Adult Services


The transition team, work with young people age 14 years to 25 years, who are transitioning from Children services to Adult services, leaving care, who may have a Learning disability, Autism Spectrum Condition, or additional needs that require intervention from the Transitions Team.

We are committed to a progression model, to maximise the independence of all those who need services, by:

  • Meeting assessed individual need, planning for the future, supporting the young person to reach their full potential.  
  • Work alongside the young person, families and carers
  • Provide services in a fair, transparent and consistent way.
  • Provide services which are effective and meet clear standards.
  • Work in partnership with Children Services, Education, Health Services, and 3rd Sector Agencies, this is not an exhausted list.

Transitions : Moving from Children's to Adults' Services

Multi-agency Transition Protocol

Current Status & Date: Agreed November 2019 /Date Last Approved November 2019

Lead Social Services

  • Manager/s
  • Head of Head of Adult Care
  • Head of Inclusion
  • Head of Children’s Services

Version Control

  • V9 Nov 2019 Transition Policy Agreed at DMT
  • V9 7/04/2019 Jean Davies – Further changes to introduction following feedback.
  • V9 7/04/2019 Operational group changes made at meeting.
  • V8 5/11/2018 J Davies – Draft with further changes from the operational transitions group and Nicky Ashfield
  • v7 9/07/2018 J Davies – Draft with Children’s Services changes and Additional Learning Needs Act information.
  • v6 7/03/2017 J Davies - Draft with suggested changes from stakeholders

The Transition approach (Transition Protocol) in Pembrokeshire

The Guidance on Transition

Pembrokeshire Partners in Transition

Transition Pathway

What young people and their families can expect

Who will help plan and monitor Transition



Additional Learning Needs

Continuing Health Care



Appendix one

The Transition approach [Transition Protocol] in Pembrokeshire

Transition means change. It is about how the support that is needed changes as a child becomes an adult. It is also about who will provide the support as it changes. This document explains how young people will be supported to transition from Children’s to Adult services and from school to college, employment or day time opportunities.

We support young people with disabilities and additional learning needs and those who are vulnerable. This includes those who are at risk of physical and emotional harm. We do this by talking with young people and their families to find out what is important to them and how we can support them to achieve their goals.

We will talk about:

  • Education and if college is an option.
  • Getting a job.
  • Family and people who are important to the young people.
  • Where the young person lives and where they would like to live in the future.
  • Hobbies and interests.
  • Health and Well-being.

We start the transition process when a young person turns 14. A lot changes at this time and this means there are lots of decisions to be made. Starting transition planning at 14 gives us plenty of time to think about the future and to discuss options and agree on the right support.

A number of organisations have worked together to develop Pembrokeshire’s approach to support young people as they move through education and then on to adulthood and independent living. The support they need will change as their needs change and may be provided by different organisations. We will work together to make sure there is no break in service.

Our approach will promote:

  • Independence
  • Integrated Planning
  • Holistic Approach
  • Choice and Control
  • Wishes and Aspirations for the young person.

We have used government guidance to help develop this approach.**

The Guidance on Transition

The guidance from the Government tells us to make sure that young people, as young as age 14, who are vulnerable or have disabilities and additional learning needs:

  • have their needs assessed and reviewed at the right time;
  • have a plan in place at each key transition stage;
  • have the right support from the right people at the right time;
  • are provided with input from the right organisations for plans and reviews.
  • will have a say and will work with those who support them.

Pembrokeshire Partners in Transition

A number of organisations and professionals work together and with young people and their families to ensure they have the support they need.

Advocacy Services
  • Young people and their families views are heard and they understand the process and plans.
PCC Education Department and Schools
  • Additional learning needs are identified, referrals made, review meetings are held and plans are developed.
  • Access to support.
PCC Social Services

Provide social care assessments and reviews and develop care and support plans where needed.

  • Access to support.
Careers Wales
  • Development of education and learning and skills plans.
  • Support into education, training and work opportunities.
Hywel Dda University Health Board
  • Health needs are assessed and support and treatment provided as needed.
Third Sector Organisations
  • Information, advice and assistance to access support.
Partnership Groups –Stragegic and Operational and Complex Needs Panel
  • Government guidance is followed.
  • Make sure partner organisations work together.
  • Outcomes and performance are measured and monitored.

Transition Pathway

Young people who need support will have integrated well-planned and coordinated support through their transition into adulthood. This support will be structured to meet their needs and help them achieve their personal outcomes. There are a number of factors that could influence eligibility for health and social services support and a multi agency transition plan. Most young people who already have a social worker and/or specialist health input, will require support from the multi agency transition process.

Children and young people could be referred to transition services in a number of ways:

  • For Looked After Children (LAC) aged 14+ transition will be looked at during Care Plan reviews chaired by Idependent Review Officers in conjunction with the Corporate Parenting Team
  • Referred by schools
  • Referred by the Child In Need(CIN) team
  • For young people aged 14+ who are known to the Children with Disabililities team, transition will be looked at during the Disability, and Education Care and Support plan reviews, which are held at the schools. This will be done together with the Transition team.

What young people and their families can expect

  • Young people will be at the centre of transition.
  • Young people will be provided with an assessment of their needs.
  • Young people, carers and families will be involved in developing assessments, transitions plans, care and support plans and reviews.
  • Young people, carers and families will be fully involved and will be kept informed at each stage of the process.

Who will help plan and monitor Transition

Throughout the transition process:

  • A young person will be offered the choice of having an Advocate to support them in voicing their wishes and aspirations
  • Information will be distributed by the School Adminstrator or Children’s Social Worker at least 2 weeks before a review takes place 
  • A Care and Support plan will be developed after the review and should be sent to the school at least 6 weeks before the annual review is due. This will be circulated within 10 days of the review
Age 14
  • School will complete a Personal Education Plan
  • If the young person is looked after by Children’s Services then the Social Worker will complete a Looked After Child (LAC) Review, one every six months.
  • Careers Wales will be invited to attend the reviews.
  • Health Professionals will be invited to attend the reviews.
  • Young people who are not Looked After will have a annual review by the team they are working with.

Standards and timescales: A school led review or care and support plan will take place at age 14. An adult Transitions Social Worker needs to be invited and a referral to Adult Social Care Transitions will be made at this stage.

Age 15
  • School will review the Personal Education Plan
  • The Social Worker will complete a LAC Review, one every six months.
  • Careers Wales will be invited to attend the reviews.
  • Health Professionals will be invited to attend the reviews.
  • Age 15½ the Social Worker will create a Pathway Plan.
  • Children’s Services will allocate a Personal Advisor.
  • The Personal Advisor will be introduced to the young person at the 2nd LAC Review.
Age 16
  • The Social Worker will review the Pathway Plan
  • The Social Worker will complete a LAC Review, one every six months.
  • Young people who are not Looked After will have a annual review by the team they are working with.
  • Careers Wales will be invited to attend the reviews.
  • Health Professionals will be invited to attend the reviews.
  • The Personal Advisor will make a referral to Targeted Youth Team for outreach support.
  • The Personal Advisor will make a referral to Vultrans (Vulnerable Transition Group) Vultrans has representatives from all Pembrokeshire Post 16 service providers, Careers Wales, The Youth Service and PCC Education Service

Standards and timescales: At age 16 continuing health care needs must be considered by Health and the Childrens’ Scoial Worker so an ‘agreement in principle’ is in place at age 17.

Age 17 - 17 1/2 
  • The Social Worker will complete a LAC/Pathway Plan Review, one every six months if the young person is still looked after.
  • When the young person reaches the age of 17/17½ years, Adult services will start their integrated assessment.
  • The Personal Advisor will complete a Pathway Plan Review, one every six months if the young person no longer looked after.
  • Careers Wales will be invited to attend the reviews.  Health Professionals will be invited to attend the reviews.
  • Care leavers and young people who are not looked after will have a review every 6 months

Standards and timescales: 

  • By Age 17 an agreement in principle for Continuing Health Care needs will be in place.
  • At age 17/17½ Adult Social Care Transitions will start the Integrated Assessment and Care and Support plan
  • Adult Social Care Transitions will require an up to date Childrens’ Integrated Assessment and appropriate care plans prior to commencing the Adults Integrated Assessment.
  • The Care and Support plan will reflect the needs of the young person and their support needs in their transtions to educational provision and to Adult Services
Age 18
  • The case will be closed by Children Services and the services cease
  • Adult Services will continue to work with the young person
  • The Personal Advisor will continue to review the Pathway Plan every six months for care leavers, while the young adult is in full time education, up to Age 25.
  • Adult safeguarding input


We will monitor our progress in transitions and against this protocol by making sure everyone has a voice.

The multi-agency partners involved in transition include:

  • Young people
  • Advocacy Services
  • Pembrokeshire County Council: o Education – Inclusion Service and Schools and Youth Services o Social Services – Children’s Services and Adult Care
  • Careers Wales
  • Hywel Dda University Health Board: Children and Adult Mental Health Services
  • Pembrokeshire College
  • Third Sector Organisations

The transition process is governed by both strategic and operational transitions groups.

The Strategic Transitions Group (STG)
  • Chaired by the Head of Adult Care 
  • Education is represented by: Head of Inclusion, Integrated Services Manager, Deputy Head Portfield School, Advisory Teachers Team Lead and Lead Officer YEPF/NEETS.
  • Strategic Commissioning Manager and the Service Manager for Learning Disabilities and Mental Health also represent Social Services.  There are also representatives from Hywel Dda University Health Board, Pembrokeshire College and Careers Wales.
  • This group meets bi-monthly and will consider updates from the Complex Needs Panel and the Multi-Agency Transition Group (operational transitions group). The STG will also consider strategic regional planning of transitions support.
Multi-agency Operational Transition Group (MOTG)

The MOTG will consider requests for support and will make decisions on whether support is appropriate. The MOTG will report on transitions at monthly intervals to the Strategic Transitions Group. This will include monitoring of:

  • Confirmation of referrals received
  • Numbers currently in transition
  • Identification of unmet needs and resource development which feeds into the Transitions Strategic Group
  • Number of young people who will be transitioning each year and how many may attend residential schools/colleges in the future.


We must ensure we spend our budget in a responsible way so we are able to provide services to those who need them. We will, therefore make sure that:

  • All possible appropriate local options are explored prior to consideration of specialist placements.
  • Placement options are discussed with Adult Social Care prior to the commencement of the placement if the young person is aged 14 or over.
  • Young people will have an assessment with the local education provider to outline how their needs can be met and who is best placed to do so.
  • Only if local education providers can not meet needs will a residential college or school be considered.

Additional Learning Needs

The Additional Learning Needs and Education Tribunal (Wales) Act 2018 (ALN Act) sets out requirements for supporting young people with ALN.

  • Maintained schools and nurseries, pupil referral units and further education institutions (FEIs), will be required to have a designated Additional Learning Needs Co-ordinator (ALNCo).
  • Local authorities will be required to appoint an Early Years ALN Lead Officer.
  • If specialist placement options will need to be discussed with the young person, family members and the relevant Careers Wales, Health, Education and Social Services professionals. This should ensure that all funding and transition implications are considered. 
  • Any unmet needs of young people who will be attending day opportunities should be discussed within the Transition Operational Group. This discussion will be referred to the Transitions Strategic Group or Complex Needs panel.

Continuing Health Care

If continuing health care support may be required into adulthood, Social Services and Health professionals will need to discuss the implications of this with the young person, and family members at 16.

  • If needed, a Continuing Healthcare (CHC) Assessment will be arranged as early as possible. This will be facilitated by the most appropriate professional.
  • The assessment for eligibility under the Adult CHC Criteria should commence during the individual’s 16th year. This will ensure an ‘in principle’ decision is made by the young person’s 17th birthday.
  • The Multi-Agency Transition Group should be alerted if there are any problems with this Assessment process.
  • It is the responsibility of the Childrens Social Worker to complete the CHC process with Health professionals, commencing at the age of 16.

Closing Transitions Cases: Transfers or exit

If the young person starts work-based training, employment or some other daytime activity, they can continue to develop their Transition Plan. The Care and support Plan will be reviewed by the Adult Social Care Transition Worker.


Complaints, compliments and disputes should be directed to the lead organisation involved. First with the lead worker and then using the organisation’s complaint’s process. The young person and family must be given an opportunity at review meetings to voice concerns.

Appendix one

Government legislation

This protocol aims to integrate the assessment and planning processes of the various agencies into a single system that satisfies legislative requirements. The most significant of these are:

  • The Social Services and Well-being (Wales) Act 2014
  • Children Act 1989 & 2004
  • NHS and Community Care Act 1990
  • Education Act 1996
  • Disabled Persons (Services, Consultations and Representations) Act 1986
  • United Nations Convention on the Rights of the Child 1989.
  • Additional Learning Needs and Education Tribunal (Wales) Act 2018 (ALN Act).
  • SEN Code of Practice for Wales
  • Continuing NHS Healthcare: a Framework for Implementation in Wales’.
ID: 6943, revised 11/08/2022