Inspection of 29 February 2024 — Inspection Report
Immediate action notice. This inspection was triggered by information received by the Tusla inspectorate. The inspection process included a review of the regulations relevant to the information submitted. An immediate action notice was issued following the inspection, on the 1st of March 2024, in relation to safety. The registered provider responded on 4th of March 2024. Please see details in this report under regulation 23. The Registration and Inspection Manager held a regulatory compliance meeting on the 2nd of May 2024, to advise of the registration and regulatory enforcement process, and promote compliance.
Immediate action notice. decisions about compliance with regulatory requirements. Where the registered provider fails to meet the statutory requirements an escalation process may be commenced. The inspectorate reserves the right to edit responses received for reasons including clarity, completeness, and compliance with administrative and legal processes. The contents of the report are compiled by the inspectorate body.
Immediate action notice. Non-Compliance Information (1)(3) On the day of inspection, the person in charge, informed the early years inspectors that an additional separate service was operating for children who are not registered to the Ballinasloe Therapeutic Project. However, it is not a separate service as the staff member was working in the registered service at this time. The staff member was providing 1-to-1 care and consultation with children and their parents, when the registered service was in operation and when the staff member was rostered to be working in the registered service. Additionally, there was no differentiation from the documentation presented of these two services. The early years inspectors were advised that a child under the age of 2 years was availing of this service and was not registered to the registered service. This pre-school is registered to operate for children between 2 to 6 years of age. Corrective & Preventive Action submitted by the Registered Provider On the 25th of March and 11th of April 2024, the registered provider advised of the following Corrective and Preventive Action Children under 2 years of age are not admitted to the pre-school session. The additional separate service is no longer operating during the pre-school sessional service. Supporting documentation submitted The registered provider advised in writing that the service would operate under its registration status. The registered provider submitted a change in the name of the pre-school to Ballinasloe Social Services Ltd. Summary Comment The inspectors have reviewed the actions and evidence submitted. The non-compliance identified under Regulation 8 have been adequately addressed.
Regulation 9 — Management and recruitment
- The service did not show evidence of a system that ensured that all employees, unpaid workers, and contractors were appropriately supervised and provided with appropriate information, and where necessary training, including in relation to the policies, procedures and statements of the service and the Regulations. There was no evidence of training or an appraisal system for each staff member. There was no evidence of the staff supervision policy being implemented
- On the 4th and 11th of April, and the 9th of May 2024, the registered provider advised of the following: Corrective and Preventive Action A staff supervision book has been implemented. Staff meetings and all topics discussed are recorded and signed. All staff training will be recorded
Regulation 10 — Policies, procedures etc. of pre-school service
- 1. There was no documented evidence in relation to the name, position, qualifications and experience of the employees, unpaid workers, and contractors. 2. There were no details of a daily staff roster system. The staff rosters and time sheets were generic, with first name of the staff member only, and am or pm presence. 3. The children’s attendance records were handwritten, with a tick only system. There was evidence of a pre-recorded entry and exit times. The records were not specific, there was no details of adult child ratio, no staff details, no details of any child attending the settling-in programme, and no date of births / age range. 4. Nine out of forty-seven enrolment forms were not presented, on the day of inspection. Enrolments forms are required for each child attending the service for child’s contact details, authorisation, immunisations, allergies, consents, and the names of persons to contact in cases of emergency. 5. The service’s behaviour management policy did not clearly state that children shall not be subjected to any form of corporal punishment, degrading, or neglectful practices. 6. There was no outing policy included in any of the documents presented, however there was evidence that the children went on a trip to Dublin on the 7th of December 2023. 7. The information on the creation, storage and archiving of all records required detail development. 8. There was no policy on supervision and staff training. 9. The nappy changing policy on display, on the sanitary door and in a folder presented had conflicting information. 10. The inclusion policy did not advise how the physical environment supports inclusion and reflects diversity. The policy inspected did not advise how the service recognises and responds to bias and discrimination. 11. The accident and incident policy did not define how information is documented regarding accidents and incidents, and how notifiable incidents would be informed to the Early Years Inspectorate. There was no evidence that a risk assessment was taken following an accident or incident occurring in the service. On the day of inspection, there was no evidence of a daily risk assessment system and a risk management policy. 12. The settling in policy, did not advise how children’s transitions were supported and did not advise of a key person system. On the 7th of March 2024, the inspectors received a further policy folder dated ‘March 2024’. The early years inspectors noted there were various names for the service on this policy folder. The registered provider advised that the policies would be further updated during the Easter break 2024
- On the 7 th of March , the 11 th of April, the 9th and 22 nd of May 2024, the registered provider submitted the following; Corrective and Preventive Action 1. The name, position, qualifications, and experience of the employees are now available and displayed in the lobby. 2. A new attendance record book has been purchased. Specific staff attendance details including time of arrival and departure, will be recorded daily. 3. A new attendance record book has been purchased. Children’s attendance records will now be recorded in this daily attendance book with specific details in relation to the adult child ratio, the child and staff details, details of any child attending the settling-in programme, and details of births / age range. 4. The nine out of forty-seven enrolment forms were completed to include the child’s contact details, authorisation, immunisations, allergies, consents, and persons to contact in cases of emergency. 5. The behavioral management policy was updated and clearly states that children shall not be subjected to any form of corporal punishment, degrading, or neglectful practices. 6. The outing policy was submitted and included advise of specific insurance cover for outings. 7. The timeframes regarding the storage, retrieval and retention of children, staff and fire records was updated. 8. The policy on supervision and staff training was updated and included evidence of a system for recording ongoing staff training and professional development. 9. The nappy changing policy was updated and there were records regarding an individual child’s nappy change. 10. The inclusion policy now advises on how the physical environment supports inclusion and reflects diversity. The policy includes how the service recognises and responds to bias and discrimination. 11. The accident and incident policy was updated and includes how notifiable incidents would be informed to the Early Years Inspectorate. There was evidence that a risk assessment was taken following an accident or incident occurring in the service. On the day of inspection, there was no evidence of a daily risk assessment system and a risk management policy. 12. The settling in policy, advises how children’s transitions were supported and the use of a key person system
Regulation 16 — Record in relation to pre-school service
- (k) On the day of inspection, the last recorded details of any accident, injury or incident involving a pre-school child attending the service was dated 22nd of September 2022. The accident and incident book did not have a section for remedial action taken and for the parent(s) or guardian(s) signature
- On the 11th of April, and 9th of May 2024, the registered provider advised of the following; Corrective and Preventive Action The accident and injury book is implemented for all incidents. All incidents will be recorded, remedial action outlined and signed by the parent(s) or guardians(s)
Regulation 23 — Safeguarding health, safety, and welfare of child
- General Safety: 1. An immediate action notice was issued on the 1st of March 2024, as the drive through main entrance double gates, off the main road and the walk-through gate into the social services premises / car park remained open throughout the inspection and while the children went to and from the outdoor play area. Infection Control: 2. On the day of inspection, the children did not wash their hands after outdoor play and prior to their going home, posing a cross infection risk. This was previously noted on the inspection dated 26th October 2022. 3. There was no designated nappy-changing unit, and designated wash-hand basin to enable a child to have their nappy changed. A nappy-changing unit and mat must be smooth and easy to clean and available for the children attending the service, wearing nappies. 4. The blue rolls and disposable aprons were loosely stored on the windowsills or on top of the cisterns in the children’s sanitary areas, while dispensers were required to prevent cross contamination. 5. There was evidence of dust and debris on the mechanical ventilation covers on the walls of the children’s sanitary areas, that required cleaning. The mechanical ventilation covers need to be included in the service’s cleaning checklist / schedule. 6. The service cleaning schedule showed only the initials of the staff member, or ticks and no staff signature. There was no evidence of the cleaning procedure process in line with public health guidance. Action submitted by the Registered Provider On 4th of March, 11th of April, and the 22nd of May 2024 the registered provider advised of the following;
- General Safety: 1. Evidence that a system was in place to ensure staff close and secure the outdoor gates when children were accessing the outdoor play area was submitted. The double gates will be closed each time the children are coming to or going from the outdoor play area to the pre-school. This practice will be implemented at all times when the children are moving between the outdoor area and pre-school. Infection Control: 2. The children will wash their hands after outdoor play before they go home each day. The staff have been advised to ensure children wash their hands, after outdoor play. 3. A nappy-changing record will be kept of each child when their nappy has been changed. A nappy changing unit has been purchased. 4. Dispensers for the storage of disposable aprons, gloves and hand towels have been installed. 5. The mechanical ventilation units will be included in the cleaning schedule. 6. The cleaning schedule was upgraded to show staff names and details of the areas cleaned. The cleaning schedules will be adhered to
Regulation not named in the report text
- (1)(3) On the day of inspection, the person in charge, informed the early years inspectors that an additional separate service was operating for children who are not registered to the Ballinasloe Therapeutic Project. However, it is not a separate service as the staff member was working in the registered service at this time. The staff member was providing 1-to-1 care and consultation with children and their parents, when the registered service was in operation and when the staff member was rostered to be working in the registered service. Additionally, there was no differentiation from the documentation presented of these two services. The early years inspectors were advised that a child under the age of 2 years was availing of this service and was not registered to the registered service. This pre-school is registered to operate for children between 2 to 6 years of age
- On the 25th of March and 11th of April 2024, the registered provider advised of the following Corrective and Preventive Action Children under 2 years of age are not admitted to the pre-school session. The additional separate service is no longer operating during the pre-school sessional service
Found compliant: Regulation 11, 19, 32.