HSC
South Eastern Health
J and Social Care Trust
Quality"of Staffirtg-, Managemen-t & Leadership
Inspection Report
Sessional & F
Sarp.
Name of Service:
Addrass of Sorvice:
Tiddliwinks playgroup
68 Groomsport Road
Bangor
Postsode:
BT206NE
Telephone No:
Name of Registored Person:
Name of Manager:
Days service provided..
07929465421
pamgibb@sky.com
Gillian Cassidy
Monday -Friday
Hours service provided:
9AM- 12PM
(please tick as appropriate)
ull Day
. Car?
Play.
group
Oth•r
(pleasa
advlse
8Ghool
Privats
Profit
, Numbor,of Childroni. .
Re
istered for
Range
2 years 10
.Numb•rAofts.
Chi
.Numbbt.'Of'""'
oom1.
26
16
months -
statutory
school a
Claire Goldring
.Pate of inspection..::
15.06.2023

HSC
South Eastern Health
J and Social Care Trust
The following inspection was carried out by the Early Years TÉam,
Southern Health & Social Care Trust
Under the Children (Nl) Order 1995 settings are required to be registered with their
local Trust if they provide a service as a day nursery, crèche, playgroup, out of
school club or holiday club.
The Trust is then required to inspect the setting at least once per year. The setting is
required to adhere to the requirements of their registration certificate and to the
Childminding and Day Care for Children under Age 12 - Minimum Standards. The
Standards contain a number of Quality Areas. The Standards can be downloaded at
ervice
The following are the definitions used when inspectors make a requirement for
compliance or a recommendation for improvement
R•qulr?ment lor Complianc•
A requirement for compliance is a statement which sets out what the Registered
Provider must do to improve the outcomes for people using the service. It will be linked
to a non-compliance of a condition of registration andlor legislative r8quir8ments or
regulations, andlor the Childminding and Day Care Minimurn Standards for under 12
(July 2012) and Implementation Guidance.
Re¢omm•ndations for Improvom•nt
A recommendation for improvement is a statement which sets out the actions a
registered provider should take to improve or develop the quality of the seprfice. It will
be linked to the Childminding and Day Care Minimum Standards for Children under
12 (July 2012) and accompanying Implementation GuidanGe' Regional or National
guidance issued by other professional bodies associated with day care provision
and/or Best Practice guidance.
,'Ins
ection Details
The Minimum Standards document contains four Quality Areas which all providers
are expected to meet.
The8e are:
Quallty of Care.
Quality of Staffing? Management and L•adorship;

HSC
South Eastern Health
J and Social Care Trust
Quality of the Physical Environment;
Quality of Monitoring and Evaluation.
The Inspection process operates on a 4 year cycle. Each year the Health and Social
Care Trust will inspect each registered setting on 1 of th• 4 Quality Areas. This
means that all 4 areas will have been inspected in a 4 year period
This was an announced inspection assessing the Minimum Standard quality area of
Staffing, Management and Loadorship.
The quality of staffing, management and laadership impacts directly and indirectly on
children's care. Strong, competent and effective management means efficient running
of a setting and high standards set for others. Staff who are happy in their role, secure
in the knowledge of their responsibilities and well-trained to deal with all aspects of
their job provide an environment wharo children can thrive. A culture of professional.
reflective practice and a willingness to challenge practice is vital. A whole-team
approach and ownership of the setting is key to ensuring a Safe, high-quality service
for children, parents and families.
Safeguarding has been placed at the stsrt of this section as safety is at the cantre of
a quality service.
These Standards will help reassur8 parents that their children are receiving quality
care in a safe environment.
Standard 1 Saf•guardlnq and Child Protoctlon is included in all Inspections.
This inspection considered the following stsndards.
Saf•guarding and Child Protsction (stsndard 1)
Managemènt and Monitorlng Arrangements ( Standard 10)
Organisation of tha Sotting (standard 11)
Sultabl• Person (8tandard 12)
.8elf' Èvlttta710n..
As part of the Inspection process all registered day care providers are required to
complete and submit a Self-Evaluation Form prior to the Inspection which provides
information on how they operate their service. This is a component part of the overall
inspection process.
The Self-Evaluation tells the Health and Social care Trust how a Provider views the
performance of their service. It also sets out how a Provider meets specific criteria
within some of the Standards. Providers are encouraged to be open and honest,
sharing all appropriate information as part of the Self-Evaluation proGess. Providers
are asked to confimi the information they submit is complete and accurate.
By completing the Self-Evaluation, provider8 will reflect on practice and therefore
engage in tha inspection process.

HSC
South Eastern Health
J and Social CareTrust
ection
Date of previous Inspection:
16.06.2022
Quality Area Ins.pected:.
Quality of Care part 2
ro
ra
ac
R'érfo'irgménts for'Complian¢o.with, LvgislatiC•n:.:and;tho Minimum, Stsndards
All requirements for compliance have been completed.
No recommendations were made.
'Tri•ws'troin.Chlldre,ri Par.en.ts.and_Carers
An important part of tha Inspection procass is to obtain the views, where possible, of
the children who are being cared for in the facility and also the opinions of the parents
and carers who have chosen to use the facility for their childlchildr8n.
.Children's Views
During the Inspection a range of children were spoken with.
The following comments were made by the children
'1 like coming to school.,
'M favoun'te thin
outside with m
As part of the Inspection process the Early Years Social Work Team seeks to issue
questionnaires for completion by parentslcarers and staff.
Due to legislation relating to the protection of personal information and confidentiality,
the Provider is asked to supply the names and contact details of parents with children
attending the facility. Normally this consent will have been p
provided as part of the enrolment prO￿3s. however where it has not we ask that the
providÉr advigo the parents of Inspection and seek written consent.
is
la
fvends,

HSC
South Eastern Health
J and Social Care Trust
Parpntal Quostionnairgs,
A total of 15 questionnaires were sent out to parents.
One questionnaire was returned by the time of writing this report.
This is a low retum and was discussed with management who said they
would remind parents and asked that the link to the questionnaire be
sent again. One possible reason for the poor response was that it was
near the end of the term. There were 5 questionnaires returned last year
and all but one was positive.
The parental responses indicatod that they fèel their children are well cared for
n the setting.
e parental responses in
icate
att
ey feel the setting is manage
The following are some of the comments made by parents
A wonderful inclusive and fn'endly atmospherp. My child settled in so easily. With
(some) difficulties P and staff went over and above to make sure
was supported
and I was infomied. Very grateful to have had such an amazing experience for my
(child).
well.
****
(Child) talked about lovely friends. Enjoyed sharing drawings at home and was able to
talk about them. Loved getting outdoors with friends. The excitement of the book bag
comin
hom
ch
fantasti
S-taff Qu•stionnairos , I...
A total of 5 questionnaires were sent to stsff.
A total of 3 questionnaires were retumed by the time of wrrting this report.
taff responses indicated that they feel equippe
setting.
to carry out their role in the
.1 would raise any issue ￿th my manager and feel comfortable to do so".
.1 understand that rf I have concems about a child or rf someone reported concems to
m& I would recoml and report this to my Leader who will take the matter further if
needed. If a child Game to me and told me something which raised concems I would
reGord exaGtly what was told to me and again report to leader. If leader was not
available or Goncems were raised bout leader I know to report to Social SeNices,
Gateway, Health Visitor orpoliGe".
We can approaGh our leader with any concems at any time and through staff
Ge

HSC
South Eastern Health
J and Social CareTrust
.Quality of Care
Children are safeguarded through systems and practicos that are consistent
w.ith-,the.Regio.nal C,hildJPrffiOte,¢.tion,PoJ.iGio.4an￿P[oSe,<urO5.,:.........--,: .
From the evidence provided through provision of recordsldocumentation, discussion
and observation on the day of Inspection, the Registered Person demonstrated that
children are safeguarded through systems and practices that are consistent with the
Regional Child Protection Policies and Procedures.
There is a written Safeguarding and Child Protection Policy and Procedure in
place which clearly states it is the Setting's responsibility with regard to the
reporting of suspected or actual child abuse or neglect and includes relevant
contact names and telephone numbers. This was evident at tima of
Inspection and included:
Trust protocol for reporting concerns;
Reporting concerns Without delay to the appropriate HSC Trust.
Maintaining a signed and dated record of anything which causes them
concern., and
Kee
in
concarns confidential to those who need to know.
The
elf-Evaluation Form stated the Setting had received relevant training
and demonstrated through discussion at Inspection an understanding of the
r8sponsibilities and duties in respect of Safeguarding and Child Protection
and awareness that trainin
must be u
dated eve
ears.
All parents had been made aware at enrolm8nt of the procedures for
Safoguarding and Child Protection, including the need to pass information
without parental consent if there is a reasonable concern that a child may be
at risk of or is sufferin
abuse or ne
lect.
Through discussion it was evident that parents are encouraged and
facilitated to express any concerns they rnay have ft)r their child's care and
are given details regarding who to contact in the event that they are uneasy
about the standard of
rotection afforded to their children.
he Self-Evaluation Form stated that there 13 a written policy and procedure
for:
Intimatelpersonal care and that parents are made aware at enrolment of
the procedures for children's personal care.
The use of Information and Communication Technology (ICT)
equipmenusocial Networking. Staff and volunteers have agreed and
signed up to this policy at recruitment.
Code of Conduct in relation to mobile phones, particularly those with
cameras or video ca
abili
and artici
ation in social netsiorkin

HSC
South Eastern Health
J and Social Care Trust
websites. Staff and volunteers have agreed and signed up to this policy
at recruitment.
Taking photographs and that parents give written permission for their
children to be photographed and the use of these photographs is clearly
explained (e.g. displays, child records, promotional material).
Tha use of CCTV (if applicable).
Whistle blowing which encourages staff to report any concern they have
regarding the practice of colleagues, volunteers or trainees, relating to
the care of children.
The Registered Person ensured that Contact Persons, names and telephone
numbers are readil
available to staff.
The Inspector observe
that the arrangem8nts for safeguarding chi
were reviewed on an annual basis.
Through discussion the Inspector was satisfied that staff demonstrated an
understanding of child protection issues and safe carin
ractices.
There is a system in place to ensure that children are collected from the
setting by parents or those with parental responsibility or persons authorised
by them to do so. Unless they are parents, persons authorised to collect
children are a
ed 18 or over.
The Self-Evaluation Form stated and also through discussion with the
Leader it was èvidant that there is a Designated Child Protection Officer with
responsibility for Safeguarding and Child Protection who has attended
relevant training which is updated every 3 years. She is available at all times
during the hours of service provision for contact and consultation with staff
and to offer instruction, advice and support. Through discussion, staff were
aware of the arrangements of how to contact the Designated Child
Protection Officer when nec8ssary. This officeWs details were available to
arents and carers.
Through discussion with the Leader the Inspector was satisfied that t
Leader knew how to respond rf a complaint or allegation was made against
her or others in the setting.
uirome
dren
Re
None
Recommendations for Improvèmènt
The Safeguarding PoliGy Gould outline the different types of abuse and offer a
brief definition and examples.

HSC
South Eastern Health
J and Social Care Trust
Quali
of Staffin
, Management & Léadershi
standard 10
T..here are effoctive and offieient management and monitoring
arrangements in the setting to support the work of staff and the care of ,.
children.
Inspectors Comments
From the evidence provided to the inspecting social worker and through observations
and discussion on the day of inspection the Registered Person partially demonstrated
there were effective and efficient management and monitoring arrangements in the
setting to support the work of staff and the care of children.
A record of the name and telephone numbers of the Registered Person was
maintained and a contact point was available for parents.
There was evidence of monitoring reports from the Person in Charge to the
Registered Person on at least a quarterly basis as required to facilitate the
re
ular review of the
uali
of the service.
There were written roles and responsibilities in plac8 for tha management
committeelTrustees of the setting and these are audited regularly.
A sample of minutes demonstrated these meetings were used to
facilitate the sharing of information and to promote the developmant of a
common ethos of work with children and their
arents.
Minutes of the Management Committee were comprehensive and
demonstrated that appropriate monitoring is completed and action is taken to
address issues related to compliance with the Minimum Standards.
The Self Evaluation Form stated that there was a mechanism in place to
ensure that those fulfilling their roles were accountable for their contribution to
the
uali
of the service.
The Self Evaluation Form stated that the registered person hae had all job
descriptions, person specifications and contracts approved by the Gommittee.
The Self Evaluation Form stated that the Registered Person ensured that the
setting's recruitment and retention of staff practices complied with equal
opportunities and fair em
loyment I
islation.
Discussion with a sample of staff indicated they were supported to work
together as a team to plan their work with children and to address issues such
as the management of Ghildren's behaviour and
assessment of their
individual needs indicated that they have adequate resources and time to
address these issues.

HSC
South Eastern Health
J and Social CareTrust
The Inspector obserded that staff were employed in sufficient numbers to
meet statutory requirements.
The Self Evaluation Form stated that all staff were over 18 years.
The Self Evaluation Form ststed that the Registered Person or Person in
Charge ensures that staff respect the privacy of children and parents and only
share information in line with the Infonnation Commissioner's Data Sharing
Code of Practice.
'The ICO re
istration had la
The
sed but was renewed the same da
elf Evaluation Form stated that there were measures to ensure that
training and developmental needs of stsff were identified and addressed to
facilitate staff to avail of develo
mental o
portunities.
The Self Evaluation Fomi stated that records are maintained of training,
including dates and attending staff.
The Self Evaluation
orm stated that tha Registered Person had identified a
process of assessing the effectiveness of training provided for staff. whether
internal or external, and used this information to inform future trainin
There were rninutes of staff meetings held at least every two months.
lans.
There was evidence of regular supervision but this should be more in depth
and annual appraisals are reportedly taking place but there is not a
standardised record of this.
iscussion with some staff demonstrated that they recognise
ow their
individual work contributed to the attainment of the setting's aims and
objectives and how consistency and tsamwork contribute to children's
wellbein
and develo
ment.
Requirements for
ompliance with
glslatlon an
Staff supervisions should be more detailed, in line with Minimum Standard
requirements.
A staff appraisal form needs to b8 dev81op8d and utilised annually.
The setting's registration with the Information Commissioners Office had expired.
This was renewed on the same day but management should make a note of the
renewal date so this continues to be kept in date.
the Minimum
tan
ards.
Recommendations for Improv•mont
None

HSC
South Eastern Health
J and Social CareTrust
standard 11
Adultlchild ratios, space and resources are organised to meet the children's
needs effectively and to comply with the stipulations on the Registration
Certificate.
Inspectors Comments
From the evidence provided to the inspecting social worker and through observations
and discussion on th8 day of inspection the Registered Person demonstrated through
discussion and observation that adultlchild ratios, space and r8sources are organised
to meet the children's needs effectively and to comply with the stipulations on the
Registration Certificate.
The Self Evaluation form stated that there was a suitably qualified Person in
Char
e of the settin
at all times and that
arents can identi
this
erson.
It was evident from the self-evaluation form that the managers have a current
Safe
uardin
and Child Protection Certificate.
From the self-evaluation form and from checking staff records it was evident
that any staff who are required to attain QCF level 5 in Child Care Learning
and Developm8nt have now achiaved this qualification or an 8quivalent
ualrfication.
From discussion with the Person in Charge it was evident that all planned
absences of whatever duration of the Person in Charge as well as on-going
unplanned leave such as sickness was covered by the deputising of a
ualified
erson.
From discussion with the Person in Charge it was evident that arrangements
were in
lace to cover emer
encies and unex
ected staff absences.
Evidencè showed that within on8 month all newly appointed staff received
induction training that covered as outlined in the standards.
The setting's policies and pro￿dures.
Child protection, including whistle blowing"
Manaoement of children's behaviour.
Recording;
Working with parents;
Health and safety" and
portunities.
There was written evidence that staff had read, understood and agreed the
settin
olicies and
rocedures.
It was evident from the self*valuation and from discussion with the manager
that existing staff who do not hold a qualifiGation are encouraged to attend
trainin
10-

HSC
South Eastern Health
J and Social CareTrust
Evidence showed that any staff who were appointed since the Minimum
Standards were published, and they did not hold a relevant child care
qualification, have since achieved a relevant child care qualification.
Individual records on all staff were kept securely, were comprehensive as
re
uired b the standards and available for ins
ection.
There are no studentsltrainees on placement currently however the setting
are aware that there must not be more than one student at an
one time
From discussion with the Person in Charge, it was apparent staffing ratios
were reviewed whenever a child with additional needs attended.
From the selféva
uation form an
daily register it was evident that any
volunteers that were included in the staff ratio did not compromise the
ualification r
uirement for the settin
he Person in Charge ensured that the number of staff avai
able to
accompany childr6n on excursions or visits out of the setting was sufficient to
safeguard them. The arrangements took account of individual children's
needs and the nature of the outin
From the inspection of records it was evident that a Risk Assessment has
been completed re
arding children's outin
arents were awar8 of outings and gave written consent
artici
ation.
The
elf Evaluation Fonn stated that a cook was not employed.
As this is not required.
eirc
The daily register contsined the required information as determined in the
standards.
A daily record was maintained of all visitors to the setting which included their
arrival and de
arture times.
The Self Evaluation Form ststed that the Statement of Purpose was mada
available to
arents on re
uest.
Staff demonstrated that they had a shared sense o
the aims and ob"ectiV88 of the settin
The Self Evaluation Form indicated at
east 500/0 of all child care staff in
addition to the Person in Charge and any Deputies were suitsbly qualified as
re
uired b Minimum Standards.
The deployment of staff was effective within the setting to promote the safety,
wellbein
and develo
ment of the children's full
The setting had a
otential.
tatement of Purpose, t
liant with Minimum Standards.
e contents of which were
com
Records demonstrated that staff developed an understanding of each child's
needs and wishes and that signifiGant information was recorded, collated and
exchanged with
arents.
A minimum ratio of 1 stsff member to 8 children was maintained at all times.
Regardless of the group siza, at least two staff were on duty in each room at
all times.
purpose In
eeping wit
Requirements for Complianc• with Legislation and tho Minimum Standards.
11-

HSC
South Eastern Health
J and Social CareTrust
None
Recommendations for Improvament
None
'Th05e working with children in oither a paid or voluntsry capacity, or who have
.'gubstantial. ac¢ossit•ptha,ffj
Insp•ctors Comm•nt8
From the evidence provided to the inspecting social worker and through observations
and discussion on the day of inspection the Registered Person demonstrated through
discussion that those working with children in either a paid or voluntary capacity, or
who have substantial access to th8m, are suitable individuals to do so.
Staff selection and recruitment arrangements ensured the safeguarding and
rotection of the children.
Records indicated that those working in the setting or who have substantial
access to the children have had Enhanced Disclosure Ghecks.
The Self Evaluation Form stated that the Registered Person had ensured all
appropriate checks had been carried out on all those working with children
as per the requirements of Minimum Standards to ensure that they were
suitable individuals to do so.
The Self Evaluation Form demonstrated that appropriate vetting of students
had been com
leted b the trainin
establishment.
Evidence from Trust records demonstrated that fit person interviews ha
been completed as necessary on th8 R8gistered Person, Person in Charge,
De
ut Person in Char
e and Desi
nated Child Protection Officer.
Records demonstrated that a15 those who assist in looking after a child,
including all those living on the premises and regular visitors had all
appropriate checks carried out and all those working with children have
An Access Nl Enhan￿d Disclosure Certificate;
A letter confirming Trust clearance.
Pre-employment health assessment.
Ability to provlde waim and Goll5151ent Gare which promotes children's
development"
Inte
ri
and ability to be flexible in their work;
12-

HSC
South Eastern Health
J and Social CareTrust
Knowledge, understanding and commitment to treat all children as
individuals and with equal concern. and
ro
riate knowled
e, skills, ex
erience and
ualifications.
Requiremgnts for Compliance with Legislation and the Minimum Standards
None
Recomméndations for Improvomont
None
Were ther8 issues arising at Inspection that are required to
be dealt with that were not part of the Quality Area
ins
6Cted?
The children were sitting outside sitting in the shade from the sun. The staff were
reading stories to them and were using dressing up clothes and props to make it
more interactive. There was water freely available and the children had snack of
cream crackers, breadlbutter and fruit.
They were then asked to form a line, come indoors and sit quietly on the mat. They
followed instruction well. The staff made sure that they had gained everyone's
attention by asking, "Are we all listening?" The children had been making scrolls and
photo frarnes for father's day and the staff used this opportunity to hand these out.
The staff praised the children for the artwork that they'd produced.
The staff then led the childr8n in singing 'Days of the week, song and 'Twinkle
Twinkle traffic lights" The children were clearly enjoying this as well as developing
their language skills.
The Playgroup is in a large hall which is zoned with various table top activities, home
and readin
corner and substantial floor s
ace for
h sical and free
la
13-

HSC
South Eastern Health
J and Social CareTrust
No complaintslconcerns have been expressed about this setting since the last
annual Inspection.
S.elf.Év.aluatlon.
A completed S8lf-Evaluation document was received within timescales. This
document was completed to a comprehensive standard.
. Inspection Summary:
Tiddliwinks Playgroup has been registered since 1997 and is located in an urban
setting. The facility is registered for a total of 26 places.
On the day of Inspection there were 16 children present.
Tha childr8nlstaff were preparing for the end of term but the routine was still apparent
and was managed in a calm and confident way by the Staff. The staff appeared to work
very well together.
The outdoor area is a relatively new addition and it was good to see them fully utilising
It is the responsibility of the Registered Person to ensure that the réquirements to be
met to comply with legislation, the Minimum Standards and Implementation Guidance
as detailed in the report are actioned without delay.
The Registered Person must submit an action plan which addresses the above
requirements to the Trust within the required timescale.
. Requiroments for Compliance with Legislation and the Minimum Stsndards:
Staff supervisions should be more detailed, in line with Minimum Stsndard
requirGmenta.
raisal fomi needs to be develo
ed and utilised annuall
Astaff a
14-

HSC
South Eastern Health
J and Social CareTrust
The setting's registration with the Information Commissioners Office had
expired. This was renewed on the same day but management should make a
note of the renewal date so this continues to be kept in date.
ecommendations for. Improvement-. ,
The Safeguarding Policy could outline the di￿rent types of abuse and offer a brief
definition and examples.
Name of,Ingpactor,.
Claire Goldring
Signature: ¥
26.10.2023
"*ocial Work Manaèer.
ignature:
ate:
Karèn Harri8
0410112024
,£ignature:
Date:
CONTAGT DETAILS
15

HSC
South Eastern Health
J and Social Care Trust
Early Years Team
Grove House
Antrim Road
Ballynahinch
BT24 8BA
Tel.. 028 4451380
16-