Skip to main content

0-25 Together Service


This chapter addresses some of the processes that are specific to disabled children / young people.

It should therefore be read in conjunction with other relevant procedures within Part 3 of this manual, Children in Need and Safeguarding and Part 3 of this manual, Children Looked After and Care Leavers.

Please also see the separate chapters concerning Direct Payments for Disabled Children Procedure and Short Breaks Procedure and Transition Pathways for Disabled Children Procedure.

This chapter should also be read in conjunction with SEN and Disability (SEND) 0-25 Local Offer.

For over 18's see Adult Social Care Policies and Procedures (Intranet Page).

For general information about Adult Social Care, see HCC Adult Social Services Page.


This procedure was revised and updated fully in March 2019 and should be re-read in its entirety.

1. Definition of Disability and Eligibility for 0-25 Services

The Equality Act 2010 defines a disabled person as someone who has a physical or mental impairment, and that impairment has a substantial and long term adverse effect on that person's ability to carry out normal day to day activities. This definition is the basis for determining whether or not a child/young person should be regarded as disabled. Examples are physical or mental impairments which might (depending on the individual's circumstances) fulfil the criteria for a disabled child/young person, which are:

  • Special sensory impairments: hearing loss, visual impairments, deaf-blind etc.;
  • A significant learning disability;
  • Multiple and complex health needs;
  • A chronic physical illness;
  • Autism (Autistic Spectrum Disorder) and Communication Disorders with significant impairment of intellectual functioning or communication;
  • Significant pre-school developmental delay;
  • Young people who have a diagnosed mental illness which significantly impacts activities of daily living; services are usually provided by the Child and Adolescent Mental Health Service (CAMHS);
  • The child/young person would usually meet the eligibility thresholds for DLA;
  • The need for a carer's assessment should be carefully considered in such cases.

Eligibility Criteria

The decision about whether a child is disabled within Hertfordshire's agreed definition is always based on a consideration of the impact of the child/young person's condition on their needs, and not purely on the basis of whether the child has or does not have a particular diagnosis.

See Social Care Criteria - Deciding if the 0-25 Together Service Can Help You for details regarding eligibility.

Other definitions of disability are included in the following legislation and guidance:

  • Disability Discrimination Act 1995;
  • Children Act 1989;
  • The Chronically Sick and Disabled Persons Act 1979;
  • Disabled Persons (Services Consultation and Representation) Act 1986;
  • Education Act 1996;
  • Together from the Start Guidance (2003).

Other legislation and guidance highlighting the assessment and support needs of children with disabilities include:

  • Children and Young Person's Act (2008);
  • Children and Families Act (2014);
  • Care Act (2014);
  • Working Together to Safeguard Children.

Click here for LCS Guidance.

2. Principles and Key Worker Allocation for Disabled Children/Young People and their Siblings

For Adult Social Care Safeguarding Procedures, see HCS 084 Safeguarding Adults at Risk.

See also 0-25 Together Referral Process.

Children/young peoplewith significant disabilities might receive personalised resources to ensure that appropriate support is in place to meet their often complex and multiple needs. The 0-25 Together Service routinely manage risks relating to impairment and disability alongside family support and sometimes safeguarding concerns. Where children/young people are assessed as eligible for support by the 0-25 Together Service, they will also receive a holistic assessment of risks they face through daily living, including risks they may be exposed to through the support services that they use.

Children/young people with disabilities are particularly vulnerable to abuse and neglect, as symptoms of abuse may be inappropriately attributed to the child/young person's impairment. Research tells us that there is sometimes more reluctance to believe a disabled child/young person is at risk of abuse; assumptions can be made that the child/young person may not be a credible witness; behaviour and symptoms related to impairment can be similar to those following abuse; and there can be a reluctance to challenge carers. It can also be more difficult for the child/young person to disclose abuse and it can be difficult to identify a perpetrator of abuse where a child/young person is receiving care from many carers. Practitioners must continually strive to achieve effective and meaningful communication to ascertain the wishes and feelings of disabled children/young people.

It is important to ensure that assessments completed with children/young people with disabilities are completed with one Key-Worker for the whole family, including where there are siblings without disabilities. This will ensure:

  • Least disruption for the family;
  • Multi-agency partners have one contact with the Local Authority;
  • A central point for information gathering overall;
  • One line of management oversight and direction;
  • A single action plan for the child and their family.

Customer Services and the Multi Agency Safeguarding Hub (M.A.S.H) need to ensure they have checked LCS and IES thoroughly in relation to addresses and relationships to ensure that any new referrals are sent to the appropriate team, particularly looking out for siblings of an identified child/young person within a referral who may be open to 0-25 Together Service.

2.1 Safeguarding Pathway Responsibilities for Children/Young People with Disabilities

Safeguarding for children/young people with disabilities can be provided by the 0-25 Together Service or the Family Safeguarding and Assessment Teams. The table below details the pathways for both services.

Disabled Children Family Safeguarding and Assessment Teams
Child/young person already open to 0-25 Together Service and information of a Safeguarding nature is received regarding that child. Any siblings must be opened to 0-25 Together Service and all children/young people assessed by 0-25 Together Service. Family not open to CS. Referral received regarding sibling group, one of whom has a disability. Concern is regarding all children in the family. 0-25 Together Service will provide consultation about the impact of disability, and possible available support services, as required.
Child/young person is already open to Children's Services (CS) and information of a Safeguarding nature is received for a sibling of that child/young person. Sibling/s must be opened to 0-25 Together Service and assessed by 0-25 Together Service.  

2.2 Children Act 1989 and Chronically Sick and Disabled Act (CSDPA) 1970

Children/young people with disabilities are assessed under the CA 1989. If following social care assessment a child/young person's needs do not extend beyond the local authority care and support in and around the family home, the service provision will be dealt with under the CSDPA 1970.

The CSDPA 1970 forms the basis for the provision by local authorities of practical assistance and a range of services including equipment, adaptations and homecare to eligible disabled people.

All work with disabled children/young people and their families in the context of the Children Act should be based in the following principles;

  • The welfare of the child/young person should be safeguarded and promoted by the provision of services;
  • A primary aim is to promote access for all children/young people to the same range of services;
  • Children/young people with a disability are regarded as children first;
  • Recognition of the importance of the parent(s) and families in children/young people's lives;
  • Partnership between parents/carers, the local authority and other agencies.

Services to children with a disability may be provided via s2 CSDPA 1970 or the S17 Children Act or both.

3. Referrals and Assessments

The 0-25 Together Service has a robust system for managing a high volume of activity.

If a parent/carer requests an assessment the local authority must undertake one as it has a duty under S17 of the Children Act. The assessment must identify what support/services the child/ young person and family need.

A referral for assessment should be made to the 0-25 Central Team only when it has been identified that the impact of the child's/young person's impairment is too great to be met by universal and targeted services and the child/young person may be "in need" (i.e. disabled).

Disabled children/young people should be assessed via Child and Family Assessments using the Framework for Assessment of Children in Need (see Criteria and Threshold Guidance - Meeting the Needs of Children and Families).

The assessment should be multi-agency it should include consideration of health, social care and educational needs. The assessment framework of need has to result in a plan of action. This is set out in a plan. Additionally, their parents and carers are entitled to a carer's assessment.

3.1 Child and Family Assessment

This section should be read in conjunction with the Hertfordshire Safeguarding Children Partnership Procedures Manual, Contacts and Referrals Procedure.

When a team receives a referral for assessment from Customer Services, the responsibility for responding to the referral will remain with that team unless a negotiation takes place and a manager in another team agrees to accept the referral and takes over responsibility for undertaking the Child and Family Assessment

Referrals about disabled children/young people within the terms of the HCC definition (see Section 1, Definition of Disability and Eligibility for 0-25 Services) will normally be passed to the appropriate 0-25 Together Team.

In referrals where the primary concerns are not specific to a disabled child/young person, these referrals will go to the Assessment Teams in the usual way. Where there is a need for specialist advice or input relating to the disabled children/young people, liaison with the 0-25 Together Service should take place.

In considering children/young people who are or who may be eligible for a Specialist Service as a disabled child/young person, the following factors are relevant:

  • What is the primary reason for the referral, e.g. is it a child protection referral re concerns for the safety of all the children/young people in the family, of which one has a disability? Does the disabled child/young person have needs which require assessment beyond the risk assessment required in response to the referral?
  • Does the disability of the child/young person fall into the HCC definition of a disabled child/young person above;
  • How does the child's/young person's disability affect her/his ability to function in everyday life?
  • Are there other children/young people in the family? Are they included in the reason for the referral? Are they also disabled?
  • What is the consequence of the child's/young person disability for the family and the parents' ability to care for her/him and siblings?

The decision about whether a child/young person is disabled within Hertfordshire's agreed definition is always based on a consideration of the impact of the child's/young person's condition on their needs when compared to other children/young people of the same age, and not purely on the basis of whether the child/young person has or does not have a particular diagnosis. The impact of the child's/young person's condition which is likely to be life long, would be that the disability significantly restricts the child's/young person's daily life leading to poorer outcomes for him/her and their family if services were not provided.

Once an assessment is completed the law does not require that a service be provided in every case. The provision of service is determined by the assessed need(s).

In line with the Children Act 1989, Section 17 states:

Before determining what (if any) services to provide for a particular child/young person in need the local authority shall:

  • Ascertain the child's/young person's wishes and feelings regarding the provision of those services; and
  • Give due consideration (having regard to his/her age and understanding) to such wishes and feelings of the child/young person as they have been able to ascertain; and
  • Any service provided by an authority in the exercise of functions conferred on them (as per Section 17) may be provided for the family of a particular child/young person in need or for any member of his/her family, if it is provided with a view to safeguarding or promoting the child's/young person's welfare;
  • Before giving any assistance or imposing any conditions, a local authority shall have regard to the means of the child/young person concerned and of each of his parents;
  • Ascertain the child's/young person's wishes and feelings regarding the provision of those services; and
  • Give due consideration (having regard to his/her age and understanding) to such wishes and feelings of the child/young person as they have been able to ascertain; and
  • Any service provided by an authority in the exercise of functions conferred on them (as per Section 17) may be provided for the family of a particular child/young person in need or for any member of his/her family, if it is provided with a view to safeguarding or promoting the child's/young person's welfare;
  • Before giving any assistance or imposing any conditions, a local authority shall have regard to the means of the child/young person concerned and of each of his parents.
Any assessment must also check that the parents/carers are aware of benefits (e.g. Disability Living Allowance for Children, Disability Living Allowance (over 16), Personal Independence Payment (PIP) (Over 16)) that they may be able to claim in respect of the extra demands entailed in caring for a disabled child. Additional advice is available from the Money Advice Unit.

The Children and Families Act 2014 also stipulates that young carers (under the age of 18) must be assessed to determine the appropriateness of their role and in accordance with Working Together to Safeguard Children they should be identified as early as possible to ensure their needs are met and they are safeguarded against any potential risk of harm. For further information, please refer to the Young Carers Procedure and Carer's Assessment Procedure.

3.2 Outcomes of Assessments

General Principles

Under s17(11) Children Act 1989 that a disabled child is a "child in need".

For children/young people who are not able to verbally communicate their views, the social worker should ensure that observations of the child/young person are made in their placement and also in other settings, for example, school. Information and opinion (evidence based) should also be gathered from other professionals about their presentation. An advocate may be required. An assessment of needs can lead to a number of different personalised plans, they are:

  1. No Plan;
  2. Short Breaks Review Plan / Chronically Sick and Disabled Persons Act 1970 (CSDPA);
  3. Child in Need Plan s17(10)(c) (Disability Only);
  4. Child in Need Plan s17(10)(b) (Disability and Family Support);
  5. Child Protection Plan;
  6. Child Looked After Plan.

i. No Plan

Upon completion of the Child and Family Assessment where the family does not reach the threshold for personalised services, they will be signposted to other relevant statutory and voluntary agencies for support and/or information (Universal and Targeted Services). A carer's assessment must be considered / offered and should typically be incorporated within the Child and Family Assessment process. A note to this effect must be documented on the child/young person's file.

Families need access to local resources: Hertfordshire Directory of Local Offer Services.

Families need good information about short breaks: SEND Short Breaks Booklet.

Families need to know how we take decisions about them and their needs: Short Breaks Local Offer - Eligibility and Access to Short Breaks.

ii. Short Breaks Review Plan / Chronically Sick and Disabled Persons Act 1970 (CSDPA)

Short Break Review Plans are for children/young people with often complex needs that can't be met by universal or targeted services, such as 'short break local offer'. These children or young people need a personalised care plan that can be guided, day to day, by their parent / carer. They do not need a regular social work service.

These children/young people will receive ongoing services that usually occur in or around the family home and are defined within s2, Chronically Sick and Disabled Persons Act (1970). Typically these might be:

  • The provision of practical assistance for a disabled child/young person in his/her home (Homecare services);
  • The provision for a disabled child/young person of leisure, games, outings or other recreational facilities outside his/her home or assistance to that person in taking advantage of local facilities available to him/her;
  • The provision of assistance for a disabled child/young person in arranging for the carrying out of any works of adaptation in his/her home or the provision of any additional facilities designed to secure his/her greater safety, comfort or convenience.

When the Social Worker concludes their Assessment of Need and has defined outcomes and services, they then decide if a 'Short Break Review Plan' can be issued. Where such a plan can be issued, the case can then be considered for 'Step Down', where the following criteria are met:

  • C & F Assessment has been completed;
  • CIN / Short Break Review is within one year and child was seen or school consulted;
  • Overnight care arranged by HCC taking place in family home;
  • The risk assessment checklist is up to date and confirms no or low risk.

Reviewing Need:

These cases will be reviewed by the Short Break Review Team as part of the review of the Education, Health and Care Plan (EHCP) process. Reviews will be undertaken no less than annually. We will aim to develop a range of review methods that will include self-assessment and telephone, importantly protective factors surrounding the child must be considered and reviews proportionate to circumstances. Any significant changes to needs or circumstances will be managed by the 0-25 Together Service.

iii. Child in Need Plan s17(10)(c) (Disability Only)

Some children/young people, because they have complex disability related needs, require services that go beyond the scope of a "Short Break Review Plan". The Child in Need Plan should be in writing and set out clearly all the outcomes to be achieved as well as the services that are to be provided to meet the child's needs. These plans will need regular oversight and the level of which will be decided at each review or when a significant change occurs in circumstances. This can be provided by a Family / Preparing for Adulthood Practitioner and/or a Social Worker from the 0-25 Locality Team. The plan will also set out expectations of the child, parents, carers and other agencies. See Box 1 for illustration of likely presenting circumstances at this level:


The child:

  • Complex and multiple needs, unstable periods of health with the need for multi-agency response;
  • Requires ongoing services away from the family home (overnight short breaks);
  • Some disturbance to child/young person and parent carer's sleep due to impact of child/young person's disability;
  • Child/young person shows signs of distress in one or more settings on a regular basis;
  • Child/young person's behaviour presents a significant risk to self and/or others; and requires some additional monitoring, supervision and /or behavioural management to be safe;
  • Child/young person's physical or learning disabilities impact on their daily living where they are at significant risk of social exclusion, harm abuse or exploitation;
  • Child/young person is unable to access any Community Short Break Extra Activities without additional support;
  • Child/young person has limited ability to understand and express their views, wishes and feelings at a time when important decisions about their welfare are required.

The parent carer:

  • Parent carer has significant health concerns;
  • Accommodation which, despite adjustments, does not meet some of the needs of the disabled child/young person;
  • Limited support networks and /or limited access to local community and universal services;
  • Relationship difficulties within the family that negatively impact on the disabled child and the family as a whole;
  • Parent carer has limited understanding of the impact of their child/young person's disability.

The siblings:

  • Siblings have emerging support needs of their own e.g. social isolation and attention seeking behaviour;
  • Siblings are providing a level of care; which makes them young carers.

Many families with disabled children/young people receive a range of services to meet their child's/young person's needs. Wherever possible there should be a single plan which includes the full range of family support services on a multi-agency basis. The plan will show outcomes, including how the short break will meet the needs of the child/young people and family identified in the assessment.

Reviewing Need:

These cases will be reviewed by a named Social Worker or most likely a Family/ Preparing for Adulthood Practitioner. Any significant changes to needs or circumstances will be managed within the Locality Teams with cases transferring to Social Workers wherever required.

These plans may be reviewed on a 6 monthly basis, however the frequency of review will be determined at the initial planning and review stages and should be proportionate to risk and needs.

In certain circumstances it may be appropriate for intermittent telephone reviewing to take place where no significant risks or needs are identified by the partners who work with the child/young person on a daily basis.

iv. Child in Need Plan s17(10)(b) (Disability and Family Support)

Some 'Children and Need' are such because whilst they may have a range of personalised needs because they are disabled or have a diagnosed health issue, they also need support because their parent / carer is not able to create the environment or a parenting style that is appropriate to meeting their needs. These children/young people will have an allocated Social Worker.


The child/young person:

  • Child/Young Person has a poor level of attendance at school and/or is at risk of exclusion. Child/Young Person is not achieving to their potential;
  • Child/Young Person has limited ability to understand and express their views, wishes and feelings at a time when important decisions about their welfare are required.

The parent carer:

  • Parental stress affecting the day to day lives and may impact on the child/young person and wider family's well being;
  • Issues such as domestic violence, mental ill health, alcohol or substance misuse are present.

In accordance with Part 3 of this manual, all children/young people who are worked with as Children in Need under s17 (CA '89) will be visited with a minimum frequency of 6 weekly.

Reviewing Need:

These cases will be reviewed by the allocated social worker. Where the assessed need of the child and family are addressed or the level of need reduces the status of the case will likely change to CIN Plan (Disability only).

v. Child Protection Plan

See Part 3 of this manual, Children in Need and Safeguarding and also the Hertfordshire Safeguarding Partnership Procedures, Children with a Disability and Child Abuse.

vi. Child Looked After Plan

There may be instances where a child may become looked after. All of the procedures and processes relating to children who are looked after (see Part 5 of this manual, Children Looked After and Care Leavers).

3.3 Adult Social Care Reviews

Everyone who is open to a worker or open and receiving a service must have regular reviews. Reviews must be person centred and outcome focused. The review is an essential part of the review process. The first review should take place within 6 weeks as a review of the Care and Support Plan. Thereafter, reviews must be scheduled at least annually, or more often as is necessary.

There are 3 types of review: planned reviews, unplanned reviews, and those reviews which have been requested by the person/carer. The review should be focussed on care that is responsive and proportionate to the need.

Reviews can take place as a telephone review, face to face review or multi-agency review depending on the needs of the service user.

The purpose of a review is to:

  • Review progress in using a personal budget to achieve the outcomes in the Care and Support Plan. Identify any further steps to achieve these goals. Clarify if the person's support needs have changed and whether a more detailed reassessment is needed;
  • Check if the person is still eligible for social care;
  • Update the care and support plan;
  • When arranging the review the worker should make this person centred and seek the views of the person as to where and when they would like their review to happen;
  • If the person has eligible needs which have changed then the Review form should be used to assess the new eligible needs.

Other Considerations

Statutory guidance (Care Act (2014), para 13.16) states that there should be a range of review options including telephone and face to face meetings. The type of review required is likely to relate to the reasons why the review should take place.

Reviewing the Needs of People in a Care Home Placement

For people in long and short term Care Home placements and Nursing Homes refer to HCS 673 Arranging & Reviewing Care Home Placements for full details of how to prepare for and carry out reviews in these settings.

4. 0-25 Resource Allocation / Panel Meeting

Resource Allocation and Panel Meetings are the mechanisms in which decision are made with regards to allocation of resources.

4.1 Funding Decisions

This section covers requests for a care package for children and adults from 0-25 to ensure, needs are met and resources are allocated appropriately and matched against eligibility criteria

0-25 Together Senior Managers will make resource allocation decisions in cases that do not require presentation at HARP or MAP. See Hertfordshire Access to Resource Panel (H.A.R.P) or Multi Agency Panel (MAP) and Delegated Authority for Resource Agreement

0-25 Funding decisions will be made by Head of Service and Service Managers. These Practice Leaders will take decisions independently within the boundaries set by the SODA.

4.1.1 Future Planning Meeting

Future Planning Meetings will take place to support planning for cases requiring long term accommodation, where needs are complex or services required are high cost. Practice Leaders will collaborate and seek advice from other colleagues or agencies as required. Attendees at the Future Planning Meeting will include representation from:

  • 0-25 Together Practice Leadership;
  • Community Solutions Team;
  • Finance Representative.

This meeting will be scheduled monthly.

The meeting will support management of resources allocated to disabled young adults and their families.

Decision makers will seek to ensure quality standards are adhered to in file and case management, including:

Outcomes First

When considering how outcomes might be met, it is of critical importance that consideration is first given to how universal services and community resources might be used by the citizen. Outcomes need to support children, young people and young adults to participate in their local community and develop skills in independent living at an age appropriate level. Connected Lives comes first.

Panel applications should be developed with the cooperation of the Community Solutions and/or the Brokerage Service Provision Team who will provide advice and guidance about service solutions that are appropriate, value for money and responsive to identified needs.

Quality Support

Maintaining excellence in the delivery of social care supports is essential.  

When taking decisions 0-25 Practice Leaders will serve to support continuous service improvement and casework audit. Practitioners must take responsibility for file cleansing prior to ANY case submission.

A number of basic compliance checks will be made prior to all submissions by the Team Manager or Advanced Practitioner /Consultant Social Worker.

  1. There will be a timely assessment or review, no less than one year prior to planning
  2. Risks will be documented within an up to date Risk Assessment
  3. Description of Language, Ethnicity and Disability will be recorded on case file.
  4. Involvements and Nearest relative details will be up to date
  5. There will be a completed Financial Assessment wherever required
  6. Carer's Assessments and Contingency Plans as required.
  7. Capacity Assessments and Best Interest Decisions  as required
  8. Application for DOLS as required
  9. Packages within the indicative budget for over 18's

Resource Allocation

Social Workers, PFA and Family Practitioners will be responsible for collating evidence in order to justify allocation of ALL resources, this will usually be undertaken during Assessments and / or Review Meetings. Evidence will be gathered and will be used to populate:

  • SRF and Associated Plans for Under 18's;
  • HCS Care and Support Plan; and
  • A case  note under case summary for cases over 18.

Case note should record the following:

  • Reasons for Request: New Request/Change in Need/In Principle Decision;
  • Planned Outcomes by provision of this Request;
  • Community Resources explored to meet need;
  • Current Support Plan;
  • Proposed Support Plan;
  • CHC Funding / Other Resources to meet need;
  • HCS8B, Care Payments, any debt or financial issues;
  • Capacity and BI if applicable and date completed;
  • Last Assessment Completed.

Support Packages that should be brought to Senior Management for Authorisation include:

  • All Community Based Packages 0-25;
  • All Accommodation Requests 18 plus.

Requests to accommodate Children & Young People and manage the funding for such arrangements are undertaken as follows, requiring Operations Director approval:

  • Social Services only funding – HARP Panel;
  • Multi Agency Funding – MAP Panel.

Packages that can be authorised by Team Managers:

  • Any reductions of packages;
  • Any conversion of package for example homecare to Direct Payments.  Increase can be authorised as a result of the conversion up to an increase of £1000 per year;
  • Direct Payment Packages: Children moving to adults, extension authorised for 4 months only;
  • Carers Direct Payments to be authorised for 1 year only.

Emergency Packages

Emergency will be considered by the Service Managers in the following scenarios:

  • Due to behaviour of a young person that has impacted on the package or parent/carer suddenly became unwell or police involvement requires change of care package;
  • Poor care planning will not be considered as an emergency.

Application Process

  • All packages for U18 will be on LCS via a SRF sent to Manager for Authorisation;
  • All packages for over 18 will be on ACSIS with a Care and Support plan and case note sent to Manager.

4.2 Herts Access to Resources Panel (HARP)

See Hertfordshire Access to Resources Panel (H.A.R.P) and Delegated Authority for Resource Agreement Procedure.

Where there are requests for family support, an independent placement and associated costs relating to the non-disabled children/young people in the family these requests will be presented to HARP using (CSF0158F1 Access to Resources Panel Referral Form).

4.3 Multi-Agency Panel

The Multi-Agency Panel, consisting of representatives from Children's Services across Education, Health and Care. The panel meets twice per month to ensure children and young people with assessed additional needs receive appropriate support through agreed packages of interventions. MAP will receive requests from Children's Safeguarding and Specialist Services, Education and Early Intervention and Health services.

Multi Agency agreement about a given care plan should be achieved prior to presentation at panel. This means that the lead professional agency must convene a pre-map meeting to obtain the views of appropriate agencies and ensure their views are captured in the process of support planning.

  • Packages which are agreed best meet the needs of children/young people and families;
  • Agreed packages represent best value for money;
  • Joint packages can be agreed at one meeting;
  • Decision-making takes into account the budgetary position of all organisations;
  • Frequent and accurate budgetary monitoring by CS and Health;
  • Children and young people needs are met within County wherever possible;
  • The Multi-Agency Panel is designed to make funding decisions on joint packages of services for children/young people. The panel will not consider service responses which are single agency, nor for equipment or adaptations;
  • Review arrangements will be agreed by panel as part of the decision making process, this will include a focus on the outcomes that were identified when the package was agreed;
  • Emergency decisions by Heads of Service can be taken outside of this panel process to meet immediate needs, and will be brought to the next meeting for longer-term multi-agency decision making.

Click here for further details about the MAP Panel.

5. Preparation for Adulthood


This section provides guidance with tasks that need to be completed from age 14 (Year 9) onwards.

Formal transition planning will start for most young people with EHCP at 14 (Year 9) who will leave school at 16 (Year11). It is noted that most young people  with more complex needs will stay on in school until 18/19 and then may go on to college or other provisions.


The Special Education Needs and Disabilities Code of Practice (2014) says that we need to start thinking about Preparing for Adulthood from an early age, and be making specific plans from Year 9 onwards.

It is recognised that preparing for adulthood is a process that all young people go through when they move on from being a teenager and become an adult. It is an exciting time but it has been recognised that this can be a difficult time for some young people, especially those with special educational needs and disabilities. It can sometimes take longer and take much more careful preparation than for other young people of a similar age. It is therefore essential that there is a worker that is trained and available to support a young person and their family during this process.

Objectives of the Preparing for Adulthood (PFA) Practitioner

  • To ensure that information about adulthood services is shared to families and young people from age 14.
  • Be a point of contact and a key worker for the young person during this process.
  • Ensure that all referrals to relevant agencies are completed timeously.

Age 14 -16 (Year 9/10/11)

The 0-25 Central Team will obtain Connexions Grid to assess young people who may need social care input.

A preparation for adulthood practitioner will attend the EHCP Review or provide relevant information if attendance is not required. PFA practitioners will usually be linked to a number of schools, colleges and settings to deliver preventative advice and routine care reviews.

One page profile should be developed withall young people receiving a service from the 0-25 Together Service and updated at each Review.

Social Care Review to include:

An emphasis on independence and discussion on what is required to support young person to independence in all domains and to be included in their plan as follows:


A discussion should take place to identify the life skills that the young person would like to develop and identify the resources to support this development for example travel training, money management, having your say, making networks and friends.

This should be reviewed at each EHCP/Social Care Review.


Young people and parents/carers need to be made aware of what changes will happen in terms of the health provision in the coming years.  If a young person has an EHCP plan it is important that it is recorded in this document.

At Year 11 Review the health section in the EHCP needs to be clear on what services the young person will be discharged from and who will be taking responsibility for the young person's health needs.  It is crucial that the role of GP is discussed.

Alert LD nurses on young people that may be coming to their attention in the coming years and to check if young people can be signposted to other health services.

Employment/Further Education

Although it may seem a bit early for these discussions at year 9  it is crucial these discussions commence at this stage and to note that some young people will require work experience in Year 10.

Continued work with Connexions should take place at each Review and there should be a clear plan as what the young person will be doing in the future years whether that is to remain in school, college, supported employment and apprenticeship.

Commence parallel planning with school, Connexions if there is concern about post 16 provisions.

Housing Pathway

It is important at Year 9/10 that young people and their families start to think about where the young person would like to live post 18. Information should be provided on all the options available.

It is essential in Year 11 that parents/carers and young people are provided with information on how to apply to be on the local housing register and have all information they need about welfare benefits, housing benefits and funding streams that are available to support people to live independently

Developing friends, relationships and community (Social Network)

We know that it is very difficult for our young people to develop social networks and therefore it important to explore this in the reviews and how the current care package can be used to support this. Community resources need to be explored.

If the young person is leaving school at Year 11 it is important that a discussion takes place on how contact with the friendship group will be maintained.

Having your say and being in Control

When developing a Transition Pathway Plan for a disabled young person who is looked after, at aged 15.75 years his or her mental capacity to manage his or her own affairs must be considered under the Mental Capacity Act 2005 and Mental Capacity Act Code of Practice. Practitioners should ensure information is provided and early conversations should commence with parents/carers regarding capacity, best interest assessments, DOLS and becoming an appointee.

At Year 11 to commence with capacity assessment and best interest assessments as required and provides parents with information on becoming an appointee and their right to deal with benefits of their son/daughter who can't manage their own affairs due to their disability.

Parent/Carers should be offered a carer's assessment.


Ensure that information is provided and checked that young person and parent and carer are in receipt of all appropriate benefits.

Parents/Carers and Young Person needs to be provided with the following information:

From 16th birthday, a young person might be able to claim one or more benefits in their own right, such as:

  • Disabled Living Allowance (DLA) or Personal Independence Payment (PIP);
  • Job Seekers Allowance;
  • Employment and Support Allowance (ESA).

There may be an impact on the benefits that parents or carers claim as well depending on:

  • The disabled young person's education or employment status;
  • The benefits that the disabled young person claims in their own right;
  • If the young disabled person in the family is a parent themselves.

Advise parents/carers to contact Money Advice regarding benefits and tax credits to ensure you are claiming to correct benefits. Provide parents with the information on the charging policy for adults.

Age 17/18/19 (Year 12/13/14)

The PFA worker must attend school review and EHCP Review and review the post school plan for the young person.

Assessment to commence in line with adult requirements to determine the young person's needs, desired outcomes and the provision that will meet them. A transition needs assessment will be completed at 17, 5 years so that young person and carer know what care and support they will be entitled to as an adult.

Social Care Review should focus on the following:


Review skills that have been achieved and what further needs to happen if young person still needs to develop these skills. Assess if these skills cannot be achieved what ongoing support the young person will need from hereon for example with travelling.


EHCP must clearly document the health plan for the young person and it there is concern on the handover from one health professional to the other, it is important that this is raised with the school nurse if he/she is still involved or the GP.

Young people that are receiving a service from Children's Continuing Health Care must be referred to the Adults Continuing Care for an assessment as criteria is different and parents and young people need to know what changes in the health provision will take place.

Employment/Further Education

Some young people would still be in school and it is important that there is clear plan where the young person will be moving to once school finishes. Young people that are attending college, it is important that the College professionals are involved in the Review.

Continued work with Connexions should take place at (and between) each Review and there should be a clear plan as what the young person will be doing in the future years whether that is to remain in school, college, supported employment or apprenticeship during these years.

Under the Care Act 2014 the local authority has a duty to provide support to children/young people who are likely to have needs for care and support after becoming 18. See Care Leavers and Transition to Adulthood Procedure.

Whilst 0-25 Together administer all support plans, resources are managed separately by both Children's and Adult services

Disabled young people who meet the eligibility criteria of 0-25 Together Service and attend a local school, and who are in residential education, remain the financial responsibility of Children's Services rather than ACS until the end of the academic year in which they are 19 (this is a local Hertfordshire County Council agreement). The exception is for young people in receipt of Direct Payments, for example during the school holidays.

Where young people aged 18+ in out of county residential placements need respite care during school holidays, these are funded by ACS. For young people placed within Herts, CS retain funding responsibility for respite placements until the young person's educational statement ends.

See also Managing Disability Allowances for Children Looked After and Staying Put Supported and Staying Put Lodgings.

Housing Pathway

It is important to discuss future living arrangements at the review meetings. There are a number of options available and the Education, Health and Care plan should include what actions need to be taken to support the option chosen. Important that all relevant assessments and referrals to funding panels are done in sufficient time so that transition from one setting to the next is planned. Applications for general needs housing must be considered. 

Developing friends, relationships and community (Social Network)

This increasingly should become a very important aspect discussed at the Review and what support is required to maintain or develop these networks. Important to identify what technology is available to support these friendships and relationships.


It is very important for a young person and their family and carers to get all the right benefits. At ages  17, 18 and 19 a disabled young person may be able to claim different benefits depending on their circumstances.

There may be an impact on the benefits that parents or carers claim as well, depending on:

  • The disabled young person's education or employment status;
  • The benefits that the disabled young person claims in their own right;
  • If the young disabled person in the family is a parent themselves.

Benefits and tax credits are complex and it is important to get specialist advice to ensure that you are getting everything that you are entitled to, and to find out the impact of making new or different claims.

Ensure that referrals are made to Money Advice to support the young person and the parents/carers.

Ensure information is provided on social care charges.

Becoming an appointee

Parent/ Carers can apply for the right to deal with the benefits of young adults who can't manage their own affairs because they do not have capacity or are severely disabled. This is called an appointee.

There are other ways of becoming responsible for managing someone's affairs in the long term, such as Enduring or Lasting Power of Attorney, and detailed information can be found on the Citizens Advice website.

Legal information and Assessments

Ensure that parents/carers and young adults are provided with all the necessary information for necessary assessments that need to take place. Capacity and best interest assessments need to occur as required and in advance so this does not prevent any delay in planning for the young adult. There also needs to be consideration to ensure a young person (aged 18 plus) residing in a care home has safeguards in place to prevent any Deprivation of Liberties (Deprivation of Liberties Code of Conduct).

Young people who are over compulsory school age have the right to participate in decisions about the provision that is made for them. Any decision that is then made should be made in the person's best interests.

Ensure that parent/carer is offered a carers assessment or the carer's assessment is reviewed if it has taken place some time ago.


It is important that a discussion takes place with the young adult and parent/carers on the need for an advocate for the young adult and referrals should be made to the appropriate service.

Age 19 to 25

Some young people may remain in education as the EHCP can remain until the young person is 25 and school /college will need to continue to hold annual reviews of the EHCP. The PFA practitioner will need to attend these reviews.

Social Care Review should focus on the following:


Review of any new skills required and how this can be achieved with support by the young adult. Some young adults will always need support with some skills and it is important to review that the support provided is appropriate and meeting the need.

Education/ Further Employment

Young adults that are still in education setting need to have annual EHCP Reviews. An exit plan from any education setting needs to be clear and a transition plan to the next setting needs to be carefully planned with the young adult and parent/carer. Close liaison with Connexions is imperative.

Some young adults may be in employment and it is important to review that all support is in place to support the employment.

Housing Pathway

Young adults should now be or moving into their long term housing arrangements.

Young people who have lived away from home, either in a residential special school or an independent specialist college will need to plan carefully for their move back to their local area. Planning must include education, employment, health, accommodation, social needs, travel training, and care and support needs.

Developing friends, relationships and community (Social Network)

As the young adult moves to different settings and service this social work network is very important to be maintained or to develop new relationships.


Young adults and parents/carers should be referred to Money Advice to ensure that they are receipt of the correct benefits.

Provide information on the charging policy for adults.

Personal Budgets

Legal Information and Assessments

It is important that the young adult and parent/carers are aware that the mental capacity assessment and best interest assessment takes place every time a significant decision is required.

Carer's assessments should be reviewed with parents/carers.

6. Occupational Therapy Assessments for Disabled Children and Young People and Adults

Occupational Therapy to children (and adults) is a service provided under part 2 of the Chronically Sick and Disabled Persons Act (1970). An assessment for a child's need for assistance in arranging adaptations, or provision of additional facilities, to promote their safety, comfort or convenience, is an assessment under part 2 of that Act. Hertfordshire Community NHS Trust provides the Children's Occupational Therapy Service in Hertfordshire. This has information for service users and professionals.

Please see the following links for For staff access to the OT Policies and Procedures for Adult Social Care and the Adults Practice Development Team Information.

For further details regarding the HAP panel, including the application process, please view the Disabilities - Adaptations for People with Disabilities page on Compass.

7. Local Offer and Hertfordshire Additional Needs Database

Local Offer and Hertfordshire Additional Needs Database (HAND)

Local Offer

The Local Offer is Hertfordshire's online "one-stop shop" to identify support and services for children and young people aged 0 – 25 who have special educational needs and disabilities (SEND).

All local authorities are required to have a Local Offer under the Children and Families Act 2014.

Parents, carers, young people and professionals are encouraged to feedback their experiences of using the Local Offer, which is acted upon wherever possible.

See Hertfordshire's SEND Local Offer.

Hertfordshire Additional Needs Database (HAND)

HAND is Hertfordshire's database for children and young people aged 0 – 25 whose additional needs and/or disabilities have a significant impact on their everyday life.

All local authorities are required to have a register of disabled children under the Children Act 1989.

It is voluntary to register on HAND, an average of 30 new registrations are made each week.

The criteria for registering a child is that their additional need or disability must have a significant impact on their everyday life; however we do not require a diagnosis, as even though a child may have substantial additional needs, a diagnosis is sometimes not possible.

Those who register receive a HAND card which often helps with reduced entry fees at leisure venues or avoiding the need to queue. Concessions are completely at the discretion of the venue.

See Hertfordshire Additional Needs Database (HAND).

Trix procedures

Only valid for 48hrs