Preparing for adulthood (PfA)

Age 14 (Year 9)

If you have an EHC plan, it will be amended in Year 9 to incorporate the Preparing for Adulthood outcomes. All reviews from now on should focus on the support you will need to prepare for becoming an adult and what you would like to achieve.

The EHC team flag up young people who are likely to need or be eligible for support from adult social care as adults, and they are placed on the Transitions Planning Agenda.

Age 15 (Year 10)

If you have an EHC plan, your annual review will focus on what you want to do when you leave Year 11.

SENCO and schools career guidance officers will support any developing action plans. If you are Educated Other than in School, you will be offered alternative arrangements.

Age 16 (Year 11)

The EHC team will amend your EHC plan if you are moving between settings. Next Steps Careers Guidance will be offered if you have been identified by your SENCO as needing additional support.

All placement and funding requests including funding applications for college places are referred to a multi-disciplinary panel.

Age 17 (Year 12)

The annual review will be used as a mechanism to facilitate joint planning with you and your family, particularly around preparation for adulthood and transition to adult services.

Annual reviews for education health and care (EHC) plans

Your EHC plan will be updated to reflect this, along with any changes to your special educational needs, support required and the outcomes you expect to achieve for the future.

Age 18 (Year 13)

The annual review will be used as a mechanism to facilitate joint planning with you and your family, particularly around preparation for adulthood and transition to adult services.

If you are moving between provisions, for example, from vocational pathways or college to university at the end of year 13, the PFA team will liaise with you and your family to identify the next steps and amend or cease your EHC plan as appropriate.

Age 19 to 25

Support, including employability programmes and mentoring, is available if you are transitioning from school or college into work or further education.

The annual review will be used as a mechanism to facilitate joint planning with you and your family, particularly around preparation for adulthood and transition to adult services. There will be a particular focus on destination planning and identifying the steps to get there.

If you are moving between provisions, for example, from vocational pathways or college to university at the end of year 13, the PFA team will liaise with you and your family to identify the next steps and amend or cease your EHC plan as appropriate.

Age 14 (Year 9)

If you have an individual Health Care Plan, the school team will continue to review this with you and your health professionals to make sure it is up to date.

If you already have a diagnosed Learning Disability, you will have an Annual Health check with your GP every year from now on.

If you have complex health needs, a discussion should be held by professionals who know you well about whether you might be eligible for Adult Continuing Healthcare (CHC). This decision will be made when you are 17 years of age.

Age 15 (Year 10)

If you have an individual Health Care Plan, the school team will continue to work with you and your health professionals to make sure they are up to date and start thinking about how these might need to change when you leave school.

Monthly transitions planning meetings including the Transitions Team and Integrated Care Board (ICB) continue to monitor young people with complex health needs and to ensure the needs are understood.

Age 16 (Year 11)

If you are getting help from specialist health services (such as mental health services, specialist doctors and therapies), your EHC plan annual review and pathway plan if you are a cared for child will explore how things will change when you turn 18.

If you have complex health needs, you may be flagged as likely to need or be eligible for adult CHC. The Integrated Care Board (ICB) and the Transition Teams meet fortnightly to discuss young people to ensure a seamless transition.

If you require support around emotional wellbeing and mental health this can be provided by the mental health in school teams and CAMHs.

f you have complex mental health needs which means you are likely to need support from adult mental health services. CAMHS will start thinking about this with you and might involve the young adult partnership (YAP Team).

From 2025 young people can also self-refer to the Talking Therapies Service (IAPT) via the website or by asking their GP.

Visit the NHS West London website for details of the mental health transition policy.

Age 17 (Year 12)

If you have complex needs and are receiving support from children's continuing care, a referral will be made by Children's Continuing Care to Adult's Continuing Healthcare when there is a positive checklist.

For young people on the pathway with complex health needs who may be eligible for CHC, a checklist should be completed and the CHC team will complete an assessment where there is a positive checklist. Child and Adolescent Mental Health Service (CAMHS) and Children with Disabilities Team (or other relevant H&F Teams) will contribute to this process for the relevant young people as appropriate.

If you are receiving support from CAMHS, the 16-25 Link Workers work with CAMHS and MINT Teams to support young people prior to turning 18 to ensure they will get the correct support from adult's services.

For young people requiring ongoing support, whether due to mental health needs, a learning disability, an eating disorder or a personality disorder then a CAMHS Care Coordinator will begin discussions with the relevant adults team when the young person turns 17 and make referrals as needed. Referrals will include information on current medication, relevant health assessments, Education Health & Care Plans, risk assessments, and key contacts in the network. Once referred and accepted young people will be allocated a lead healthcare professional from adult services to help facilitate the transition.

Young people who only need specific care for eating disorders might be referred to a separate eating disorder team in CNWL.

For young people for whom the transition pathway is not clear or complex their case can be referred to the multi-disciplinary panel.

Active transition planning should start when the young person is 17 and 6 months. This should be agreed by CAMHS and the relevant Adult Mental Health and Social Care team. This transition will be supported by the YAP team. Young people supported for their learning disability will typically be referred to the appropriate learning disability service.

Some young people supported by CAMHS may not meet the criteria for adult services in such cases CAMHS may explore referrals to other organisations or agencies, this work will take place when the young person is 17 and 6 months. When it is uncertain about which service is best placed to support you, your case might be discussed at the multi-disciplinary panel.

When young people are 17+

If you have been open to the Early Intervention for Psychosis Service for less than 3 years you will remain with them even after turning 18 and a transition plan is not necessary.

Young people who are in-patient on a CAMHS ward may need to transition to an adult ward when they turn 18, preparation for this should begin as early as possible in line with CPA policy. The relevant adult ward and/or community team will be invited to arrange transition.

If you are a cared for child living outside of Hammersmith & Fulham borough your transition will be managed with local CAMHs service with support from our in-house Children Looked After CAMHS service. If you will be returning to H&F they will liaise with the YAP team.

Age 18 (Year 13)

If you are still open to CAMHS when you turn 18, the same process as above will apply as the clinical team feels it is appropriate to transition. The discussions around this will likely happen when you are 17

Adult Learning Disability Service referrals are accepted. This can either be by the young person or a professional.

The Adult Learning Disability Team and Continuing Health Care will provide assessment and signposting as per needs. If you are eligible, your transition to Continuing Health Care support will happen when you reach 18. If you have an EHC plan, this should help to coordinate all the different education, health and care plans you have.

Age 14 (Year 9)

Fortnightly multi-disciplinary team meetings flag children as likely needing support as adults including EHC Team, Children Looked After Team, Children with Disability Team and Family Support Team.

If you are helped by the Youth Justice Service, you will have a termly meeting with everyone working with you to review how to support you back into education and training. If you have an EHC plan, one of these meetings should be combined with your annual review.

Age 15 (Year 10)

Children's services and adult social care meet on a regular basis to plan transitions. Young people can be flagged and added at any point.

Age 16 (Year 11)

Referrals, in which information on diagnosis and support needs are contained, are made to adult social care by the children's services social worker and logged on a tracker. N.B. It may be appropriate for some people with complex needs to be referred at an earlier stage, this will be decided through discussion between children's services and adult social care.

If your parents or carers receive Disability Living Allowance (DLA) to help you, this will stop when you reach 16. You can apply for Personal Independence Payments (PIP) instead. You can also apply for PIP from age 16 if you have not already received DLA but you think you might be eligible.

Age 17 (Year 12)

Young people are allocated to a transition's social worker in adult social care in order to complete the Care Act Assessment.

N.B. It may be appropriate for some people with complex needs to be assessed at an earlier stage. This will be decided at the multi-disciplinary team meetings.

Young people with a learning, physical, or sensory disability are assessed by the Learning Disability Transition Team (LDTT). Those with mental health needs are assessed directly by the Adult Mental Health Team.

A Care and Support Plan taking into account the young person's strengths, abilities and wishes and a funding application will be submitted to the multi-disciplinary panel. A mental capacity assessment will also be completed if there are concerns that the young person lacks capacity to make decisions about their care and support.

Age 18 (Year 13)

A Care Act Assessment will be completed by the Transitions Team if you are eligible. If the Care Act assessment results in an Adult Care and Support Plan, the Transitions Team will remain involved whilst the young person has an active EHC plan.

If eligible, your new adult care and support package should be in place on your 18th birthday. If there is a delay in the transition to adult social care services, support from children's services will continue their support for you until the care and support plan starts.

The council and health teams will work together to ensure that any joint funding arrangements are in place via multi-disciplinary meetings.

Age 19 to 25

Once the EHC plan ceases and you have a Care and Support Plan, the Transitions Team will hand over to the adult social care team.

Age 14 (Year 9)

As part of your annual health assessments, the children looked after nursing team will tailor your Health Action Plan to your individual needs. Independence skills and planning for future health needs will be included in this every year.

You will have 6-monthly statutory reviews where your Care Plan is discussed to make sure it provides you with the help you need.
You will have support from the Virtual School to make sure you are getting all the help you need with your education and learning. You will have a Personal Education Plan (PEP) which is reviewed termly.

Multi-disciplinary meetings start from the point that a child or young person becomes looked after and continue until a permanency plan is achieved (before age 18).

If you are likely to need support as an adult, you will be flagged to adult social care through regular discussions.

Age 15 (Year 10)

You will be given information about the Leaving Care Team (LCT).

Multi-disciplinary meetings will continue between children's services and adult social care on a regular basis. Young people can be flagged and added at any point.

Age 16 or 17 (Year 11 and 12)

Multi-disciplinary meetings continue and focus on the staying put arrangements, which includes Shared Lives. If you are not in foster care, then permanency planning meetings will focus on gaining independent living skills in a residential or semi-independent home.

Between the ages 16 and 18 you will have a Pathway Plan which is part of the six-monthly review process. Your social worker will support you and help to coordinate the services working with you. Your pathway plan will consider your current circumstances and the key things that have to be achieved to help you in your journey towards independence living. These may include your:

• accommodation
• education training and employment
• health and development
• independent living skills
• family and social relationships
• participation and social life
• finances
• and a contingency plan (alternative actions if the agreed action in the pathway plan do not go according to plan).

To inform your Pathway Plan, your social worker will introduce you to the Preparation for Independent Living Skills Toolkit. This toolkit offers ongoing support with independence skills development at your pace. This will be introduced to you, your carer, and your key worker when you first become looked after and will journey with you alongside your pathway plan until you are 21. Your social worker will monitor your progress through the toolkit during visits and contact.

You will also complete the Independent Living Skills Courses run by MyBnks which focuses on money management.

If you are in semi-independent living, you will also be given support to improve your independent living skills, building on the toolkit.

Once you have demonstrated the ability to manage a tenancy, a referral will be made to a multi-disciplinary panel to provide you with support into private renting or through the housing register.

If you require continued social care or health support into adulthood, before you turn 18 the Leaving Care Team will refer you for a Care Act Assessment which will help to determine which team is best to support you.

If you have a diagnosed learning disability, or are undergoing clinical psychological assessment, you may be referred to the Learning Disability Teams in adult social care and health.

If you have continuing social care needs, you may be referred to to adult social care services for ongoing information, advice and support.
If you have continuing mental health support needs, you may be referred to an adult service. The type of referral and support offered will depend on your needs. A referral may be made by specialist services if you are already receiving support (for example from CAMHS or the Early Intervention Psychosis Service), or by the Leaving Care Team. If you need ongoing support for complex mental health challenges, you will be referred to Adult Mental Health Services. A concurrent referral to the multi-disciplinary panels may also be made if you require a specialist placement.

For any other needs identified, you may be signposted to community services for ongoing information and advice.

Year 13 (Age 18)

Your Pathway Plans will focus on independence.

Your social worker will support an application for Universal Credit 28 days prior to your 18th birthday.

You will have a final review health assessment before your 18th birthday. The report you will receive will include a summary of your health, immunisation record, detailed information on how to access GP services/dentists/support and crisis services and an action plan that sets this out in simple terms. This is often referred to as Health Passport.

Age 19 to 25

After 18 and six months, Pathway Plan reviews will focus on independence and you can step down into less supported accommodation in a manner that is appropriate for your care needs.

Age 14 and 15 (Year 9 and 10)

Travel training is available from H&F to those with the potential to achieve independence. Travel training support is provided by Woodlane School. We expect young people to travel independently when they have the skills to do so and will support those who don't to develop them wherever possible.

Age 16 (Year 11)

A review is conducted of all young people in Year 11 and they will be asked to re-apply for travel support from H&F for Year 12. This is the opportunity to assess whether transport needs have changed based on independence and plans post-Year 11.

This decision will be based on H&F's post-16 policy. Young people with significant SEND may continue to receive some form of travel assistance post-16, this will be based on H&F's post-16 policy. Travel assistance may take a different form than provided previously. For those with significant SEND, travel assistance provided by H&F may continue for the duration of their school or college placement.

Age 17 (Year 12)

For those with significant SEND, travel assistance provided by H&F may continue for the duration of their school or college placement.

Age 18 (Year 13)

Young people eligible for support from adult social care, who have had a change of placement and have moved on to college, may be able to get travel support as part of their care package, assuming they cannot do so independently. For more information, please see the Social Care Pathway. The aim will be to ensure young people can travel independently when they have the skills to do so and will support those who don't to develop them wherever possible.

Age 19 to 25

For those with significant SEND, travel assistance provided by H&F may continue for the duration of their school or college placement. Young people receiving support from adult social care may be able to get travel support to go to college and access the community. There will be a continued effort to work with young people to make independent travel achievable.