Agreeing Needs, Making a Formal Record and Next Steps (Transition Assessment)

Throughout the process of information gathering to establish needs you should talk to the young person (or their representative), their parents and others about the level of current and likely future need apparent, endeavouring to reach an agreement about this as the process progresses.

Whether or not an agreement about needs is reached, the Local Authority is responsible for making the final decision about the level of current and likely future need that a young person has. As such this is your responsibility as you are the Local Authority's representative.

When determining the level of need you must give regard to:

1. the views of the young person about the level of current and likely future need;
2. the views of the young person's parents about the level of current and likely future need;
3. the impact of the current need on the young person's wellbeing;
4. the impact of likely future needs on the young person's wellbeing;
5. the views of any carer about the level of the young person's current and likely future need; and
6. the views of anyone else consulted or involved in the assessment process.

The decision that you make about the level of need must be evidence based and robust. This means you must be able to demonstrate the information that you have used to reach a decision about need if challenged.

The decision you reach may be in line with the views of the young person (and others) but equally it may not be if the evidence does not support that judgement. This is appropriate as long as you have a clear rationale for your decision and have given regard to the young person's views, their parent's views, their wellbeing and the views of others.

If you are unclear about the level of need a young person has, you should consider the benefit in gathering any additional information or consulting with any other person. If you remain unclear about the level of need you should seek advice from your line manager about how best to proceed.

All recording should be made in line with local requirements.

The Care Act does not specify a timeframe for making a formal record of a transition assessment only that this should be done in a timely way.

Timely recording will:

1. reduce the likelihood of inaccuracies;
2. prevent any unnecessary delays for the young person;
3. support the timely development of any transition plan; and
4. ensure that any current identified needs can be met as soon as possible.

If the timeframe for assessment that you use leads to inaccuracies or a delay in meeting needs, then it is not timely.

The following information must be clearly recorded in all cases:

1. The identified areas of need that the young person has now;
2. The identified areas of need that the young person is likely to have when they become 18 (using the Care Act needs domains);
3. The nature of needs that the young person has in each area where needs exist;
4. The views of the young person, their parents, any carer and any other person in relation to need now and in the future (and how these have been regarded);
5. The views of the young person, their parents, any carer and any other person in relation to how current need impacts on wellbeing (and how these have been regarded);
6. The views of the young person, their parents, any carer and any other person in relation to how likely future needs will impact on wellbeing);
7. The evidence that has been used to reach a determination about the level of current and likely future need;
8. How the impact of the decision on wellbeing, both now and in the future, has been considered;
9. A proportionate record of the options explored to meet current needs and achieve outcomes, clearly demonstrating a strengths based approach;
10. A proportionate record of the information given about the ways that Adult Care and Support may be able to meet likely future needs and achieve outcomes, clearly demonstrating a strengths based approach;
11. A proportionate record of conversations about risk, clearly demonstrating a positive approach to risk;
12. A proportionate record of any general information and advice that has been given about the transition process and Adult Care and Support;
13. A proportionate record of the preventive measures that have been explored; and
14. A proportionate record of any actions and next steps agreed (for example, transition planning or an adult needs assessment).

The following information should also be clearly recorded where relevant:

1. Safeguarding concerns raised and action taken;
2. Deprivation of Liberty concerns raised and action taken;
3. A proportionate record of specific information and advice given (for example, around finances or Lasting Power of Attorneys);
4. The evidence that has been used to demonstrate the level of fluctuating need; and
5. Any difference in views about need that have occurred.

Following the assessment process the young person must be given a written record of their assessment.

It is important that the young person understands their assessment and the outcome of it. To this end it should be provided in a format that is accessible to them.

If the assessment has been provided in a format that you know or suspect the young person will not be able to understand, you should:

1. consider any steps that you can take to support them to understand it (for example, summarising it in a simpler format); and
2. consider the duty to make an Independent Advocate available.

If an advocate is already involved, they should be informed when the assessment has been provided to the young person so that they can support them to understand it.

In all cases a copy of the record must be provided to the young person's parents and any carers.

A copy should normally be shared in full with any carer unless an agreement has been reached to only share a partial record with them (for example, when a young person with capacity/competence has not consented to particular information not relating to needs being shared).

Where the assessment was carried out jointly with another organisation to avoid duplication (for example, housing or health) a copy of the assessment must be made available to the other person that carried it out with you.

A copy of the record can only be shared with anyone else with:

1. the young person's consent; or
2. if the young person is over 16, lacks capacity and if a best interests decision is made to this effect; or
3. if the young person is under 16, lacks competence and a person with parental responsibility consents.

A copy must also be shared with anyone that the young person requests you share a copy with, even if they were not involved in the assessment itself.

Concerns about a request

Sometimes the young person will request a copy of the assessment is provided to a person who was not involved in the process. You must provide a copy of the assessment to anyone that the young person requests you to unless:

1. they are over 16, lack capacity and you make a decision that sharing would not be in their best interests;
2. they are under 16, lack competence and a person with parental responsibility does not consent; or
3. you are concerned that doing so could put the young person (or another vulnerable adult or child) at risk of abuse or neglect.

If this situation arises you should seek advice from your line manager and decide whether:

1. to share the record in full as requested;
2. to share the record partially, omitting sections where information could put the young person at risk; or
3. to decline to provide a copy of the record (although the young person can of course still choose to make a copy available from their own record).

Sometimes the young person (or their parents/carer/representative) may ask for amendments to be made to the assessment. For example:

1. They feel that there is information missing; or
2. They feel that the record is a misinterpretation of something that was said or agreed.

In this case you should:

1. consider the request;
2. if the young person did not make the request consult with them (or their representative if they lack capacity/competence);
3. consult with the young person's parents;
4. consult with others where relevant (for example, a carer or anyone else that was involved); and
5. review any evidence or information you have which may support or refute the request.

You should not make the amendment regardless of the existence of evidence and a rationale for doing so. If you reach a decision not to amend the record you should be clear about your reasons for not doing so, and you should make the person aware of their right to complain about your decision.

If a decision is made to make the amendments, you should proceed to do so. Where doing so results in 2 versions of the same assessment being available on the system, it must be clear which the amended version is.

The amended record should be circulated to the same people as the original record, unless:

1. the young person has capacity/competence and does not consent; or
2. the young person is over 16, lacks capacity and if a best interests decision is made to this effect; or
3. the young person is under 16, lacks competence and a person with parental responsibility does not consent; or
4. doing so would put the young person (or another vulnerable adult or child) at risk of harm or abuse.