4.1.8 Adult Social Care Transition Policy

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1. Introduction

Transition is the process that is followed to support young people and their families as they move from services they receive as a child into those they may need as an adult.

Services should work together to identify as soon as possible, those children and their families who are likely to have eligible social care needs when they reach 18 years, based in the Care Act 2014 eligibility criteria (See Eligibility chapter).

2. Policy Aim

This policy aims to:

1. Enable a smooth transition to adulthood for young people and their families, ensuring that there are no gaps in support.
2. Incorporate person-centred planning into transition planning, enabling choice and control when planning for the future.
3. Clarify the processes, roles, and responsibilities to enable a co-ordinated and transparent approach, which is monitored across partners at both an operational and strategic level.
4. Improve the outcomes achieved by young people in relation to:

• • Employment
  • Independent living
  • Community inclusion
  • Health.

3. Principles of Good Transition

The overarching principle for young people preparing for adulthood is that support provided should be:

“Based on what disabled young people say is important to them. Ultimately, young people want to have full lives with choices about their future and control of their support.”

Preparing for Adulthood website.

Both the Children and Families Act 2014 and the Care Act 2014 place duties on local authorities regarding arrangements for young people with care and support needs as they prepare for adulthood.

Through our work with young people and their families, Lancashire County Council will ensure that:

• Young people are supported to make their own choices in planning for their future.
• Young people are placed at the centre of decision making so that any plans reflect their wishes and best interests.
• Young people and their parents or carers are provided with good information throughout, both about what to expect as they approach adulthood and the range of options for the future.
• Young people and their circle of support are fully involved in planning.
• Information is gathered from all the agencies involved in supporting the young person to develop a comprehensive plan.
• Young people are supported to develop skills to be as independent as possible; and
• High quality data is provided in relation to projected needs across Lancashire to help ensure that commissioners have the information they need to develop services which reflect local needs.

Where a young person is also a Child in our Care (looked after), they are likely to have specific needs in relation to accommodation and post 16 support and plans to assess and meet these needs must be made in a separate plan called a Pathway Plan. The role of the Transition Service for children who are in the care of Lancashire County Council is to ensure that their social care needs are assessed in good time to make robust person-centred plans for their 18^th birthday. See also Lancashire Children’s Social Care Procedures.

4. Transition in Lancashire

4.1 Eligibility for support from the Transition Service.

The Transition Service is a specialist team working with young people between 14 and 19 years old.

Young people who require support with transition planning are those likely to have eligible Care Act needs when they turn 18 years of age, they are also likely to have an existing Education, Health and Care Plan (EHCP).

Where the Transition Service becomes aware of a young person meeting the eligibility criteria, they will begin planning with them from Year 9.

If the Transition Service is unable to accept a referral, they will explain the reason for this decision in writing and provide signpost the referrer to universal or preventative services- this may be through the Council’s Local Offer.

The Transition Service accept referrals from a number of sources including Children’s Social Care, SEND Service and schools. Young people and families can also self-refer for a transition assessment. For more information, see the Local Offer.

4.2 Support provided by the Transition Service

Children in our Care will be contacted by the Transition Service around Year 11 (15-16 years old), to support completion of the Pathway Plan.

Further contact from the Transition Service will usually occur during Year 13 (17-18 years old) to complete the Transition Assessment and Support Planning.

The Transition Service will remain in contact with young people still in education during Year 14, to support planning for any new social care arrangements required for young people leaving school.

The Transition Service will end its involvement with young people no later than the Summer following their 19^th birthday. Responsibility for social care will then transfer to the most suitable Adult Social Care Team.

4.3 Transition Assessment (Care Act)

The Transition Service will complete a transition assessment where there is likely to be significant benefit to the young person and the young person is likely to have social care needs.

Eligibility for Adult Social Care services is determined by the Care Act 2014 criteria (see Eligibility chapter). If the current level of need indicates that the young person is not likely to have eligible needs for care and support, then Children’s Services will not make a referral to Adult Social Care. There may be other services available to these young people and their carers, and information about these can be found on the Local Offer website.

The transition assessment will be completed at the point in time when there is significant benefit in doing so, based on the specific circumstances of the young person. This will usually be after the young person’s 17^th birthday but must allow sufficient time for any necessary services to be identified and arranged. In the case of young people likely to need Supported Living or complex packages of support, the Transition Service will seek to identify these needs prior to age 17 to support the effective commissioning of services.

The transition assessment will be used to identify the strengths, needs and aspirations of the young person and to plan resources and commission services.

The transition assessment will specifically focus on:

• current needs for care and support and how these impact on wellbeing.

• whether the young person or carer is likely to have needs for care and support after the young person reaches 18 years.
• if so, what those needs are likely to be, and which are likely to be eligible needs.
• the outcomes the young person or carer wishes to achieve, their aspirations for the future and how they might be supported to achieve them.

The transition assessment will indicate which needs for care and support are likely to meet the Care Act eligibility criteria once the young person turns 18, so that the young person understands the care and support they are likely to receive and the differences in the way support is provided for adults and children.

Where the transition assessment identifies that there are no eligible needs, this will be stated clearly, and the young person will be informed of other potential sources of support available via the Lancashire Local Offer.

4.4 Eligibility for provision of services following assessment

See Eligibility policy, National Eligibility Criteria for People with Care and Support Needs. 

4.5 Support planning

Following the transition assessment, a support plan will be produced, specifying how the needs identified will be met (once the young person has transferred to adult services). This may include services funded by Lancashire County Council, as well as those which do not require specific funding and support provided by informal carers (family and friends).

The Personal Budget available to meet the young person’s support needs will be detailed within the support plan.  See Personal Budgets chapter.

4.6 Complex health needs

Responsibility for transition for young people with complex health needs lies with Continuing Health Care (CHC) Children’s Services. The NHS CHC also has a responsibility to notify the Transition Service and the relevant Integrated Care Board (ICB) when such a young person turns 14.

The Transition Service will complete a CHC checklist at the age of 16 with young people who are likely to be eligible for NHS Continuing Health Care. As soon as practicable after the young person’s 17th birthday, eligibility for adult NHS Continuing Healthcare should be determined in principle by the relevant ICB, so that, wherever applicable, effective packages of care can be commissioned in time for the individual’s 18th birthday.

Following the transition assessment, the Transition Service will complete a support plan detailing the identified needs of the young person and how those needs will be met including any commissioned services as well as universal services.

5. Carers and Young Carers’ Assessments

All carers are entitled to an assessment which will identify their needs in relation to:

• Ability to care effectively and safely.
• Making use of IT and assistive technology.
• Making choices about their own lives, for example managing care and paid employment.
• The ability to find support and services available in their area; and
• Accessing the advice, information and support they need including information and advice on welfare benefits and other financial information and about entitlement to carers’ assessments.

Lancashire County Council has a published eligibility criteria for carers, as defined in the Care Act 2014 for access to services. We use a person-centred approach throughout, involving the carer and supporting them to have choice and control.

Lancashire Young Carers (provided by Barnardos) assess all young carers who are under the age of 18 and who provide regular and ongoing care and emotional support to a family member who is physically or mentally ill, disabled or misuses substances and are significantly affected by their caring role.

6. Advocacy

See also Independent Care Act Advocacy policy.

The Care Act 2014 gives eligible people the right to advocacy support under certain circumstances if they have “substantial difficulty” being involved in arrangements for their care and support and have no-one else to support them. This includes people in transition.

The Lancashire Advocacy Hub (for adult non-carers), Carers Count (for adult carers) and the National Youth Advocacy Service (for young people) provide support to people and their families.

Advocacy services can also support people to make a complaint about health and social care services and – if people struggle to understand information, advice and guidance about interacting with these services more generally – these services can provide help and support.

7. Consent, Mental Capacity and Best Interests Decisions

The Transition Service will seek to establish the consent of the young person and their carer(s) in relation to the transition process and any Adult Social Care support that is arranged. Once a young person reaches the age of 16, they have the right to make their own choices; this includes decisions about where they would like to live; how and by whom their care and support will be provided; and who will manage their finances.

The Mental Capacity Act 2005 (which applies to people aged 16 or over) is clear that services must assume everyone has mental capacity until assessed otherwise on a balance of probability. If a professional or carer has concerns that a young person does not have the mental capacity to make a decision because they cannot understand, retain, weigh up and communicate information to enable them to make an informed choice, then a Mental Capacity Assessment must be completed (see Mental Capacity).

Where there is reason to doubt the mental capacity of any person in contact with the Transition Service an assessment of Mental Capacity will be completed for those 16 years of age and older. For young people below the age of 16 the relevant test will be that of Gillick competence.

As Mental Capacity is decision specific, more than one assessment may be required as some young people will be making several decisions at this point in their lives.

The Transition Service will ensure that young people are supported to make decisions about their future as far as they are able to do so. Where a young person is assessed as lacking mental capacity in relation to a specific decision, any decisions will be made in their best interests, following the principles of the Mental Capacity Act. The Transition Service will ensure that the voice of the young person is heard, making use of advocacy when required, and that the young person’s needs and wishes are central to any decisions made.

The person completing a Mental Capacity Assessment should be the person best placed to do so. Where this relates to proposed social care support arrangements from 18 this will usually be the Transition Service.

Mental Capacity Assessments and best interest decisions for arrangements prior to 18 will remain the responsibility of the relevant Children and Young People’s service(s).

Young people with special educational needs and/or disabilities, will be supported to make their own decisions about their education where possible in line with the SEND Code of Practice (gov.uk).

8. Court of Protection

The Court of Protection is a specialist court which makes financial and health and welfare decisions on behalf of people who lack capacity to make those decisions for themselves.

The Court can also give these powers to someone else such as relative or close friend who can manage their loved one’s affairs. This usually happens if there is a need to make decisions on a long-term basis. If the Court gives these powers to someone else, they are called a deputy.

Lancashire County Council will ensure that the adult care arrangements it makes for young people in transition are made in accordance with The Mental Capacity Act. Where there is a need for authorisation by the Court of Protection for a proposed support plan being developed by the Transition Service, applications will be made with support from Lancashire County Council Legal Services.

9. Preparing for Adulthood – Young People with Education, Health and Care Plans

Preparing for Adulthood is a term used to describe the process of moving from childhood into adulthood. Young people with Special Education Needs and Disabilities (SEND) should have equal life chances as they move into adulthood.

Preparation for Adulthood should be considered throughout a child or young person’s life, but particular focus is given to this from school Year 9 (13 or 14 years old). It may continue beyond the age of 19, for some young people, if it is considered that they require a longer period in education or training to achieve their outcomes and make an effective transition. Transition support from other agencies, such as supported employment, may continue until the young person is 25.

Where the Transition Service are involved with a young person who is supported by Children’s Social Care or the Child and Family Wellbeing Service, the allocated workers from both services will collaborate and share information to support the young person and their family through the assessment and transition period.  The allocated Transition Worker will be invited to relevant reviews or planning meetings and the young person’s allocated worker from Children’s Social Care or the Child and Family Wellbeing Service will ensure they maintain appropriate communication with the Transition Worker, keeping them up to date with any relevant changes to the circumstances of the young person and their family and their plan of support, so that this can be considered as part of the young person’s Transition assessment and support planning.

For children and young people with an Education, Health and Care Plan (EHCP), all reviews of the plan from Year 9 onwards must include a focus on Preparing for Adulthood, covering employment, independent living and participation in society. This transition planning is built into the EHCP review processes and, where relevant, will also include effective planning for young people moving from Children’s Services to Adult Social Care and Health services. The views, wishes and feelings of the young person will be a key part of the process and will inform planning and decision making in relation to the young person’s future needs.

In most cases, annual review meetings will be held at the young person’s educational institution; the school or college are usually best placed to host a review meeting as they know the young person well and will have the clearest information about possible next steps and will therefore ensure that the appropriate people involved with planning for the young person are invited to make sure there is a wide discussion covering all the areas important to them.  Other arrangements will be put in place where a child or young person is not attending an educational institution.

The preparing for adulthood planning review of the EHCP should include support:

• preparation for higher education and / or employment. This should include identifying appropriate post-16 pathways that will lead to these outcomes. Training options such as supported internships, apprenticeships and traineeships should be discussed.  The review should also cover support in finding a job and learning how to do a job (for example, through work experience opportunities or the use of job coaches) and help in understanding any welfare benefits that might be available when in work.
• preparation for independent living, including exploring what decisions young people want to take for themselves and planning their role in decision making as they become older. Local housing options, support in finding accommodation, housing benefits and social care support should be explained to inform discussions about where the child or young person wants to live in the future, who they want to live with and what support they will need.
• maintaining good health in adult life, including effective planning with health services of the transition from specialist paediatric services to adult health care. Helping children and young people understand which health professionals will work with them as adults, ensuring those professionals understand the young person’s learning difficulties or disabilities and planning well-supported transitions is vital to ensure young people are as healthy as possible in adult life.
• participation in society, including understanding mobility and transport support, and how to find out about social and community activities, and opportunities for engagement in local decision-making. This also includes support in developing and maintaining friendships and relationships.

When a young person is nearing the end of their time in formal education, annual reviews will consider good exit planning. EHCP processes will support the young person to make a smooth transition to whatever they will be doing next, and which could include moving on to higher education, employment, independent living or adult care. Some young people with EHCP may need longer in education or training to achieve their outcomes and make effective transition into adulthood.  However, this does not mean there is an automatic entitlement that those with an EHCP should remain in education until age 25.

10. Safeguarding

See also Adult Safeguarding Policy.

Although everyone has the right to refuse an assessment, Lancashire County Council must undertake an assessment if it suspects that a young person is at risk of abuse or neglect.

The named Transition Worker and/or allocated social worker, carrying out tasks in line with this policy, must remain mindful of their responsibilities to adhere to the policies and procedures of the council in respect of Safeguarding Adults and Safeguarding Children.

11. Transfer from the Youth Offending Service

Where the Transition Service is involved with young people who are in custody or on a community order and are required to work with the Youth Offending Service, from the age of 17 the named Transition Worker will seek to involve Adult Probation Services in planning for the young person’s transfer to adult services. Depending on the young person’s needs, this will usually happen at 18 but could be later.

12. Transition to Adult Healthcare

For young people with long-term health conditions, active transition planning should start at age 14. The exact timing of transition from children to adolescent or adult health services varies from person to person and service to service, but most young people’s care is transferred to adult health services between 16 and 19.

13. Further Reading

Building independence through planning for transition (NICE and SCIE)

Transition from children’s to adults’ services: QS140 (NICE)

Strengths-based approach: practice framework and practice handbook (Department of Health and Social Care)

Preparing for adulthood: tools and resources (NDTi)

Special educational needs and disability code of practice: 0 to 25 years: statutory guidance for organisations which work with and support children and young people who have special educational needs or disabilities (Department for Education and Department of Health and Social Care)