The Transition Plan (Carers)

1. When to use this Procedure

You should use this procedure whenever you have been asked to start a Transition Plan for a carer/young carer that is not a Support Plan.

2. The Purpose of a Transition Plan

Supporting a carer/young carer 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 carer/young carer 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 young carer's assessment or child's carer's assessment has been completed.

Transition planning is a process that supports a carer/young carer to consider and be provided with the support they will need to make the transition to adult Care and Support. As such, transition planning may not be of significant benefit in the following situations;

1. When a young carer is already (or imminently) 18; or
2. When the young person that an adult carer provides Support to is already (or imminently) 18.

In either of these cases it may be more appropriate to carry out an adult carer's assessment, establish eligible needs and provide any transitional support as part of the statutory Support Planning process.

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

1. The views of the carer/young carer; and
2. Where the young carer is not yet 18, the views of anyone with parental responsibility; and
3. The impact of the decision on the carer/young carer's Wellbeing.

4. Who to Involve in the Transition Plan

Unless there have been any changes in consent or the carer/young carer'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

You should consider whether the advocacy duty applies whenever;

1. A young carer lacks capacity or competence to be involved in the plan; or
2. A carer or a young carer has substantial difficult being involved in the plan.

If a young carer is under 16

When a young carer is under the age of 16 you must involve;

1. The young carer;
2. The young carer's parents;
3. Anyone who has parental responsibility;
4. Anyone else that the young carer 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 carer or anyone with parental responsibility).

If a young carer is over 16 but under 18

When the young carer is over the age of 16 you must involve;

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

If the carer is an adult (over the age of 18)

When a carer is over the age of 18 you must involve;

1. The carer;
2. Anyone else that the carer asks you to involve;
3. Anyone else that the carer consents to be involved.

5. Combining Transition Plans

Where the carer/young carer is caring for a young person who is also making the transition to adult Care and Support consideration should be given to combining the carer/young carer's Transition Plan and the cared for young person'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/young carer is in agreement; or
5. The young carer is under 16, unable to consent but a person with parental responsibility is in agreement; or
6. The young carer is between 16 and 18 years old, is unable to consent and the Local Authority makes a best interest decision to this effect; and
7. 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 carer/young carer. It should broadly consider the following things;

1. When it may be of significant benefit to carry out a proportionate assessment to confirm the carer/young carer's needs for adult Care and Support;
2. When it may be of significant benefit to set an indicative personal budget and begin Support Planning (when needs for adult Care and Support have been confirmed and found eligible);
3. Whether there are any other assessments or services that the carer/young carer would benefit from;
4. What outcomes the carer/young carer may want to achieve from the time the plan is developed until the time of transition;
5. What things are likely to be important for the carer/young carer in the future;
6. Understanding what the carer/young carer's circumstances and informal networks may be in the future-are they likely to change?
7. What future support options may be and when/how to start exploring their suitability;
8. 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.

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

7. Recording the Transition Plan and Next Steps

Recording the Plan

You are responsible for establishing the current framework used by the service 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.

What should be included in the Plan

The plan should include;

1. What the carer/young carer's outcomes are now;
2. What the carer/young carer's outcomes may be in the future;
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 carer/young carer; 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 carer/young carer, and to anyone else who is involved in it.

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

Where the young carer 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. The carer/young carer's consent; or
2. In the case of young carers, the consent of a person with parental responsibility if they are unable to consent and under 16; or
3. In the case of young carers, a Local Authority best interest decision if they are unable to consent and over 16.

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

Amending the Plan

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

Any revised copies of the plan should be provided to the same people as the original, unless the carer, young carer (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.