care arrangements from

children to adult services. For the most part, transition to adult services for those with EHC plans or

engaged with other aspects of Children Service’s will begin at an appropriate annual review and in

many cases will be a staged process over several months or years.

Under the Care Act (2014) Local Authorities must continue to provide a young person with support

services until they reach a conclusion about the young person’s needs and support plans as an adult.

This is to ensure that there is no gap in provision. In some circumstances this may include an

agreement to continue to provide care and support from children’s services after the young person

has turned 18.

Statutory Care and Support Plans and Education, Health and Care (EHC) Plans

A Care and Support Plan (for young people with care and support needs) or a Support Plan (for

carers) will be created regardless of the setting where needs are met. The plan should ‘belong’ to the

individual and the council’s role is to support its production and to ‘sign off’ the plan. The planning

process should involve the young person or adult, their carers and any other person that they choose

to involve. This could be a friend or relative, support planner or another professional. Where young

people aged 18 or over continue to have EHC plans, and are receiving care and support, this will be

provided under the Care Act 2014. The statutory adult care and support plan should form the ‘care’

element of the young person’s EHC plan. While the care part of the EHC plan will meet the

requirements of the Care Act 2014 and a copy should be kept by adult services, it is the EHC plan

that should be the overarching plan that is used to ensure that these young people receive the right

support to enable them to achieve their agreed outcomes.

The Transition to Adulthood Panel will ensure that young people with both EHC and care and support

plans do not have to attend multiple reviews, provide duplicate information, or receive support that is

not joined up and co-ordinated. When a young person’s EHC plan is due to come to an end the

Transition to Adulthood team will put in place effective plans for the support they will be receive from

adult services. Where a care and support plan is in place, this will remain as the young person’s

statutory plan for care and support. The Transitions to adulthood team will review the provision of

adult care and support at this point.

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Statutory Care and Support Plans and Education, Health and Care (EHC) Plans

A Care and Support Plan (for young people with care and support needs) or a Support Plan (for

carers) will be created regardless of the setting where needs are met. The plan should ‘belong’ to the

individual and the council’s role is to support its production and to ‘sign off’ the plan. The planning

process should involve the young person or adult, their carers and any other person that they choose

to involve. This could be a friend or relative, support planner or another professional. Where young

people aged 18 or over continue to have EHC plans, and are receiving care and support, this will be

provided under the Care Act 2014. The statutory adult care and support plan should form the ‘care’

element of the young person’s EHC plan. While the care part of the EHC plan will meet the

requirements of the Care Act 2014 and a copy should be kept by adult services, it is the EHC plan

that should be the overarching plan that is used to ensure that these young people receive the right

support to enable them to achieve their agreed outcomes.

The Transition to Adulthood Panel will ensure that young people with both EHC and care and support

plans do not have to attend multiple reviews, provide duplicate information, or receive support that is

not joined up and co-ordinated. When a young person’s EHC plan is due to come to an end the

Transition to adulthood team will put in place effective plans for the support they will be receive from

adult services. Where a care and support plan is in place, this will remain as the young person’s

statutory plan for care and support. The Transitions to adulthood team will review the provision of

adult care and support at this point.

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7. Transition Pathway Overview

Young person identified as eligible for support through the

transition process and potentially eligible for support from

Adult Services and entered onto the Transition Register

From year 9 - Multi -agency EHC Plan review meeting with

an initial discussion on preparing for adulthood

The transition team and relevant SEN staff identifies the

needs and wishes of the young person and their families

and develops a transition plan to include recommendations

for education, employment, financial support, health housing

and leisure

The transition team coordinates regular planning meetings

with Children and Adult services and any third party provider

the progress monitored by the Transition Panel.

Final transition plan is agreed with young person and family

in time to ensure smooth transition process to adult

provision and services

Transfer of responsibility from children to adult services on

their 18th Birthday

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Year 9 (Age 13-14) Transition review meeting

Key Objectives

What outcome do we want to achieve? How will we measure this?

Meaningful discussion between young person, parents/carers and professionals.

Written record of discussion.

Identify the young people likely to require transitional arrangements

Transition Register

Hold the Year 9 Annual Review of EHC plan or transition plan

Record of Review

Written Record of proposed plans Record of Review

Key Tasks

Who is responsible Task When Measurement

Young person and parents

Engagement with professionals

Throughout the year

Recording of discussions

Children’s Social services

SWs would identify likely candidates for transitions. Inter-agency liaison.

By the time of the Year 9 Review

Recording of discussion.

Adult Social Services AOPS aware via Transitions Register

Transition Team AOPS aware via Transition Register Where appropriate attend Year 9 review

Year 9 review Record of discussion

A relevant LA officer (e.g. SEN, social Worker or other involved persons) SEN team

Attend Review EHCP to reflect and shape the transition proposals Issue revised EHC plan focussed on Preparation for Adulthood outcomes

Year 9 Review Record of Discussion.

School Arrange and host review (of EHC plan) or develop transition plan for young people on SEN support) Prepare young person and family/carers for review and provide record of the meeting

Year 9 review Provide record of review and then sent to families and all attending review

Health Services Contribute to Year 9 Review if relevant.

Year 9 Review Record of discussion

Housing To contribute to individual plans as appropriate

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Year 10 (Age 14-15)

Key Objectives


Developing discussion and exploring options



Transition Register

Hold the Year 10 Annual review of EHC plan or transition plan

Record of Review


Key Tasks

Who is responsible

What to Expect When Measurement


Engagement with professionals Throughout the year



SWs would identify likely candidates for transitions. Inter-agency liaison.

By the time of the Year 9 Review


Adult Social Services

AOPS aware via Transitions Register

Transition Team AOPS aware via Transition Register Where appropriate attend Year 9 review

Year 10 review Record of discussion

A relevant LA officer (e.g. SEN, social Worker or other involved persons)

Attend Review EHCP to reflect and shape the transition proposals where appropriate


School Arrange and host review of EHC plan or transition plan Prepare young person and family/carers for review and provide record of the meeting


Health Services Contribute to Year 10 Review if relevant. Children’s services need to identify young people who are likely to be eligible for NHS Continuing Health Care (Adults) and inform the CCG


Housing To contribute to individual plans as appropriate

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Year 11 (Age 15-16)

Key Objectives


Developing discussion and evaluate options including



Transition Register

Hold the Year 11 Annual Review of EHC plan or of transition plan

Record of Review


Key Tasks

Who is responsible What to Expect When Measurement


Explore options Engagement with professionals

Throughout the year



SWs would identify likely candidates for transitions. For LAC 6 monthly review meetings and develop pathway plan More detailed discussion with young person and families/carer re post 18 options

Throughout the year At Annual Education Review At LAC reviews.



AOPS aware via Transitions Register

Transition Team Case can be presented to Transitions Panel. Update Register/Tracker Spreadsheet

Year 11 review Transitions Panel from 16th birthday

Record of discussion

SEN Service/Prospects/ Allocated Worker SEN team

Attend Review Update EHCP to reflect and shape the transition proposals Discussion with the family re potential education options Decide whether EHC plan will continue and agree provision for young people leaving school where necessary and amend plan


School Arrange and host review of EHC plan or transition plan Prepare young person and family/carers for review and provide record of the meeting


Health Services Contribute to Year 11. Attend Review if relevant. formal referral / checklist needs to be completed and sent by children’s service to adult CCG


Housing Options To contribute to individual plans Year 11 Review

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Year 12 (Age 16-17)

Key Objectives


Look at firm transition proposals Written record of discussion.

Consideration at Transitions Panel and agreed plan.

Written and agreed Panel Decision Plan


Record of Review


Key Tasks



To be clear about outcomes sought for the young person To make proposals about the outcomes/resources required to meet these aspirations. To be recorded as part of the transitions assessment.

Transitions Panel – tracking discussion



SWs should be preparing assessment and presentation to Transition Panel. For LAC 6 monthly review meetings and review of pathway plan

Transitions Panel by 17th birthday At Annual Education Review At LAC review and on-going visits with young person



Chair and Lead Transitions Panel and invite multiagency contribution to discussion/agreement with planning. Decisions made regarding relevant team responsibility.

Transition Team Case should be presented to Transitions Panel. Transitions Team to commence information gathering, attend multiagency meetings, and attend LAC reviews. Update Register/Tracker

Year 12 Education Review Transitions Panel from 16th birthday

Records of discussion

SEN Service/Prospects/ Allocated Worker

Attend review to reflect and shape the transition proposals where appropriate Discussion may be required re alternative options Start to advise on options for post 19 provision

Year 12 Education Review

Records of Discussion.

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School or college Arrange and host review Prepare young person and family/carers for review and provide record of the meeting

Year 12 Education review

Provide record of review and then sent to all attending review

Health Services Attend Review if relevant. Continuing Care checklist completed and forwarded to CCG (Checklist to be submitted by best positioned professional this could be Social worker, school nurse, CCN, GP, SENCO etc.) CAMHS to refer to appropriate Adult MH service (CMHT/CLDT) Adult Health Services will need to be identified and referrals made to ensure timely transition.



Housing Options Appropriate Housing Nominations to be made Shared Lives Residential/Supported Living services identified by 17th birthday

Adult Service Commissioning Team

Attend Transitions Panel and identify any commissioning issues and trends.

Transitions Panel

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Year 13 (Age 17-18)

Key Objectives


Young Person transitions to Adult Services (Social Care or Continuing Care)


Possible further consideration at Transitions Panel to oversee agreed plan.

Written and agreed Panel Decision Plan


Record of Review

Adult Care assessment completed and funding agreed for support

Record of Review

Key Tasks



To be clear about outcomes sought for the young person To make proposals about the outcomes/resources required to meet these aspirations. To be recorded as part of the transitions assessment.

Transitions Panel – tracking discussion



SWs should be preparing assessment and presentation to Transition Panel. For LAC 6 monthly review meetings and review of pathway plans

Transitions Panel by 17th birthday At Annual Education Review At LAC review and on-going visits with young person



Following Transitions Panel decisions, Appropriate adult team to be made aware of and plan for the transfer of the case from the Transitions team

Transition Team Named Transitions Team Worker to conduct and complete Adult focused assessment.

Year 13 Education Review Possible further discussion at Transitions Panel.


SEN Service/Prospects/ or relevant Allocated Worker

Update EHCP Hold SEND post 19 Panel Attend Review to reflect and shape the transition proposals where necessary Communicate the outcome of the Panel’s deliberations. Discussion may be required re



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alternative options



Provide record of review and then sent to families and all attending review

Health Services Contribute to Year 13. Attend Review if relevant. Continuing Care checklist for children (if under 18) or the NHS Continuing Healthcare Checklist of adult (if over 18) completed and forwarded to CCG (Checklist to be submitted by best positioned professional this could be Social worker, school nurse, CCN, GP, SENCO etc.) CCG need to assessed and a health care package for those who are eligible needs to be commissioned by the young person’s 18th Birthday CAMHS to refer to appropriate Adult MH service (CMHT/CLDT) Adult Health Services will need to be identified and referrals made to ensure timely transition.




Adult Service Commissioning Team

Attend Transitions Panel and identify any commissioning issues and trends.

Transitions Panel

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Year 14 (Age 18-19)

Key Objectives


Smooth transition from school or college environment to either Further Education placement, employment or social care/community based support.



Record of Review

Review plans Record of Review

Key Tasks



To participate in review processes (Education/Social Care etc.) as far as possible To continue to contribute to transition processes, particularly in preparation for leaving school.

Year 14 Education Review. Social Care Review Health reviews (including CLDT/CMHT reviews) To be combined if possible



If young person had been Looked After by RBG CS, allocation of Personal Adviser or Social worker to maintain Leaving Care responsibilities. Pathway Plan to be maintained.

Year 14 Annual Education Review At LAC review and on-going visits with young person



Adult Service to take over case responsibility from Transitions Team. Adult Service to contribute to EHCP and education plans or to make arrangements for alternative support plans. Adults Service possibly to contribute to any residential/therapeutic costs of education placement.

Transition Team Transitions Team Worker to forward case management to appropriate Adult Team (as identified previously via Panel or during assessment). Contribute to Year 14 Education Review



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SEN Service/Prospects/ Allocated Worker

Attend Year 14 Education review (last school review). SEND post 19 Panel will confirm Post 19 provision. Communicate the outcome of the Panel’s deliberations. Discussion may be required re alternative options

Year 14 Education Review Formal confirmation of Post 19 provision.




Provide record of review and then sent to families and all attending review

Health Services Contribute to Year 14 Review and attend Review if relevant. CAMHS to refer to appropriate Adult MH service (CMHT/CLDT) Adult Health Services will need to be identified and referrals made to ensure timely transition.




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8. Roles and responsibilities

The Transition to Adulthood Team

The Transition to Adulthood team is based in the Woolwich Centre and is managed by the

Community Learning Disability Team (CLDT). The team works operationally across the Royal

Borough with all agencies involved in transition planning for young people with complex needs

moving onto adult services.

The team maintains the Transition Register that holds information on all young people with

statement or EHC plans from Year 9 onwards and, when notified, other young people requiring

transition support. The Transition Register identifies future needs and the likelihood of needing adult

services and other specialist provision. It is also used for financial planning. The purpose being to

ensure that the budget profile between children and adults is clearly identified and able to support

the budget setting process. The team is also responsible for:

The organization and administration of the Transition to Adulthood Panel.

Maintaining the Transition Register.

Liaising with key professionals and agencies for children and adult health and social care services.

Ensuring agreed work has been undertaken in a timely way.

The Special Educational Needs (SEN) Team

The SEN Team is the team that can undertake EHC needs assessments, prepare and review EHC

plans. They also ensure that the provision is put in place to meet the requirements of the EHC plan.

In this work they follow the requirements of the SEN Code of Practice they can help with questions

about a child/young person's EHC Plan, EHC Needs Assessment or Statement.

Prospects Services

The Prospects Service is an organization contracted by Royal Greenwich to provide an Information,

Advice and Guidance Service on careers, to Greenwich schools. The contract includes specific input

to EHC Plans for Statemented Students in Secondary Schools, to advice on appropriate on-going

educational provision.

The Greenwich Children with Disabilities Team (CWDT)

The CWDT provides specialist help for children and young people up to the age of 18 years with a

complex and severe disability. The team undertakes assessments of need and puts in place support

plans where necessary. It is also responsible for identifying and addressing any safeguarding issues

for these young people. Before the young person turns 18 the team will make sure that we have

developed plans to ensure a smooth transition to adult services for young people who need on-going

services.

24

Young People’s Teams and Looked after Children (LAC) The Greenwich Young People’s Teams have responsibility for children and young people who are

‘Looked After Children' (LAC)) in the Royal Borough of Greenwich. The teams have a duty to ensure

the standard of care the child receives is of the highest quality. The teams will provide young people,

their parents and carers with information on the process of transition to Adult Services and will attend

transition-planning meetings and will track the young person’s progress. The teams will retain

responsibility for all aspects of case management up to the age of 18 and will monitor young people

who have left care up to the age of 21, or up to the age of 25 if remaining in education.

The Virtual School will record details of the independent and non-maintained special schools that all

LAC young people are attending and be available to provide advice on education matters. This

information will include current cost of placements, funding split between agencies and the date when

responsibility passes to Adult Services.

Schools and Colleges Schools, sixth form colleges, independent and maintained schools commissioned by The Royal

Borough of Greenwich to provide education for individual students, will hold annual reviews of

Education and Health Care Plans or statements in accordance with the SEN code of Practice.

Reviews in Year 9 and above will pay particular attention to preparations for the transition to

adulthood including employment, independent living and participation in the community. The young

person and their parents or carers will be involved fully in the EHC Plan or statement review meeting.

For young people who do not have a statement or EHC plans but are on ‘SEN support’-the school or

college is responsible for developing and reviewing a transition plan from yr 9 onwards.

The young person will be supported to be able to take a full and active part in the review, using

person-centred approaches, including advocacy, where required, for the young person. Following the

review meetings an EHC plan review or annual review report will be and circulated in accordance with

the SEND Code of Practice. The implementation of the EHC will be monitored, ensuring that actions

are completed to enable young person to achieve prescribed outcomes.

Greenwich Clinical Commissioning Group (CCG)

Greenwich CCG is responsible for Health Funding. Young People who are funded through Children’s

Continuing Care (CC) should be considered for Adult Continuing Healthcare (CHC) in good time

before their 18th birthday by the completion of a Continuing Healthcare Checklist. The CCG is also

represented on Transition to Adulthood Panels so that timely decisions can be made about health

resources. The current arrangements by the CCG are:

As a young person a children’s social worker will present that young person to the Transition panel for consideration for adult services. The appropriate adult team will screen (carry out a Care Act Assessment) to determine eligibility for adult social care.

At this point a CHC checklist will be completed to notify the CHC team of a pending assessment.

When allocated to an adult social care worker that worker will notify the CHC team and invite to the assessment (a joint assessment on eligibility)

If a CHC nurse is allocated before a social care worker they will notify CLDT of allocation and ask for a representative.

In either case a Transition worker can be invited to attend a CHC assessment.

25

In all cases a young person should have other professionals such as school nurse, teacher etc. involved in their care who can be part of the MDT

If a CHC nurse is allocated before a social worker they will notify CLDT of allocation and ask for a representative

Oxleas Children and Adolescent Mental Health Services (CAMHS)

Oxleas CAMHS supports the Transition Panel in tracking young people with mental health

support requirements who will require support from Adult Mental Health Services.

Housing

The Housing Team ensures that young people with SEN and their parents or carers who may

need support with housing are provided with good quality information and advice so they can

understand what support is available and what they need to do to access support. The

housing team also supports young people putting themselves on the housing register at 16 if

appropriate.

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Appendix A

Further Information and Guidance For more information on the types of services on offered please refer to The Local Offer. This is an information resource for children and young people with special educational needs and/or disabilities, their parents or carers and practitioners. The Local Offer lists services for children and young people with special educational needs and disabilities in the borough of Greenwich. http://www.royalgreenwich.gov.uk/info/200034/disabilities/1671/about_the_local_offer The Law and Statuary Guidance The Children and Families Act 2014 and the Care Act 2014 create the legislative framework for transition with a focus on personalised, outcome-based approaches. Relevant sections and further guidance is outlined below:

The Care Act (2014) Guidance

Guidance about care and support responsibilities for adults care and their unpaid carers. https://www.gov.uk/government/publications/care-act-statutory-guidance/care-and-support-statutory-guidance

Mental Capacity Act Code of Practice Code of practice giving guidance for decisions made under the Mental Capacity Act 2005.See Chapter 12 How the Act applies to children and young people https://www.gov.uk/government/publications/mental-capacity-act-code-of-practice Special Educational Needs and Disability (SEND) Reforms Bringing together education, health and care for young people and families to age 25. https://www.gov.uk/schools-colleges-childrens-services/special-educational-needs-disabilities

Special Education Needs Code of practice Guidance on the SEND system for children and young people aged 0 to 25 https://www.gov.uk/government/publications/send-code-of-practice-0-to-25

Looked After Children and Leaving Care Regulations and guidance for care leavers to help them move successfully in to adulthood https://www.gov.uk/government/publications/children-act-1989-transition-to-adulthood-for-care-leavers Transition National Institute for Health and Care Excellence NICE) Guidance on Transition from children’s to adults’ services for young people using health or social care services https://www.nice.org.uk/guidance/ng43 Continuing Health Care The National Framework for NHS Continuing Health Care and NHS funded nursing care. https://www.gov.uk/government/publications/national-framework-for-nhs-continuing-healthcare- and-NHS-funded-nursing-care

Care and Support Statutory Guidance https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/315993/Care-Act- Guidance.pdf

http://www.royalgreenwich.gov.uk/info/200034/disabilities/1671/about_the_local_offer

https://www.gov.uk/government/publications/care-act-statutory-guidance/care-and-support-statutory-guidance

https://www.gov.uk/government/publications/care-act-statutory-guidance/care-and-support-statutory-guidance

https://www.gov.uk/government/publications/mental-capacity-act-code-of-practice

https://www.gov.uk/schools-colleges-childrens-services/special-educational-needs-disabilities

https://www.gov.uk/government/publications/send-code-of-practice-0-to-25

https://www.gov.uk/government/publications/children-act-1989-transition-to-adulthood-for-care-leavers

https://www.gov.uk/government/publications/children-act-1989-transition-to-adulthood-for-care-leavers

https://www.nice.org.uk/guidance/ng43

https://www.gov.uk/government/publications/national-framework-for-nhs-continuing-healthcare-%20and-nhs-funded-nursing-care

https://www.gov.uk/government/publications/national-framework-for-nhs-continuing-healthcare-%20and-nhs-funded-nursing-care

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/315993/Care-Act-%20Guidance.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/315993/Care-Act-%20Guidance.pdf

27

Appendix B

B Joint Directorate Management Team (JDMT) JDMT oversees monitors and reviews the effectiveness of procedures, policies and protocols for transition to adult services across the Royal Borough of Greenwich. JDMT meets quarterly and is co-chaired by the Director of Adult and Older People Services and the Director of Children Services for the Borough. The JDMT ensures that agencies work together with young people and their families towards maximising their independence, supporting and raising young people’s own aspirations for social inclusion, education, employment and quality of life. The JDMT will:

Provide critical challenge to proposals where appropriate, to balance the needs, aspirations, wishes and resources available across the transition landscape

Consider proposals on strategic issues and emerging themes from the Transition’s Team that require a more strategic response and resolution, formulating proposals to the appropriate governance board.

Monitoring and Annually reviewing the effectiveness of this protocol

Resolving strategic issues with the aim of improving the transition process by identifying trends and gaps in service possess or practice.

Membership

Position Organisation

Director of Children’s Services Royal Borough of Greenwich

Snr Assistant Director Safeguarding and Social Care

Royal Borough of Greenwich

Children’s Services Finance Manager Royal Borough of Greenwich

Snr Assistant Director Inclusion Learning and Achievement


Assistant Director Commissioning and Resources


Assistant Director Early Help Royal Borough of Greenwich

Director Adults & Older People Royal Borough of Greenwich

Assistant Director, Transformation Royal Borough of Greenwich

AD, Commissioning & Business Support Royal Borough of Greenwich

Director, Public Health Royal Borough of Greenwich

Senior Assistant Director, Operations & Partnerships


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Appendix C

B Multi-Agency Transition Panel Terms of Reference The Multi-Agency Transition Panel operational responsibility for driving transition processes forward in the Royal Borough of Greenwich. A senior officer from Adult/Children’s Services chairs the group and attendees include officers from all agencies that have a role or responsibility for planning transition. The group meets on a monthly basis. The group is responsible for developing mechanisms to ensure that the quality of provision meets appropriate standards and that the transition process is as effective as possible. This includes:

The transition panel will meet monthly

Tracking all children and young people in the transition process via the maintenance of a Transition Register

Capturing feedback from young people, their families and other stakeholders.

Receiving qualitative and quantitative information and data about transitions.

Ensure due diligence of the transitional pathway, ensuring proposals are person-centred and meet assessed, and where appropriate, eligible need.

The Panel will ensure that through the transitions pathway, improved outcomes for children and young people with disabilities and complex needs are achievable within available resources and that access to interventions and services are delivered in an equitable, sustainable and timely manner. The Panel will ensure that agencies work together with young people and their families towards maximising their independence, supporting and raising young people’s own aspirations for social inclusion, education, employment and quality of life. Administrative Support The Transitions Business Support Officer supports the Panel. This post plays a key role in the development of the transition service and ensures that there are effective administrative arrangements in place, which support a smooth transition for young people from Children’s Services to Adult Health and Social Care provision. Membership

Position Organisation

Head of the Community Learning Disability

Services


Transitions Co-ordinator, Royal Borough of Greenwich

Team Manager, Specialist Social Work Team Royal Borough of Greenwich

Young People’s Team Greenwich CCG

Continuing Care Lead Nurse Greenwich CCG Greenwich CCG

Community Mental Health Team Oxleas NHS Trust

Children and Adolescent Mental Health Services Oxleas NHS Trust

Shared Lives representation Royal Borough of Greenwich

Adult Commissioning Royal Borough of Greenwich

Special Educational Needs Post 16 Officers Royal Borough of Greenwich

Children with Disabilities Team manager or

professional lead


SW Young Carers Lead Royal Borough of Greenwich

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The Children and Young People in Transition Team

The Woolwich Centre,

Wellington Street,

Woolwich SE18 6HQ

020 8921 4860

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