Flintshire County Council Transition Planning Protocol Children's

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                        Flintshire County Council
                      Transition Planning Protocol
                  Children’s Services to Adult Services
                           Issue 2 August 2008

Aims and Objectives

The aim of this protocol is to ensure a smooth transition for young people with
disabilities including mental health, during the transition from childhood to adulthood.

To achieve a smooth transition, the protocol is intended to:
   • Provide clarity about the roles of different agencies at different stages of
   • Ensure the identification of young people who will require services beyond
   • Identify ways of communicating with and providing information to young
      people and their families
   • Formalise ways of tracking the progress of young people
   • Ensure that young people with disabilities and their carers can take an active
      part in this process
   • Use all resources jointly available to meet young people’s needs.

Strategic Management Group

A strategic management group will meet 3 times a year to give strategic oversight.
The group will comprise:
   • Assistant Director Social Services for Adults FCC
   • Assistant Director Social services for Children FCC
   • Directorate General Manager Child, Family & Community NWT
   • Directorate General Manager Mental Health NWT
   • Head of Inclusion Service, Education FCC
   • Director of Nursing Flintshire LHB

The strategic management group will
   • Approve and then annually review the transition planning protocol
   • Consider and agree the commissioning arrangements and requirements for
       any changes to services.

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   • Consider joint commissioning
   • Receive reports as required
   • Consider mental health process
   • Consider children in exceptional circumstances who are challenging/causing

Service Managers will be invited to attend the group at the discretion of the group
members to provide updates as necessary.

Identification of young people with disabilities

In Year 8 (2nd year), the Inclusive Education Assessment Service Manager will
identify, from the list of statemented children, those young people who may require
assistance from other agencies through the transition period or beyond. Ordinarily
this group of young people will be restricted to those who meet the criteria for a
service from the Childrens Integrated Disability Service (CIDS) or Child and
Adolescent Mental Health Service (CAMHS) and who will meet the eligibility criteria
for adult Learning Disability or adult Mental Health Services. However, on occasion,
young people known to children’s services that have complex problems may be put
forward for consideration as cases for vulnerable adult support. The expectation is
that this group of young people will be small in number and restricted to those who
present the most challenge to Children’s Services and have longstanding issues
which remain unresolved and impact significantly upon their ability to cope
independently in the community.

Children with mental health difficulties may not have a statement and a request will
be made to Children and Adolescents Mental Health Service (CAMHS) to identify
them from the Specialist CAMHS multi agency panel (SC-MAP) referral process.

An Identification Panel chaired and convened by the Childrens Integrated Disability
Service Manager (which is part of the existing transition panel business once a year)
will then take place to identify those children to be discussed at Transition Panel in
the future. Professionals involved in this process should include

   •   Children’s Integrated Disability Service (CIDS) –Service Manager (convenor)
   •   Community Paediatrician / School Doctors
   •   Audiology Consultant Paediatrician
   •   Children’s nursing representatives nominated by the CIDS Service Manager
   •   CAMHS and HAS Service Manager
   •   Chair of Transition Panel (Learning Disability Service Manager)
   •   Physical Disability and Sensory Impairment Service Service Manager
   •   Adult Mental Health Service Manager

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   • Behavioural Support Team Manager Education
   • Local Health Board representative
   • Specialist Advisory Teachers – visual and hearing impairment
   • Inclusive Education Assessment Service Manager
   • Careers Wales

Schools will be informed of children who have been identified, by the Inclusive
Education Assessment Service Manager. This will assist the preparation for the Year
9 review, which will involve identifying dates, informing students, carers and advice
givers with appropriate preparation offered to student and carer. A letter will also be
sent to the young person and their family by the Local Education Authority (LEA) to
inform them of the process.

Assessment by Children’s Integrated Disability Service (CIDS)

A number of these young people will already be known to CIDS and may also be
receiving services.

Young people (and their families) who are identified at the Identification Panel and
who meet the CIDS criteria but not in receipt of a service should receive a letter from
the Children’s Integrated Disability Service (CIDS) offering an Assessment
(Framework for Assessment for Children in Need and their Families & Section 5 & 6
Assessment of the Disabled Persons Act which will take place at age 16). In order to
be referred a multi-agency referral form would need completing and consent given
by the parent.
CIDS will maintain a spreadsheet of those families offered and refusing an
Referrals for the Paediatric Occupational Therapy Service should also be made
using the multi-agency referral form and parental consent is necessary.

Young people with mental health needs will be referred to CAMHS using the
Specialist CAMHS multi agency panel (SC-MAP) referral form. With the young
persons consent and involvement, and that of the family and/or carers where
appropriate, CAMHS will discuss with Adult Mental Health Services the transfer of
care for the young person between the ages of 16 and 18 and a transition plan will
be agreed. A Care Programme Approach (CPA) care plan should be in place prior to
the transfer.

Referral can also be made to the Family Group Meeting Project Leader. This could
facilitate discussion on the family’s needs and could result in plans being formulated

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to aid the transition process.
Young Carers Assessments and Cares Assessments will be offered and undertaken
as appropriate.
Consideration should be given to the use of an advocate in appropriate cases and
particularly where the views of the carer and the child appear to differ. Contact
numbers for the advocacy service can be obtained from any Children’s Services

Year 9 ( 3rd yr) Annual Reviews

Young people on the Transition Identification Panel list who are statemented will
receive a year 9 Review. The purpose of the Year 9 Review is to review the young
person’s statement, explain the process to the student and to begin to identify
aspirations and future needs and to draw up a Single Plan. This plan should be
written in language that all can understand and should include those issues that are
important to the student and carer, which will incorporate continuing education,
careers and vocational training. Responsibility for calling the meeting and drawing
up the Transition Plan lies with the Head Teacher at the young person’s school.
However within mainstream schools this function is delegated to the Special
Educational Needs Co-ordinator based in the school. Consideration needs to be
given to the need for advocacy and who could do this.

Young people who are not statemented should also be offered a Year 9 Review as a
matter of best practice.

Who will be invited to the review? – (as stated in the Code of Practice on the
Identification and Assessment of Special Educational Needs)

   •   Child and parent / carer / foster carers
   •   Class Teacher in Special School
   •   Special Educational Needs Coordinator
   •   Careers Wales
   •   Relevant Education Inclusion Service Members
   •   Plus other professionals as deemed necessary E.g. Therapists, Community
       Paediatrician, Social Worker, Care Coordinator.

Health professionals and CIDS representatives involved in the management and
care of the young person will attend the Review whenever possible, but otherwise
will provide advice towards transition plans in writing.

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Pro-formas for professionals/ young people and families are available and their use
should be encouraged.

Subsequent Annual Reviews

In subsequent years the young person’s statement and Transition Plan will be
reviewed and amended where necessary. The responsibility for arranging and
chairing these reviews remains with the Head Teacher. Careers Wales also have a
particular responsibility to provide guidance from Yr. 9 and to provide an assessment
in the year in which the young person leaves school.

Other relevant professionals will attend these reviews as appropriate.

Adult Social Care and Specialist Health Services will aim to attend all reviews in the
final school year. A representative from Adult Social Care and/or Specialist Health
Services will attend earlier reviews when it has been identified that a young person’s
care needs are likely to need longer term planning or when a family have specifically
requested early involvement.

Where a young disabled person has a statement and has not got a school place and
is in year 11 or below, responsibility will transfer to the manager of the Inclusive
Education Assessment Service.

Where a young disabled person, who is not statemented, has not got a school place
and is in year 11 or below, responsibility will transfer to the manager of the
Behaviour Improvement Service.

Introduction to Adult Services

A Transition Panel will meet at least six times a year (one of which being the
identification Panel) to:
   • Monitor the progress of all young people in their final year at school and other
        young people that the Panel have identified as requiring cross-agency co-
   • Identify an agreed long term goal for an individual and recommend the most
        appropriate joint working arrangements to achieve that goal.
   • Ensure the maintenance of a single accurate spreadsheet identifying the year
        the young person is intending to leave school, their age, school, disability,
        relevant professionals involved and outcomes – this spreadsheet will be held
        and maintained by the Service Manager Learning Disability, Adult Social Care

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The Panel will be convened and co-ordinated by the Service Manager, Learning
Disability ASC and will be made up of:
   • Service Manager and Team Manager- Children’s Integrated Disability Service
   • Social Workers, (CIDS)
   • Service Managers - Learning Disability, Mental Health and Physical Disability
       and Sensory Impairment - Adult Social Care
   • Team Managers - Learning Disability, Physical Disability and Sensory
       Impairment - Adult Social Care
   • Team Manager Health Learning Disability Service
   • Care Manager(s), Adult Social Care Services
   • Transition Coordinator Learning Disability Service
   • Careers Wales
   • Paediatric Learning Disability Nurses
   • Specialist Adult Services Health Care staff
   • Representatives from mental health services from both Adult and Children’s
       services when appropriate
   • Inclusive Education Assessment Service Manager
   • Relevant staff representatives for those young people who may require
       support as vulnerable adults

The Panel records will include clearly identified needs including short term care
(respite care), housing needs, employment, complex/challenging casework and
those young people who are Looked After Children (LAC) between the ages of 14
and 25 if appropriate.

Service Managers, Adult Social Care will take commissioning issues to the Strategic
Management Group through their respective channels. Information relating to service
users for the budgetary planning strategy Adult Social Care need to be identified in
August/September in the previous financial year, and raised via the management
and financial planning process.

The Transition Coordinator, Learning Disability Service, will work with young people
to provide information, promote planning and discussion about life options and
choices during the transition process. They will act as a central reference point for
the young person and their family during transition.

During January and February, the designated Services Manager from Adult Social
Care will make available to each young person and their family an information pack
and an invitation to an open evening during the spring term. Schools and other
professionals involved with the young person and their family will be notified of the

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event, and will encourage the young person and their families to take an active part
in this information sharing.

The pack will include information about:

   •   The process of transition (see Contact a Family information)
   •   Day opportunities
   •   Supported Living – options and realistic aims
   •   Support for carers
   •   Charging policy
   •   The Integrated Care Management process
   •   The Independent Living Fund
   •   Direct Payments
   •   Specialist Health Services
   •   Equipment and adaptations – Occupational Therapy
   •   Advocacy
   •   Social and leisure activities
   •   Transport
   •   Youth services
   •   Specialist further education
   •   Employment
   •   Welfare benefits
   •   Family Group Meeting Project

The information evening will have representatives from as many of the following as

   •   Day Opportunities Team, Learning Disability Service
   •   Short Term Care Team, Learning Disability Service
   •   Community Learning Disability Team, Adult Social Care and Health Trust
   •   Physical Disability and Sensory Impairment Team
   •   CIDS team
   •   Mental Health Services including CAMHS
   •   Specialist Health Services
   •   Children and Young Peoples Partnership
   •   NEWCIS (Carers Project)
   •   Flintshire Disability Forums
   •   Self Advocacy
   •   Careers / Employment Services
   •   Local employers
   •   Welfare Rights / Benefits advice

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   • Sports Development and Leisure Services
   • Colleges
   • Transition Years co-ordinator(s)
   • Other appropriate voluntary sector representatives and clubs
   • Elected members

For the majority of young people an initial visit from Adult Social Care Services will
be offered in the summer prior to the transfer to Adult Services and will take place
between July and September.

The purpose of this visit will be for the allocated Practitioner and Team Manager to
introduce them selves and to answer initial questions about the transfer from
Children’s Services to Adult Services. Prior to undertaking this task appropriate
information sharing will have taken place from CIDS, LEA, Schools and Health via
the Transition Panel and the referral to Adult Social Care. Where the young person
and family are well known to Children’s Services, a joint initial meeting is

It will also be an opportunity for the Practitioner from Adult Social Care to gather an
initial indication about the young person’s expectations and likely needs after leaving
school. This information will enable Adult Social Care Services to explore options
and to plan its services and budgets for the next financial year.

The organisations will work towards Adult Social Care Services formally taking
responsibility for providing services for young people with disabilities when the young
person reaches the age of 18. The Transition Panel will agree on individual cases
when a referral is to be made to the Department of Adult Social Care. For young
people who are looked after the Leaving Care Team may retain some responsibilities
beyond these dates, via the Children Act 1989, Children Act 2004 and the Children
(Leaving Care) Act 2000.

Assessment and Care Planning for Adult Social Care and Health Services

The designated practitioner will commence an assessment under the Community
Care Act, through a Unified Assessment, by the October of the final school year.
Health professionals will be involved as appropriate.

The assessment and draft care plan will be completed by the end of December, and
be forwarded to Careers Wales who co-ordinate the applications to the National
Council – Department for Children, Education, Lifelong Learning and Skills
(DCELLS) to fund any recommendations for Specialist Colleges and make
arrangements for placement follow-up. Careers Wales then submit the
recommendations to the National Council –DCELLS by the 31st January of the final

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year. The National Council – DCELLS aim to provide a decision on any applications
by May of the final year.


A range of mechanisms will be developed to seek parent and young person
feedback on the protocol and transition practices, which will be collated into an
annual report for the Strategic Managers Group.
These will include:
   • Consultation with young people via a range of mechanisms.
   • Questionnaire which will be formalised by a task and finish group identified by
      Transition Panel and sent out one year after the young person starts to
      receive services form Adult Social Care.
   • Relevant commentary from children’s services user surveys

Similarly mechanisms will be developed to seek professional’s views & involvement
in the process:
    • Questionnaire for panel members and for schools
    • Attendance and involvement of panel members

Reviewing the Transition Protocol

Transition Performance Indicators, containing both national and local performance
indicators relevant to Children’s and Adult Social Care Services and Health Services
will be used to undertake, as a minimum, an annual quality audit of local transition
processes. The quality audit will be made available to the Strategic Transition
Management Group and to other stakeholders including young people and their

The Transition Panel will make recommendations to the Strategic Transition
Management Group to inform the annual review of the Transition Protocol. Using the
above information the Transition Protocol will be annually reviewed and formally
agreed by the Strategic Transition Management Group

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       Task                                      Why                                 Who                          Timescale
 1     Identify from list of statemented To plan service delivery                    Identification Panel chaired By the Summer
       children, those with physical and/or                                          by CIDS Service Manager.     term, end of year 8
       learning disabilities who may need To ensure all children included                                         (2nd year)
       assistance from other agencies                                                This meeting is usually part
                                                                                     of the Transition Panel
                                                                                     agenda in the spring/
                                                                                     summer term

 2     Children and their families informed that To inform, seek consent and assist Inclusive Education           Spring/Summer
       they will be discussed at an planning                                        Assessment Service            term, end of year 8
       Identification Panel                                                         Manager LEA                   (2nd year)

 3     Schools informed of children identified   To assist planning for 14+ review   Inclusive Education          Summer term, end
                                                                                     Assessment Service           of year 8 (2nd
                                                                                     Manager LEA                  year)

 4     Children’s Services offer assessment to Ensure needs are fully understood Co-ordinated by Team             Summer onwards
       those children not previously known to                                    Manager CIDS                     prior to 14+ review
       them and CIDS will maintain a Meet legislative requirements as
       spreadsheet of those families offered specified
       and refusing an assessment.

 5     Children’s Service will, with parental Ensure needs are fully understood      Co-ordinated by Team         As identified
       consent, refer on those children with                                         Manager CIDS

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       Task                                       Why                                    Who                             Timescale

       additional needs e.g. to the paediatric Meet legislative requirements
       O.T. service, to CAHMS

 6     Preparation for 14+review – identifying    To maximise the benefit of the         Head Teacher for special        Year 9 ( 3rd year)
       dates, informing students and              review for the young person and his/   schools
       parent/carer and advice givers. Offer      her family
       appropriate preparation to student and                                            SEN      co-ordinator      in
       parent/carer.                                                                     mainstream schools

 7     14+ Review                                 To review the statement, explain the Head Teacher in special           Year 9 ( 3rd year)
                                                  process to the student and begin to schools
                                                  identify aspirations and future needs.
                                                                                         SEN co-ordinator in
                                                                                         mainstream schools

 8     Write the Single Plan in language that     Document the agreements reached, Head Teacher in Special               Begin in Year 9
       all can understand and include those       recognising that this is a living Plan School                          (3rd year)
       issues that are important to the student   which can be changed and added to
       and parent/carer, which will include       as the young person identifies         SEN co-ordinator in
       continuing education, careers and
                                                                                         Mainstream schools
       occupational training.

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       Task                                      Why                                     Who                            Timescale

 9     Subsequent annual reviews to include To review the Statement and the              Head Teacher in Special        Year 10/11/12/13
       an invite to Adult Social Care, Single Plan                                       Schools
       particularly where the young person’s
       care needs are likely to need longer To assist in planning processes              SEN Co-ordinator in
       term planning                                                                     Mainstream Schools

10     Open Event                                Using different mechanisms to           Service Manager Learning Annually, spring
                                                 inform young people and their           Disability, Adult Social Care term
                                                 families of options available to them
                                                 regarding future occupation,
                                                 education leisure, specialist health
                                                 and adult social services.

11     Initial visit where appropriate by Adult Introductions and to begin transfer of   Referrals made by              Summer prior to
       Social Care, in partnership with responsibility from CIDS to Adult                appropriate staff from CIDS,   the
       colleagues       from    CIDS     where Social Care.                              Education or Health when       commencement of
       appropriate                                                                       identified at Transition       final school year
                                                The aim is to work towards this          Panel.
                                                taking place at the age of 18 for all
                                                young people no matter what the

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       Task                                      Why                                  Who                          Timescale

12     Unified Assessment and Care plan by To plan long term service delivery         Care Co-ordinator ASC        Complete by
       Adult Social Care                                                                                           December of final
                                                                                                                   school year when
                                                                                                                   a request is being
                                                                                                                   made to DCELLS
                                                                                                                   for funding for
                                                                                                                   further education

13     Care Programme Approach (CPA) care        Ensure needs are fully understood    Co-ordinated by Team         Between the ages
       plan agreed for young people with                                              Manager CAMHS and Adult      of 16 and 18.
       mental health needs                       To plan long term service delivery   Mental Health Services
                                                 Meet legislative and best practice

14     Young     Carers  Assessment/Carers To document identified needs               Care Co-ordinator            Throughout
       Assessment offered and undertaken as                                                                        transition process
       appropriate                          To inform and assist planning

15     Information relating to service users To inform budgetary planning             Service Managers        Adult August/September
       needs is collated                     strategies and support business          Social Care                   of the previous
                                             planning                                                               financial year

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       Task                                      Why                                   Who                         Timescale

16     Multi agency funding sought to meet To ensure that the young person Adult Social Care; Specialist January of                 final
       future needs, as appropriate.       and family are aware of the future Health Care servicesCareers school year.
                                           plans by the Easter of the final year. Wales to DCELLS

17     Transition Panel will meet at least 6 To monitor the progress of all young      Appropriate         Service At least 6 times a
       times a year                          people in their final school year and     Managers in Adult and Child year
                                             other young people who the panel          Care. Chaired by Service
                                             have identified as requiring cross        Manager Learning Disability
                                             agency co-ordination. To document         Service
                                             identified needs including respite
                                             care, housing needs, employment
                                             and Looked After Children

18     Identification and sharing of information To ensure most appropriate planning   Chair of Child Care Panel to From age 16
       on young people in exceptional of coordinated services                          appropriate          Service
       circumstances who are challenging and                                           Manager in Adult Social
       causing      concern,    via   Children’s                                       Care. Reporting update to
       Services Child Care Panel                                                       Transition Panel

19     Measurement of the success of the To measure the success of this Lead by Service Managers Autumn Term
       Transition Protocol by developing a protocol in meeting the needs of and reporting to Strategic
       range of mechanisms for consulting with young people and their families Transition Group annually
       young people and their families and
       other professionals.

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       Task                                        Why                                 Who                        Timescale

20     A Quality Audit of transition processes     To measure the success of transition Lead by Service Managers At least annually
       in Flintshire will be undertaken at least   processes in meeting the needs of and reporting to Strategic
       annually.     Transition    Performance     young people and their families      Transition Group
       Indicators, containing both local and
       national P.I.s will be used to undertake    To measure performance and
       the quality audit.                          compliance with agreed transition

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Transition Protocol Issue 2 August 2008