Preparing for Adulthood

Transition Protocol

(A living document)

Southend Borough Council, Southend Clinical Commissioning Group Essex Partnership Trust and other key partners, families and young people are currently working together to review the ‘Preparing for Adulthood’ transition protocol. We are developing a comprehensive pathway and will work to co-produce a number of easy read guides to support children, young people, families and professionals who are preparing and moving towards adult life.

Date:27 June 2017

Version: 2.0

ContentsPage Number

Preface and Introduction03 - 09

Part 1

Education Responsibilities10 – 29

Health Responsibilities29 – 42

Social Care Responsibilities42 - 78

Part 2

Preparing for Adulthood Flowcharts80 - 84

Part 3

Appendices

•Preparing for Adult Life (Leaflet)86 - 87

•Transition Pathway (quick reference)88

•Health Service Transition Pathway89 - 90

•Children’s Services Transition Pathway91

•Young Person/Parent Carer/Professional Transition Pathway 92

“Services at transition should be aimed at moving a person into work/adult life in such a way as to promote their independence and so reduce their long term needs for care and support”.

Care and Support Alliance

Preface

The aim of this protocol is to set out the processes and responsibilities across agencies for managing the transition of young people with disabilities and/or additional needs from childhood to adulthood.

Its intention is to ensure that all agencies are able to work together to make timely and effective contributions to the transition planning process as part of their role in supporting young people as they prepare to leave school.

Introduction

This protocol sets out the transition process which should be followed by all professionals in Southend on Sea who support young people with disabilities and/or additional needs as they prepare for adult life. It reflects both good practice considerations within SouthendBorough Counciland its partner agencies, and the underpinning statutory guidance on planning transition to adult life contained in recent legislation.

Beginning in Year 9 (age 13/14) and continuing up to the age of 25,the aim of this protocol is to provide an overarching document setting out how the actions of each agency link together to form a clear transition pathway to adult life. Its intention is to support current multi-agency working practices and thereby deliver successful transition planning and client outcomes across education, health and social care.

Whilst this document recognises that the aim of transition planning is to help young people in getting the best from life rather than providing a dependency on specialist education, health and social care services, some young people will nevertheless require both universal and specialist funded resources in order to make their transition journey.

Where, following an assessment, specialist funded services are recognised as the only option, the support being funded should reflect the desired outcomes of transition planning as set out in both the Children and Families Act 2014 and The Care Act 2014, namely: good health outcomes,finding employment,finding somewhere to live and community participation.

Our vision-building principles for transition planning

The vision for the Preparing for Adult Life protocol is to ensure that all young people (aged 13-25) with Special Educational Needs and disabilities achieve the best possible outcomes when making their progression into adulthood.

They will be supported to do this through local provision which has been planned and developed according to young people’s aspirations and needs.

The intention is to have a cohesive and effective assessment and planning process across all agencies which is consistent in its coordinated approach to transition across the Borough of Southend on Sea. This will be achieved by ensuring that there is a strong professional interface based on a common understanding of respective roles and responsibilities.

The guiding principles that support this vision are:

  • All professionals will be familiar with the Sec 19 Principles of the Children & Families Act 2014 which state that local authorities must have regard for the views, wishes and feelings of the young person and his/her parents. (See also SEN Code of Practice 1.3-1.12 & 9.20-9.29).
  • Every young person remains at the centre of their transition planning and is able to make informed choices and exercise control over their life.
  • All professionals will be familiar with Sec7 Care Act 2014 –the duty to cooperate.
  • All those working with young people in transition will work together in partnership to achieve a smooth transition to adulthood dedicated to achieving the best possible adult outcomes.
  • All professionals are familiar with their roles and responsibilities
  • An identified lead person(s) is identified to act as a main point of contact for young people, their families and other professionals.
  • All professionals will share information
  • No young person who may need support into adulthood is overlooked by professionals.

Protocol Content

The protocol is set out as follows:

  • A colour coded transition planning process outlining each agency’s task at each stage of the young person’s transition pathway from Year 9 onwards.
  • A multi-agency flowchart detailing the age and stage approach to transition support from Year 9 onwards.
  • An appendix of supporting information detailing: referral processes, quick reference transition pathways, eligibility criteria and funding streams, all of which are intended to enhance professional understanding of the often complex transition journey taken by young people.

Young people covered by this protocol

  • Young people in receipt of or who may be eligible for Children’s Services
  • Young adults in receipt of or who may be eligible for Adult Services
  • Young people with an Education Health & Care Plan (EHC plan) or SEN Support
  • Children in receipt of or who may be eligible for Continuing Care or who have complex health needs.
  • Young adults in receipt of or who may be eligible for adult Continuing Healthcare
  • Care Leavers and Looked After Children preparing for adulthood
  • Young Carers preparing for adulthood
  • Children and young people with SEN who are in youth custody

Agencies involved in this protocol

  • Children’s Services– Southend Borough Council including schools and colleges
  • Adult Services –Southend Borough Council
  • Southend Health Services

Vision and Commitment

This protocol covers all young people with Special Educational Needs and/or disabilities, as well as those who may require additional adult social care support as a result of being either a Care Leaver or Young Carer.

Its intention is to ensure that transition planning maximises a young person’s education, training and employment opportunities, as well as enabling them to enjoy social relationships and live a healthy and independent life.

In order for this protocol to deliver support to all the young people it embraces as they manage their transition to adult life,a coordinated multi-agency support model across all services needs to be adopted. This means having the correct people working together to get the transition right.

Supporting young people in a person centred, holistic and consistent way, which focuses on the pursuit of good life outcomes and personal goals, set by the young person, meets statutory obligations. The young person and their parent/carer must be at the centre of all care planning.

Central to the duty that Southend Borough Councilhas in supporting a young person to achieve their personal goals, is the need to ensure that there are no gaps in service provision when a young person transfers between Children’s Services and Adult Services, and that transition assessments for adult social care are undertaken at the most appropriate time for the young person in order to be of most benefit to them.

Of equal importance is the need to have a robust tracking system in place designed to ensure that no young person who may be in need of adult social care remains unidentified.

To this end, the role of the Transitions Team – Special Educational Needs (SEN)has been established in the transition process and will be reliant upon social care departments and partner agencies to provide up-to-date information of all young people who may be in need of Adult Services.

As this protocol applies to a diverse cohort of young people, its application will differ depending on individual circumstances such as whether a young person is in receipt of an Education Health and Care Plan, SEN Support or Continuing Healthcare, and this will subsequently determine the level and nature of professional involvement.

Key Working

It is also necessary to note that although the protocol attempts to underpin a structure of pre-determined roles and responsibilities across agencies involving key professionals in the transition planning process, it also subscribes to the view that individual professionals seek an expansive rather than a limited role based on the concept of Key Working.

Key Working here defines a way of working rather than its traditional meaning of identifying a principle professional for coordinating a young person’s support. While this can be a facet of Key Working, the use of the term here envisages professionals taking a wider perspective of their involvementwhich is outside of their sometimes narrow professional role with the aim of being able to recognise that it is everyone’s job to seek the best possible outcomes for each child.

Key Working calls for professionals to adopt a set of functions aimed at building strong and resilient families by ensuring that their practice. It requires co-production – listening to young people and their parents, and ensuring that they participate fully in the transition process, with the effect that young people and families can live ordinary lives, that all assessments are integrated, that young people and their families have informed choices and that agencies work together to ensure a continuity of care.

All professionals reading this document should therefore be mindful that its intention is to reflect these Key Working functions as a way of achieving the best possible outcomes for young people rather than merely outlining a process which limits the scope of professional input to a list of limited actions.

In short: The protocol is the process and key working is the culture underpinning that process.

Protocol Layout

Part 1: The Transition Planning Process

This part of the protocol has been set out in threesections: Education, Health and Social Care, with each section colour coded to identify the organisation responsible for each action arising from every stage of the planning process. Each section contains the‘Required Action’which details the specific professional responsibilities and client input which establish the transition pathway.

In order for the ‘Required Action’ to give effect to a shared vision of transition planning for all young people it seeks to support, the responsible partner agency has been ascribed the first column with the second column recording the activity required of them.

The input of the young person and their parent/carer is then represented in the third column, followed by a fourth column outlining the step being taken along the planning pathway

The fifth column underscores each stage of the process by reference to the statutory guidance, regulations and procedures which direct good practice.

Part 2: Preparing for Adulthood Flowchart

The flowchart offers a basicoutline of professionalagency involvement from Year 9 and what progress needs to be made annually. It also asks all professionals working with any young person aged between 13 and 25 years who they feel may require support in adulthood to consider the following:

  • Does the young person have Special Educational Needs & Disabilities (SEND),are they a Care Leaver, Young Carer or a young person in specific circumstances? The SEND Code of Practice identifies the latter group as

Looked after children

Care leavers

Children and young people with SEN and social care needs, including children in need

Children and young people educated out of area

Children and young people who are educated at home

Children and young people in alternative provision

Children and young people who have SEN and are in hospital

Children of service personnel

Children and young people in youth custody

  • If so, does the young person have an Education Health and Care Plan?
  • If not, do you feel that the young person may still require the support of Adult Social Services or Specialist NHS Health Services?

If Adult Services or Specialist NHS Health Services are being considered then:

  • Identify the lead worker for the young person in Children’s Services
  • Identify the lead worker for the young person in Adult Services
  • Confirm with Southend Borough Council Transitions Team (SEN) that the young person is known to Transition Services.
  • Confirm that a referral to Adult Services or Specialist NHS Health Services has been or is being made.
  • Undertake a professional consultation with the lead worker to discuss anyon-going professional interventions required in the transition process.

Part 3: Appendices

The intention of the supporting information contained in the appendices is to enable allprofessionals to make appropriate and timely referrals to other agencies whilst mindful of their own continued input and the various funding stream configurations needing consideration in delivering multi-agency support.

Note: This protocol uses the following terms:

  • ‘Code of Practice’ - refers to the SEN Disability Code of Practice which is the statutory guidance to the Children and Families Act 2014.
  • ‘Guidance’ - refers to the Care and Support Statutory Guidance to the Care Act 2014.
  • ‘National Framework’ - refers to the National Framework for Children and Young People’s Continuing Care (2016) DoH and the National Framework for NHS Continuing Healthcare and NHS Funded Care (2012)DoH.
  • NICE -refers to the National Institute for Health and Care Excellence-Transition from children to adult services for young people using health or social care services (2016).

Note: An easy read version of this protocol is also available, entitled:

‘Preparing for Adult Life: A good practice guide to the ‘Preparing for Adulthood’ Transition Protocol for young people with Special Educational Needs and Disabilities

1

1.2 Required Action: Reference to or evidence of transition planning needs to be included in all required actions

Education Responsibilities from Year 9 to Year 14

School
Year (Age) / Responsible Professional / Action / Young person and parent carer input / Planning Pathway / Statutory regulations, guidance and procedures
1.2.1 / Year 9
(13-14) / Special educational needs teams/ school/SENCO / Special Educational Needs Team will initiate transfer reviews converting Statements to EHCP’s.
School will initiate annual review and invites young person, parents and relevant professionals.
The school or college will ensure all appropriate health professionals (including any CCG representation) and social workers from both Children’s and Adult Services are invited.
The review will focus on both education targets and preparation for adult lifewhich includes health, employment, independent living and participation in society.
Independent Advice and Information Service (IASS) can offersupport for parent/carers and young people where required
Any adult Transition/Needs Assessment should be aligned with the annual review. / Planning begins
Year 9
Young person is encouraged to participate fully by being supported to think about preparing for adulthood-what is important to them, their hopes aspirations and outcomes.
Families are able to articulate their hopes and aspirations for the future and are aware of any nominated lead professional.
Young person updates personal One Page Profile and is offered a Transition Passport document to record additional information.
Information should only need to be given once. / Multi-agency planning approach.
EHCP Case Officer identified. Lead & key health workers identified.
Children’s and Adult Services lead workers identified along with all representatives from partner agencies with a planning role.
EHCP Case Officer may identify an overall lead professional or ‘key worker’ to deliver integrated care and help reduce bureaucracy.
School holds Transition Review.
Clarity established about how key partners work together to deliver support.
Preparation for Adulthood planning underway. From Year 9 onwards the focus of all person centred EHCP reviews will be preparation for adulthood.
The transition planning must be built into the EHCP and updated annually, recording hopes, aspirations and required outcomes
Integrated Transition Plan formulated within an acceptable timescale. / SEN Code of Practice 8.62 & 9.173-9.176
SEN Code of Practice 8.24 & 9.172
SEN Code of Practice 1.40 &9.184
Care Act Guidance 16.11
Care Act Guidance 16.39
SEN Code of Practice 8.59
Guidance 16.11
SEN Code of Practice 9.32-information sharing arrangements.
Care Act Guidance 16.48 &16.49
SEN Code of Practice 8.9, 8.13 & 8.24.
Note:Transition Support Requirement Form to be used to transfer useful information from one education provider to another whenever there is a change of school.
1.2.2 / Year 9
(13-14) / School SENCO / SENCOs (Special Educational Needs Case Officers) should inform young people with autism and their parent/carer of their right to an adult needs/transition assessment. / Consider if there may be a need for Adult Services support in the future / School considers all children and young people who may need Adult Services support including all those on the autistic spectrum. / SEN Code of Practice 8.26 and 8.64
Autism Act 2009 – Statutory Guidance on the implementation of the Adult Autism Strategy.
Care Act Statutory Guidance.
1.2.3 / Year 9
(13-14) / Education professionalsworking with children and young people with EHC plans who are receiving Elective Home Education / Share information