Inspection of 14 May 2026 — Inspection Report
Regulation 9 — Management and recruitment
- See Statutory Notice section in relation to Immediate Action Notice IAN0823 served
- Documentation reviewed evidenced that the procedures specified above under 9(2) had not been carried out for all adults prior to commencing employment in the service, as detailed above under regulation 9(2) and as follows. - Garda vetting available for two adults was dated after the adult’s commenced employment. One adult commenced employment on 11 September 2023 and Garda vetting was obtained on 03 October 2023. One adult commenced employment on 09 September 2024 and Garda vetting was obtained on 28 October 2024. - References for one adult were sought and validated after the adult commenced employment. The adult commenced employment on 09 September 2024. The first reference was dated 22 October 2024 and had been validated on 01 November 2024. The second reference was dated 12 November 2024 and had been validated on 13 November 2024. This regulation was non-compliant on the last inspection on 14 January 2026. The corrective and preventive actions submitted by the registered provider did not prevent recurrence of this non-compliance
- There was no evidence available to demonstrate that one adult who was employed to work directly with the children in the service held a relevant major award in Early Childhood Care and Education on the National Framework of Qualifications or equivalent
- Whilst it was acknowledged that there was an induction process and training in place, inspectors found that the registered provider did not demonstrate that they had taken all reasonable measures to ensure that all employees were appropriately supervised and provided with sufficient information and training to safeguard the health, safety and welfare of children attending the service and to comply with the regulations as follows. • The staff training policy in place stated that training needs are identified through support and supervision. Through a review of records and discussions with staff, it was evident that all staff had not received regular support and supervision. A sample of six staff supervision records were reviewed. There was no record of formal supervision available for one staff member and the most recent records of formal supervision for three other staff were dated 29 and 30 October 2025. This was at variance with the service staff supervision policy which stated that supervision meetings will occur every two months. • It was not evident that management and staff had received appropriate training and information from the registered provider regarding the risk assessments carried out in the service. Records of daily risk assessments were available and completed. However, the most recent monthly risk assessment for the service was dated March 2026. Inspectors observed a number of significant risks in the service which had been assessed as low or no risk in the daily and monthly risk assessments as detailed under regulation 23
Provider's corrective action:
- A full review of all personnel files was completed following the inspection to ensure that Garda Vetting, references, qualifications and all recruitment documentation are now in place and available for all staff members. The Registered Provider reviewed recruitment records and identified where recruitment procedures had not been fully completed prior to staff commencing employment. Personnel files have been updated and audited to ensure compliance with Regulation 9. The Registered Provider has implemented a revised Recruitment and Safer Recruitment Procedure to ensure that no adult will be appointed, assigned duties, commence employment, undertake induction, shadow staff or have access to children until all requirements under Regulation 9 have been fully completed. The following measures have been introduced: A Recruitment Compliance Checklist must be completed and signed by the Registered Provider before any start date is confirmed. A staff member's start date cannot be entered onto the rota until the Recruitment Compliance Checklist has been completed and authorised. A Recruitment Tracking Register has been introduced to monitor Garda Vetting, references, qualification verification and employment history checks for all new recruits. A monthly personnel file audit will be completed by management to ensure ongoing compliance with recruitment requirements. Management responsible for recruitment will receive refresher training on Tusla recruitment requirements and safer recruitment procedures. Evidence of Garda Vetting and validated references will be reviewed and signed off by the Registered Provider prior to issuing any contract of employment. Recruitment Procedure, Checklist and Recruitment Register implemented by June 2026. Monthly audits to commence from June 2026. A Pre-Employment Documentation Checklist has been developed and will be issued to all successful candidates at the offer stage. The checklist clearly outlines all documentation required prior to commencement of employment, including Garda Vetting, validated references, proof of qualifications, identification and any mandatory training certificates. Candidates are informed in writing that employment is conditional upon the satisfactory completion of all pre-employment checks and that no start date will be confirmed until all required documentation has been received, reviewed and approved by management
- Following the inspection, the Registered Provider conducted a review of all personnel files to verify that evidence of qualifications was available for all staff working directly with children. The staff member identified during the inspection was requested to provide evidence of their qualification. A copy of the qualification certificate and any relevant qualification recognition documentation has now been obtained and placed on the employee's personnel file. A full audit of staff qualification records was also completed to ensure that evidence of qualifications is available and accessible for all employees working directly with children. The Registered Provider has updated the Recruitment and Personnel File Procedure to ensure that evidence of qualifications is obtained, verified and recorded before any employee commences employment in the service. The following measures have been implemented: Qualification certificates must be submitted and verified prior to employment commencing. A Qualification Verification Checklist has been introduced as part of the recruitment process. A Qualifications Register has been established to record staff qualifications, verification dates and any qualification recognition requirements. Personnel files will be audited quarterly by management to ensure qualification records remain complete, current and readily available for inspection. No employee will be permitted to work directly with children unless evidence of a relevant qualification, or recognised equivalent qualification, has been received and verified by management. The Registered Provider will review qualification documentation during all future recruitment processes to ensure compliance with Regulation 9(4). A Qualifications Register has been created containing the qualification held by each employee, the date verified, the location of supporting evidence within the personnel file and, where applicable, confirmation of DCEDIY recognition. Qualification audit completed immediately. Qualification Verification Checklist and Qualifications Register implemented by 25/06/2026. Quarterly audits to commence from 25/07/2026
- • Following the inspection, the Registered Provider completed an immediate review of all staff supervision records. Formal supervision meetings were scheduled and completed for all employees where records were overdue or unavailable. Supervision records have been updated and placed on individual personnel files. To ensure that all employees receive regular support and supervision in accordance with the service Staff Supervision Policy, the following measures have been implemented: A Staff Supervision Schedule has been developed for all employees, ensuring that formal supervision meetings are conducted every two months as required by the service policy. A Supervision Monitoring Register has been introduced to record supervision dates, actions identified and future review dates. The Person in Charge will review the Supervision Register monthly to ensure all supervision meetings are completed within the required timeframe. Supervision compliance will form part of quarterly personnel file audits and will be reviewed during management meetings. Staff training needs identified during supervision meetings will be documented and incorporated into the annual training plan. Any missed supervision meetings will be rescheduled within two weeks and recorded accordingly. Supervision Schedule and Monitoring Register implemented and to begin on July 6th 2026. Monthly monitoring and quarterly audits ongoing thereafter. • The Registered Provider reviewed the service risk assessment procedures and completed a full review of existing risk assessments. Identified hazards and risk ratings were reassessed to ensure they accurately reflected the risks present within the service environment. Findings and required control measures were communicated to all staff. To ensure that management and staff have the knowledge and skills required to effectively identify, assess and manage risks within the service, the following measures have been implemented: Management and staff will receive refresher training on risk identification, risk assessment, hazard reporting and implementation of control measures. Management have submitted a Better Start application for Quality Practice Development- whole setting approach- to last 12 months with a better start specialist. Awaiting first visit from Better Start specialist. A Risk Assessment Review Checklist has been developed to support consistency when evaluating hazards and assigning risk ratings. Monthly risk assessments will be reviewed by management to ensure that identified hazards accurately reflect the environment and activities within the service. Risk assessments will be discussed during staff meetings and supervision sessions to ensure all staff understand identified risks, required control measures and their responsibilities in maintaining a safe environment. Significant hazards identified through daily observations, incidents, accidents, complaints or inspections will be reviewed immediately and risk assessments updated where required. A quarterly audit of risk assessments will be completed by the Registered Provider to ensure risk ratings remain accurate and that appropriate control measures are in place. Risk assessment refresher training and Risk Assessment Review Checklist implemented by July 2026. Monthly reviews and quarterly audits ongoing thereafter. Meeting will take place with KCCC on June 25th to plan the topics and dates for whole staff training and extra additional training for particular individual staff
Regulation 16 — Record in relation to pre-school service
- (i) While it is acknowledged that a staff roster was available, it was not adequately detailed to evidence planning for sufficient cover to maintain the required staffing levels. The roster did not include four staff members who were present on inspection. This non-compliance was present on the last inspection on 14 January 2026. The corrective and preventive actions as stated by the registered provider did not prevent recurrence of this non-compliance. (k) A sample of 10 accident and incident records were reviewed and had been completed. However, an incident form had not been completed for an incident where a child exited the premises unsupervised on 11 May 2026. The person in charge and deputy person in charge stated that they were unaware that an incident form was required for this incident. This is at variance with the accident and incident policy in place which stated that all accident and incidents are recorded in an accident record sheet
Provider's corrective action:
- (i) Following the inspection, the Registered Provider completed a review of rostering procedures and identified that the daily roster did not accurately reflect all staff members present within the service. The roster template has been revised to include all employees, relief staff, students, agency staff and any other adults working within the service. Management reviewed current staffing records and ensured that daily rosters accurately reflect staff attendance and room allocations. Staff responsible for preparing and maintaining rosters have been reminded of the requirement to ensure that rosters accurately reflect staffing arrangements and are updated where changes occur. To ensure compliance with Regulation 16(1)(i), the Registered Provider has implemented enhanced roster management procedures. A revised Daily Staff Roster Template has been introduced which records all adults present in the service, including permanent staff, relief staff, students, agency staff and management. The daily roster will identify staff room allocations, working hours, break cover arrangements and staffing deployment throughout the day. The Person in Charge or designated responsible person will verify the accuracy of the roster each morning and update it immediately if staffing arrangements change during the day. Monthly audits of staff rosters will be undertaken by management to ensure compliance and identify any discrepancies. Roster compliance will be included as a standing item during management reviews to ensure continued oversight and adherence to regulatory requirements. (k) Following the inspection, the incident involving a child leaving the premises unsupervised on 11 May 2026 was formally reviewed and an incident record was completed and retained on file. The Registered Provider reviewed accident and incident recording procedures with the Person in Charge, and all staff to ensure clarity regarding the requirement to record all accidents and incidents in accordance with the service policy. A review of recent accident and incident records was completed to ensure that all reportable incidents had been appropriately documented. To ensure compliance with Regulation 16(1)(k), the Registered Provider has strengthened accident and incident reporting procedures throughout the service. Refresher training has been provided to management and staff on accident and incident reporting requirements, including examples of incidents that require formal documentation. The Accident and Incident Policy has been reviewed with all staff and signed acknowledgement records will be maintained on personnel files. An Accident and Incident Reporting Checklist has been introduced to support staff in determining when an incident record is required. All accident and incident records will be reviewed weekly by the Person in Charge to ensure incidents have been appropriately documented and followed up. Accident and incident reporting will be discussed during staff meetings and supervision sessions to reinforce understanding and ensure consistent implementation of procedures. Quarterly audits of accident and incident records will be completed by management to monitor compliance and identify any gaps in recording practices. Staff refresher training completed by July 17th (in full), they began week of June 22nd with KCCC and Better Start week of June 15th for Quality Development- whole setting. Weekly reviews commenced immediately. Quarterly audits ongoing thereafter. An Accident and Incident Reporting Guidance Leaflet has been developed and issued to all staff. The leaflet clearly defines what constitutes an accident and an incident, outlines reporting responsibilities and provides examples of events that require formal documentation. Staff will sign to confirm receipt and understanding
Regulation 23 — Safeguarding health, safety and welfare of child
- General Safety: 1. See Statutory Notice section in relation to Immediate Action Notice IAN0822 served. 2. See Statutory Notice section in relation to Improvement Notice IN0942 served. 3. Procedures and practices in place in relation to risk assessments were inadequate and contrary to the service policies on risk assessments and accidents and incidents posing a potential risk to the safety of children as follows. a. A risk assessment had not been completed and mitigating measures had not been put in place following an incident on 11 May 2026 where a child exited the service unsupervised. b. There was no individual risk assessment in place for a child who staff stated required additional supports and who was observed in the corridor and kitchen unsupervised on the day of inspection as detailed under regulation 27. c. The most recent monthly risk assessment for the service was dated March 2026. This is at variance with the risk assessment policy which stated that monthly risk assessments of the entire building will be carried out as appropriate. d. Inspectors observed a number of risks in the service which had been assessed as low or no risk in the most recent monthly risk assessment available as follows. - The risk of a child exiting the service was assessed as low or no risk. - The risk of a child accessing the kitchen was assessed as low or no risk. - Risks in the outdoor area were assessed as low or no risk and the area was noted as being “well maintained and in good condition”, however risks were observed as outlined below in point 4. e. The daily risk assessment of the outdoor area completed in the Willow room on the day of inspection did not accurately reflect the risks observed in the outdoor area. The outdoor area was noted as being “free of tripping and falling hazards”, however risks were observed as outlined below in point 4. f. An accident form which was reviewed under regulation 16(1)(k) detailed an accident where a child fell in the outdoor area. The preventive measures detailed on the accident form stated, “remembering to tell children that we don’t run in the garden”. The risk management measures did not adequately identify and address the risk that caused this accident. 4. A number of risks were observed in the outdoor play area which posed a potential risk of injury to a child as follows. a. A large, unsecured piece of wooden play equipment was observed on uneven ground posing a risk of the equipment falling on a child. b. The artificial grass surfacing was curled up in several areas posing a risk of tripping to the children. c. Three covers of access junctions for the wastewater system were protruding from the uneven ground around them posing a risk of tripping. d. The plastic step on a slide had a large crack posing a risk of tripping to the children. Administration of Medication: 5. A review of documentation evidenced that the care plan of one child who was present on inspection in the Willow room stated that they may require medication for a mild allergic reaction. This medication was not available in the care room. When asked, staff were unsure where the medication was stored. This posed a safety risk of delaying appropriate medical attention if the child became unwell. Action submitted by the Registered Provider
Provider's corrective action:
- a. Following the inspection, a formal risk assessment was completed in relation to the incident that occurred on 11 May 2026 where a child exited the service unsupervised. The circumstances surrounding the incident were reviewed by management and control measures were identified and implemented to reduce the likelihood of recurrence. The service risk assessment documentation was updated to reflect the identified risks and control measures. Management also reviewed recent accident and incident records to determine whether any additional risk assessments were required and updated records where necessary. To ensure compliance with Regulation 23, the Registered Provider has strengthened procedures for responding to accidents, incidents and identified hazards. Post-Incident Risk Assessment Procedure implemented by senior management. Weekly reviews commenced immediately. Quarterly audits ongoing thereafter. The registered provider is rostered to be based in the service at least one day per week for additional support. The aerial manager will also be in Celbridge one day a week at least from July for additional support. Additional training will be provided for people in charge on supervision policy, critical incident policy, risk assessment and health and safety policy, managing behaviour policy and indoor and outdoor play policy. b. Following the inspection, an Individual Risk Assessment was completed for the child identified as requiring additional support. IEP templates were used and discussed with key workers, parents and senior management. The child’s better start specialist was consulted and we used aspects of their AIM folder to create IEP. Meetings were held with parents over a two week period regarding all needs and behaviours. Parents have made the decision to remove the child from the service at the end of the term. (end of June) However, these practices will inform best practice with other current children and future children. The child's supervision requirements, behavioural presentation, environmental risks and support needs were reviewed by management and room staff. Appropriate control measures were identified and implemented to reduce identified risks and support the child's safe participation within the service. The Registered Provider also reviewed whether any other children attending the service may require individual risk assessments based on their level of supervision needs, behaviour, additional needs or identified risks. To ensure compliance with Regulation 23, the Registered Provider has introduced a formal Individual Risk Assessment Procedure for children identified as requiring additional support or presenting an increased risk to their own safety or the safety of others. Individual Risk Assessments will be completed for children where additional supervision, behavioural support or environmental adaptations are required. Individual Educational Plans (IEP) will be created for each child availing of the AIM programme, in additional to their learning goals and better start plan- will be developed with parents and management as well as key workers and external agencies if required. IEPs will also be put into place for children who may be displaying varying levels of need but may not be meeting the requirements for the AIM scheme. Risk assessments will consider risks associated with leaving the room, accessing restricted areas, absconding, impulsive behaviour, transitions, outdoor play and any other identified vulnerabilities. Individual Risk Assessments will be developed in consultation with parents/guardians and relevant professionals where appropriate. All room staff will be informed of identified risks and control measures and will sign to confirm that they have read and understood the Individual Risk Assessment. Risk assessments will be reviewed following any incident, near miss, significant behavioural event or change in the child's needs. The Person in Charge will review all Individual Risk Assessments monthly to ensure that control measures remain appropriate and effective. Individual Risk Assessments will form part of the child's support planning and supervision arrangements within the service. Individual Risk Assessment completed immediately. Procedure implemented by 19th June 2026. Monthly reviews ongoing thereafter. c. Following the inspection, the Registered Provider completed a full monthly risk assessment of the service environment and reviewed all outstanding risk assessment documentation. The risk assessment schedule was reviewed to ensure that all required monthly assessments are completed, documented and retained within the service records. Management reviewed the Risk Assessment Policy with relevant staff to reinforce the requirement for monthly reviews of the service environment. To ensure compliance with Regulation 23, the Registered Provider has strengthened the monitoring and oversight of monthly risk assessments. A Monthly Risk Assessment Schedule has been implemented to ensure that a comprehensive risk assessment of the service environment is completed every month. Responsibility for completing and reviewing monthly risk assessments has been assigned to the Person in Charge, with oversight provided by the Registered Provider. A Risk Assessment Monitoring Log has been introduced to record completion dates, review dates and management sign-off. Monthly risk assessments will be reviewed during management meetings to ensure that identified risks, control measures and required actions are monitored and addressed promptly. Quarterly audits of risk assessment records will be completed by the Registered Provider to verify that monthly assessments are being completed in accordance with the service policy. Any overdue risk assessments will be identified through the monitoring log and addressed immediately by management. Monthly Risk Assessment Schedule and Monitoring Log implemented by Aerial Manager. Monthly reviews commenced immediately. Quarterly audits ongoing thereafter. Monthly risk assessments have been incorporated into the service compliance calendar. Automatic reminders and management oversight will ensure that assessments are completed, reviewed and signed off each month in accordance with the service policy. d. Following the inspection, the Registered Provider completed a full review of the service risk assessment documentation. All identified hazards were reassessed to ensure that risk ratings accurately reflected the likelihood and potential impact of the risks present within the service. Particular attention was given to risks relating to children exiting the service, accessing restricted areas such as the kitchen and risks identified within the outdoor environment. Risk ratings were amended where necessary and additional control measures were identified and implemented to reduce risk and enhance children's safety. The revised risk assessments were reviewed with management and staff to ensure a shared understanding of identified hazards and required control measures. Two mechanical magnetic lock and keypad doors were installed on inner hall doors and kitchen doors, also the main doors access and exit button were raised beyond shoulder height. To ensure compliance with Regulation 23, the Registered Provider has strengthened risk assessment procedures and oversight arrangements. Management and staff have received refresher guidance on hazard identification, risk evaluation and the assignment of appropriate risk ratings. A Risk Assessment Review Checklist has been introduced to support consistent evaluation of risks and ensure that risk ratings accurately reflect the likelihood and potential consequences of identified hazards. Monthly risk assessments will be reviewed jointly by the Person in Charge and the Registered Provider prior to sign-off. Any accident, incident, near miss, inspection finding or emerging concern will trigger an immediate review of relevant risk assessments. Risk assessments will be discussed during staff meetings and supervision sessions to ensure that all staff understand identified hazards and control measures. Quarterly audits of risk assessments will be completed by the Registered Provider to ensure that risk ratings remain accurate and proportionate to the hazards identified within the service. Risk assessment review completed immediately. Refresher guidance and review procedures implemented by senior management July 2026. Monthly reviews and quarterly audits ongoing thereafter. e. Following the inspection, the outdoor area was immediately reviewed by management and all identified trip, fall and environmental hazards were assessed. The daily outdoor risk assessment process was reviewed with staff and any hazards identified during the inspection were incorporated into the service risk assessment documentation. Control measures were implemented and communicated to staff. Management also reviewed current daily risk assessment records to ensure that identified hazards are accurately documented and addressed. To ensure compliance with Regulation 23, the Registered Provider has strengthened procedures for completing and reviewing daily environmental risk assessments. Staff have received refresher guidance on identifying hazards within the indoor and outdoor environments and accurately recording findings on daily risk assessment forms. A Daily Outdoor Environment Checklist has been introduced to support staff in identifying common trip, fall and environmental hazards. The Person in Charge or designated responsible person will complete weekly spot checks of daily risk assessments to verify that identified hazards accurately reflect the environment. Any hazards identified during daily inspections will be documented immediately and appropriate control measures implemented before children access the area where possible. Risk assessment findings will be discussed during staff meetings and supervision sessions to promote consistency and improve staff awareness of environmental hazards. Monthly audits of daily risk assessment records will be completed by management to monitor compliance and identify any training or support needs. Outdoor risk assessment procedures reviewed immediately. Newly updated Daily Outdoor Environment Checklist implemented week of June 22nd, 2026. Weekly monitoring and monthly audits ongoing thereafter. f. Following the inspection, the accident record was reviewed by management to consider the underlying factors that may have contributed to the accident. The associated environmental risks, supervision arrangements and contributing factors were reassessed to determine whether additional control measures were required. Relevant risk assessments were reviewed and updated where necessary. Management reviewed accident recording procedures with staff to ensure that future accident investigations consider all contributing factors and identify meaningful preventative measures. To ensure compliance with Regulation 23, the Registered Provider will strengthen accident review and risk management procedures. A Post-Accident and Post-Incident Review Process will be implemented by Senior Management and linked to the service Critical Incident Policy. Following any accident or incident that is reportable to Tusla, or any accident, incident or near miss that identifies a significant risk to the health, safety or welfare of children, staff will be required to complete a structured review of contributing factors, including environmental conditions, equipment, supervision arrangements, children's developmental abilities and any other relevant circumstances. A Post-Accident Review Form will be introduced to support staff in identifying underlying hazards, assessing risk factors and determining appropriate corrective and preventative actions. Staff training will be provided between the 6th and 17th July through flexible training sessions to maximise staff attendance. The training will focus on accident and incident reporting, identifying underlying risks, completing accident and incident documentation accurately, determining appropriate preventative actions and understanding when risk assessments require review. Where staff are unable to attend training due to annual leave, illness or other personal circumstances, additional training sessions will be arranged to ensure all staff receive the required training. The Person in Charge will review all significant accident and incident records on a weekly basis to ensure that identified control measures adequately address the risks involved and that required follow-up actions have been completed. Where an accident, incident or near miss highlights a previously unidentified hazard or ineffective control measure, the relevant risk assessment will be reviewed and updated immediately. The Person in Charge will complete the monthly service risk assessment only after reviewing room-based risk assessments to ensure consistency across documentation and to ensure that the overall service risk assessment accurately reflects the risks identified throughout the service. Accident, incident and risk assessment trends will be reviewed quarterly by Senior Management to identify recurring hazards, training needs and opportunities for continuous improvement
- a. Following the inspection, the wooden play equipment identified was removed from use immediately and access to the area was restricted until the risk could be addressed. The equipment was assessed by management, and appropriate action was taken to ensure that it was either securely positioned, relocated to a suitable surface or removed from the outdoor environment. The outdoor area was reviewed to identify any other equipment that could present a similar risk and any hazards identified were addressed immediately. Furthermore, a new picket fence is being installed on Friday 26th June 2026 to close off the area where this large wooden piece of play equipment was after the area is resurfaced to ensure restricted access to air conditioning but removed the original covering as an extra safety precaution. The whole garden is being resurfaced with additional drainage and a new astro turf surface installed on top of 804 stone and pea pebble with new drainage and fencing to fully ensure there are no more non-compliances in relation to the garden safety. The work is being completed by a registered contractor at the cost of €16,000 to ensure fully finished, low risk play area with level surfaces in all areas. Work will be completed on Friday June 26th and Saturday June 27th and pictures will be sent to inspectors following this for reference. New risk assessments templates are being created to ensure staff complete them prior to each outing to the garden with their class. b. The astroturf was pulled tight and nailed down with specific artificial grass fasteners to ensure it remained flat as a temporary measure until June 26th when the whole garden is to be resurfaced with extensive new drainage, including land drains and eco drains, hiring the ground level and altering the fall level to ensure no pooling of water to create further subsidence. Engineers and contractors are renovating and resurfacing garden with new drainage both land drains and eco drains and altering the fall of the ground to ensure no pooling of water or subsidence. Two different levels of subsurface are being installed prior to a new astroturf top surface (of a higher quality) to ensure that there will be no further occurrences of non-compliances such as this. c. On June 26th when the whole garden is to be resurfaced with extensive new drainage, including land drains and eco drains, raising the ground level and altering the fall level to ensure no pooling of water to create further subsidence. The Access junctions and manholes will get extended to be in line with the new ground level which will be raised to alter the fall and gradient of the surface while also removing areas of subsidence. The above works will be inspected after a month and then 6 months and a year by the contractors to monitor if there is any change to surface levels but there isn’t expected to be as this is a permanent solution. d. The plastic slide has been removed from the garden and a new one installed. We have hired a new maintenance man for Cookies’ ELC overall and will be responsible for carrying out maintenance on equipment and areas when informed by branch management or senior management that there are issues or areas in need of attention. Administration of Medication: 5. A parent has brought in a new bottle of antihistamine for the care room. It is in the care room in a clear plastic box with the child’s care plan attached. The spare bottle was in the office that we use as an unopened service bottle in case of emergencies, but the one in the room had need to be changed due to length of time open and needed to be replaced, which we were waiting on on the day of the inspection. The second bottle of emergency unopened medication will be transferred into the care room instead of being kept in the medication cabinet in the kitchen/office in situations such as this when awaiting new bottle provided by the parent guardian. Parent or guardian will sign our new authorisation form for this to take place, to ensure that no period of time lapses in which the medication is not in the care room in line with the care plan
Regulation 24 — Checking in and out and record of attendance
- The registered provider did not ensure that the details of all visitors to the service were documented on entering the service. An adult from an external company, who was present in the office on the inspector’s arrival, had not been checked in to the service by an employee at their time of arrival
Provider's corrective action:
- Following the inspection, the visitor management procedures were reviewed with all management and staff. The visitor sign-in process was reinforced, and all staff were reminded that any person entering the service who is not a child attending, parent/guardian collecting or dropping off a child, employee or unpaid worker must be approved by a member of staff and recorded in the Visitor Register immediately upon arrival. The Visitor Register was reviewed to ensure that visitor records are completed accurately and consistently. The Person in Charge has completed a review of the Visitor Management Policy with all staff to ensure that visitor approval and recording requirements are clearly understood. Staff have been reminded that no visitor, contractor, maintenance worker, delivery person, external professional or company representative may enter the service without first reporting to a member of staff and signing the Visitor Register. Prominent signage has been installed at the main entrance and reception area advising all visitors that they must report to a member of staff and sign the Visitor Register upon arrival. The Person in Charge will review the Visitor Register daily to ensure that visitor records are complete and accurately reflect all visitors present within the service. Visitor management procedures will form part of staff induction, refresher training and regular staff meetings to ensure continued compliance. Management will complete regular audits of visitor records to monitor compliance and identify any gaps in visitor recording practices
Regulation 27 — Supervision
- The registered provider did not ensure that adequate supervision was in place for all children on the day of inspection as follows. • A child who attended the Oak room was observed running from the care room, the full length of the corridor, to the main door of the service three times between 12:08 and 12:35. • At 14:24, the same child ran from the care room through the kitchen, where two pots of food were cooking on the hob, and into the office. On these occasions, the child was observed to reach the main door and the office before a staff member reached them to bring them back to the care room. This is at variance with the supervision of children policy in place which stated that children must not be allowed in the corridor unaccompanied and that appropriate supervision should take account of individual children’s needs
Provider's corrective action:
- The registered provider liaised and consulted with staff working directly with the child, the management team, the child’s parents, external agencies and the service’s Better Start specialist in relation to the child’s AIM plan and goals. A meeting and an IEP was developed with the child’s parents which was relative to his AIM goals and other recommendations. The child’s mother has decided that the child will be finishing up with us in the next two weeks but all necessary steps were taken in the meantime. Further to the above, as part of the IAN, two keypad magnetic doors were installed both in the hall and on the kitchen door. Staff training is being provided between the dates of July 6th to July 17th for all staff including training on managing challenging behaviours, risk assessments, policy updates including supervision of children and safeguarding procedures. Staff who work with children under the AIM process will have more frequent contact directly with the better start specialist assigned for our service and can reach out to them if they are having more specific concerns that original observations at the beginning of the AIM observation and support role. IEP’s will be created for every child under the AIM programme and also other children who do not qualify for the AIM scheme but show varying levels of need. The newly installed keypad systems will also prevent further concerns of children accessing the front section of the premises outside of the care rooms
Regulation 31 — Notification of incidents
- (e) The registered provider had not submitted a Notification of Incident form to the Agency following an incident on 11 May 2026 where a child exited the service unsupervised. The person in charge and deputy person in charge stated that they were not aware that a Notification of Incident form was required for this incident
Provider's corrective action:
- (e) Following the inspection, the Registered Provider reviewed the incident that occurred on 11 May 2026 where a child exited the service unsupervised. It was identified that a Notification of Incident should have been submitted to Tusla in accordance with Regulation 31(e). The decision not to submit a notification was reviewed by senior management and corrective action was taken to address the failure to follow reporting requirements. Management responsibilities and reporting obligations were clarified with Person in Charge and Deputy Person in Charge. The incident was reviewed as part of the service's safeguarding and compliance processes to ensure learning was identified and shared. To ensure compliance with Regulation 31(e), the Registered Provider has strengthened incident notification procedures and management oversight arrangements. A review of incident notification procedures was completed with Person in Charge and Deputy Person in Charge to ensure clarity regarding incidents that require notification to Tusla. Additional training has been provided to management teams on incident classification, mandatory notifications, safeguarding responsibilities and regulatory reporting requirements. The Deputy Person in Charge attended further training supported by senior management relating to incident management, safeguarding and reporting procedures. Learning from this training has been shared with staff teams. A Notification of Incident Guidance Document has been developed to support management in determining when a notification to Tusla is required. Any incident involving a child leaving the room unsupervised, leaving the premises, being unaccounted for or any event that may fall within the notification requirements will be escalated immediately to senior management for review. Weekly management meetings are held across all services to review incidents, discuss safeguarding matters, support Persons in Charge and ensure consistent implementation of policies, procedures and regulatory requirements. Incident records and notification requirements will be reviewed during management audits to ensure that reportable incidents are identified and notified within required timeframes. The service has adopted a precautionary reporting approach whereby uncertainty regarding the reportability of an incident will result in immediate escalation to senior management rather than reliance on individual interpretation
Regulation 33 — Furnishing of information to agency
- The person in charge and staff did not furnish the inspectors with relevant information required to enforce the Regulations regarding an adult who was on the premises during the inspection as follows. • On the inspector’s arrival the person in charge stated that an adult present in the office was on induction reviewing paperwork. The person in charge stated that this adult was not currently working in the service as their Garda vetting was not yet in place. • The person in charge stated that the adult had arrived at 09:30 and would be leaving at 11:00. • In discussion with staff in the care rooms, all staff stated that the adult had not been working in the care rooms. • On review of accident and incident documentation at 14:55, two forms, dated 05 May 2026, were found to have been completed by this adult. • This information was presented to the person in charge who confirmed that the adult had been employed in the service since 21 April 2026 without Garda vetting in place
Provider's corrective action:
- The registered provider would like to stress that this non-compliance in particular is completely at odds with the policies of Cookies’ and our ethos and management procedures. It does not represent the registered provider, nor Cookies’ management as a whole. The person in charge has undergone a disciplinary process and is no longer an employee of Cookies’ ELC. All actions described in the bullet points are actions and decisions made by an individual that was not in accordance of Cookies’ policies and procedures. The staff who followed suit with the same representation have also undergone disciplinary processes and received formal disciplinary action as a result. The person in charge furthermore did not follow Cookies’ training and induction or recruitment processes in regards to vetting. The person in charge on the day of the inspection is no longer the person in charge in Cookies’ Celbridge branch. The deputy person in charge (will be PIC) has received full training from both the aerial manager, the registered provider, KCCC and also our Cookies’ branch aerial quality support manager in recruitment and best practice in relation to staff initial training and induction. Formal communication was issued to all staff currently employed in this branch as to the importance of regulation 33 and their obligations to uphold the integrity of their responsibility with children and vulnerable people, whilst always maintaining compliance under Tusla regulations. Some staff faced disciplinary action (those involved) and training is being provided by KCCC during the 6th to the 18th July 2026
Regulation not named in the report text
- (1)(3) It is acknowledged that the registered provider submitted a change in circumstance form to the Agency regarding a change to the person in charge with effect from 04 May 2026. However, the person in charge confirmed that they had been in their role since 09 March 2026 prior to approval of the change. This regulation was non-compliant on the last inspection on 14 January 2026. The corrective and preventive actions submitted by the registered provider did not prevent recurrence of this non-compliance
Provider's corrective action:
- (1)(3) Upon identification of the non-compliance, the Registered Provider reviewed the appointment process relating to the Person in Charge role and confirmed that the Change in Circumstances notification had not been submitted within the required timeframe. The relevant notification has now been submitted to the Agency and all records relating to the appointment have been updated to accurately reflect the approved change. A designated responsibility assigned to both the Registered Provider and the Management Team to review any proposed changes that may require notification to Tusla, including changes to the Person in Charge, Registered Provider details, service address or operating arrangements. A Change in Circumstances Register will be introduced to record proposed changes, the date the change was identified, notification submission dates, approval status and implementation dates
Found compliant: Regulation 10, 11, 19, 29, 30.