5.2 Disabled Children Transition Protocols

Multi-agency Transition Protocol
Short Version of the Protocol
Key Stakeholders in Transition
Leaflets Available

1. Multi-agency Transition Protocol

This protocol has been adopted by Education and Children's Services, Adult and Community Services, Richmond and Twickenham PCT and South West London and St George's Mental Health Trust. The full protocol is available from the Transition Co-ordinator or the Disabled Children's Team.

Principles of the Protocol

Young people with disabilities, sensory loss or mental health problems and their parents/ carers must have clear information about transition and options available for the future.
There must be a seamless transition between services.
Young people and their parents or carers should be fully involved in the making of all decisions which affect their lives.
There must be excellent partnership working, information sharing and communication between the young person, their family and all services involved or potentially involved with them.
The role of Connexions must be clear for young people in transition and the options they present must be discussed as part of the transition planning.
The client's eligibility for services and most appropriate adult service must be established at least a year before their 18th birthday.
Responsibility for the provision of resources and any funding implications must be clear and explicit prior to transfer.

Eligibility for Service

Any young person over eighteen with needs assessed according to the Fair Access to Care Services (FACS) criteria as Critical, Substantial or Moderate will be eligible for a service from an adult service.

2. Short Version of the Protocol

Transition System Information in Richmond (April 08)

Making Referrals

The transition tracking group identifies if a young person will need support from an adult team and if so which one. The tracking list is shared with team managers.

If the Person is age 14-15

The school will invite the adult care manager and child's social worker to the year 9 statement of educational need (SEN) review (age 14). The attendance of both will help everyone understand options for young people when they become adults.
The social work team will start to complete the Transition Information Referral form informed by the review minutes completed in the same format.

If the Person is age 15-16

The social worker will update the Transition Information Referral form and send it to the adult team identified by the tracking group before the year 11 SEN review. Information should be sent by secured e-mail. Please list any other information being sent by post (and send on the same day).
The adult team will acknowledge receipt of the information and when allocated inform the referring team the name of the care manager and if any specialist health referrals have be made.

If the Person is age 16-17

If not already done or if things have changed the Transition Information Referral form will be completed or updated and sent to the identified adult team ideally before the year 11 SEN review. Information should be sent by secure e-mail. Please list any other information being sent by post (and send on the same day).
The adult team will acknowledge receipt of the information and when allocated inform the referring team the name of the care manager
The school will invite appropriate professionals i.e.: health specialists, the social worker and care manager to attend the year 11 SEN review (age 16)
After the review the adult care manager will meet with the family and young person to help them complete their Self Directed Support self assessment questionnaire (SAQ). The care manager will verify the assessment of their needs and make any specialist health referrals needed.
The children's social worker will work with the care manager, family and young person and any other relevant professionals to create a support plan. This will act as a transition plan to help the person know about and decide between options for their adulthood.
The support plan once completed will be agreed in principal by the adult team manager.
Once agreed an action plan is created by the care manager liaising with the social worker, family, young person and other professionals agreeing tasks before handover at age 18, including sending the support plan to panel in good time.

If the Person is Between 18-25

The referrer will be asked to complete the Transition Information Referral form. A care manager will complete a contact assessment, start the self assessment questionnaire and then the support plan. If required referrals to specialist health services will be made by the care manager.
If not using the self directed support model the care manager will make contact with the referrer, individual and family do an initial assessment. They will write a care plan.
Support and services as per the care plan/ support plan are arranged or delivered.

3. Key Stakeholders in Transition

	Title/ Group	Role
1	Young person	To say what they want, need and value to create their plan enabling them to make informed decisions and have a full, active life.
2	Parent/carer	To support and enable the young person, be involved with planning for the future to help the young person achieve their full potential.
3	Transition Co-ordinator/Worker	To recommend, oversee and monitor the development and implementation of clear transition protocols. To work directly with young people, families and professionals to ensure transition is seamless and supportive.
4	Disabled Children's Team (DCT)	Social workers from this team complete assessments and provide services to young people with disabilities and their families.
5	Children Looked After Team (CLAT)	Provides support to Looked After Children, (for example children in Foster care) and their carers.
6	Leaving Care Team (LCT)	This team offers help to young people leaving care and enables them to become independent in the community.
7	Special Educational Needs Team (SEN)	This team works with schools, parents and young people. They issue, monitor and review statements of special educational need for children needing specific or extra help to learn. Contact details
8	Transition Support Worker	A Transition Support Worker works directly with teenagers and organises social opportunities. Contact details.
9	Services for Adults	Made up of the Community Learning Disabilities Team, Physical Illness and Disabilities team, Sensory Services Team, Drug and Alcohol Team, Community Mental Health Team and HIV & Aids Team. Care managers from these teams complete assessments and help arrange services. They also complete separate carers' assessments to help carers in their role.
10	Schools	In Richmond there are two special schools. Many young people with disabilities attend mainstream local schools or out of borough specialist schools. Some are educated out of school.
11	Learning and skills council (LSC)	The LSC fund individuals' placements at schools and colleges when local provision cannot meet the particular needs of children/ young people. Contact details
12	Connexions Personal advisor	Connexions provide information and advice to young people from age 14 onwards. This includes information about education, work, housing, health and money. They have a statutory requirement to attend the SEN reviews at Year 9 (age 14), and Year 11 (age 16) and create a plan with the young person before they leave school. This includes liaising with the LSC to secure funding for education. Contact details
13	Continuing Care Co-ordinator/ Assessor	Where a person's health needs are very high their care and support may be wholly or part funded through the Primary care Trust. The continuing care co-ordinator completes the assessments and monitors the package of care.
14	Health	In education, children's and adult's services there may be specialist health professionals including for example psychologists, Occupational therapists and nurses. They may attend annual reviews and become involved in care planning.
15	Person Centred Planning Project	Person centred approaches help people to plan for their own future, to consider their wants, wishes and dreams then communicate them to others. The person centred transition plans and support plans started after the school review in year 9 (age 14) may form part of a person centred plan in adulthood.
16	Transition Steering Group	This group oversees the work of the Transition Co-ordinator. It feeds into higher planning/strategy meetings in the council and Primary Care Trust (PCT). This group is made up of Transition champions (parents, counsellor) user representatives, senior managers/ relevant staff from children's and adult services and representatives from voluntary organisations.
17	Tracking/ operational group	This group tracks young people from age 13. They consider if and which adult service the person will need. They request assessments where this is unclear. This group will also monitor the post education options (at age 16 and 19 or 19 and 22)
18	Person centred review facilitator	The trained facilitators help the young person prepare and be at the centre of the meeting in new person centred style reviews.
19	SEN annual reviews and appeals	Reviews with family, teachers and other professionals ensure young people have the support they need to learn. If the statement changes requested at the review meeting are not accepted discussions with a case office from the SEN department, SENCo, parent partnership worker or head teacher may help. If still unresolved, the Disagreement Resolution Service could be contacted before ultimately going to Special Educational Needs and Disability Tribunal. Further info and contacts are available on the Richmond website.
20	SENCo	Special Educational Needs Co-ordinators provide advice, support and training in promoting inclusion for children who have a range of special educational needs.
21	Children's and Adult's Funding Panels	These panels decide whether to fund the support recommended by social workers and care managers in children's and adult's services.
22	CAMHS care co-ordinator	Children and Adolescent Mental Health Services offer a range of specialist services.

4. Leaflets Available

The following leaflets are available from the Transition Co-ordinator or the Disabled Children's Team;

Transition and beyond - a guide for parents or carers of young people with a disability.

Part One - What is transition?

Part Two - Leaving school- What next?

Part Three - Towards independence

Part Four - Health and relationships (still in preparation)

Part Five - Money matters

Part Six - Sport and Leisure

End