Transition Planning for Young People with Disabilities

• The legal basis for the work of transitions co-ordinators is found in The Care Act 2014 Chapter 1 Sections 58 – 66. The Care Act (2014) gives young people with disabilities and their carers a legal right to request an assessment before they turn 18. This is to help them to plan for the adult care and support services they may need.

More recently, other legislation and guidance has strengthened the procedures and expectations around transition planning for disabled children. See Relevant Legislation and Guidance above.

The Team Managers of the Children's Disability Services team (Fieldwork) are responsible for planning and facilitating the 6-monthly transition co-ordination meetings

The purpose of these meetings is to:

• Identify young people, known to the team, currently aged 14 and above, who are likely to need services from the Adult Social Care, Health and Public Protection Department;
• Ensure sufficient communication and co-ordination takes place for all young people with disabilities moving to adult services;
• Ensure that adult services receive a sufficiently early alert about what financial commitments and planning will be needed. It will not always be possible to be clear about what exact services a 14 year old will need (or be eligible for) once they are an adult. However, if it is likely that a young person will need supported living / residential accommodation as an adult, this should be identified by the children's social worker and Team Manager by the time the young person is 16 at the latest. The information should be passed to the relevant transitions co-ordinator and discussed in the next transitions co-ordination meeting. Where a young person’s needs increase unexpectedly after the age of 16 resulting in an immediate or future need for full time accommodation and support the transitions co-ordinator should be notified as soon as possible;
• Act as a "progress chasing", task setting and overview meeting rather than one where a detailed discussion of the needs of the young person takes place. The meeting does not replace statutory reviews (e.g. children looked after reviews) or education annual reviews, where the transition plan will be developed in detail and reviewed.

The meeting should generally follow this format:

• The Team Managers of the Children's Disability Team are responsible for facilitating, chairing and taking minutes of the meetings. The Transitions Team Manager must be invited. Minutes should be circulated after the meeting. Separate meetings for each district within the locality may work best;
• The meetings should take place every 6 months;
• Agreed actions with timescales must be recorded on the young person's file;
• Meetings concerning Deaf and visually impaired children may either be locality based or county wide, whichever is found to be most efficient.

This is not a comprehensive list but it includes issues which may be usefully discussed and agreed:

• Roles and responsibilities clarified between workers e.g. attendance at school reviews;
• Is joint work on assessment and planning needed? Joint work may be required if decisions need to be made now for children's services which will impact on planning and funding post 18;
• Role of other agencies clarified and any areas of work appropriate for other agencies;
• Identification of those young people who may meet Continuing Health Care Criteria in order to clarify potential Health contribution to the package;
• Identification of any actions, with attached timescales, for the following 6 months.

The children's social worker has a responsibility to think beyond the 18th birthday. Young people with disabilities should be supported to have more independence as they become adults. Independence here means being more involved in choices about their own life, alongside carers and support systems. Supporting young people to make choices and to contribute to planning for their services will help them to become more independent in this way. The family of the young person may also need support to allow the young person to make more decisions for themselves as they move through the teenage years.

The Mental Capacity Act will have an impact on how we work with young people aged 16 and 17 years about decisions that affect them. They should be treated as young adults in terms of being part of any decision making that affects their future.

Particular responsibilities of the children's social worker include:

1. Liaising with the transitions co-ordinator once the young person reaches 14;
2. Ensuring that, between the ages of 14 and 16, the young person and their parents have an appropriate level of contact with the transitions co-ordinator so that they can start to prepare for the changes that transition to adult services will bring;
3. Attendance at the transitions co-ordination meetings;
4. Highlighting to adult services at an early stage (i.e. from age 14), those young people who are likely to need complex or costly care packages in adulthood.

The Team Managers of the Children's disability team have a responsibility to maintain a database containing details of all the young people aged 14 and over, known to the team. The data base must include details of the services each young person is receiving (i.e. amount or frequency of each service per year). This database can be maintained by the team admin support and must be updated at least six-monthly. It must be held so it is available to the countywide transitions co-ordinator and other colleagues from the Adult Social Care,Health and Public Protection Department.

There is no "automatic" transfer into the Adult Social Care teams. In order to achieve a smooth and well planned transition for each young person, it is essential for the Children's Social Work teams to alert the transitions co-ordinators to young people who may need Adult Social Care services, when those young people are 14. Funding issues must also be highlighted at an early stage. The proper processes for gaining agreement to funding from Adult Services must be adhered to, so there is time for the necessary planning to take place.

See Section 7.3, for the role of the locality transitions co-ordination meetings.

This section is under review

SEND will notify the Adult Services Group Managers of all pupils who are:

• All year 8 children with a Statement of SEN who will have a Transitional Plan Review in the following year, and children who are at School Action Plus stage of the Code of Practice 2002;
• Young people between the end of Year 11 and Year 14 who are eligible to leave school in the Summer Term, and who have a Statement of Educational Needs, or who are at School Action Plus stage of the Code of Practice 2002.

A list of all young people so identified, with information about the nature of their impairment, will be made available to the Adult Services Group Managers each May by the data management officer of SEND.

SENCOs are responsible for identifying any additional young people, not on these lists, who may need transitions planning, and passing their details to the Countywide Transitions Team.

The transition co-ordinator will obtain as much information as is necessary to make an informed decision as to whether the young person is eligible for an assessment under the Care Act 2014.

It is likely that many of the students in Special School 16+ provision will have the right to an assessment of need. There will also be increasing numbers of students who have an impairment in mainstream provision because of Nottinghamshire's inclusion policy. Young people with physical and/ or sensory impairments or medical conditions may easily be overlooked because they often do not have an EHC plan; however, transition planning may be vital. Where a young person has a combination of moderate impairments (e.g. loss of some sight and hearing) they may be eligible for a Care and Support Assessment via referral to the Countywide Transitions Team.

Children already receiving services through the Children's Disability Team are almost certain to fall within the transition co-coordinator's remit. For young people who are in receipt of social care services as children, and who are likely to be eligible for services as an adult, the transition co-ordinator should attend the Children In Need (CIN) or Children Looked After (LAC) reviews once the young person reaches 16 in all cases, and from an earlier stage if necessary.

The young person, his/her parents/carers and the school should be informed, preferably in writing, when the young person has been allocated a transitions worker. The offer of an assessment can be refused - by the young person if s/he is 16 or over, or by her/his parents if the young person is not yet 16.

The timing of an assessment will vary with each young person. In general, the more complex the young person's needs, the earlier the assessment should commence.

If social care services are not required when the young person turns 18, it can be agreed with the young person and their family, that assessment documentation will not be completed then but can be returned to at a later date.

Where a young person, is not eligible for a Care and Support assessment, signposting to other services and linkage to other agencies may be appropriate.

For a small number of young people a decision will be deferred on the basis that it is unclear as to whether the young person. will require social care services when they become 18 or when they leave school. The transition co-ordinator will remain involved and attend subsequent school reviews at least until a decision has been made. The final decision will be made clear to the young person and their carers.

• Develop links with children’s services in social care and education. Link with every Special Educational Needs school in their district. Ensure that SENCOs at mainstream school are aware of the referral process for the Countywide Transitions Team. Attendance at the Year 9 Transition Plan Reviews of those young people with disabilities who are likely to need social care services when they are 18.andattendance as appropriate at subsequent reviews;
• Attendance at the last review before a young person leaves full time education;
• Ensure the accurate maintenance of departmental systems for receiving referrals, monitoring progress, commissioning and reviewing services and developing and updating database information. This is undertaken with Team Manager oversight and responsibility.

The assessment will follow departmental practices and should draw together existing assessment material and reports from other professionals. A copy of the final documentation should be given to the young person and their carer/family unless there are exceptional reasons why this would be detrimental to the wellbeing of any of the parties involved.

Transition co-ordinators, with Team Manager oversight and responsibility, should ensure the accurate maintenance of departmental systems for receiving referrals, monitoring progress, commissioning and reviewing services and developing and updating database information.

The Care and Support Assessment should be proportionate to the needs of the individual.The assessment will inform the development of an Adult Service Social Care Plan and package of support and it will be completed in time for funding streams to be agreed and services to start.

The transition co-ordinator will usually become the care manager/key worker when a young person reaches 18 and when funding becomes the responsibility of adult services. They will continue to develop the Adult Service Social Care Plan, review progress and make necessary changes until the care plan has been reviewed and the person can be transferred to an Adult Social Care Team. The timing of this will vary from person to person.

For Deaf young people and those with a visual impairment, there will be a particular need for close working between the transitions co-ordinator and the Adult Deaf and Visual Impairment Service (ADVIS) Some of these young adults' cases will already be open to this service but they will still need assessment from a transitions co-ordinator who should work very closely with colleagues from the Children's Disability Team and the ADVIS.

Many young people experience a lengthy transition process e.g. school to college, then to different colleges, then into work-based learning and later a move to supported living. Transition co-ordinators are responsible for the first stage of this process. Once a review is completed and the young person is considered to have made a successful transition the review and monitoring of their support will pass to an Adult Social Care team.This is to ensure that transitions co-ordinators have capacity to start work sufficiently early with new young people at age 14.