Reviewing a Transition Plan (Transition to Adult Care and Support)

1. When to use this Procedure

This procedure should be used whenever you have been asked to review a Transition Plan.

If you need to review and Education, Health and Care Plan for a young person under the age of 18 you should refer to relevant children's services procedures.

2. The Purpose of Reviewing the Transition Plan

The purpose of reviewing the Transition Plan is to:

1. Ensure that actions have been carried out as agreed;
2. Discuss and agree timeframes for a proportionate assessment to confirm needs and eligibility or commence Care and Support/Support Planning;
3. Review progress towards outcomes in the plan and identify new outcomes;
4. Establish any changes required to the plan; and
5. Agree any further actions required to progress transition.

3. Who should be Involved

Unless there have been any changes in consent or circumstances it is normally appropriate to involve the same people in the Transition Plan review as were involved in developing the Transition Plan.

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 in reviews of the plan.

The advocacy duty

You should consider whether the advocacy duty applies whenever:

1. A young person/young carer (under the age of 16) lacks competence to be involved in the review; or
2. A young person/young carer/parent carer (from the age of 16) has substantial difficulty being involved in the review.

If the young person / young carer is under 16

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

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

If the young person/young carer is over 16 but under 18

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

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

If the young person/carer is over 18

When the young person/young carer/parent carer is over the age of 18 you must involve:

1. The young person/young carer/parent carer;
2. Any carer (where transition relates to a young person with care and support needs);
3. Anyone else that the young person/young carer/parent carer asks you to involve;
4. Anyone else that the young person/young carer/parent carer consents to be involved; and
5. In the case of a young person with care and support needs who lacks capacity, anyone else that you feel it is in their best interests to involve.

4. Combining Transition Reviews

Where a young person with care and support needs and their carer both have a Transition Plan consideration should be given to combining reviews.

Reviews can be combined so long as:

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

5. Reviewing the Transition Plan

When to review

Unless an unplanned review is requested or required the Transition Plan review should be carried out to the timeframes agreed:

1. When it was developed; or
2. At the last review

The timeframe should be proportionate and appropriate to the specific transitional needs of the young person/young carer/parent carer and their circumstances.

The timeframe should be flexible and bringing a planned review forward should always be considered whenever it is requested by anyone involved in the plan.

Method of review

The method of review should ensure the involvement of the young person/young carer/parent carer and may be:

1. Face to face;
2. Telephone communication;
3. E-mail communication.

Where a young person with care and support needs lacks capacity (over the age of 16) or a young person/young carer lacks competence (under the age of 16) you should meet with them face to face to review the plan. This should be with the support of an appropriate person or an independent advocate.

What to include in the conversation

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

1. Whether the outcomes in the plan are progressing as planned;
2. Whether the support being provided to prepare for transition is working as intended, or whether changes are needed to the support;
3. Where likely needs from the point of transition have not yet been confirmed through a proportionate adult needs or carers assessment, when it may be of significant benefit to do so;
4. Where likely needs from the point of transition have been confirmed and found eligible, when it may be of beneficial to set an indicative personal budget and begin Care and Support / Support Planning;
5. Where likely needs have been assessed and found not eligible, what alternative options for support from the point of transition need to be explored;
6. If there have been changes to the young person's/young carer's/parent carer's needs or circumstances (now or likely in the future), what the impact on the plan is;
7. Whether the plan is still an appropriate and proportionate way to support transition;
8. Whether anyone else needs to be involved in then plan (for example a health professional);
9. New actions required to progress the plan;
10. What monitoring of the plan may be required to ensure progress following the review;
11. When the plan should next be reviewed.

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/young carer/parent carer to maximise their engagement.

First and foremost you should have regard for any available practice guidance or good practice examples provided by the Local Authority.

The following are additional tools and guidance that may be useful:

See SEND resources for healthcare professionals for a range of tools specifically to support young people with both care and support needs and Special Educational Needs (SEN) up to the age of 25.

See: Building Independence through Transition, a guide to support transition planning produced by SCIE.

tri.x has also developed a range of person centred tools that can be sued to support a young person/carer to think about what matters most to them, now and in the future.

See Resources for Person Centred and Strengths Based Conversations.

6. Recording and Next Steps

Recording the review

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

The timeframe for making a record

There is no statutory timeframe for making a record of a Transition Plan review, but this should be done in a timely way and in line with local requirements.

What should be included in the record

The review record should include:

1. What progress has been made towards outcomes in the plan;
2. What support has been provided to the young person/young carer/parent carer to support them to manage the transition, and how this has worked;
3. What has been discussed or agreed in regard to any proportionate assessment to confirm needs, setting an indicative personal budget or Care and Support / Support planning;
4. Whether there are any changes required to the plan, including the young person's/young carer's /parent carer's outcomes and the transitional support being provided support;
5. Whether anyone else is going to be involved in the plan;
6. What new actions have been agreed to progress the plan;
7. How the Plan will be monitored and when the next review will be.

Providing a copy of the record

A record of the review should be provided to the young person/young carer/parent carer and to anyone else who is involved in the plan.

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

Where the young person/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 record should be shared with anyone else you can only do so:

1. With the young person's/young carer's/parent carer's consent (from the age of 16);
2. In the best interests of a young person with care and support needs (from the age of 16 if they lack capacity); or
3. With the consent of a person with parental responsibility (if a young person/young carer is under the age of 16 and lacks competence).

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

Revising the Transition Plan

The process for revising the Transition Plan should be as simple as possible to reflect the fact that it may need to be revised on many occasions throughout its lifetime.

If you are not familiar with the process for revising a Transition Plan you should seek advice from your line manager.

7. Ending the Transition Plan

When to end the plan

The timeframe for ending a Transition Plan will be different for each young person/young carer/parent carer and no legislation sets a time limit on ending or continuing a Transition Plan.

Some plans will end as soon as adult Care and Support begins to meet eligible needs, some may end before this time and some may continue beyond it.

Indicators that a Transition Plan may no longer be required include:

1. All outcomes in the plan have been met with no further action required;
2. The young person/young carer/parent carer has no eligible needs from the point of transition and has made appropriate alternative arrangements which do not require monitoring;
3. The Transition Plan has been incorporated into an adult Care and Support / Support Plan and will be monitored as part of the statutory Care and Support Plan review;
4. The young person/young carer/parent carer has successfully transitioned to adult Care and Support / Support and there are no further transitional objectives to be met.

Any decision to end the Transition Plan must be agreed with:

1. The young person/young carer/parent carer;
2. The young person's/young carer's parents (under the age of 16);
3. Anyone with parental responsibility (where the young person/young carer is under 18).

Where the young person/young carer/parent carer is over the age of 18 any decision to end the Transition Plan must be made with regard for:

1. Their views about ending the plan;
2. In the case of a young person with care and support needs, the views of any carer about ending the plan; and
3. The impact of ending the plan on the individual Wellbeing.

If the young person/young carer/parent carer is not in agreement with the decision to end the plan you must make them aware of their right to complain.

Ending the plan

If a decision has been reached to end the Transition Plan you should:

1. Ensure that measures are in place to follow up on any on-going elements of the Transition Plan via other plans or adult Care and Support processes; and
2. End the Transition Plan.