Inspection of 30 October 2024 — Inspection Report
Immediate action notice. Where statutory requirements are identified as not being met, the registered provider must demonstrate how they have rectified the non-compliance and will prevent any non -compliance from re occurring. The Corrective Action and Preventive Action plan (CAPA) will be used to inform decisions about compliance with regulatory requirements. Where the registered provider fails to meet the statutory requirements an escalation process may be commenced.
Regulation 9 — Management and recruitment
- (7) (a) There was no written evidence available to demonstrate that staff members had ongoing supervision. Although it is acknowledged that there was a staff handbook there was no written evidence of induction training and that the staff had read and signed off on the services policies and procedures
Provider's corrective action:
- An Induction Pack is now available for all staff members along with the Employee Handbook. It outlines all the policies and procedures including staff training and staff supervision. A staff meeting was held and all staff members received a copy of both documents which they signed off on. The registered provider will ensure that regular team meetings and one to one supervision meetings will be held with all staff and that all new staff will have induction training
Regulation 23 — Safeguarding health, safety and welfare of child
- General Safety: The following safety measures were not in place on the day of inspection: In the front outdoor play area, the following was observed: 1. Wooden logs placed on concrete slabbing had slippery surfaces which poses a fall risk to a child. 2. A small wooden bench had flaking wood on the seating area which poses a splinter risk to a child. Action submitted by the Registered Provider
Provider's corrective action:
- General Safety: 1.The front outdoor play area contains a lot of wooden equipment and will be risk assessed during wet weather to determine if it is suitable for use. A second outdoor play area is always available as an alternative option. 2.The seating area on the wooden bench has been replaced
Regulation 32 — Complaints
- (1)(a)(b)&(c) A detailed record in writing was not maintained of the recent complaint and the steps taken in the complaints process. Although it is acknowledged that notes were taken of contact with parents and evidence of emails sent and received a clear account of events were not recorded by the registered provider. (2)(a) &(b) The Complaints Policy was not implemented in practice as a detailed record was not maintained of a complaint and the steps taken in the complaints process
Provider's corrective action:
- (1)(a)(b)&(c)A detailed record is now documented in chronological order of steps taken in the complaints process. (2)(a) &(b) A complaints log is now available for logging complaints. The registered provider will ensure that the complaints policy is implemented in practice
Found compliant: Regulation 10, 11, 16, 19, 20, 21, 22, 25, 26, 28.