The Transition Plan (Transition to Adult Care and Support)

1. When to use this Procedure

You should use this procedure whenever you have been asked to start a Transition Plan.

If a 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/young carer/parent 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 young person/young carer/parent 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 transition assessment has been completed.

Transition planning is a process that supports a young person/young carer/parent 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 when the young person/young carer/parent carer is already (or imminently) at the point of transition may not be of significant benefit unless a young person/young carer 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 or carers assessment, establish eligible needs and provide any transitional support as part of the statutory Care and Support/Support Planning process.

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

1. The views of the young person/young carer/parent carer;
2. The views of any carer (when a young person with care and support needs is going through transition);
3. The views of anyone with parental responsibility (when the young person/young carer is not yet 18); and
4. The impact of the decision on Wellbeing.

4. Who to Involve in the Transition Plan

Unless there have been any changes in consent or circumstances 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 person/young carer lacks capacity or competence to be involved in the plan; or
2. A young person/carer/parent carer has substantial difficult being involved in the plan.

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

If Transition Plans are developed after 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.

5. Combining Transition Plans

Consideration should be given to combining the Transition Plan of a young person with care and support needs and their carer whenever the carer will be continuing to provide care and support in adulthood.

Plans 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. A young person / young carer lacks competence and a person with parental responsibility consents (under the age of 16); and
4. 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 / young carer / parent carer. It should broadly consider the following things:

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

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.

tri.x has also developed a range of person centred tools that can be used 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.

7. Recording the Transition Plan and Next Steps

Recording the Plan

You are responsible for establishing the current framework used by the Local Authority for recording a Transition Plan. 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 local requirements.

What should be included in the Plan

The plan should include:

1. What the young person's/young carer's/carer's outcomes are now;
2. What the young person's/young carer's/carer's outcomes may be from the point of transition;
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/young carer/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.

tri.x has developed a tool that can be used as required to action plan.

See: Action Planning Tool.

Providing a copy of the Plan

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

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, 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 plan 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.

Amending the Plan

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

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