SCOPE OF THIS CHAPTER
This Transition Protocol will ensure the smooth Transition from Children's Services to Adult Services where children and young people are assessed as needing and are eligible for services.
This Protocol should not be used in isolation and is not a substitute for the policy.
- Principles of Effective Transition
- Decisions that can be made at the Transition Planning Meeting
- Dispute Resolution
- Information Gathering
- Action Agreed where Children and Young People are known to Education and not previously known to Children's Services
- Roles and Responsibilities Children's Services
- Roles and responsibilities of Adult Services Worker
- Management Oversight
- Service Managers Transition Forum
The purpose of this protocol is to ensure an effective transition to Adult ACM Services for young people with a range of different disabilities including:
- Learning Disability;
- Physical Disability;
- Sensory Impairment;
- Mental Health Needs.
- Are assessed as being eligible for services under Fair Access to Care and current eligibility criteria;
- Are identified as receiving services through a process of assessment;
- Where the failure to provide agreed services through the process of assessment and against the eligibility criteria will lead to a breakdown in the current arrangements and present unacceptable risks to the potential service user and his/her family/carers.
This protocol exists between Children's Services and the Adult Team commissioned with the responsibility of providing services to Adults as described above
2. Principles of Effective Transition
- Child Focused;
- Involving the potential service provider (Adult services);
- Involving appropriate agencies in identifying solutions;
- Early discussion with all parties including its representatives/managers of appropriate services;
- Modelling of appropriate service provision by the Children's Disability Team, including evidenced discussion by Social Workers that reflects differences in expectations.
Action required - Open Cases
Children and young people with a range of needs known to a social worker within Children's Services.
Children's Services social worker to attend the year 9 review (14 years old) convened within School and by School.
Children's Services social worker to determine with School that all-appropriate agencies are represented. See Inter Agency Transition Policy for best practices
Where a young person is Looked After, the Aftercare Service should be advised that Transition planning has begun, and the appropriate Adult Team will attend at least two Looked After Reviews prior to the young person's 16th Birthday - for further details see Leaving Care and Transition Procedure.
The Transition Planning should also inform the pathway planning process this should constitute a single assessment process and be conducted by a Lead Professional. An informed and recorded discussion should inform the decision as to whether the Lead Professional is the social worker or a Personal Adviser from the looked after support service.
Any planning should be conducted by a worker who is well known to the young person.
Information gathered at the Transition meeting as described above, should form the basis of a Child and Family Assessment of need/care assessment, which in turn will form the basis for transition planning.
Within the Initial Transition Planning Meeting, consideration should be given as to who the Lead Professional should be to support individual young people through the Transition process. This should be someone who is well known to the young person and may change.
3. Decisions that can be made at the Transition Planning Meeting
- Agree initial plan;
- Agree when to refer to Adult Services in a formal way, subject to young person meeting eligibility criteria, unless a case is particularly complex; this would not normally be prior to a young persons 17th birthday. Upon referral, Adult Services would be expected to allocate a social worker or nurse (if young person's needs are complex) to work alongside the Children's Disability Team worker;
- Agree which tool to use to provide an individual Transition Plan;
- Agree continued nature of school provision;
- Agree when to involve the Aftercare Service if appropriate.
4. Dispute Resolution
Where there is disagreement about when to involve Adult Services or which Adult Services Team to involve that cannot be resolved by Team Managers, resolution should be sought from Service Managers.
5. Information Gathering
In beginning to identify the needs of individual young people, then the Team Manager of the Children's Disability Team in conjunction with discussion with all Locality Team managers must advise the Commissioning Officer with responsibility for Children and Young People with complex needs who will report to appropriate partnership boards, on overall needs map and service provision.
6. Action Agreed where Children and Young People are known to Education and not previously known to Children's Services
- Education may contact Children's Services Locality Teams including Children's Disability Team requesting attendance on Transition review;
- A decision would then need to be made as to whether the child/young person meets the threshold for assessment. If that is met then the process should be followed as described.
7. Roles and Responsibilities Children's Services
The roles and responsibilities of the social workers within Children's Services are as follows:
- To trigger the involvement of the Adult Team as defined above;
- To prepare and inform carers prior to the Adult Services Worker involvement, levels of service entitlement including significant changes e.g. charges. Service availability, respite and transport costs;
- To undertake an assessment of needs based on the Assessment Framework for Children in Need and their Families and up to date Children's Plan, and/or case summary highlighting the key issues and action thus far;
- To lead on the introduction/integration into assessed services as agreed and in conjunction with the Adult Services Worker and any significant others;
- To write up a Children's Plan, and assist the Adult Services Team Worker in translating this into an Adult Care Plan prior to the point of transfer.
8. Roles and responsibilities of Adult Services Worker
The roles and responsibilities of the social worker within the appropriate Adult Service are as follows:
- To respond to the request for involvement for Children's Services in a timely and appropriate manner;
- To engage in an assessment process through the single assessment process that enables effective planning identification of needs and service delivery;
- Participate in discussions with Children's Services colleagues in respect of the impact of change for example changes for service etc;
- Participate in case conferences where children and young people are described as having particularly Complex Needs (more than one impairment for example).
9. Management Oversight
To ensure effective service planning in respect of young people with disabilities who may require ongoing services from Adult Social Services.
It will be the responsibility of the manager of the Children's Disability Team, to inform Adult Services of the numbers of young people likely to need ongoing services, or be eligible for assessment under Fair Access to Care.
The manager of the Children's Disability Team will be responsible for co-ordinating any information in respect of a young person receiving a service from locality Children's Services who may be:
- Eligible for assessment under Fair Access to Care from adult services;
- Eligible for ongoing services from Adult Services.
Reporting on this information to Adult Services, managers should meet every two months from a young person's 16th birthday to plan and track progress including identifying costs.
This forum should be chaired by a service manager from Adult Services, and all decisions made recorded.
Where a young person has complex health needs, consideration should be given to the need for presentation to the appropriate Adult Service Continuing Care Panel.
10. Service Managers Transition Forum
All young people presented for discussion at this forum will have been involved in a Child and Family Assessment and had their needs clearly identified and assessed.
Responsibilities of Service Managers Transition Forum
- Meet every two months from a young person's 16th birthday;
- Record decisions;
- Ensure a constructive organizational response to managing Transition;
- Engage in problem solving and sign posting where appropriate.