Transition Team Operational Policy |
Contents
1. Introduction
What is the Transition Team?
The Transition Team consists of professionals from a range of disciplines including social work, health, education and housing. Our purpose is to ensure a co-ordinated, comprehensive, multi-agency approach for transition to adulthood for disabled young people with severe/complex needs.
Transition Workers can act as Lead Professionals, providing the young person and their family with a named point of contact. The Transition Team uses a number of flexible, person-centred approaches to ensure the young person is able to fully participate and that the focus remains on his/her views, wishes and feelings.
What we do:
The Transition Team works with disabled young people in group and one-to-one settings. These settings are arranged at home, school or visits to other social environments. The Transition Team works in conjunction with schools to lead on sessions introducing and discussing the many elements of transition to adulthood (i.e. health, housing, jobs etc.).
Who we work with:
The Transition Team works with disabled young people who live in Islington, with severe and complex needs, whose transfer to adulthood social care requires careful co-ordination.
The Transition Team will automatically work with Islington Young People 14yrs +
- At The Bridge School;
- At Richard Cloudesley School.
The Transition Team works with young people from the age of 14, until he/she is settled in his/her first adult placement. Cases are closed in a flexible and sensitive manner. Each case is reviewed between six and 12 weeks after the young person has moved into his/her first adult placement. If the young person is settled, adult services takes on the responsibility of co-ordinating his/her future care. If the young person is not settled, the transition worker continues to support them, and the case is reviewed again.
There is a master list of the names of the young people that attend the Bridge, Richard Cloudesley, and have Band 6/7 statements. This is also cross referenced with young people funded by the Joint Agency Panel, and known to Islington Specialist Children’s Service. It is the responsibility of the Transition Team Manager and Team Administrator to liaise with the schools and other appropriate professionals to ensure this list is updated twice a year (every September & January).
Young People can also be referred directly to the Transition Team and will be considered for eligibility on an individual basis. If he/she is not eligible they will be signposted to other services, including Information, Advice and Guidance (IAG) Team.
Contact Details:
| Islington Transition Team Drayton Community Care Centre 52d Drayton Park N5 1NS |
|
| Main Contact Number | 0207 527 3108 |
| Team Manager | Gill James |
| transition.team@islington.gov.uk | |
| Name | Job Title | Mobile | Extension |
| Gillian James | Team Manager | 07826 904 761 | 3612 |
| Tracy Caton | Social Worker | 07826 904 330 | 3428 |
| Elleny Page | Employment Officer | 07826 904 327 | 7806 |
| Beth Cox | Social Worker | 07826 904 326 | 6708 |
| Laura Tittley | Social Worker | 07826 904 328 | 6316 |
| Barbara Lowe | Support Worker | 07826 904 726 | 6138 |
| Stella Nmecha | Social Worker | 07826 904 329 | 3570 |
| Jayne Moran | Team Support Officer | n/a | 3108 |
2.
Transition Team - General
2.1 Mission Statement
The Transition Team will provide high-quality, person-centred preparation and support for disabled young people with complex needs, moving into adulthood in the Borough of Islington. It will work directly with the young person and their family/carers to ensure that their views, wishes and feelings are central in the planning of their future life as an adult. The Transition Team will also ensure that parents/carers are involved in every step of the process by sharing knowledge and information, enabling them to make informed decisions about their child’s future.
The team will work proactively to co-ordinate children’s and adult’s services encompassing social care, education, health, commissioning and the voluntary sector. We will offer stakeholders the opportunity to evaluate our service on an ongoing basis. This will ensure that we are constantly improving the information, support and planning we provide during transition to adulthood.
2.2 Aims and Objectives
The following aims are set out in the Strategy for Integrated Transition Planning document. The Transition Team will fulfil these objectives in the following ways:
Outline a shared understanding and agreed principles of good practice in transition planning.
All members of the Transition Team will undergo frequent training and refresher courses to gain confidence and understanding of a variety of person-centred approaches. The team will link closely with The Bridge, Richard Cloudesley and Samuel Rhodes schools to develop flexible, appropriate approaches and formats for their young people whilst ensuring continuity across them all.
The Transition Team will offer support and training to other professionals in using the person-centred approaches, which, in-turn, will increase positive outcomes for young people.
To ensure that the London Borough Of Islington's Children's Services and partner agencies fulfil their statutory duties and support the Borough's Vision for Children and Young People.
The Transition Service will:
- Introduce themselves and the transition process to young people and their families/carers in the summer term of year 8, using introductory sessions and guidance documents. The guidance document will highlight all statutory responsibilities and the time in which they must be fulfilled;
- Work closely with schools, families and other services to ensure the young person feels supported in the preparation for their initial transition plan in year 9. Education will still have the statutory responsibility to ensure that the review takes place. Information, Advice and Guidance (IAG) has an obligation to attend this review;
- Will undertake the role of the lead professional, co-ordinating all services to ensure they meet their statutory duties within a timely manner, whilst providing the young person and their family with a single point of contact.
The statutory duties include:
Yr 9
- The Head Teacher has a responsibility to ensure a transition review meeting takes place, and that a Transition Plan is created;
- An IAG advisor must attend this review;
- If a social worker is assigned they must attend this review;
- Health professionals should support young people to create a health action plan.
Yr 10 & 11
- The Head Teacher is responsible for organising an annual review of the transition plan;
- School is responsible for organising a work placement;
- IAG advisor to provide information about post-school opportunities, ensure applications for options post Yr 11 are made and timed to meet deadlines;
- IAG complete a Section 140 assessment for all young people in the last year of full-time education;
- The Transition Team will highlight to adult services the young people that will enter into their service in the upcoming years.
Yr 12 Onwards
- The school provides additional curriculum activities including work experience;
- The Head Teacher together with IAG should facilitate the transfer of relevant information to ensure that young people receive any necessary specialist help or support;
- IAG support young people applying to higher education;
- The young person should be in the process of transferring from paediatric to adult health services;
- The Transition Team will carry out a community care assessment for each young person that meets the thresholds for adult services.
Ensure services for young people in transition are accessible and provide an easy journey to adult life.
The Transition Team will:
- Work closely with The Bridge and Richard Cloudesley schools to create a number of flexible approaches for disabled young people moving into adulthood. These approaches will include a variety of accessible resources and formats. Approaches will include group sessions within schools, for both young people and parents, follow up individual sessions at home and Lough Road;
- Ensure that the young person and their family understands the process and has adequate time to fully prepare. The Transition Team will spend time building rapport with young people and their families.
Ensure improved, strong, collaborative, co-ordinated and joint-working practices across children’s and adult’s services and between partner agencies.
The Transition Team:
- Is a multi-disciplinary team with links to health, social care, employment and housing. The Transition Team is responsible for co-ordinating information-sharing through a variety of methods, paperwork, meetings and reviews;
- Will chair a multi-agency subgroup of the Adult Islington Learning Disability Partnership Board. Representatives from children’s and adult’s services include: social care, health, education, commissioning and the voluntary sector amongst others;
- Will ensure that there is a named professional from health/education/social care that can participate in or inform the transition plan;
- Will complete community care assessments for young people aged 17 years that will meet the thresholds for adult services - to inform adult services about the young people that will be referred to them and how their needs can be met.
Improve accountability, clarity and transparency in the transition planning process for all agencies involved, through clear procedures and an effective local model for transition planning.
The Transition Team will:
- Produce a guidance document for parents of young people in the summer term of year 8 that will clearly define the time scales and procedure of transition. It will also clearly explain the aims and objectives of the team, and provide contact details of all team members;
- Monitor the involvement of all professionals working with individual young people;
- Track the progress of the young person’s involvement in the transition planning.
Ensure that the young person and their family are central to the planning and decision-making process.
The Transition Team will:
- Highlight which young people it will work with. The young people will receive introductory information about the service in the summer term of year 8. The parents will also receive an early support pack, which enables them to become more involved and monitor the process;
- Advocate on the behalf of the young person to communicate with people in an appropriate and accessible manner (including non-verbal young people) whilst working closely with Speech and Language Therapists to ensure appropriate communication systems are used;
- Ensure that all families have access to interpretation services if required;
- Provide accessible, easy to read documents, available in different languages;
- Introduce/signpost parents to local support groups including centre 404.
Improve the Young Person's experience of the planning and review process.
The Transition Team will:
- Ensure increased involvement of the young person in preparation, participation, feedback of all meetings and reviews if they wish to attend;
- Support the implementation of transition sessions into the schools’ curriculums;
- Increase understanding and clarity of the process, timescale and options by using creative resources and directly working with young people/families in a variety of settings and group sessions;
- Co-ordinate early involvement of adult services, providing young people and their families with time and opportunities to ask questions;
- Allocate a named contact/lead-professional to act as a point-of-contact for transition co-ordination for every child within the defined group;
- Obtain the views of young people & families regarding their feelings and opinions of the Transition Team processes at the beginning and the end of the process. These will act as an evaluation to determine the quality of the service.
Improve the choice and control young people have over their lives as they move into adulthood.
The Transition Team will:
- Spend time building rapport with young people and their families and will ensure they understand the process and options available to them;
- Ensure views, wishes and feelings are heard, respected and listened to regarding the young person’s future, desires and needs;
- Provide a guidance document that is transparent and highlight opportunities and processes;
- Inform and influence adult commissioning, highlighting areas for development in service to meet the needs of young people entering into adult services.
Provide equality of opportunity in order to enable as many disabled young people as possible to participate in education, training or employment.
Signposting / highlighting opportunities
Working with IAG.
To ensure that the process of transition is streamlined, minimizing the number of meetings, assessments and plans, with a single and central Transition Plan to be shared between agencies and the family and updated on an ongoing basis.
Transition Team to co-ordinate all elements of transition.
Improve the support and continuity of care for the young person and their family
Smooth transition in to adult services
Named worker.
2.3 Philosophy
Islington Transition Team works in partnership with parents to provide the best possible transition from children’s to adult’s services for young people with disabilities. The team will proactively establish and maintain collaborative working relationships across children’s and adult’s services, incorporating education, social care, health and the voluntary sector within the London Borough of Islington. Young people and their families will be supported with high-quality, flexible services meeting specific objectives which relate to their identified needs.
The Transition Team works with the young person and their family to create a personal transition plan to move on.
2.4 Background
The team was formed in 2006, and was jointly funded (50/50) by Islington Specialist Children’s Services and Islington Learning Disabilities Partnership until April 2011. The team is now fully funded by Adults Social Services.
The Transition Team is a vital component of the Islington Specialist Children’s Service and Adult services (Islington Learning Disabilities Partnership and Locality Teams). The team has a clearly defined role in terms of the population it serves, the discrete services it provides and the processes by which it ensures effective integration and communication between statutory and voluntary services. The team are a case holding team. To ensure person-centred approaches are the focus each worker will be allocated between 20 and 25 cases at any given time.
In addition to case holding each member of the transition team will have a specific area of responsibility. They will attend an Islington Learning Disability Partnership Sub Group, sharing information about the transition team, and share this information at the transition team meetings. Areas of responsibility will be housing, health, person centred planning, getting a life, employment and transition.
The statutory responsibility to ensure transition plans are developed and followed remains with Cambridge Education Authority and Information, Advice & Guidance (former Connexions Service).
2.5 Operational Role
- The team will work with individual young people to create a unique transition plan to meet their needs. The process will be enjoyable and accessible, ensuring the young person is central to the planning at all times;
- The team will inform commissioning, about the type of services young people are requesting, compared to those that are already available;
- The team will provide a forecast of future needs and budget implications to adult services for young people aged 14yrs +
2.6 Population Served
The Transition Team works with disabled young people who live in Islington, with severe and complex needs, whose transfer to adulthood social care requires careful co-ordination.
The Transition Team will automatically work with Islington Young People 14yrs +
- At The Bridge;
- At Richard Cloudesley;
- All young people with a global learning disability;
- All young people with a significant physical disability.
The Transition Team works with young people from the age of 14, until he/she is settled in his/her first adult placement, this could be at age 16 ½ up to 20 years old. Cases are closed in a flexible and sensitive manner, each case is reviewed between six and twelve weeks after the young person has moved into his/her first adult placement. If the young person is settled, adult services takes on the responsibility of co-ordinating his/her future care. If the young person is not settled the transition worker continues to support them and the case is reviewed again.
There is a master list of the names of the young people that feature in the above-mentioned target groups. It is the responsibility of the Transition Team Manager and team administrator to liaise with the schools and other appropriate professionals to ensure this list is updated twice a year (every September and January).
Young People can also be directly referred to the Transition Team and will be considered for eligibility on an individual basis. If he/she is not eligible they will be signposted to other services, including Information, Advice and Guidance (IAG) Team.
3. Transition Team - Intake
3.1 Joint Working with Information, Advice and Guidance
The Transition Team & the IAG team work together to support young people with severe/complex needs. IAG will concentrate on the education & employment element of the transition, whilst the Transition Worker will co-ordinate all elements/professionals within the process, and will also complete the Community Care Assessment and /or Supported Self Assessment Questionnaire Appendix F: Transition Time Line.
3.2 Joint Working with the Islington Specialist Children’s Services
The Social Workers hold overall case management responsibilities for Young People.
This includes the following:
- Completion of Single Assessments and allocation of provision, including reviews of services/short breaks;
- Co-ordinating and recording Child in Need visits and meetings;
- Visits to CLA YP within the team;
- Child Protection Concerns.
The Transition Team will only support young people transferring to Islington Learning Disabilities Partnership or young people with physical disabilities eligible for services from the Adult Locality Teams.
The Transition Team will:
- Work with the YP and family to complete an ‘about me’ highlighting a young persons wishes and feeling about the future;
- Attend all education reviews;
- Complete a Community Care Assessment at age 17 years;
- Support family to complete ‘supported assessment questionnaire’ & support plan for personal budgets at age 17 ½ yrs;
- Present the cases to appropriate ILDP panel/meetings;
- Manage case Post 18 yrs until transfer of responsibility to Adult Teams;
- Complete reviews of CCA & PB support Plan;
- Transfer Summary & Hand over to ILDP & Locality Teams.
When possible the Social Worker and Transition Social Worker should carry out joint initial visit to young person & family.
3.3 Joint Working with Child Looked After/ Leaving Care Service
Child Looked After Teams should refer Young People to Transition Team at age 13 years. Within the referral (Appendix E - to follow) there must be evidence that the YP is eligible for Adult Services (has a Global Learning Disability or is Physically Disabled). If this information can not be determined, the case will be allocated to the Transition Health Worker who will complete a detailed scoping exercise and an Assessment of Motor and Process Skills (AMPS) if required.
CLA responsibilities:
- To collect reports/evidence to show that the YP has a Global Learning Disability or is Physically Disabled before referring to the transition team;
- Refer to the transition team at age 13 yrs;
- Provide named social worker to YP;
- Provide YP with a Personal Advisor;
- Work with the YP to create an accessible pathway plan, feedback this plan to them (transition worker to support);
- To arrange/organise pathway plan;
- To support young people to apply for supported living;
- Review placement;
- Carry out Social Work responsibilities - check appropriateness of placement & support, safety, development of YP, support to complete forms, DLA/Benefits;
- Leaving care services will support the young person into appropriate accommodation.
Transition Team responsibilities:
- Team manager to assign worker;
- Worker to complete Community Care Assessment (CCA)when YP is 17 yrs old;
- Joint work with SLCS to ensure pathway plan is appropriate;
- Present CCA to ILDP panel to ensure eligibility and highlight what services are likely to be asked for post 18 yrs;
- Complete a Supported Self Assessment Questionnaire for an Personal Budget at age 17 ½ yrs which will provide support to the placement;
- Create an accessible support plan for the Personal Budget;
- Review the Personal Budget;
- Complete transfer summary - hand over to ILDP.
Click here to view 'Process: Child Looked After/ Leaving Care Service' flowchart
3.4 Joint Working with Lough Road (LRC) and King Henrys Walk (KHW)
Lough Road Centre Responsibilities:
- Provide Transition Team Manager and Support Officer with regularly updated (quarterly) lists of allocated Key Workers for all Islington young people age 13 yrs +
- Key Workers to support Transition Worker collating information from the young people;
- Key Workers to attend annual reviews when possible;
- Workers within the service to support YP to carry out intro visit to KHW - within the time they would be at LRC. This should take place aged 17 ¾ yrs;
- To arrange transport for staff & YP to be able to carry out these intro visits;
- To transfer all information/behaviour plans directly to KHW at 18 yrs.
Transition Teams Responsibilities:
- Transition Worker ensures young person view and wishes about the future are captured in the ‘about me’ preparation document for the annual review, this will include visiting YP at LRC;
- Transition Worker to ensure that all Key Workers are invited to annual reviews;
- Provide KHW with regularly updated (quarterly) lists of all young people aged 17 yrs, highlighting those that access LRC;
- to either provide families with contact details for KHW or to support them to visit;
- Transition Worker to complete Self Assessment Questionnaire for Individual Budget and support plan at age 17 ½ yrs. This will flag if KHW is within the support plan;
- Transition Workers to invite Key Workers to be involved in the support planning process;
- Transition Team to provide LRC with support plans for all young people that access LRC. Latest age 17 ¾ yrs;
- Transition Team to provide KHW with support plans, for young people planning on accessing this service. Latest age 17 ¾ yrs.
King Henrys Walk (KHW) Responsibilities
- Provider to meet with parents/transition worker to show them around the centre;
- Provide a named worker to support the introductory visits, supported by LRC, from age 17 ¾ yrs;
- Provide LRC with photos of staff & rooms at KHW to support the transition.
Click here to view: Process: Lough Road (LRC) & King Henrys Walk (KHW)
3.5 Joint Working with the Self Directed Support and Adults’ Direct Payments Team
Self Directed Support Teams Responsibilities:
- Inform Transition Team when a young person turns 17 years;
- Inform parents that the Children’s package will come to an end, the Sunday of the week the young person reaches 18 yrs old, however they can carry over 4 weeks of pay;
- Will claim back any money owed (under-spent);
- Write to family to confirm when the funding has ended;
- Complete a risk assessment & monitoring, forward this to Adults DP team when the Young Person is aged 17 ¾ yrs.
Transition Teams Responsibilities
- To support Young Person/Family to complete Supported Assessment Questionnaire and Support Plan at age 17 ½ yrs;
- To refer to Adults Direct Payments team, via IAS, once an indicative budget has been agreed;
- Complete a joint visit with the DP team to create support plan with costings;
- Complete a joint review 8-10 weeks after the support plan is implemented;
- If there is a delay in completing the SAQ - to ensure Adult Services consider funding the Children’s Package until the SAQ & Indicative Budget can be agreed;
- To complete a review of the package before young people leaves school to ensure it will continue to meet their needs.
Adults Direct Payments Team Responsibilities:
- Complete a joint visit with Transition Team to assist with Support Planning;
- Support family to complete all relevant paperwork, including bank detail forms and Personal Budget agreement;
- To support the family with creating a job description, advertising/recruitment and employing a support worker;
- To complete financial monitoring of the package at three, six and twelve month periods.
Click here to view 'Process: Self Directed Support and Adult’s Direct Payments Team' flowchart
3.6 Joint Working with Islington Learning Disabilities Partnership
Transition Team Responsibilities:
The Transition Team will:
- Complete Independent Living Fund Paperwork at age 16 yrs if appropriate, or make a recommendation for it to be completed when the young person leaves college;
- At age 17 yrs complete the Community Care Assessments on IAS, which will be signed off by the Transition Team manager;
- If looking for residential support, paperwork presented at eligibility panel, (17 ¼ yrs), and then referred to brokerage for support. Complete joint meeting with family to discuss accommodation options;
- If looking for community support, Transition Worker to support YP/family to complete Supported Assessment Question/Resource Allocation System for Personal Budget, at age 17 ½ yrs;
- Transition Worker to refer to Adult Direct Payments Team for support;
- Transition Worker & Direct Payments team to support YP/Family to complete support plan;
- Transition Worker to validate Support Plan with Transition Team Manager, and present to Personal Budgets Breakfast Meeting for sign off;
- Transition Worker and Direct Payments Worker to review the package 8-12 weeks after initially set up;
- Transition worker to support the move out of school (age 19 years);
- Transition worker to complete review Support Plan before they leave school;
- Transition worker continues to manage case as YP leaves school and starts in new placement;
- To organise and facilitate a hand over from paediatric to adult health teams;
- The Transition Team complete a Transfer Summary before transferring to ILDP, and transfer the case 8-10 weeks after the young person starts at College/adult placement;
- Transition Team & Care Manager to carry out joint work when transferring cases that will need ongoing care co-ordination (Level 2 or 3);
- Transition Team to work closely with ILDP Service Manager to agree emergency packages outside of panel;
- be responsible for investigations regarding adult safeguarding on cases allocated within the team.
Islington Learning Disabilities Partnership Responsibilities:
- Provide Safeguarding Advice to Transition Team as required;
- Deputy Manager - will support with complex cases that need additional input from adult services;
- Service Manager and Health representative to attend health hand over meeting at the Bridge School in May;
- Adult Brokerage to carry out joint work to support looking for suitable accommodation, this might include completing the Care Cost Calculator;
- Service Manager to agree emergency packages outside of packages;
- Service Manager to allocate Care Manager to complete joint work, prior to transfer, for complex cases.
Click here to view 'Process and Timescale of Transfer to ILDP' flowchart
4. Recording Systems
Information Recorded about all YP
Referral Form
Initial Contact
- Summary of all meetings or visits within case notes;
- All correspondence regarding the YP;
- Supervision notes about a YP are recorded within their file;
- Reports & assessments;
- Preparation for transition planning - ‘About Me’;
- Agreed Transition Plans with Action Plan.
All YP under the age of 17 yrs
All information for young people under the age of 17 years will be saved on the social services shared drive, within the transition file. The team administrator will create new files once the team manager has accepted new referrals, and will save the referral form directly into the file. The administrator will also support staff to scan information relating to new cases. The allocated worker will then be responsible for updating and maintaining the files. This will be checked periodically by the team manager.
For YP that will be Accessing Adult Services
Workers use IAS (adults system) as soon as the young person turns 17 years. All correspondence, case notes, assessments and referrals will be recorded directly on to this system.
For YP not going to Access Adult Services
All information for young people 17+ that will not access adult services will continue to be saved in the social service shared drive, within the transition file.
Team Meetings
- To be held monthly for two hours from 8:30am-10:30am. All members of the team are required to be present, unless previously authorised by the team managers;
- Agreed to have a rotating Chair and minute taker;
- Chair to be responsible for sending agenda round to the team early in the week for them to add any additional discussion points;
- Set agenda and include one “flexi hour” for caseload discussion and any other business;
- Guest speaker slot to be arranged ad hoc. Team Support Officer to liaise with the guest speakers and arrange dates and times. Team to highlight which speakers they would like.
Administrative Systems
Room Bookings at ILDPAll rooms at ILDP are on calendars on the system. Ask the Team Support Officer for assistance to book rooms.
Room bookings (other locations), e.g. Islington Town Hall/ 222 Upper St/Laycock Professional Development Centre/Schools:
- Team members to let administrator know of any room bookings and facilities/equipment needed as soon as possible;
- Administrator to arrange/coordinate booking prior to the meeting;
- Details of location to be added onto the Transition calendar for team members to view;
- Administrator to update room tracker spreadsheet with costs where applicable.
Room Cancellations:
Team members to let administrator know of any cancellations, in advance, where possible. Team administrator to cancel any bookings on behalf of the team.
Travel Procedure:
- Team members to let administrator know of any travel requirements a week in advance (where possible) before visit;
- Team member to fill in travel warrant authorisation form on the shared drive and send to team administrator in order to complete warrant, and for filing purposes;
- Team Support Officer to use information from the authorisation form to complete travel warrant;
- Team Support Officer to update details of visit on the travel tracker spreadsheet saved on the shared drive for invoice and filing;
- Team Support Officer to send travel tracker spreadsheet and receipts to finance on a quarterly basis, or when requested in order to track costing.
Post:
- All team members have a pigeon hole where post will be date stamped and then stored on receipt;
- Leave any post with the reception desk and it will be sent out on a daily basis.
Appendix A: Islington Transition Team Sharing Initial Information Form
Click here to view Islington Transition Team Sharing Initial Information Form
Appendix B: The Bridge Transition Processes
Click here to view The Bridge Transition Processes
Appendix C: Richard Cloudesley - Transition Processes/Protocol
Click here to view Richard Cloudesley - Transition Processes/Protocol
Appendix D: Referral Form to Transition Team
Click here to view Referral Form to Transition Team
Appendix E
To follow
Appendix F: Transition Time Line
Click here to view Transition Time Line
End