The Transition Plan (Disability Locality Teams and Transitions)

1. When to use this Procedure

You should use this procedure whenever you have been asked to start a Transition Plan for a young person that is not:

1. Part of an Education, Health and Care Plan; or
2. A Care and Support Plan.

If the young person has an EHC Plan the Transition Plan should normally be incorporated into the EHC Plan, as there is a statutory duty to plan for transition as part of the EHC Plan.

2. The Purpose of a Transition Plan

Supporting a young person through the transition to adult Care and Support is a statutory duty of both the Care Act and the Children and Families Act. The Transition Plan can prove an effective way to:

1. Identify what needs to be done to support the young person through transition in a proactive planned way;
2. Agree who will take responsibility for what needs to be done; and
3. Review progress and take further action to ensure a smooth transition.

3. When to Transition Plan

The Transition Plan can take place at any stage where it is deemed beneficial to do so. This can be before or after any child's needs assessment has been completed.

Transition planning is a process that supports a young person to consider and be provided with the support they will need to make the transition to adult Care and Support. As such, transition planning when the young person is already (or imminently) 18 may not be of significant benefit unless the young person is not going to transition to adult Care and Support until they finish their education at the age of 19.

It may be more appropriate to carry out an adult needs assessment, establish eligible needs and provide any transitional support as part of the statutory Care and Support Planning process.

Any decision not to develop a Transition Plan must be made with regard for:

1. The views of the young person;
2. The views of any carer;
3. The views of anyone with parental responsibility (when the young person is not yet 18); and
4. The impact of the decision on the young person's Wellbeing.

4. Who to Involve in the Transition Plan

Unless there have been any changes in consent or the young person's situation it is normally appropriate to involve the same people in the Transition Plan as were involved in any recent assessment process.

Consideration should be given as to the stage in transition where it would be helpful for a person with expertise and knowledge in adult Care and Support to become involved.

The advocacy duty

Where the young person lacks capacity (or competence under the age of 16) you should consider whether an independent advocate is required to ensure their involvement.

If the young person is under 16

When the young person is under the age of 16 you must involve:

1. The young person;
2. The young person's parents;
3. Anyone who has parental responsibility;
4. Anyone else that the young person asks to be involved;
5. Anyone else that a person with parental responsibility asks you to involve;
6. Anyone else that you feel needs to be involved (with the consent of the young person or anyone with parental responsibility).

If the young person is over 16 but under 18

When the young person is over the age of 16 you must involve:

1. The young person;
2. Anyone with parental responsibility;
3. Anyone else that the young person asks to be involved;
4. Anyone else that the young person consents to be involved (for example a parent or family member that does not have parental responsibility);
5. Where the young person lacks capacity, anyone else that you feel it is in their best interests to involve.

If the young person is over 18

If Transition Plans are developed after the age of 18 you must involve:

1. The young person;
2. Any carer;
3. Anyone else that the young person asks you to involve;
4. Anyone else that the young person consents to be involved; and
5. Where the young person lacks capacity, anyone else that you feel it is in their best interests to involve.

5. Combining Transition Plans

Where the young person has a carer who will be continuing to provide Care and Support from the age of 18 consideration should be given to combining the young person's Transition Plan and the carer's Transition Plan.

Plans can be combined so long as:

1. The young person is in agreement; or
2. The young person lacks capacity and a decision is made in their best interests (over the age of 16); or
3. The young person lacks competence and a person with parental responsibility consents (under the age of 16); and
4. The carer is in agreement; and
5. Combining plans is technologically possible.

6. The Transition Plan Conversation

What to include in the conversation

The Transition Plan conversation should be proportionate and appropriate to the specific transitional needs of each young person. It should broadly consider the following things:

1. When it may be of significant benefit to carry out a proportionate assessment to confirm the young person's needs for Care and Support from 18;
2. When it may be of significant benefit to set an indicative personal budget and begin Care and Support Planning (when needs from the age of 18 have been confirmed and found eligible);
3. When it may be of significant benefit to assess any carer's needs for Support when the young person is 18;
4. Whether there are any other assessments or services that the young person would benefit from (for example health assessments);
5. How to introduce the concept of change to the young person and whether they need specialist support to manage and understand the whole transition process;
6. What outcomes the young person may want to achieve from the time the plan is developed until the time of transition;
7. What things are likely to be important for the young person from the age of 18;
8. Understanding what the young person's circumstances and informal networks may be from the age of 18-are they likely to change?
9. What future support options may be and when/how to start exploring their suitability;
10. Whether there is any information about Adult Care and Support that needs to be established (for example information about finances).

Tools to support the conversation

There are a range of tools available to you to support effective conversations during the Transition Planning process. You should consider the tool/s that you feel are best suited to the young person and will maximise their engagement.

A range of tools available to support any transition process with a young person up to the age of 25 with Special Educational Needs (SEN). See SEND resources for healthcare professionals.

Click here to access a tri.x tool that can support a young person to think about what matters most to them, now and in the future.

Click here to access 'Building Independence through Transition', a guide to support transition planning produced by SCIE.

See: Making finance decisions for young people: parent and carer toolkit, a guide for parents and carers to make financial decisions for a young person who lacks capacity.

7. Recording the Transition Plan and Next Steps

Recording the Plan

You are responsible for establishing the current framework used for recording purposes. If you are unclear you should speak to your line manager before proceeding to make a formal record of the Transition Plan.

The timeframe for making a record

There is no statutory timeframe for making a record of a Transition Plan, but this should be done in a timely way and in line with the Local Standards for Timeliness of Recording. The standards can be found in the Local Resources area by clicking here.

What should be included in the Plan

The plan should include:

1. What the young person's outcomes are now;
2. What the young person's outcomes may be from the age of 18;
3. What has been discussed and agreed in terms of actions required to support an effective transition;
4. What has been agreed in terms of tasks, roles and timeframes;
5. Anything else that you feel needs to be included in the plan based on the specific needs of the young person; and
6. How the Plan will be monitored and reviewed.

It may be useful to prepare a simple written action plan alongside the Transition Plan for the purpose of recording and monitoring what has been agreed, and the steps that different people will be taking to progress the plan.

Click here to access a tri.x tool that can be used to action plan.

Providing a copy of the Plan

A copy of the plan should be provided to the young person, and to anyone else who is involved in it.

You must also provide a copy to anyone else that the young person asks you to, unless you feel that doing so will place the young person, or another vulnerable adult or child at risk of harm or abuse.

Where the young person is under the age of 16 you must also provide a copy to anyone who a person with parental responsibility asks you to provide a copy to.

If you feel that the plan should be shared with anyone else you can only do so:

1. With the young person's consent (from the age of 16);
2. In their best interests (from the age of 16 if they lack capacity); or
3. With the consent of a person with parental responsibility (under the age of 16 if the young person lacks competence).

If you are unsure whether to share a copy you should seek advice from your line manager.

Amending the Plan

If the young person, or anyone else requests any amendments to the plan these should be considered and made in agreement with the young person.

Any revised copies of the plan should be provided to the same people as the original, unless the young person (from the age of 16) or their parents (under 16) advise otherwise.

Agreeing how to monitor and review the Plan

It is important the any Transition Plan is regularly reviewed to ensure effective progress, and to be able to respond appropriately to any changes in outcomes or actions required.