Agenda Item No


The Vale of Glamorgan Council


Scrutiny Committee (Social Care and Health): 31st October, 2011


Report of the Director of Social Services


Review of Transitions Services for Disabled Young People


Purpose of the Report

1.             To provide Scrutiny Committee with an update on how disabled young people are helped to make the transition from Children and Young People Services to Adult Services.


1.             That Scrutiny Committee notes the content of this report.

Reason for the Recommendation

1.             To ensure effective scrutiny of a key function undertaken by Social Services.


2.             The transition process facilitates a young disabled person's journey from childhood to adulthood, primarily between the ages of 14 and 21 years.  Multi-agency and multi-professional input is required to ensure that the change is managed well by organisations with a responsibility for providing support and help to these young people.

3.             In 2009, a case management inquiry in the Vale raised issues about information exchange and care planning at key transition/move on points, both between teams within Children’s Services and between Children’s and Adult Services.  An action plan was put in place to address these concerns.

4.             A CSSIW follow up review  in 2010 noted the following:

-     The arrangements for ‘transition’ and ‘move on’ planning, whether to the leaving care team or adult services were effective and the quality of work mainly good.  Work was mainly underpinned by good assessments, clear planning, service user engagement and a professional approach.


-     The transitions staff reported that case transfer and 'move on' processes between teams had improved and was well managed, particularly between the child care teams and the leaving care team and from the children with disability team to Adult Services, where the role of the transition workers was particularly effective.

-      Delays in starting early transition planning with the Education Department for children not previously known to Social Services was not in line with the Authority's policy of transition, which required commencement at 14 years of age.


-      Multi-agency planning processes were challenged by the service requirements of young adults with very complex needs but overall services were found to be responsive to individual needs and wishes

Adult Services tended to become actively involved in planning to receive cases at a very late stage. CSSIW recommended that the Authority should review these arrangements to ensure that Adult Services become fully engaged at an appropriate stage that is purposeful.


5.             Sustainable Social Services for Wales: A Framework for Action sets out the longer-term intentions of the Welsh Government in this area of work.  The paper acknowledges that more needs to be done in setting a national framework.  The Welsh Government will:

-      consider extending entitlement under the Children Act 1989 beyond the age of 18, possibly up to 21;

-      work with stakeholders to determine arrangements to assist young people towards independent living and to take advantage of opportunities for education and work; and

-      weigh up the case for appointing transition workers, to take a key co-ordinating role between agencies.

Relevant Issues and Options

6.             There are currently 55 young people aged between 14 and 18 years who are involved with the Child Health and Disability (CHAD) Team in Social Services and part of the transition process.  Of these, 11 will reach their 18th birthday between April 2011 and March 2012 and transfer to Adult Services.  The projected number transferring to Adult Services between April 2012 and March 2013 is 14. Some of these young people have very costly and complex care packages.

7.             In addition to referrals from the Transition Referral Interface Group (TRIG), the Adult Services Transition Team also receive referrals from voluntary agencies, hospitals, housing providers or from families and young people who have previously declined services. In 2010-2011 this equated to a further 16 referrals. This year, Adult Services have received an additional 6 referrals to date.  The Transitions service business process is outlined as a flow chart at Appendix 1.

8.             A number of improvements to transitions services have been achieved since the follow up review by CSSIW. These demonstrate the benefits of having a unified Social Services Directorate, with a focus on people in the context of their families and communities and fewer barriers to collaborative working across Children's and Adult Services.

-     A multi agency transition protocol for young people in the Vale of Glamorgan was drawn up in April 2005 and agreed by the Vale of Glamorgan Council, the Cardiff and the Vale Parents Federation, the Cardiff and Vale NHS Trust, Bro Morgannwg NHS Trust, the Vale of Glamorgan LHB and Careers Wales. It has been reviewed every two years to ensure that it reflects current working practices, guidance and regulation.

-     A member of the CHAD Team attends all SEN transition meetings from the age of 14 years, for those young people known to the team.  With the consent of the young person and their family, a team member now attends transitions meetings for those who are not known when they are requested to do so, thereby addressing the issue raised within the CSSIW review.

-     For young people leaving care, the Council has a statutory duty to provide them with a Young Persons Advisor (YPA) who offers a level of independent advice and support and enhances the planning for young care leavers.  Historically, the YPA service has been commissioned from a third sector provider but in 2010 the service returned in-house.  Under the previous arrangement there was no allocation of a YPA to relevant children within the CHAD Team.  However, a clear referral system has now been established with good communication between the two team managers (CHAD and Fifteen Plus) and there are currently 6 young people in the CHAD Team who have an allocated YPA.

-     TRIG has expanded as a multi-agency group, enabling young people to access a broader range of services, with representation from the CHAD Team, Adult Services Transition Team, Fifteen Plus Team (as required), Careers Wales, Cardiff and Vale UHB, ABMU Learning Disability Local Health Manager, Education Pupil Support Service and the Housing Homeless Officer.  The inclusion of the Homeless Officer has enabled early identification of future housing accommodation needs.  The CHAD Team Manager co-ordinates and chairs this group.

-     In July 2010, the Transition Team within the Community Support Team (Adult Services) was formed to support young disabled people moving from Children's Services to Adult Services. The Transition Team supports 16-25 year olds and works closely with the CHAD Team.  Case responsibility transfers to the Adult Transitions Team when the young person reaches 18 years of age. A Transition Information Pack has been compiled.

-     Several Transition Information events based in the schools have been organised by the two Teams in partnership with Education and Career Wales during 2010/2011. A multi-agency Transition event took place in August 2010 at Barry Leisure Centre, which was very well attended.

-     Earlier engagement of Adult Services is now evident, with attendance at all reviews from the age of 16 onwards.  Staff are involved in drawing up the transition plan and joint work with the CHAD key worker between the ages of 16 to 18, when required.


9.             Two detailed case studies are attached at Appendix 2 to illustrate the Transitions service in action.

10.        Further developments are planned.

-     At the first Transition Planning meeting a key worker should be identified who is responsible for the co-ordination of the plan (not the implementation of all the objectives).  The key worker system requires further development involving NHS and Education personnel, as this role does not automatically need to be fulfilled by Social Services.  The protocol states the key worker should be from an agency who will have regular involvement with the young person and carer and who will be in a position to co-ordinate progress on achieving the plan's objectives. This key worker will be the information contact point for the young person, carer and other agencies involved with the plan.  The further development of a key worker system will assist those young people who are not known or do not require a service from the CHAD or the adult services Transition Team.

-     Further work needs to be done on producing 'a single transition plan' incorporating the various statutory plans that have to be completed within Children's Services and ensuring that electronic systems are compatible and accessible across the Social Services Directorate.

-     The transition arrangements for those who receive Continuing Health Care funded by the NHS or may be eligible for it needs to be stipulated within the Transition Protocol, incorporating the recently revised national protocols.'

-     An appropriate health representative needs to be identified to sit on the Multi-Agency Complex Needs Panel, where decisions are made in relation to specialist placements for children with complex health and emotional needs.  Being able to identify and secure early commitment for Continuing Health Care provision will assist in securing appropriate provisions for children.

-     Discussions regarding the need to join together the Transitions Team in Adult Services) and the Transitions worker in CHAD have concluded that the current 'virtual team' working arrangement is more effective.  Further consideration will be given to possibility of two practitioners within CHAD having case responsibility for all transitions work, thus developing more specialist knowledge and a clear point of contact for the Transitions Team.

Resource Implications (Financial and Employment and Climate Change, if appropriate)

11.        Future service developments will need to be achieved within available resources.

Legal Implications (to Include Human Rights Implications)

12.        There are no specific legal implications as a result of this report.  However, within the Transition process, staff have to give due regard to statutory entitlements to service and the rights of young people and adults to experience non-discriminatory practice. .

Crime and Disorder Implications

13.        There are no crime and disorder implications as a direct result of this report.

Equal Opportunities Implications (to include Welsh Language issues)

14.        Transitions services apply to all disabled young people identified as having Special Educational Needs and who are going through the Transitions process.

Corporate/Service Objectives

15.        Vale of Glamorgan Council's Corporate Plan 2010-14 has the following corporate priority:

Develop multi-disciplinary transition services for young people in need moving into adulthood, independence and between services.

Policy Framework and Budget

16.        These are matters for Executive decision.

Consultation (including Ward Member Consultation)

17.        There are no matters in this report which relate to any individual Ward.

Background Papers

Appendix 1    Transitions Flow Chart

Appendix 2    Illustrative Case Studies

Contact Officer

Carol Davies, Operational Manager Children and Young People Service

Officers Consulted

Ceri Spence, Child Health and Disability Team Manager, Children and Young People Service

Linda Woodley, Senior Social Work Practitioner, Transition Team, Adult Services

Sue Power, Acting Operational Manager, Adult Services

Responsible Officer:

Lance Carver, Head of Adult Services

Gareth Jenkins, Head of Children and Young People Services