Impact Story - Hope and Amari
Supported Community Assessment
Hope’s experience of WillisPalmer's Supported Community Assessment service
In what ways have the Family Support Workers been helpful to you and your family? “They were really good at assisting me with Amari when I was having episodes and offering good advice”
Have you found the advice and guidance provided by the Family Support Workers to be valuable? “Yes, I have”
What worries or concerns did you have at the start of the Supported Community Assessment, and were the team able to reassure you about them? “I was worried about not getting on with the staff, but yes they were able to reassure me”
Background
Hope is a 22-year-old first-time mother. When we began working with her, her baby boy, Amari, was just 8 weeks old. Hope has been diagnosed with Autism Spectrum Disorder and Emotionally Unstable Personality Disorder, and she has a history of self-harm and hospital admissions under the Mental Health Act. She experienced a challenging childhood, which involved social care intervention and led to her becoming looked after by the local authority during her early teens.
The local authority requested a Supported Community Assessment from WillisPalmer because the residential assessment placement Hope and Amari were in proved difficult for Hope. She struggled to live alongside other families while also adjusting to the demands of new motherhood.
Overview of the assessment model
The Supported Community Assessment (SCA) was conducted in Hope and Amari’s home by an Independent Social Worker (ISW) with specialist experience of working with and assessing parents with complex mental health needs, alongside a team of experienced Family Support Workers (FSWs). The process was overseen by WillisPalmer’s Consultant Social Worker. Hope’s parenting capacity was assessed using the ParentAssess framework, an assessment model tailored for parents with additional needs and/or disabilities.
The Supported Community Assessment included:
- 10 weeks of support and supervision, in the home and in the community
- Dynamic risk assessment based on Hope’s historical and current functioning
- 24/7 safeguarding observation by FSWs during the first half of the assessment
- Individualised parenting intervention through guidance, teaching, and modelling
- Eight structured assessment sessions with Hope
- Daily observations of parent-child interactions
- Planning and progress review meetings with professionals
- Weekly multi-agency meetings and professional consultations
- A structured reduction in FSW support during the second stage, concluding with just three welfare visits in the final week
- Quality-assured FSW session reports shared weekly with the local authority
- Review of psychiatric and behavioural assessments
- A quality-assured final assessment report with recommendations, completed within 10 weeks
Key Outcomes
Despite Hope’s complex mental health and emotional challenges, the assessment team effectively managed risks through tailored, continuous support, skill-building, and phased transitions. This led to clear improvements in both Hope’s parenting ability and emotional resilience.
Family Support Workers provided constant support to manage crises safely, helping Hope develop calming techniques and personalised emergency plans that significantly reduced panic episodes. Reflective sessions with the Independent Social Worker improved Hope’s self-awareness, enabling her to anticipate distress, express emotions, and use coping strategies, resulting in more consistent and attuned parenting.
A phased reduction of support maintained stable routines and increased Hope’s confidence in independent caregiving, demonstrating the success of the Supported Community Assessment model in fostering sustainable parenting skills. The team’s proactive multi-agency plan also helped Hope manage the emotional risks of a housing move smoothly, ensuring consistent care for Amari.
In conclusion, Hope can safely parent Amari with ongoing structured support. Recommendations focus on maintaining emotional resilience, risk monitoring, and care continuity as formal support decreases.
Risk Management in Action
Emotional dysregulation and panic attacks
Hope’s history of emotional dysregulation and panic attacks presented a significant safeguarding concern. During the first half of the assessment, a Family Support Worker (FSW) always remained with Hope and Amari, ensuring an immediate response to protect Amari in the event of a crisis.
On one occasion, Hope experienced a severe panic attack that left her temporarily incapacitated. The FSW, already present in the home, immediately took over Amari’s care and called emergency services. The on-call Team Manager liaised with the local authority, allowing the FSW to remain focused on supporting Hope and ensuring Amari was safe.
Importantly, the FSW did not just respond to the crisis, they used the experience as a teaching opportunity. Once Hope had recovered, the FSW worked with her to model how she could manage a similar situation independently in the future, when support might not be immediately available. This included:
- Identifying early warning signs of emotional escalation
- Practicing calming techniques and grounding strategies
- Creating a personalised emergency plan for Amari’s care
- Discussing how and when to seek help from professionals or trusted contacts
This approach helped Hope build confidence and emotional resilience, reinforcing her ability to parent safely even in moments of crisis.
Hope’s limited insight into the impact of her behaviour on others
Hope initially struggled to recognise how her emotional responses and behaviours affected those around her, including Amari. This presented a risk to her ability to maintain consistent and attuned parenting, particularly during moments of stress or interpersonal conflict.
To address this, the Independent Social Worker (ISW) engaged Hope in regular reflective sessions following incidents or emotionally charged interactions. These sessions were structured to help Hope:
- Identify emotional triggers and patterns in her behaviour
- Understand the ripple effect of her actions on Amari’s emotional wellbeing
- Explore alternative responses and coping strategies
- Practice empathy and perspective-taking, particularly in the context of parenting
Over time, Hope began to demonstrate greater emotional insight and self-awareness. She was able to anticipate situations that might overwhelm her and proactively use strategies discussed with the ISW and Family Support Workers. For example, she began to:
- Verbally express when she was feeling dysregulated, allowing for timely support
- Use calming techniques to self-regulate before engaging with Amari
- Reflect on her parenting decisions and adjust her approach to better meet Amari’s needs
This shift was evident in her daily interactions with Amari, which became more emotionally attuned, consistent, and nurturing. Professionals observed a marked improvement in Hope’s ability to maintain routines, respond sensitively to Amari’s cues, and recover from emotional setbacks without compromising his care.
The assessment team noted that this development was a key indicator of Hope’s growing resilience and capacity to parent safely, even as formal support reduced.
Risk of regression during support reduction
One of the key challenges in any intensive support model is ensuring that progress is sustained as professional involvement decreases. For Hope, this was a particularly sensitive transition due to her history of emotional instability and reliance on external support during times of distress.
To mitigate the risk of regression, the SCA team implemented a carefully phased reduction in FSW presence, designed in collaboration with Hope. She was fully informed and actively involved in planning each stage of the transition, which helped reduce anxiety and promote her sense of control.
The reduction was structured in two stages:
Stage One: Gradual reduction from 24/7 support to daytime-only presence, with Hope maintaining full care of Amari under observation.
Stage Two: Transition to scheduled welfare visits, culminating in just three visits during the final week of assessment.
Throughout this process, the team closely monitored Hope’s ability to:
- Maintain consistent routines for Amari (feeding, sleeping, play)
- Respond to Amari’s emotional cues with sensitivity and attunement
- Manage her own emotional regulation without immediate professional intervention
- Seek help appropriately when needed, using her support network
Hope responded positively to the phased approach. She began to demonstrate greater confidence in her parenting, and her ability to manage daily challenges independently improved significantly. The team observed that:
- Hope was able to anticipate and prepare for emotionally challenging situations, using strategies developed earlier in the assessment
- She maintained a stable and nurturing environment for Amari, even in the absence of constant support
- She showed increased emotional resilience, recovering from setbacks without compromising Amari’s care
This outcome was a testament to the effectiveness of the SCA model in building sustainable parenting capacity, rather than dependency on services. By the end of the assessment, Hope had transitioned from needing intensive support to being a parent who could safely and confidently care for her child with support from community-based universal services.
Risk of emotional destabilisation due to housing move
Hope’s housing move during the assessment period posed a significant risk to her emotional stability. Given her history of trauma, mental health challenges, and difficulty coping with change, the transition had the potential to trigger emotional dysregulation, which could in turn impact her ability to care for Amari safely and consistently.
Recognising this, the Supported Community Assessment team took a proactive and preventative approach. Rather than waiting for signs of distress, the team worked collaboratively with Hope and her wider professional network to put a robust support plan in place ahead of the move. This included:
- Increased visits from Hope’s allocated Social Worker and mental health Key Worker during the transition period
- Weekly Health Visitor appointments to monitor Amari’s development and provide parenting support
- Early access to Dialectical Behavioural Therapy (DBT) to equip Hope with tools for emotional regulation and distress tolerance
- Ongoing emotional support from the Family Support Workers, who helped Hope prepare practically and emotionally for the move
The FSWs also used this period to model coping strategies and reinforce Hope’s ability to manage stress independently. They supported her in:
- Creating a structured plan for the move, including packing, logistics, and childcare
- Practicing grounding techniques and emotional regulation strategies in anticipation of stress
- Identifying safe spaces and routines in the new home to help Hope and Amari settle quickly
As a result of this coordinated support, Hope was able to navigate the housing move without significant emotional disruption or additional services from the local authority. She maintained her caregiving routines, responded sensitively to Amari’s needs, and demonstrated increased confidence in her ability to manage change.
This outcome highlighted the effectiveness of the SCA model in building resilience and safe continuity of care. By anticipating potential risks and embedding support around Hope, the team ensured that Amari’s emotional and physical needs continued to be met, even during a period of significant transition.
