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Quality & Governance

We are committed to embedding an open and collaborative culture where learning from past experiences is encouraged and each individual member of staff is supported to improve their practice.

Positive CIW Inspection reports

We are delighted that Ty Seren has just received two positive first CIW inspection reports (the two most recent).

CIW refer to the “strong organisational culture of openness and transparency” and that all historic issues (arising under previous leadership) have been fully addressed with lots of examples of good practice highlighted in the report.

A parent is quoted as saying to CIW:

…if I don’t succeed it will be my doing… they do everything to help me and I can trust them to be honest…. I feel safe here…

The Directors and Manager thanked all the staff team for their hard work and commitment to families and concluded with:

We see this positive news as a key early milestone in our ongoing improvement journey.  Let’s continue to improve the experience we provide for all of our families and staff.  This is the best way to ensure we will be successful and achieve our mission of supporting each child to have the best start in life“.

The CIW report can be read in full here:

CIW Inspection Report – June 2022

CIW – Inspection Report – October 2022

The '3 lines of Defence' approach to governance

The 3 lines of defence approach used within the Centre and organisation are as follows:

1st line of defence: operational assurance

Day to day operation of the centre including procedures such as handovers, checklists, agendas etc.

2nd line of defence: management assurance

Weekly and monthly oversight of the Centre and the service provided to families.

3rd line of defence: independent assurance

It is the responsibility of the Responsible Individual to ensure that the 3 lines of defence are working effectively within the organisation and kept under review.

It is the responsibility of the manager to ensure that the centre operates in accordance with the principles and mechanisms described above and that this is kept under review.

Pandemic governance

It is the responsibility of the lead Health and Safety officer (being the Operations Lead for the organisation) to monitor pandemic guidance from Public Health Wales, the Welsh Government, CIW, Cwm Taf LHB and Bridgend Local Authority to identify any changes required in protocols or our approach to minimising the risk of harm to all individuals. It is the Operations Lead’s responsibility to ensure any such changes are communicated, with proposed documentation, to the manager of the centre.

It is the manager’s responsibility to ensure the centre operates in accordance with agreed pandemic guidance and procedures.

CIW Inspection Report for Ty Seren


Weekly oversight

We hold weekly service-focused MDT meetings with agenda items including status of parenting assessments, complaints, feedback, incidents, change in needs, staffing issues, deployment of staffing, any identified changes in pandemic requirements and opportunities for improvement.

This is separate to the regular family-focused MDT meetings reviewing the progress of each family.

RI visits to the centre

Whilst the Responsible Individual (RI) is always available to the Manager, staff, families and other stakeholders to discuss any concerns arising in the service, regulatory RI visits are undertaken at least once per quarter.  These provide an independent overview whether individuals are satisfied with the service that they receive, what is going well and what could be better.

 All RI visits shall include a consideration of any complaints received since the last visit.

 The RI discusses all matters arising (positives and opportunities for improvement) with the Service Manager and ensures a record of their visit is maintained.

Separate to these formal visits, the RI is involved in the organisational management meetings, the management review meetings and in the six-monthly Quality Panel.  As the RI is also the Service Director, they are very much at the heart of the service and organisation.

Quality Panel

We hold six-monthly Quality meetings which has agenda items including the Responsible Individual’s own review visit, the draft Quality of Care report for the centre, an analysis of incidents, complaints, safeguarding and whistleblowing, data on the outcomes being achieved (especially in the two core objective areas), training and supervision indicators, and the tracking of key HR data such as the retention of staff.

Following the Quality Panel meeting, the manager and RI shall collaborate to finalise the Quality of Care report in line with the peer review process from the quality panel. A copy of this report shall be shared with the Board.

Additionally, a dedicated email address to report any whistleblowing concerns to Board members has been established at pfpwhistleblowing@resource.org.uk