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1 PRINCIPLES OF GOOD TRANSITIONS 2 Scottish Transitions Forum 2014

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3 PRINCIPLES OF GOOD TRANSITIONS 2 Scottish Transitions Forum 2014 i

4 Scottish Transitions Forum Compiled on behalf of Scottish Transitions Forum Members by ARC Scotland May 2014 ARC Scotland 2014 Association for Real Change is a registered charity: Registered Charity No , Scottish Charity No. SCO39129 Design by Bold ii

5 PRINCIPLES OF GOOD TRANSITIONS. 2 Foreword I welcome the publication of TPrinciples of Transition 2V and the work of the Scottish Transitions Forum to highlight the important issues surrounding transitions, and to bring them to the forefront of policy and practice relating to children and young people. This document outlines the ways in which we can all work jointly together to ensure that transitions are as smooth as possible and that the voices of children and young people are at the centre of decisions made about their future. Transition should be a time when children and young people feel empowered and excited about their options, not concerned about what lies ahead. Given the recent adoption of the Children and Young People (Scotland) Act 2014, this document serves as a timely reminder of how we can Get It Right For Every Child by ensuring that the rights enshrined within the United Nations Convention on the Rights of the Child (UNCRC) are upheld as children and young people experience transition. Transitions are important in the lives of all children and young people. starting to use adult health and social care services or starting a new job or placement, transitions can be both an exciting and a worrying time. For children and young people with additional support needs these rites of passage can become particularly concerning due to an often-complex health and social care landscape and a multitude I look forward to a future where all decisions about a child or young person are made in their best interests, their views are heard and respected and their rights are embedded within transitions practice. This document is a welcome step towards making this a reality. Tam Baillie ScotlandVs Commissioner for Children and Young People iii

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7 PRINCIPLES OF GOOD TRANSITIONS. 2 Contents Foreword by Tam Baillie, ScotlandVs Commissioner for Children and Young People The purpose of TPrinciples of Good Transitions 2V What we mean by TtransitionsV Scottish Transitions Forum The seven principles of good transition 1. All plans and assessments should be made in a person-centred way 2. Support should be co-ordinated across all services iii Planning should start early and continue up to age Young people should get the support they need Young people, parents and carers must have access to the information they need 6. Families and carers need support Legislation and policy should be co-ordinated and Principles into practice How to support TPrinciples of Good Transitions 2V

8 Scottish Transitions Forum The purpose of 1Principles of Good Transitions 29 Members of the Scottish Transitions Forum have prepared TPrinciples of Good Transitions 2V with support from ARC Scotland. Our objective is to improve the quality of care and support for young people with additional support needs who are making the transition to young adult life. We aim to achieve this by providing clear guidance to supporting smooth transitions that are shared by all professionals. Without a positive transition process, children and young peoplevs lives can be negatively impacted, leading to lost 2

9 PRINCIPLES OF GOOD TRANSITIONS. 2 This document follows the publication of TPrinciples of Good Transitions 1V in There is a need to fundamentally change the way we support young people with additional support needs to make the transition into young adulthood. This change is needed in legislation, policy and practice across all professional sectors. To help achieve this change, TPrinciples of Good Transitions 2V provides a framework of principles that can be used by the Scottish Government and civil service teams and professionals. This includes people who are responsible for planning and delivering support for children and young people with additional support needs in: social care (such as housing and welfare) 3

10 Scottish Transitions Forum We set out seven clear principles to getting transitions right. These should be adopted by all professional sectors. Throughout this document we have indicated several areas that align with the United Nations Convention on the Rights of the Child (UNCRC) and further information is highlighted. We also list actions that will help put these principles into practice, along with a brief summary of the relevant Scottish legislation and policy that underpins each of the seven principles. Owing to the rapidly changing legislative and policy framework that impacts on transition, including self-directed support, the Children and Young People Act and Health and Social Care integration, we plan to update and issue the TPrinciples of Good TransitionsV each year until We focus on the transition to young adulthood since the challenges associated with it are widely recognised as being often poorly supported. We recognise that all people make important transitions throughout their lives and we hope that the seven principles will be helpful to those who support people who are experiencing other life transitions. Further information is available on the Scottish Transitions Forum website (www.scottishtransitions.org.uk). This provides more detailed information concerning legislation, policy, practice young people telling their transition stories and other key matters of concern (eg, transport, challenges in urban/ remote areas and data/it systems). We hope that this document will also be useful to young people and their carers. We will be working with others to provide this information in accessible formats, which again will be available from the above website. 4

11 PRINCIPLES OF GOOD TRANSITIONS. 2 What we mean by 1transitions9 For the purpose of this document, TtransitionV is the period when young people with additional support needs (such as a learning disability, autism, sensory impairments, mental health, emotional and behavioural issues, exceptional health care needs and young people in care, among many others) grow from children to young adults. Professionals often associate it with the move from school or college or the Tcase transferv from child to adult services. Professionals refer to this as the Ttransitions processv. Young people moving through transitions come from a wide range of circumstances. Some may live in families, with foster carers, kinship carers or in residential or community settings. No matter their circumstances, all young people with additional support needs have a right to individualised support, to express their views and be part of deciding their own future and the support and care they may need. 5

12 Scottish Transitions Forum Reasons for support for pupils with Additional Support Needs [Rates per 1000 pupils]

13 Achieving a Tpositive destinationv in education, training, health provision or employment is often regarded as success in the transition process. This should not be the whole story. To fully appreciate what transitions are, we must move to a more holistic model where viewed as part of fundamental rights and the overall well-being of a young person. It is important to stress that transition is an active process that unfolds over a number of years and not a single event (such as leaving school). It is equally important to plan and support later transitions (such as leaving college). Transitions for children with additional support needs happen concurrently across a range of services, including health, education, housing, welfare of a smooth transitions process organisations involved having a shared understanding of how the support they provide contributes to the overall well-being of the young person. 7

14 Scottish Transitions Forum Scottish Transitions Forum The Scottish Transitions Forum aims to improve the experience of people with additional support needs, particularly those with high support needs, as they go through life transitions. The Forum focuses on the transition of young people from school or college to adult life. We seek to achieve our aim by: people with additional support needs. At the start of 2014 the Forum had over 300 members from across Scotland f as highlighted here and at Forum meetings and improving our work practice additional support needs at a local and national level. 8

15 PRINCIPLES OF GOOD TRANSITIONS. 2 The Scottish Transitions Forum began in Membership is open to anyone who is committed to improving the transitions for young people with additional support needs. The Scottish Transitions Forum is engaged in Scottish Government initiatives such as the Autism Strategy, the Keys to Life, the Advisory Group for Additional Support for Learning Act and Self-directed Support capacity-building initiatives. Other areas of engagement include Partnership Matters, More Choices More Chances, Opportunities for All and Education Scotland. The Scottish Government is also exploring how transitions can be improved within legislation and policy relating to health care. This is an agenda in which the Scottish Transitions Forum is increasingly engaged. Challenges associated with transitions have been the subject of recent reviews and research including the Doran Review, research undertaken by ScotlandVs Commissioner for Children and Young People, and the National Deaf Children Society. 9

16 Scottish Transitions Forum To LEARN MORE ABOUT US and join the Scottish Transitions Forum PLEASE VISIT OUR WEBSITE AT Or contact Telephone:

17 PRINCIPLES OF GOOD TRANSITIONS. 2 The Scottish Transitions Forum is supported by ARC Scotland. ARC Scotland promotes the development of high quality, person-centred support for people with a learning disability or other support need. We organisations, local authorities, people who use services and their carers across Scotland.

18 Scottish Transitions Forum Colin Young is the Senior Policy and Outcomes the principles of self-directed support into a person-centred health system. Colin has a background in policy having worked for Mencap as the Children and Young PeopleVs full-time roles, Colin has held positions on the Equality 2025 board and currently sits on the Scotland committee of the European Human Rights Council. health intervention on children with cerebral palsy. In his spare time Colin pursues acting for TV and on stage. 12

19 PRINCIPLES OF GOOD TRANSITIONS. 2 1I met with Scott from ARC Scotland in 2012 to talk about my always easy for me, I have worried a lot and learned to cope with change. Some things have worked out great and some things not. I still have lots of things I would love to do and look forward to living more independently in the future.9 I love Xbox, DVDs, graphic novels and super-heroes. One of the things I enjoy most about being an adult is having independence and going to meet my friends, travelling independently. I need some support initially but once I get going there is no holding me back. I left school in School wasnvt always easy for me but I had some great times and met some good friends I was ready to leave but it was a worrying time, you never really know what is going to happen until the last minute and that is not good for anyone. I enjoyed college however things didnvt work out too well. I loved making friends but college is too busy and unpredictable. I have had some amazing experiences since leaving and was really lucky to be part of a project with Artlink starting in 2011 where I met Alan Grant a Graphic Novelist from the 2000AD and Marvel fame. We wrote a story based on my interest in super-heroes and zombies. I have had lots of celebrity moments; it has been a life changing experience. 13

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21 PRINCIPLES OF GOOD TRANSITIONS. 2 The Seven Principles of Good Transitions seven principles to improve transitions: Principle 1 Principle 2 Principle 3 Principle 4 Principle 5 Principle 6 All plans and assessments should be made in a person-centred way Support should be co-ordinated across all services Planning should start early and continue up to age 25 Young people should get the support they need Young people, parents and carers must have access to the information they need Families and carers need support Principle 7 Legislation and policy should be 54 15

22 Scottish Transitions Forum This means: of their transition planning access to a personal outcomes approach and person-centred planning in its truest sense commitment to person-centred approaches across all services 16

23 This principle is supported by the following legislation and policy: on the Rights of the Child (UNCRC) in the Children and Young People (Scotland) Act 2014 and associated policy Support) (Scotland) Act 2013 options and principles planning practices and philosophies as detailed in the Children and Young People (Scotland) Act 2014 Act (2000). Guardianship and power of attorney (Scotland) Act (2007) of which person-centred is a quality ambition Care Health Policy 17

24 Scottish Transitions Forum Young people should be at the centre of their transition planning The Scottish Government and professionals have made clear, in current legislation and practice documents, that the voices of children, young people, their families and carers should be listened to and their opinions taken into account in matters or procedures 12 of the UNCRC (respect for the views of the child). Despite this, many people report that they are not fully involved or consulted in processes surrounding Young people and their families and carers are best placed to know what they need to make things work for them, provided they have access to the right information and support. Ensuring their right to say what they think should happen, to be in control of their own lives and to make their own decisions and have their opinions taken into account leads to informed choice and better outcomes. This should still be considered when there are issues concerning guardianship and capacity. All actions concerning the child should take full account of his or her best interests and this should be a primary consideration in making decisions that Young people should be given every opportunity to make independent and informed decisions about their future. Direction and guidance should be provided to young people in exercising their rights as enshrined in the UNCRC, in a manner consistent with the evolving capacities of the young person (UNCRC article 5). This should lead to their having as much say as they wish in how their parents are involved in transitions planning. This has to be balanced with the needs and wishes of parents and carers. Young people should be given every opportunity to make independent and informed decisions about their the evolving capacities of the child in the UNCRC, which means that children and young people gradually assume greater autonomy and independence, with the appropriate support and guidance of their parents and carers. Consideration must be given to the and communication styles of young people. All professionals will need to ensure the full involvement of young people in the planning process, and this means being able to communicate with and understand the child or young person. Parents and carers are usually the most appropriate source of advice 18

25 PRINCIPLES OF GOOD TRANSITIONS. 2 _At one point social work was all about keeping people safe and now it is keeping people safe while enabling them to lead a life that they always wanted to lead.` - Social worker, Putting People First on a young personvs communication style. More information can be found in the Scottish GovernmentVs TA right to speakv document. Young people should have access to a personal outcomes approach and person-centred planning in its truest sense Person-centred planning is well evidenced as a successful way to improve outcomes for young people in transition and has been used to great the voluntary sector. Despite this, these approaches are not routinely used in transition planning. A trained planner who operates externally to health, education and should facilitate person-centred plans, in their fullest sense. If the Transitions Co-ordinator (see Principle2) were trained in these methods it would be ideal for them to facilitate this process. Not all young people may want a person-centred plan in its fullest sense. However they must have their rights respected and should be provided with the relevant information they need and be supported to choose what is right for them. A choice of other planning approaches should be available. This applies to the Additional Support for Learning planning and its associated methods. Independence, choice and control and outcomes should be central to planning processes, whatever their nature, in line with the Social Care (Selfdirected Support) (Scotland) Act There should be a shared understanding and commitment to person-centred approaches across all services All assessments and plans for those in transition should follow the core person-centred principles described on page 20. Currently, there is no agreed about what Tperson-centredV actually means, and interpretation can vary. To further complicate this, other terms such as Toutcomes-based assessmentv (such as TTalking PointsV), Tco-productionV, Tco-designV and TpersonalisationV are all used to describe similar approaches. Outcomes based on self-directed support principles and guidance should form the basis of the young personvs transitions (UNCRC article 3). Too frequently, assessment decisions are based on resource or needs-led statutory concerns rather than individual outcomes. Outcomes and needs, even though linked, need represents the barriers that have to be overcome to reach outcomes. 19

26 Scottish Transitions Forum Person-centred planning, in its truest sense, is not the same as need led or client centred assessment. Needs in assessment are associated with what people are eligible for funding for via interpretation of policy and resources of the Local Authority. Person-centred planning, in its truest sense goes beyond this and explores peoplevs aspirations, and is not limited to entitlement of services. Person-centred planning is: Person-centred planning is not: respond to people commitment communities of paper work assessment service packages Person-centred planning picture of what matters for Lucy. Though several people at the meeting were really enthusiastic about the plan and said how helpful it was for them as professionals to think about their contributions to LucyVs future, the social worker was apologetic. She said, l IVm sorry we donvt recognise Essential Lifestyle Planning. We donvt have the resources to implement it. We can only The social worker was confusing assessment for council services and broader life plan. They wanted the professionals to listen to what was important to Lucy and her family and work out what they could do to contribute towards achieving these things. They also wanted help with problem solving other sources of support and resources. Taken from Helen Sanderson f What is Person Centred Planning 20

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28 Scottish Transitions Forum _I hated reviews a I came out more upset than I went in. I felt that people were talking over me a there was no eye contact. I felt like a shadow.` - School leaver, Enquire Young people should have a single plan The lack of a shared planning but overlapping aspects of the young personvs life. Each time, a young person, their parent or carer has to tell their This is frustrating for those involved, a duplication of work and not consistent with person-centred approaches. The ChildVs plan detailed in the Children and Young People (Scotland) Act 2014 seeks to remedy this. The ChildVs plan should include all plans relevant to the planning process, including the co-ordinated support plan, and should remain the property of the child or young person for whom it has been prepared. It should be a Tcare passportt that accompanies them whenever and wherever they contact health or social care services. Professionals in these areas, especially at transition, should refer to it to provide seamless assessments. In addition to availability of person-centred processes, young people should therefore have one ChildVs plan as laid out in the 2014 Act. The ChildVs plan should also include any person-centred planning input that has gone on outside of statute led planning. More information on this will be available in the guidance being issued in 2016 to support these duties in the Children and Young People (Scotland) Act The Getting it Right for Every Child (GIRFEC) assessment (which is included as part of the ChildVs plan) in childrenvs services currently has no counterpart in adult services. Outcomes-based assessment tools, used by adult health from those used in childrenvs services. If GIRFEC principles could be applied to adult services it would provide a basis for early indicative budgets (as set out in the Social Care (Self-directed Support) (Scotland) Act 2013, and lead to less duplication of assessment. In addition, parents, carers and young people will already be familiar with this assessment procedure from childhood, and therefore adoption of its principles in adult services will provide a smoother pathway. 22

29 GIRFEC TGIRFECV stands for TGetting It Right For Every ChildV and is the legislated approach within the Children and Young People (Scotland) Act It provides a consistent way for people to work with all children and young people. It is the bedrock for all childrenvs services and can also be used by practitioners in adult services who work with parents or carers. The GIRFEC approach helps practitioners for children and young people f and how they can act to deliver these improvements. GIRFEC is being threaded through all existing policy, practice, strategy and legislation people and their families. Childs Plan The Children and Young People (Scotland) Act 2014 requires a ChildVs plan to be developed for an individual child if they have a Twell-being needv that requires a targeted intervention (s.31). A targeted intervention is one that is children generally by health boards, local authorities, managers of grant aided schools or proprietors of independent schools (s.31 (4) read with s.41). The duty to prepare the ChildVs plan lies with the responsible authority (ie, the health board for pre-school children, the local authority, and grant-aided or independent school for ages 5 to 18). Existing statutory requirements remain and will become part of the wider ChildVs plan. These are: the Looked After Children (Scotland) Regulations 2009 the Education (Additional Support for Learning) (Scotland) Act The education authority prepares this when a child or young person requires education authority and from at least one other agency from outwith rights of appeal in relation to this plan.

30 Scottish Transitions Forum This means: co-ordinating transition services to transitions in each local authority area be available throughout the transitions period to all young people who need them an understanding of all aspects of transition 24

31 PRINCIPLES OF GOOD TRANSITIONS. 2 Professionals need to be aware of: the Children and Young People (Scotland) Act 2014 other post registration learning requirements. Education must take the lead in co-ordinating transition services It is suggested in recent legislation and policy consultation that a schoolvs named person or lead professional will be responsible for the co-ordination of young peoplevs transition under the terms of the Education (Additional Support for Learning) (Scotland) Act 2004, as amended, and in line with the Children named personvs duties. Up until this point statutory responsibility for co-ordination has been unclear, even though it is the duty of education to carry out transitions planning under the 2004 Act. The named person is responsible for the ChildVs plan and these new duties should strengthen this responsibility and accountability. The named personvs duties are ambiguous if a young person is in a residential school setting. It would make sense for the named person from that setting to lead the transitions planning, however this is currently under discussion (see CELCIS for more information). The ChildVs plan and other assessments should extend into adult services to help ensure continuity through the transitions period (see Principle 3). These roles are aspirational and each local authority and in line with their individual plans. 25

32 Scottish Transitions Forum There should be a co-ordinated approach to transitions in each local authority area Young people with additional support needs may come into contact with numerous practitioners in the transitional care and support at a local level is therefore critical, particularly for those with learning disabilities or multiple and complex needs. /careers advice authority representatives support, advice and advocacy and post-16 education Cross-professional partnership working does exist. However, in many cases organisations can be unsure of each othervs roles and often do not engage with one another. A local transitions forum will help to co-ordinate support and address the support needed for future transitions. The local transitions forum should consist of, but not be limited to: (UNCRC article 12) professionals from paediatric and adult health settings care representatives Other services or individuals that are key to commissioning, workforce authority should also be included. Where transition processes have been explored in a local authority (via a transitions forum, for example), it has led to improvement in local practice. However, how this will work across the whole of Scotland is still in its infancy. 26

33 What are transitions teams, forums and co-ordinators? Transitions Forums at local authority level provide a way for all those working in the area of transition to explore challenges and solutions that will help to improve practice. A good example of how this is being developed is by NDCS and Audiology in pan-ayrshire local authorities. They are currently establishing a forum that explores transitions for deaf young people. Transitions Teams (such as in the City of Edinburgh Council) is a team within the local authority created to support transitions independently from children and adult services. Each and processes and therefore the way these teams are organised can vary greatly across Scotland. However this is done, they must be tailored to meet the needs of children and young people rather than led by other drivers. Transitions Co-ordinators Transitions Co-ordinators (such as in the Highlands and the Islands) are individuals that support transitions across education, health and social work. Their role is described below. They work where their expertise is needed due to the particular needs of the child or young person. Because they are help to smooth transitions across may also be trained in advocacy and person-centred planning approaches. 27

34 Scottish Transitions Forum Case Study Transitions Teams a how do they work? Hamish left special school in Edinburgh in the summer of Prior to this he had had annual transition meetings at his school. In attendance at these meetings was Hamish, his parent/ guardian, ASL teacher (and head teacher), Skills Development Scotland representative (careers service) and duty (un-allocated) social worker. Everyone present was responsible for developing a plan for HamishVs transition. Hamish wanted to go to college when he left school, so his Skills Development Scotland worker supported him to apply for appropriate courses, and to make his own choices. The school supported Hamish to attend various taster sessions at the college so that he could feel more secure and familiar with the environment once he had left school. The social worker ensured the plan was appropriate and all agencies involved were meeting their obligations whilst gathering various pieces of information to ensure the correct supports could be put in place. Hamish was allocated a social worker from EdinburghVs. They were responsible for supporting his whole transition by ensuring that the transitions plan was put into place and continuing to be available after this had happened. HamishVs social worker completed the adult assessment and secured the funding for transport to and from college. Since he was attending a supported course he did not require any other support at this time. Hamish started college with no problems and remained there for two years. After this Hamish wanted to leave college and move on to day support. His social worker was again allocated 28

35 PRINCIPLES OF GOOD TRANSITIONS. 2 to update the previous assessment and seek the funds for day support. Hamish was assessed as having a critical level of need, meaning he could have some funded support. The next step was to discuss how this funding would be provided. His mum decided that she would like to manage a direct payment on her sonvs behalf under the principles of Self-directed Support. This means that money is put into a bank account to allow someone to buy their own services instead of the council arranging services for them. HamishVs mum decided it would be best for him to use a local provider for half of his week. This approach enabled Hamish to have a good level of independence and meant he would remain in touch with people he knew who also attended this service. The other half of his week went more variety and options to develop his interests in art. The direct payment also included respite provision for 30 nights per year. Hamish and his family decided to use 15 nights as respite and this was included in their direct payment. The provider invoiced Hamish for the costs of the service and his mum and use the DP card to pay them. HamishVs mum said: lthe process took longer than expected but the end result was the best for Hamish. The social worker was there to assist with ideas on where and who could help to get Hamish what he required, which is helpful and important for parents.m 29

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