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Transition to adulthood workbook
1.
How to use this workbook
This work book forms part of the suite of learning materials that have been
developed to support the implementation of part one of the Care Act 2014. These
materials summarise and explain the ‘Care and Support Statutory Guidance’
(October 2014) [“the guidance”] and are designed to help those involved in care and
support services to understand and implement the Act.
The suite of learning materials contains workbooks, PowerPoint presentations and
other material for each of the following topic areas:
1. Introduction and overview
2. Information and advice
3. First contact and identifying needs, including assessment and eligibility, and
independent advocacy
4. Charging and financial assessment, including deferred payment agreements
5. Person centred care and support planning, including personal budgets, direct
payments and review
6. Transition to adulthood
7. Integration, cooperation and partnerships
This workbook is about the transition to adulthood requirements of the Act and its
statutory guidance. It has been written for learning facilitators and includes
exercises, suggested group discussions, points of reflection and case studies that
facilitators can use either in their entirety or to pick and choose from as they see fit
when designing a learning programme based on the PowerPoint presentation.
The workbook can also be used by individuals who wish to learn more about this
topic area. You can watch the presentation, read the notes below, and undertake the
exercises at a pace and time to suit you.
As well as this workbook and PowerPoint presentation, there are also handouts and
a shorter overview presentation on this topic area.
The implementation of the Act requires whole systems change and underpinning this
is a need for cultural change. These learning materials alone will not affect such
change, but they are one tool that can be used to support people along the journey.
In many instances, implementing the Act successfully will require those involved in
the care and support system to change the way they work i.e. behaviour change.
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Research suggests that the way people behave is influenced by their knowledge,
skills and attitudes:
Knowledge
Skills
Behaviour
Attitudes
The PowerPoint presentation and handouts are designed to increase knowledge
about the Act or guidance. The questions and exercises in the workbook are
designed to spark conversations that encourage people to reflect on their own
attitudes and the attitudes of others. They aim to give learners the opportunity to
discuss the complexities of implementing the changes in practice, and/or provide a
safe way of challenging attitudes that go against good practice. The case studies are
designed to provide an opportunity for people to analyse and practice their skills.
Key learning point
These are used in the workbook as a way of highlighting changes that are likely to
have a significant impact on practice i.e. the major changes that the Act brings in.
The facilitators’ hints and tips in the workbook signpost facilitators to existing good
practice resources on this topic area and/or highlight key changes that are likely to
have the most significant impact on practice. The aim is to help facilitators to design
interactive learning programmes that are appropriate for their audience.
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Facilitator’s hints and tips
To successfully facilitate this module we suggest that you need to:

have read the relevant sections of the Act, regulations and guidance

have a good understanding of best practice in this topic area

remember that there are various modules available and you need to choose
the most suitable ones for your learning programme

also remember that you can pick and mix questions, exercises and case
studies from this workbook or from other topic areas

design your training session in a way that accounts for the learning pyramid
so as to maximize the experience and learning outcomes for your participants.
Average retention rates
Lecture
5%
Reading 10%
Passive teaching
methods
Audio visual 20%
Demonstration 30%
Discussion 50%
Participatory
teaching methods
Practice by doing 75%
Teach others 90%
Source: Adapted from National Training Laboratories, Bethel, Maine
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2. Who is it for?
This workbook is about transition to adulthood. It explores sections 58-66 of the Care
Act and chapter 16 of the statutory guidance. It is intended to be used to develop
learning programmes for:
 practitioners directly involved in the planning and support of young people,
including those with special educational needs (SEN) and complex needs,
who will transition to adult care and support, and their carers
 specialist information and advice workers
 managers of both the above types of roles
 managers and commissioners in local authorities with a responsibility for the
provision and market development of services for young people who will
transition to adult care and support, and their carers.
3. Contents
The workbook starts with an overview, which summarises the topic area, and
identifies relevant key words. It then contains the following sections that match the
slides in the PowerPoint presentation
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





Introduction
Children and Families Act 2014 and SEN reform
Care Act: transition assessment
Identifying young people and young carers
Issues of capacity and consent
Cooperating with professionals and organisations
Summary
Appendices: links to key resources; handouts
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4. Overview
Transition is an essential part of human life and experience. Here the term is used to
refer to the process of change for young people, and those around them, as they
progress from childhood to adulthood. This movement can be a time of celebration,
change and also challenge for all young people. It is a time when they are
considering and making decisions about their continuing education, work and
careers, their social life and where and how they will live.
The vital importance of a successful transition to adulthood for young people has
long been recognised in government policy publications and guidance. There is now
a considerable body of evidence to suggest that too many young people entering
adult services are at greater risk of marginalisation and poorer outcomes as a result
of the transition process and its conclusion. Local authorities need to have in place
arrangements to ensure that young people with complex needs have every
opportunity to lead as independent a life as possible and are not disadvantaged by
the move from children’s to adult services.
Challenges here combine organisational and attitudinal issues. For example, the
process can be managed very badly and transition to adult services has been
described as being like ‘falling off a cliff’. There is no reason in law why this should
be the case; the fundamental duties, for example for disabled young people as
adults, remain to assess their needs and provide services to meet these needs.
Some of the obstacles that young people in transition and adults face are also rooted
in their own lack of expectation and aspiration about their adult lives, often as a
result of negative messages from those around them or simply a lack of
understanding.
Alongside the availability of appropriate provision, a successful transition to
adulthood depends on early and effective planning, putting the young person at the
centre of the process to help them prepare for transfer to adult services. The process
of transition should start while the young person is still in contact with children’s
services and may, subject to the needs of the young person, continue for a number
of years before and after the transfer to adult services. There needs to be an overall
focus on outcomes and activities rather than services.
The Care Act and related reforms aims to underpin and promote the extension of
best practice in transition arrangements. The Care Act introduces new entitlements
to transition assessment for young people, young carers and carers of young people
and looks to underpin continuity in provision until adult services have a plan in place.
At the same time, changes introduced by the Children and Families Act 2014 and
special educational needs (SEN) reform introduce a system of support extending
from birth to twenty-five years of age. This means there will be a group of young
people who will be entitled to support through both pieces of legislation.
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5. Key words
The suite of learning materials contains a glossary of key words referred to in the
statutory guidance. The following key words, definitions of which can be found in the
glossary, are relevant to this topic area: abuse, advocacy, appropriate individual,
carer, education health and care plan, lead professional, pathway planning, personcentred approach, personal budget, preventative, safeguarding, significant benefit,
substantial difficulty, transition assessment, transition plan, wellbeing.
6. Introduction
Slide 1
Notes
1. This presentation forms part of the suite of learning materials that have been
developed to support the implementation of part one of the Care Act 2014. These
materials summarise and explain the ‘Care and Support Statutory Guidance’
(June 2014) and are designed to help those involved in care and support services
to understand and implement the Act.
2. This presentation is about transition to adulthood. It is intended for:
 practitioners directly involved in the planning and support of young people,
including those with special educational needs (SEN) and complex needs,
who will transition to adult care and support, and their carers
 specialist information and advice workers
 managers of both the above types of roles
 managers and commissioners in local authorities with a responsibility for the
provision and market development of services for young people who will
transition to adult care and support, and their carers.
3. The aim of the presentation is to help you reflect on the implications of the Act for
your role, so that you will know what you must do differently and what you may
need to do differently.
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Slide 2
Slide 3
Notes
1. Transition is an essential part of human life and experience. Young people (and
their parents) use the term to refer to the process of change for young people as
they progress from childhood to adulthood. This movement can be a time of
celebration, change and also challenge for all young people. It is a time when
they are considering and making decisions about their continuing education, work
and careers, their social life and where and how they will live. Transition is an
emotional as well as a practical experience.
2. Transition to adulthood happens at different ages for all young people, including
those with complex needs or disabilities. Transition isn’t defined in the Care Act
or statutory guidance. Definitions of transitions from a service transfer point of
view include:
 “…the transfer to an adult environment where they [young people] may need
to consult several different health teams, therapy teams, and adult social care
services” (CQC 2014)
 “the planned, purposeful movement of adolescents and young adults from
child-centred to adult-orientated health care systems as distinct from a single
chronological even” (RCN 2014 after Blum 1993)
 “the point at which young people move from children’s to adult services”
(‘Don’t let me down’ 2012)
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
“for many working with disabled young people and their families transition is
understood as the time disabled young people move from children’s to adult
services, rather than a natural stage of life that includes leaving school,
starting work, going to college or university, leaving home, trying out new
experiences and making new friends” (Cowen 2010).
3. The examples here are drawn from the relevant literature and point variously to a
planned process, point in time or natural stage. What is common to all four is the
expectation of change.
Questions
 What does transition mean to you? What key words do you or your
organisation use to describe transition?
 Can you give an example of a model or framework that you use/have used to
make sense of a transition experience?
 Reflecting on the quote from Cowen above, does Cowen have a point?
Facilitator’s hints and tips
This opening sequence of introductory slides provides an overview of the evidence
concerned with the organisation and practice of transition. Most of the findings will
probably be familiar, but are likely to be helpful in articulating the local context within
which the Care Act and special educational needs (SEN) reform will need to embed.
Given the diversity of service and organisational arrangements designed to support
transitions working, it is likely that the mix of experiences (including achievements,
issues and challenges) will vary from locality to locality. It will probably be helpful to
try and distil these - and their implications - for the local area/s covered by your
learning programme and check these against the ‘what works?’ material on slide 7.
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Slide 4
Notes
1. There is considerable evidence to point to the importance of the transition
experience in terms of immediate and longer-term life outcomes.
2. Transition is a time of risk. Poor transition is likely to be a key contributor to poor
outcomes: harm can be done through poor transition as evidenced in the number
of care leavers in adult prisons and in mental health services, the deaths of
young adults with learning disabilities from hate crime, and suicides of young
adults. Young people who are already vulnerable in terms of complexity of needs
and/or circumstances are at greater risk of marginalisation during the transition
process.
3. The importance of transition quoted in research includes:
 moving into adulthood is one of the most far reaching and complex transitions
for anyone but young people with learning difficulties face additional
challenges including transfer from children’s to adult health and social
services (Heslop et al 2002)
 the interface between children’s and adult health services is becoming an
increasingly important issue as more children and young people with
conditions formerly often lethal in early childhood are now surviving into
adulthood (Transition: getting it right for young people 2006)
 research shows that we can set young people up for the rest of their lives and
make a huge difference to their life chance outcomes if we share with them a
range of choices, good information and support around housing, employment,
health, and making friends and social relationships, while they are still at
school. (Getting a Life, 2011).
4. The last bullet point, from Getting a Life, illustrates the vital importance of a
successful transition to adulthood for disabled young people, which has long
been recognised in government policy publications and guidance. Local
authorities need to have in place arrangements to ensure that young people with
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complex needs have every opportunity to lead as independent a life as possible
and are not disadvantaged by the move from children’s to adult services.
Questions
 What are the characteristics common to all transitions to adulthood?
 From your practice experience, what seems to be the most critical aspect of
the transition experience for: the young person; their family?
Slide 5
Notes
1. The first quote above is from ‘Young people with life-limiting conditions: transition
to adulthood’ by Sheila Marsh et al in Public Service Works March 2011.
2. Transition to adulthood has been described as “entering into a black hole”, like
“falling off a cliff”, or “a time when young people have few options, become more
isolated and families experience a drop in levels of support’” (Report of the
Parliamentary Hearings on Services for Disabled Children (2006) and a
"nightmare” (Commission for Social Care Inspection (2007) Growing up matters:
better transition planning for young people with complex needs).
3. Self-assessment evidence from Transition Support Programme 2008-11 did
recognise some improvement but still concluded that experiences of transition to
adulthood for many individual young people remain unacceptable.
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Questions
 What do you know about the local experience of transition for young people,
families and carers?
 How does it compare to national messages/reports such as these?
 Are there recurring themes, or have the messages changed?
 Are there young people and carers you don’t hear from?
 How do you celebrate successful change and rites of passage?
Slide 6
Notes
1. Confusing isn’t it? You probably can’t read this slide or make out quite what’s
going on (a parable perhaps?). In the report ‘From the Pond into the Sea’
Professor Steve Field, Chief Inspector of Primary Medical Services and
Integrated Care said “We have put the interests of a system that is no longer fit
for purpose above the interests of the people it is supposed to serve” (CQC
2014).
2. Research, guidance and policy point to a number of problems in achieving a
coordinated approach to transition. These include:
 poor multi-agency working
 absence of a holistic approach to understanding individual and family needs
 lack of information for young people and parents
 insufficient attention to the concerns/priorities of the young person
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

lack of appropriate services/provision onto which young people can transfer
statutory planning by itself does not lead to the life outcomes that many young
people want.
3. Challenges here combine organisational and attitudinal issues. There is no
reason in law why this should be the case; the fundamental duties, for example
for disabled young people as adults, remain to assess their needs and provide
services to meet these needs. Some of the obstacles that young people in
transition and adults face are also rooted in their own lack of expectation and
aspiration about their adult lives, often as a result of negative messages from
those around them or simply a lack of understanding.
4. The key aim of the Care Act, in relation to transition, is for this to be a seamless
process for young people and their families, and one which results in young
people entering adulthood being better set up for life.
Questions
 Do you recognise any or all of the factors (note 2 above) within your own
locality?
 Which ones have been positively addressed?
 Do your local arrangements help or hinder your locality to have seamless
transition to adulthood?
Slide 7
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Notes
1. This list of principles and processes has been derived from a review of the
transitions literature (see for example Merriman S, 2009, TransMap for a concise
discussion of key principles). The key principles all appear within the legislation
and/or accompanying guidance covering Transitions as well as SEND reform.
2. ‘What works’ about transition is not set, but rather is a combination of individual
and organisational factors. The starting point is attitudinal as statutory planning
by itself does not lead to the life outcomes that many young people want (Valuing
People Now 2010). In short, transition should not been seen as a means by
which an individual is moved from one service to another. Rather it should be
seen as a way to enable and support a young person to move towards a new
stage in their life.
3. Alongside the availability of appropriate provision, a successful transition to
adulthood depends on early and effective planning, putting the young person at
the centre of the process to help them prepare for transfer to adult services. The
process of transition should start while the young person is still in contact with
children’s services and may, subject to the needs of the young person, continue
for a number of years after the transfer to adult services. There needs to be an
overall focus on outcomes and activities rather than services.
Exercise
Complete the transition to adulthood audit tool for your local service. The tool is
an adaptation of the Think Local Act Personal resource ‘Making it Real’. This utilised
a number of "I" statements developed by people who use services, carers and
citizens to describe the sort of feelings and experiences that people want from care
and support services. The statements in the audit tool act as a benchmark for
effective assessment, planning and impact of local transitions arrangements for
children, young people, carers and families. Consider each statement in turn – give
each statement a mark out of 5, where 5 = strongly agree with the statement and 0 =
strongly disagree – and justify your mark in the right hand column. Once completed,
you can use this information to develop your action plan at the end of the workbook.
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7. Children and Families Act 2014 and SEN reform
Slide 8
Notes
1. Key points, relevant to transitions, from the Children and Families Act 2014 are
set out in this and the next slide – as outlined in the SEN Code of Practice.
2. The new 0-25 special educational needs and disability (SEND) system provides
additional protections to young people in further education. From age 0-25 and
across all services this provides a huge opportunity to embed person-centred
practice, to develop life span pathways and to consolidate good practice in
transition. The Department for Education’s vision for the SEND reforms are that
they will implement a new approach which seeks to join up help across
education, health and care, from birth to 25. Help should be offered at the earliest
possible point, with children and young people with SEND and their parents or
carers fully involved in decisions about support and what they want to achieve.
3. The focus is on ensuring children and young people are at the heart of decision
making (about their own lives and support and they services and communities
work locally).
4. From 16 the ‘right to make decisions and requests’ applies to young people aged
16 people and over (the end of the academic year in which they turn 16). We
need to ensure that young people are prepared for decision making from a
younger age, that we have a good knowledge of the Mental Capacity Act, and
know how to support people to make choices with good supported decision
making.
Key learning point
The Care Act 2014 and Children and Families Act 2014 provide a single legislative
framework for transition to adulthood.
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Slide 9
Notes
1. New education, health and care plans (EHC) must be person-centred, outcome
focused and from aged14 + must focus on Preparing for Adulthood outcomes
(see slide 10).
2. Personal budgets for young people could be SEN personal budget and/or
personal health budget or social care personal budget. Young people have the
right to request a (SEN/education) personal budget as part of the EHC process.
3. The Children and Families Act instills new rights to assessment and support for
young carers and parent carers – similar to the requirements under the Care Act.
4. The Children and Families Act 2014 requires local authorities to publish a local
offer, which includes provision of information and advice for children’s social care
in their local area, including specific requirements for young people who are
preparing for adulthood. Local offers must be developed with young people and
their families, must state how they support young people to move into adulthood
with employment, independent living, community participation (friends and
relationships) and good health. It should include how to support young people to
make decisions about their own support and local services.
5. The Children and Families Act applies to children and young people aged 0 – 25
which means this also includes integration of children’s and adults’services.
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Facilitator’s hints and tips
There are a variety of implications and challenges that emerge for individual workers
and teams from the implementation of these two important pieces of legislation. This
list could serve as a prompt for further discussion.
 Understanding and embracing a new impetus at improving transition
 Developing a good awareness of the issues involved before, after and during
the experience of transition
 A commitment to more personalised ways of working
 Finding out what others do and why
 Challenge to systems and processes that don’t work well
 The reconfiguration of some services
Slide 10
Notes
1. All of the SEN reforms are intended to help young people transition to adulthood
with better outcomes. Preparing for adulthood is referred to throughout the
reforms as employment, independent living and community participation and is
expanded on in the Code of Practice. To prepare for adulthood, young people
must have high aspirations for a full adult life with the following outcomes:
 higher education and/or employment
 independent living – choice and control over lives and support with good
housing options and support
 participating in society – friends, relationships and participating in and
contributing to the local community
 being as healthy as possible (health and wellbeing).
2. The national Preparing for Adulthood programme (PfA) was commissioned by the
Department for Education to support the SEN reforms and has been delivered by
the national Development Team for Inclusion (NDTi) and the Council for Disabled
Children (CDC).
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3. PfA has developed five key messages through their work with SEND pathfinders:
 develop a shared vision of improving life chances with young people, families
and all key partners
 raise aspirations for a fulfilling adult life by sharing clear information about
what has already worked for others
 develop a personalised approach to all aspects of support using personcentred practices, personal budgets and building strong communities
 develop post 16 options and support that lead to employment, independent
living, good health, friends, relationships and community inclusion
 develop outcome-focussed multi-agency commissioning strategies that are
informed by the voice of young people and families.
Slide 11
Notes
1. Good transition planning starts before the young person is 14. This includes
raising aspirations and supporting children to make decisions.
2. For young people with special educational needs who have an Education, Health
and Care (EHC) plan under the Children and Families Act, preparation for
adulthood must begin from year 9. EHC plans must be person-centred, outcome
focused and from aged14+ must focus on preparing for adulthood outcomes.
3. Coordinated multi agency support is required to enable young people to achieve
good life outcomes. This includes providing information, advice and support on
preparing for adulthood, what adult social care is, transition assessments, and
what support they can expect. Year 9 review should trigger this. Preparing for
adulthood annual reviews should focus on planning support for SEN, health and
care needs and building on what has already been achieved.
4. The transition assessment should be undertaken as part of one of the annual
statutory reviews of the EHC plan, and should inform a plan for the transition from
children’s to adult care and support – see next slide for transition assessments.
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5. Local authorities may continue EHC plans until the end of the academic year
during which the young person turns 25. As the young person is nearing the end
of their time in formal education, and the plan is likely be ceased in the next year,
the PfA review should ensure good exit planning and ensure the necessary
support is in place to build on the outcomes and make a smooth transition into
adulthood life. Before ceasing the plan the authority must consider whether
education/training outcomes have been achieved.
Key learning point
For young people with special educational needs (SEN) who have an Education,
Health and Care (EHC) plan under the Children and Families Act, preparation for
adulthood must begin from year 9.
Facilitator’s hints and tips
For young people and their families and carers to have a good experience of
transition and achieve desired outcomes there needs to be an effective transition
pathway that all relevant agencies adhere to. The Special Education Needs and
Disability Pathfinder Programme Evaluation identified a common EHC planning
pathway. The common pathway can be found on page 9. It might be useful to ask
participants to compare this with their current transition pathway and:
 discuss whether they have a similar pathway for EHC plans
 how does it map on to any transition pathway adult services currently use?
 discuss the strengths and weaknesses of their current pathway(s)
Think about how their current pathway(s) may need to change to ensure young
people, their families and carers have a good experience, achieve desired outcomes
and children and adult services work together.
8. Care Act: transition assessment
Slide 12
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Notes
1. The emphasis of the Care Act reflects established best practice in relation to
preparation for adulthood and joint working between local authorities' adult and
children's services departments. Duties in both Acts are on the local authority, not
children’s or adult’s services, so various operating models around transitions are
possible. Both have a focus on personalised, outcome-based approaches, and a
new focus on carers as families transition rather than just the young person.
2. A key provision of the Act is the duty to carry out a transition assessment for
these 3 groups of people in order to help them plan if they are likely to have
needs once they (or the child they care for) turn 18:
 young people, under 18, with care and support needs who are approaching
transition to adulthood
 young carers, under 18, who are themselves preparing for adulthood
 adult carers of a young person who is preparing for adulthood.
3. In addition, the Act gives local authorities powers to ensure continuity so that
where a young person is receiving children's services those services will not stop
abruptly when the person turns 18, but must continue until adult services have a
plan in place (more on slide 20). The ability to continue children’s services
beyond 18, and to join up various assessments across both Acts, should mean a
more flexible framework where transition can be a personalised evolution from
14-25.
4. Note that SCIE are developing new resources about transition from childhood to
adulthood and the Care Act, including guidance on supporting both adult carers
and young carers through transition to adulthood.
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Slide 13
Notes
1. The guidance uses the phrase “young person or carer” to refer to young people,
adult carers and young carers.
2. ‘Likely to have needs’. This is highly likely to include young people and carers
who are in receipt of children’s services but not exclusively so. Local authorities
must carry out a transition assessment of anyone within the three groups where
there are likely needs for care and support after turning 18 and when there is
significant benefit to the young person and carer in doing so.
3. ‘Significant benefit’ is not related to the level of a young person or carer’s
needs, but rather to the timing of the transition assessment (16.10). This will be
informed by one or a number of circumstances e.g. upcoming exams, wishes in
terms of entering college or work, whether the young person is planning to move
out of the family home, planned medical treatment and so on. Every young
person and their family are different, and as such, transition assessments should
take place when it is most appropriate for them.
Key learning point
The local authority must carry out a transition assessment for a young person or
carer when there is significant benefit to them in doing so, and if they are likely
to have needs for care or support after turning 18.
4. The local authority may refuse to undertake an assessment if it thinks the
“significant benefit” condition is not met. In these circumstances, it must provide
its reasons for this in writing in a timely manner, and it must provide information
and advice on what can be done to prevent or delay the development of needs
for support.
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5. Where the local authority judges that a young person or carer is likely to have
needs for care and support after turning 18, but that it is not yet of significant
benefit to carry out a transition assessment, the local authority should
consider indicating (when providing its written reasons for refusing the
assessment) when it believes the assessment will be of significant benefit.
6. Transition assessments can in themselves be of benefit in providing solutions
that do not necessarily involve the provision of services, and which may aid
planning that helps to prevent, reduce or delay the development of needs for care
and support.
Key learning point
Transition assessments can in themselves be of benefit in preventing, reducing or
delaying the development of needs for care and support.
Case study
Isabelle is 15 years old and has complex needs. She attends a residential school on
a 38- week basis funded by education and social services. Care and support is
currently required on the weekends and in holidays and can continue until she is 19.
Isabelle’s parents have approached the local authority requesting at transition
assessment around the time of her 16th birthday.
When Isabelle leaves school at 19 it will not be appropriate for her to live with her
parents and she will require substantial supported living support and a college
placement. Due to the nature of Isabelle’s needs, she will need a lengthy transition in
order to get used to new staff, a new environment and a new educational setting.
The college has indicated that that they will need up to a year to plan for her start.
Questions
 Do you think that an assessment at age 16 would be of “significant benefit” to
Isabelle, and if so why?
 Is an assessment at age 16 too soon to be of ‘significant benefit’ to Isabelle? If
so, what would be your reasons for delaying the assessment?
Suggested answers
It seems likely that there would be a significant benefit for the transition assessment
to take place around the age of 16. This would look at both the funding for support
from age 18 – 19 and the longer-term options. Once the assessment has identified
the support Isabelle will likely be entitled to on leaving school, the planning process
can begin and suitable support can be put in place by the time she leaves school.
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If a transition assessment were to take place later, the local authority would be at risk
of not promoting wellbeing in the areas of family relationships (because Isabelle
could temporarily need to live with her parents while solutions are found at the last
minute, which would not be appropriate) and control over day-to-day life (because
Isabelle would very likely not have the same range of choices if planning and
preparation were to be truncated).
Facilitator’s hints and tips
It is important that there is consistent good practice in relation to transition
assessment undertaken for those with special education needs (SEN) at the age of
14 as part of the annual statutory review of the EHC plan. For those who are not
known to children’s services or who do not have an EHC plan, good, early planning
for adulthood rarely happens. Good practice guidance states the usefulness of early
conversations with local authorities and suggests that local authorities should
consider extending the use of the statutory pathway planning process for all young
people ‘likely to have needs’ rather than just those with SEN.
It might be useful to ask participants to reflect on:
 the degree to which they are currently undertaking transition assessments at
the age of 14 for young people with SEN
 the degree to which they are currently undertaking transition assessments at
the age of 14 for young people and carers ‘likely to have needs’
It will be important to help participants consider the challenges associated with this
and particularly how they might deal with the significant back log of cases they may
experience if it is not something they have been doing up to now.
Slide 14
Page 23
Notes
1. The focus on this slide is on key ‘musts’ for the local authority (from the
guidance). The guidance confirms that the same requirements and principles
apply for carrying out transition assessments as for other needs assessments
under the adult statute. These are variously set out in section 6. For example,
local authorities must undertake an assessment for any adult with an appearance
of need for care and support (6.13) and where it considers there will be significant
benefit to the individual of doing so regardless of any eligibility issues. See the
learning module on assessment and eligibility for more details.
2. The process itself must be person-centred. The young person or carer in
question (or others they wish to be involved) must be involved in the assessment
for it to be person centred and to reflect their views and wishes.
3. The guidance recognises that individuals may need additional information and
advice to engage in the assessment process in a meaningful way. So, for
instance, a young carer conducting a supported self-assessment needs to be
clear about the support available both to them and the person(s) they care for.
More complex issues may require more intensive and more personalised
information and advice, helping people to understand the choices available to
them.
4. The process itself must be appropriate and proportionate to the complexity of
the person’s needs. These are both understood to be intrinsic to good quality
assessment practice.
5. All transition assessments must include consideration of the current needs for
care and support and how these impact on wellbeing. They must establish
whether the young person or carer is likely to have needs for care and support
after the young person in question becomes 18 and, if so, what those needs are
likely to be, and which are likely to be eligible needs.
6. Transition assessments must also establish the outcomes the young person or
carer wishes to achieve in day-to-day life and how care and support (and other
matters) can contribute to achieving them.
Key learning point
The guidance confirms that the same requirements and principles apply for carrying
out transition assessments as for other assessments under the adult statute.
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Exercise
Thinking about the terms appropriate and proportionate, describe the kinds of
factors that might make supported self-assessment by a young person appropriate.
In addition, in what circumstances might a ‘light-touch’ assessment be
proportionate?
Suggested answer
A supported self-assessment might be appropriate for a 17 year old young carer who
wishes to go to University for instance. The caveat is that the local authority would
need to ensure that the young person fully understood the support available to them
and the person they care for.
EHC plans must be person centred and focus on preparing for adulthood from Year
9. The transition assessment should build on these plans which will already contain
much of the information required and hence a ‘light touch’ assessment might be
appropriate here.
Facilitator’s hints and tips
As with the other workbook topics the changes needed in implementing the Care
Act include the need for cultural change. One way of testing the culture of current
practice with your participants is to ask them to reflect on the degree to which
transition assessment is currently.
 Person centred throughout and identifies:
 the total extent of current needs and their impact
 the likelihood of future needs
 the strengths and capabilities of the person in question
 the outcomes, views and wishes that matter to the child or carer in
question
 A collaborative process
 The assessment process is adapted to an individual’s communication needs
and enables and supports co-production
 Supports preparation by providing the questions to be covered by
assessment in advance and in an accessible format
 Provides specialist interpreters where required to enable communication and
engagement in assessment
 A choice of assessment options including for example, face to face,
supported self-assessment, an outline or phone assessment, a combined
assessment.
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Slide 15
Notes
1. The focus on this slide is on key ‘shoulds’ for the local authority identified within
the statutory guidance. The transition assessment should:
 take place at the right time for the young person or carer
 be proportionate to need
 build on existing information (including an EHC plan if there is one)
 consider the immediate short-term outcomes that a child or carer wants to
achieve as well as the medium and longer-term aspirations for their life
 be carried out within a reasonable timescale
 support the young person and their family to plan for the future providing them
with information about what they can expect, be coordinated by a lead or
designated person, and involve all relevant partners. The aim here is for the
assessment to inform a person-centred transition plan.
2. In addition, assessment and planning processes can be combined where
appropriate, provided the people involved agree. For example a transition
assessment can be combined with a review or re-assessment by children’s
services. NB For children with an EHC assessment there is a clear expectation
of combination unless specific circumstances prevent it.
Example
If an external organisation (such as a hospital) is carrying out an assessment of the
individual or a relevant person, for example, the individual’s carer or someone the
individual cares for, around the same time as the local authority’s assessment, the
local authority can carry out that assessment jointly with the other organisation or on
behalf of the other organisation.
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Facilitator’s hints and tips
Achieving outcomes is one of the underlying principles of both the Care Act and the
Children and Families Act. It might be useful to explore with participants the
following questions:
 How are outcomes currently developed and monitored?
 What measures and indicators are routinely used?
 How does your agency use the information it gathers on outcomes?
 What changes might need to be made by your service/agency to ensure
more reliable reporting of the three timeframes identified within the guidance?
9. Identifying young people and carers
Slide 16
Notes
1. Identifying children not known to the local authority might include, for example,
young people with degenerative conditions or with mental health problems who
have not required children’s services but whose needs increase as they approach
adulthood.
2. The guidance also makes reference to:
 young people (for example with autism) whose needs have been largely met
by their educational institution, but who once they leave, will require their
needs to be met in some other way
 young people detained in the youth justice system who will move to the adult
custodial estate
 young carers whose parents have needs below the local authority’s eligibility
threshold but may nevertheless require advice or support to fulfil their
potential, for example a child with deaf parents who is undertaking
communication support.
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Key learning point
Local authorities should consider how they can identify young people who are not
receiving children’s services but who are likely to have care and support needs as an
adult.
Questions
 Are there other circumstances or categories of need that might be relevant
here?
 What current mechanisms do the local authority and its partners (e.g. local
educational institutions and health services) have in place to identify these
individuals and/or groups?
 How effective are these mechanisms in supporting early identification and/or
preventing the development of care and support needs?
 What are some specific examples of how they need to be improved?
 What might be the demand implications of more robust mechanisms?
Slide 17
Notes
1. The SEN code of practice sets out the importance of full-time programmes for
young people aged 16 and over. Local authorities must consider the impact on
other members of the family of the person receiving care and support. For
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example, caring responsibilities could have an impact on siblings’ school work, or
their aspirations to go to University.
2. Transition assessments for young carers or adult carers must also
specifically consider whether the carer:
 is able to care now and after the child in question turns 18
 is willing to care now and will continue to after 18
 works or wishes to do so
 is or wishes to participate in education, training or recreation (16.25).
3. The power to join up assessments applies so, for example, if an adult is caring for
a 17 year old in transition and a 12 year old, the local authority could combine:
 the transition assessment of the 17 year old under the Care Act
 any assessment of the 17 year old’s needs under section 17 of the Children
Act
 any assessment of the 12 year old’s needs under section 17 of the Children
Act
 the carer’s assessment of the adult under the Care Act
 the parent carer assessment of the adult under the Children and Families Act
4. A local authority can meet an adult carer’s needs identified through a transition
assessment before the child turns 18, having regard to what support they are
receiving under children’s legislation. If the local authority decides to meet the
adult carer’s needs through adult services, as for anyone else under the adult
legislation, the adult carer must receive a support plan and a personal budget if
their needs are eligible. However, it may not meet an adult carer’s needs for
support under the Care Act by providing care and support to the child cared for –
this will always happen under children’s legislation.
Key learning point
Transition assessments for young carers or adult carers must specifically consider
whether the carer:
 is able to care now and after the child in question turns 18
 is willing to care now and will continue to after 18
 works or wishes to do so
 is or wishes to participate in education, training or recreation.
Page 29
Facilitator’s hints and tips
The culture in children’s services has been to take into account the needs of the
disabled young person alongside parent carers and other family members.
Anecdotally, transition to adult services has focused on the young adult and the
support they require, which may leave parent carers and other family members
experiencing a lack of support in meeting their own needs. The Care Act places
emphasis on the need for local authorities to assess the needs of parent carers and
to meet any eligible needs they may have and to provide personalised information
and advice in relation to any needs that are not eligible.
In practical terms, the support carers require will differ but could include support to
allow them to continue: to work; to meet the needs of their other children; to engage
in social activities; and to meet their own health needs. Below is an example of the
types of things carers want taken from ‘Making it Real for Carers’ – what do carers
want?
 Clear, consistent, coordinated information that is easy to access, and
information giving to be a two-way process, where their voice is heard.
 The space to be someone other than a carer and to engage in activities in
their community.
 Services that talk to each other and are coordinated.
 Care workers they can trust and who are appropriately skilled for the
particular needs of the person they support. They also want access to a
good range of support services.
 To know there is help available if things go wrong and that they can access
the support they need to get on with their lives without worrying.
 To be sure that the money available for support can be used in ways that
work well for the person they care for and for the whole family. They want
good value, safe and high quality support to be available.
It might be useful to ask participants to discuss:
 What are the key challenges faced by adult services in supporting parent
carers to meet their needs when they transition to adult services?
 In what ways might a strengths-based approach to assessment, coproduction and person centred support planning help to address these
challenges?
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10.
Issues of consent and capacity
Slide 18
Notes
1. A young person or carer, or someone acting on their behalf, has the right to
request a transition assessment. The Act does not say that the child or young
person has to be a certain age to be able to ask for an assessment.
2. In all cases, the young person or carer in question must agree to the
assessment where they have mental capacity and are competent to agree.
3. Everyone has the right to refuse a transition assessment and the local authority
is not required to carry out assessment where a person refuses one, but this can
be overridden where they:
 lack capacity to take that decision and an assessment would be in their best
interests. Where there is a lack of capacity the local authority must be
satisfied that an assessment is in their (young person or carer) best interests
 are experiencing, or at risk of experiencing, any abuse or neglect.
4. Under the Mental Capacity Act (MCA) 2005 the issue of capacity is decisionspecific; this means that the test of someone’s capacity can only be made in
relation to a particular decision that needs to be made at a particular time. This is
an important safeguard against blanket assessments of someone’s ability to
make decisions based on their disability or condition. It also recognises the fact
that someone may be able to make some decisions but not others. The
underlying belief of the MCA is to ensure that those who lack capacity are
supported to make as many decisions for themselves as possible, and that any
decision made or action taken on their behalf, is done so in their best interests.
This is a necessity if the transition assessment is to be person-centred. Where a
young person or carer lacks capacity to agree, the local authority must be
satisfied that an assessment is in their best interests and the assessor must
actively apply the provisions of the MCA, particularly the five principles of the
MCA.
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5. There is a test of ‘Gillick competence’ for children below the age of 16. The 1982
ruling and subsequent decision by the Law Lords in 1985 determined that
"...whether or not a child is capable of giving the necessary consent will depend
on the child’s maturity and understanding and the nature of the consent required.
The child must be capable of making a reasonable assessment of the
advantages and disadvantages of the treatment proposed, so the consent, if
given, can be properly and fairly described as true consent…. it is not enough
that [the child] should understand the nature of the advice which is being given:
[the child] must also have a sufficient maturity to understand what is involved."
6. Where this test isn’t met a person with parental responsibility or an independent
advocate will need to be involved in the transition assessment.
7. Local authorities have a duty to provide independent advocacy where the person
would experience substantial difficulty in being involved in the assessment
process and there is no ‘appropriate individual’ to facilitate their involvement.
This duty applies regardless of whether they lack mental capacity as defined
under the MCA. For more information see the independent advocacy
workbook.
11.
Cooperating with professionals and organisations
Slide 19
Notes
1. Who is involved? Professionals from different agencies, families, friends and the
wider community should work together in a coordinated manner around each
young person or carer to help raise their aspirations and achieve the outcomes
that matter to them (16.4).
2. Avoiding duplication of effort. The SEN Code of Practice highlights the
importance of the ‘tell us once’ approach to gathering information for
assessments.
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3. The scope of cooperation. The Care Act sets out five aims of co-operation
between partners which are relevant to care and support…One of these is
concerned specifically with smoothing the transition from children’s to adults’
services. The guidance states that “co-operation between partners should be a
general principle for all those concerned, and all should understand the reasons
why cooperation is important for those people involved. (15.16). In addition to
external partners, the guidance also makes clear that, in additional ensuring
cooperation between the local authority and its external partners, there is
internal cooperation between the different local authority officers and
professionals who provide these services” (15.23).
4. Relevant partners. The Act specifies the “relevant partners” who have a
reciprocal responsibility to co-operate, which are:
 other local authorities within the area (i.e. in multi-tier authority areas, this will
be a district council)
 any other local authority which would be appropriate to co-operate with in a
particular set of circumstances (for example, another authority which is
arranging care for a person in the home area)
 NHS bodies in the authority’s area (including the primary care, CCGs, any
hospital trusts and NHS England, where it commissions health care locally)
 local offices of the Department for Work and Pensions (such as Job Centre
Plus)
 police services in the local authority areas prisons and probation services in
the local area.
5. Key-working. Often there is a natural lead professional involved in a young
person’s care who fulfils this role and local authorities should consider formalising
this by designating a named person to coordinate transition assessment and
planning across different agencies. This coordinating role – sometimes referred
to as a ‘key working’ or ‘care coordination’ can not only help to deliver personcentred, integrated care, but can also help to reduce bureaucracy and duplication
for local authorities, the NHS and other agencies. Care leavers will have
personal advisers to provide support, for example by providing advice or
signposting the young person to services. The Personal Adviser will be a natural
lead in many cases to coordinate a transition from children’s to adult care and
support where relevant.
Key learning point
There is an explicit requirement that children and adult services must cooperate for
the purposes of transition to adult care and support.
Page 33
Questions
 What is your understanding of your agency’s responsibilities, including funding
arrangements, for young people and carers who are moving from children’s to
adult services?
 Are there duplications of effort and/or gaps with other agencies?
 How do you work together to map activity?
 What plans have you to work with young people and families to map and
improve the way things work between agencies?
Facilitator’s hints and tips
A number of the more strategic issues are usefully rehearsed in Local Government
Association (2013) Must know on adult social care 10. Transitions. The guidance
also makes reference to implications for commissioning activity which will result from
getting a good operational fit between the Care Act and Children and Family Act e.g.
via the integration of services and the coherent delivery of information and advice
via Local Offers. Some of the things that will need to be considered include:
 There are organisational and cultural differences between services that need
to be overcome. Local authorities do need to build a picture of the services
that people will need over the course of their lives.
 Ensure you have appropriate and clear transition arrangements. These
include transition between services or systems not directly under the council’s
or health and wellbeing board’s control.
 Make sure that the views of children, young people and families are listened
to.
 Develop relationships with key partners to ensure there is a range of learning,
work and leisure opportunities and to meet local need.
 Ensure that your organisation has ways of measuring outcomes for young
people at the transition stage and that these are used in commissioning for
choice and improvement of services.
 Encourage an integrated approach to personal budgets and budget holding to
support transitions from children’s to adults’ services.
Page 34
Slide 20
Notes
1. Receiving services under children’s legislation refers specifically to section 17 of
the Children Act 1989 or section 2 of the Sick and Disabled Persons Act 1970 or
section 2 of the Carers and Disabled Children Act 2000.
2. The ‘relevant steps’ are if the local authority:
 concludes that the person does not have needs for adult care and support; or
 concludes that the person does have such needs and begins to meet some or
all of them (the local authority will not always meet all of a person’s needs –
certain needs are sometimes met by carers or other organisations); or
 concludes that the person does have such needs but decides they are not
going to meet any of those needs (for instance, because their needs do not
meet the eligibility threshold under the Care Act).
3. In order to reach such a conclusion, the local authority must have conducted a
transition assessment (or equivalent adult needs or carer’s assessment under the
adult statute).
Key learning point
The local authority must continue providing services until the relevant steps have
been taken.
Page 35
Slide 21
Notes
1. As set out in the SEN Code of Practice, an EHC plan will cease if someone
progresses to further or higher education, but a care and support plan is likely to
be required thereafter.
2. All higher and further education institutions have clear duties and responsibilities
under the Equality Act 2010 with regard to ensuring that disabled students do not
face discrimination or less favourable treatment whilst applying to, and studying
in these institutions. They are likely to have a learning support team or similar
that can lead transition discussions on their behalf. These conversations should
also ensure young people and carers are aware of their rights to the Disabled
Students Allowance and student loans.
3. In many cases a young person or carer studying at university will have a dual
location, for example coming home to stay with parents during weekends or
holidays. Where this is the case, local authorities must ensure their needs are
met all year round.
Slide 22
Page 36
Notes
1. The framework sets out best practice for the timing of transition steps as follows.
 Children’s services should identify young people with likely needs for NHS
Continuing HealthCare (CHC) and notify the relevant Clinical Commissioning
Groups when such a young person turns 14.
 There should be a formal referral for adult NHS CHC screening at 16.
 There should be a decision in principle at 17 so that a package of care can be
in place once the person turns 18 (or later if agreed more appropriate).
Key learning point
CCGs should ensure that adult NHS continuing healthcare is appropriately
represented at all transition planning meetings to do with individual young people
whose needs suggest that there may be potentially eligible.
Slide 23
Notes
1. We saw earlier how the Care Act 2014 and Children and Families Act 2014
provide a single legislative framework for transition to adulthood, with a focus on
personalised outcome-based approaches and carers.
2. People working across education, health and social care need to understand both
Acts and how they work together. Local authorities can achieve more by
implementing the two acts together. The two Acts can be used to design local
pathways to adulthood that lead to better outcomes and more efficient use of
resources. The national Preparing for Adulthood programme has developed a
factsheet that sets out the links between the two reforms.
3. Duties in both Acts are on the local authority, not children's or adult's services, so
a variety of operating models around transition are possible (e.g. 14-25 team).
Page 37
4. Another example is the overlap of information and advice duties in both Acts.
The Children and Families Act 2014 requires local authorities to publish a local
offer, which includes provision of information and advice for children’s social care
in their local area. The Care Act places a similar duty on local authorities to
provide information and advice about adult care and support. See the
information and advice workbook for more details. Given the similar
requirements on both children and adult services to provide information and
advice that is easily accessible, local authorities should consider jointly
commissioning and/or delivering their information and advice services for both
children’s and adult care and support as part of their approach to working
together.
5. The EHC plan requirement for preparation for adulthood to begin at 14 is a good
default position for transition planning generally and highlights the importance of
building towards adulthood over time, which is particularly important for
developing skills in independent living.
6. The ability to continue children's services beyond 18, and join up various
assessments across both Acts, means a more flexible framework where
transition can be a personalised evolution from 14-25 with no need for a "cliffedge" transition at 18.
Summary
Slide 24
Page 38
Questions
 What has struck you most about this session?
 Thinking about what you have learnt about transition to adulthood (and on any
other modules you have completed so far)...
- What links can you make between topic areas?
- How might the necessary changes impact on your current arrangements?
- What might the key challenges be?
Exercise
 What are your top three priorities in relation to transition to adulthood?
 Complete the action plan to identify the next steps for each priority.
Page 39
Appendices
Links to key resources
Beresford B (2013) Making a difference for young adult patients. Research briefing
.
Conlon L (2014) Transition Planning for Young People with Learning Disabilities in
Great Britain (NIAR 359-2014) Northern Ireland Assembly. Research and
Information Service Research Paper.
Cowen, A. (2010) Personalised Transition: Innovations in Health, Education and
Support. The Centre for Welfare Reform.
CQC (2014) ‘From the pond into the sea’ Children’s transition to adult health
services. This themed review looked at the arrangements made for children with
complex health needs as they move from children's to adult services.
Crowley R, Wolfe I, Lock K and McKee M (2011) Improving the transition between
paediatric and adult health care: a systematic review. Archives of Disease in
Childhood. 96(6) pp.548-553.
Department for Education (2011) Statutory Guidance for Local Authorities on
Targeted Support Services for Young People, with respect to supporting them
through school leaving and transition into training or work as required by the
Education and Skills Act 2008.
Department for Education (2010 revised 2014) The Children Act 1989 Guidance and
Regulations Volume 3: Planning Transition to Adulthood for Care Leavers
Department for Education & Department of Health (2014) Special educational needs
and disability code of practice: 0 to 25 years. Statutory guidance for organisations
who work with and support children and young people with special educational
needs and disabilities.
Department of Health (2008) Transition: moving on well: A good practice guide for
health professionals and their partners on transition planning for young people with
complex health needs or a disability.
Department of Health (2006) Transition: getting it right for young people.
Page 40
Department of Health (2012) Children and young people’s health outcomes strategy,
Report of the children and young people’s health outcomes forum
Getting a Life Available at http://www.gettingalife.org.uk/resources.html (no date)
(Accessed: 17 October 2014). The Getting a Life programme ran from April 2008 to
the end of March 2011, as part of the Valuing People Now employment work.
Jackson K (2010) Lost in transition? A guide to finding your way through. Second
edition. Dimensions (UK)
Lidstone Dr V (2013) The role of hospices in supporting young people in transition
from children to adult services. A working paper of the Commission into the Future of
Hospice Care.
Local Government Association (2013) Must know on adult social care 10.
Transitions.
Marie Curie Cancer Care and Together for Short Lives (2012) Don’t let me down:
Ensuring a good transition for young people with palliative care needs.
Marsh S, Cameron M, Duggan M and Rodrigues J. (with Eisenstadt N, Iskander R.
and Stone J) (2011) Young people with life limiting conditions: transition to
adulthood. Public Service Works
McNamara K (2011) Transition for young people with life-limiting conditions: the UK
picture. Together for Short Lives.
Merriman S (2009) TransMap. From theory into practice. The underlying principles in
supporting disabled young people in transition to adulthood. Council for Disabled
Children/DCSF
National Network of Parent Carer Forums (2013) What Good Integrated Care Looks
Like in Transition
National Offender Management Service (2013) Practice Guidance: Working with
Care Leavers (18-25), in custody and the community, to reduce reoffending and
promote effective transition to adulthood.
National Transition Support Team (2011) Working together to improve transition for
disabled young people
Page 41
National Development Team for Inclusion/Council for Disabled Children (2014) PfA
Factsheet: The Links Between The Children and Families Act 2014 and The Care
Act 2014
NCB (2010) Transitions between children’s and adult’s health services, and the role
of voluntary and community children’s sector.
NTSW/CfDC (2011) Information and learning from the Aiming High for Disabled
Children Transition Support Programme.
Preparing for Adulthood programme (PfA) Preparing for Adulthood Available at
http://www.preparingforadulthood.org.uk/ (no date) (Accessed: 17 October 2014). A
programme of support and resources, available to download, funded by the
Department for Education as part of the delivery support for the SEN and disability
reforms.
Royal College of Nursing (2013) Lost in transition. Moving between child and adult
healthcare services.
Royal College of Nursing (2013) Adolescent transition. RCN guidance for nursing
staff.
Social Care Institute for Excellence The Care Act: Transition from childhood to
adulthood Available at http://www.scie.org.uk/care-act-2014/transition-fromchildhood-to-adulthood/ (no date) (Accessed: 17 October 2014). SCIE is developing
new resources to help local authority staff, social workers, young people and carers
to plan for the transition to adult care services. Existing SCIE resources on
transitions are also available.
Sloper P, Beecham J, Clarke S, Franklin A, Moran N. and Cusworth L. (2011)
Transition to adult services for disabled young people and those with complex health
needs, Research Works, 2011-02, Social Policy Research Unit, University of York,
York.
Together for Short Lives (2007) The Transition Care Pathway
Handouts
Handouts relevant to this topic area:
 Exercise: Transition to adulthood audit tool
 Case Study: Isabelle