Inspection of 10 April 2025 — Inspection Report
Immediate action notice. An Immediate Action Notice was issued to the service on 11 April 2025 in relation to
Regulation 9 — Management and recruitment
- (d) Police vetting was required for four adults and two were available for review. Evidence of police vetting was not available for one staff member who required it. While there was a police vetting record available for another staff member, it was not evidenced that this had been considered as it had not been translated. (3) Recruitment and vetting procedures were not carried out in advance of appointment for all staff. The service did not consider the police vetting for two staff prior to their appointment. (4) It is acknowledged that seven of the adults held at least a major award in Early childhood Care and Education at Level 5 on the National Qualifications Framework or a qualification deemed by the Minister to be equivalent. However, evidence was not avai lable to demonstrate that one adult had the required qualification
Provider's corrective action:
- (d) One of the police vetting records has been translated and the other staff member no longer works in the service. All documents for recruitment will be in place prior to the appointment of staff going forward/ added to staff files. (3) All documents for recruitment will be in place prior to the appointment of staff going forward and added to staff files. A checklist is now in place for manager and deputy to complete before the commencement of new staff (4) The staff member is currently awaiting their certificate from QQI and this will be submitted to the Inspectorate as soon as it is received
Regulation 11 — Staffing levels
- (1) An adequate number of adults were not working with the children on the day of inspection. The following was observed; a. The person in charge confirmed the staff members assigned to prepare food for the children. On the day of inspection, the staff member working directly with six pre-school children was responsible for the preparation of the dinner for the children in the service. It is acknowledged that the kitchen is adjoining the Playschool room. However, at 11.20am the staff member was observed to prepare the dinner and was not directly available to the children in the playschool room. b. Due to the nature and needs of the children within the baby and Playschool rooms, an additional adult was required to provide support at times. Staffing levels during mealtime in the Baby room impacted on care as reported on under Regulation 19. Health, welfare and development of child. For example, o At 10.25am, there was one child aged 1 – 2 years crying in the sleep room. At this time, the staff member was soothing another child to sleep in the Baby room. An additional staff member was required to provide support at this time. o At 10.35am, a child in the Playschool room went to the toilet which was located in the hallway of the service. It is acknowledged that t he staff member was verbally checking with the child that they were okay . The child confirmed they required support from the staff member. The staff member left the care room to support the child. An additional staff member was required at this time to supervise the five children in the Playschool room and/or provide support to the child in the toilet. (2) The adult to child ratio was not maintained at all times in the afternoon. Between 12.50pm to 1.10pm, the two groups of children from the Playschool and Montessori room merged as one group. At this time, there was one adult in the outdoor area with twelve pre-school children aged 2 to 5 years attending on a full day care basis
Provider's corrective action:
- (1) Extra staff have since been recruited to meet staffing levels and support the educators throughout the day. a. An additional staff member was hired for the kitchen. b. A change in circumstance form was submitted to the inspectorate on the 11 July 2025 outlining that the baby room ceased operation. The service now offers care for children from 1 year to 6 years. (2) Extra staff have since been recruited to meet staffing levels and support the educators throughout the day. This is reflected on the roster submitted
Regulation 16 — Record in relation to pre-school service
- (i) A staff roster was available within the service however; it was not reflective of the staff members who were present within the service on the day of inspection. For example, one staff member who was present but not rostered to work and another staff member who recently left the service was rostered to work. (j) Details were not recorded of medication given to a child attending the service. It is noted that the service has an authorisation form for the administration of medication signed by the child’s parent and/or guardian which included the name and frequency of the medication. However, a record to detail the actual administration to include the child’s name, time, date, name of the medication, adult administering and adult witnessing was not available. The service’s policy did not detail the procedure to record the details in the case where medication is administered by the service. This posed a risk as the details of when a child received medication may be unknown and it may affect the medical treatment provided to the child. (k) A sample of accident and incident records were reviewed. The records were inconsistent and not completed with a staff signature or a parent signature. This was at variance of the service’s accident and incident policy which stated that the records are completed with the staff signature and the parent signature when the child is collected from the service
Provider's corrective action:
- (i) In the case where a staff member leaves the service, without notice, when cover has been arranged the registered provider will immediately change roster to reflect staff working on the day. (j) The administration of medication forms will be changed back to the services original format as this format includes all details required. (k) Accident and incident forms will be filled correctly under management’s supervision. At a recent staff meeting, sample Accident and incident forms were shown to staff members to outline the importance of correct recording. Accident & incident forms are now filled out in the presence of management to ensure correct recording and offer support if required
Regulation 19 — Health, welfare and development of child
- Basic needs 1. The staffing level and equipment available did not support the needs of children in the Baby room during lunch time. There were two high chairs available for the three children aged 1 to 2 years old on the day of inspection. At 12.30pm, the staff member was observed to feed two of the three children their dinner in the high chairs. The third child sat on the floor between the high chairs and was observed to be crying. At 12.40pm, the staff member removed one of the children from the highchai r and placed them onto the floor. This child was observed to become upset. The adult placed the third child into the high chair and began to feed them their dinner. At 1.10pm, the second child remained sitting between the two high chairs and was observed to be crying while the staff member fed the two other children in the highchairs. The lack of equipment and additional support did not promote a calm or child-led mealtime for three children in the Baby room. 2. The children aged 1 to 2 years in the Baby room were not observed to engage in outdoor play on the day of inspection. This was at variance with the service’s outdoor play policy which stated that each child spends a minimum of 30 minutes outdoors every day, weather permitting. This practice may limit the play and development opportunities for the children in the Baby room. Physical and Material Environment 3. Rest areas for children were not in place within the four care rooms to support children to rest or retreat from the group as required. 4. Equipment and mat erials were not readily accessible to children and were limited in variety . The equipment did not provide opportunity for challenging, diverse, creative or enriching experiences for children within the baby, toddler and Montessori room s in line with their stage of development. This was at variance of the service’s policy which outlined that the materials and equipment is suitable and age appropriate, while providing new exciting challenges and experiences. The policy also outlined that the layout of the room is carefully designed and the equipment is accessible to the children to encourage free choice. The following was observed; a. Staff did not ensure that a variety of equipment and toys were easily accessible to the babies to support their exploration and play. In the Baby room, the three children aged 1 to 2 years had access to one push/ pull toy, a mirror and a wall jigsaw. It is noted that play equipment was available in boxes on a shelving unit. However, as the children were continuing to develop their skills to crawl and walk, these materials were not easily accessible. It is noted that the staff members provide the children with story books and a box containing plastic toys during the inspection. b. In the Toddler room, the jigsaws were stacked on the shelving unit and were not easily accessible for the children. T here was a play kitchen in the room too, however, there were no supporting materials including food or kitchen utensils to extend the children’s play. c. In the Montessori room, the children had access to Montessori equipment, art easel, blocks jigsaws, and a sensory table. T here was also children’s dress up clothes , however, these were stored in a plastic box. (b) 5. Staffing allocation did not align with the service ’s policy objective to support the development of relationships between the staff members and children. The service’s behaviour management policy outlined that there was a key worker system in place within the service to support the development of secure, trusting relationships between staff members, the children and parents/guardians. The policy outlined that the key worker system supported children’s care routines such as mealtimes, sleep and the personal care of the child and when the key person was absent, there was a secondary key worker available who was familiar to the children. It is noted that the person in charge outlined there was a transition of staff happening between care rooms. However, on the day of inspection, within the Baby room there were five staff members intermittently working with the three children aged 1 to 2 years old. In discussion with staff members, this routine was in place on a daily basis
Provider's corrective action:
- 1. The baby room ceased operation from 11 July 2025. Additional staff members have been recruited to provide support in rooms throughout mealtimes. This is visible on the roster. 2. The baby room has closed since 11 July 2025. However, the manager reiterated the importance of daily outdoor play to staff members and support is available from the manager on heling the children while outside. All children will have unlimited daily access to the outdoor area and daily outdoor play will be stressed to staff members at the next planned meeting. 3. Each room has a defined rest area. The manager will carry out regular ad hoc checks in all rooms to ensure rest areas are available and maintained at all times. 4. The service is engaged with a quality support mentor who will provide guidance and direction regarding the environments within the service. More diverse materials are being sourced. The registered provider will also source natural, diverse, and creative age-appropriate materials for all rooms. Creative materials will be accessible and will be at a low level for all children. The service will provide more real-life materials to the home area and display them in an inviting manner for the children. the service will provide natural age-appropriate materials in all rooms. And the dress up clothing will be hung up in a more captivating manner. 5. The service is engaged with a quality support mentor who will provide guidance regarding a key worker system. Each child and group of children have a key worker assigned
Regulation 23 — Safeguarding health, safety and welfare of child
- Fire Safety: 1. The fire safety measures in place within the service posed a potential immediate risk to children . An Immediate Action Notice was issued to the service on 11 April 2025 due to the following observations; a. It was confirmed that monthly fire drills do not take place with the children in the Baby and Toddler room. The staff members outlined that the children from the pre -school and Montessori rooms take part in the fire drills. The date of the last fire drill for the children in the Baby and Toddler room was unknown to staff members and the person in charge . This was at variance with the service’s fire safety policy which outlined that monthly fire drills are conducted, with all children in the service. b. The service fire safety policy outlined that staff are provided with training to ensure that they are aware of the procedure to be followed in the case of a fire. In discussion with staff members, they described the route to take in the event of an emergency , however, this was at variance with the actual route in place. c. The route identified as the fire exit for when the children were in the back garden was blocked with two bikes/trikes and a large piece of wood. This was not in line with the service’s fire safety policy which stated that escape routes are free from obstruction to ensure that they could be used safely and effectively at all times. d. The service’s policy outlined that the attendance record is used in the event of an emergency evacuation. However, the attendance record was not maintained as children were collected from the service. At 3.20pm, there were 15 pre -school children in the service, however, there were 20 children marked as present. The above risks were brought to the attention of the person in charge by the early years inspector during the inspection on 10 April 2025. Responses detailing the immediate actions taken by the service was received from the registered provider on 11 and 14 April 2025. 2. The fire escape route within the sleep room was impeded by the storage of stackable beds which were located at the door. This posed a risk of safe evacuation in the event of an emergency. Safe Sleep: 3. The sleep practices within the service posed a potential immediate risk to the children aged 1 – 3 years in the sleep room. These practices were at variance with the service’s safe sleep policy. An Immediate Action Notice was issued to the service on 11 April 2025. The following was observed; a. Sleep checks were not consistently carried out every 10 minutes by the staff members while four children aged 1-3 years slept in the sleep room throughout the inspection. The service’s safe sleep policy outlined that sleeping infants/children would be checked, every 10 minutes, by assigned staff. b. Sleep records for children were not completed. For example, three children aged 1 -2 years were asleep from 10.40am. At 11.05am the sleep records were as follows; • Two records did not detail sleep checks from 10.40am; • One record did not detail any time the child went to sleep and/or sleep checks which took place. This was at variance with the service’s safe sleep policy which outlined that sleep information would be recorded on a sleep chart following a 10-minute sleep check. c. There was no means of ensuring the temperature within the sleep room was maintained between 18- 22 °C as the thermometer was broken. The above was brought to the attention of the person in charge by the early years inspector during the inspection. Responses detailing the immediate actions taken by the service was received from the registered provider on 11 and 14 April 2025. 4. The service’s safe sleep policy outlined that the service used a monitor and physically entered the sleep room to carry out sleep checks. On the day of inspection, the staff members were observed to carry out sleep checks from a sliding window in the Baby room which was adjoining the sleep room. This does not support a thorough check on sleeping children . This practice is at variance with the service’s policy on checking sleeping children. 5. The cot sheets on two of the three cot mattresses in the sleep room did not fit the mattresses as follows; a. One of the cot sheets appeared to be too small and the mattress was upright on one corner. This created a foothold or means to climb out of the cot. b. One cot sheet had excess material and appeared to be too large for the mattress. This was at variance with the service’s safe sleep policy which outlined the sleep room is risk assessed daily and that no loose bedding is used in cots. This practice posed a risk of injury to a child. 6. Children’s footwear was not removed prior to sleep. In the Playschool room at 12.40pm six children aged 2-4 years old slept with their shoes or welly boots on them. Infection Control: 7. Floor cushions were provided for the six children sleeping on the stackable beds. These cushions were not a suitable alternative for a pillow. 8. Individual bed linen was not provided for the stackable beds for the children in the Playschool room. This practice was at variance with the service’s safe sleep and infection control policies which stated that bed linen is used on stackable beds and that each child has their own bed linen. 9. The water in the sanitary area for the children was cold to touch. This was at variance of the service’s infection control policy which outlined that warm water was provided for handwashing. This increased the risk of the spread of infection as cold water may reduce the time spent by children while washing their hands. 10. The service’s infection control policy outlined that children are provided with paper towel to dry their hands following handwashing. On the day of inspection, the children were provided with a communal hand towel in the sanitary area to dry their hands. This posed a risk of the spread of infection. 11. The nappy changing practices were inconsistent and at variance with the service’s infection control policy. The following was observed; a. Staff members did not remove the apron between nappy changes, b. Children’s hands were not washed following a nappy change, c. Adults did not wash their hands following each nappy change, d. Gloves were worn on one hand. These practices posed an increased risk of the spread of infection. 12. The staff members assigned to prepare and cook food on the premises were observed to carry out nappy changing duties on the day of inspection. This was at variance with the service’s infection control policy which outlined that staff undertaking nappy changes are not involved in the preparation, cooking or serving of food. This posed a risk of cross contamination. 13. The nappy changing bin was at variance with the Early Years Inspectorate Regulatory notice issued in 2022 which required disposable nappies to be disposed of in a foot-operated, lined, lidded bin that is leak proof, sealable and easy to clean. A swing bin was in place in the nappy changing area. 14. The wood in nappy changing area was untreated with exposed and uneven areas. This posed an increased risk of infection as the surface could not be effectively cleaned. General Safety: 15. The service did not adhere to the re-vetting timeframes as outlined in the Early Years Inspectorate Regulatory Notice, requiring services to renew Garda vetting every three years. On review two Garda Vetting disclosures were dated over 3 years ago. 16. The wood surface on three tables in the outdoor area was uneven with a splintered edge. This posed an increased risk of injury to a child. It is noted that the service had a risk assessment for the outdoor area. however, in discussion a completed risk assessment was not available. 17. The radiator cover in the Playschool room was not secured appropriately and posed a finger pinching risk to a child. Action submitted by the Registered Provider
Provider's corrective action:
- Fire Safety: 1. A response was provided to the Immediate Action Notice (IAN). The registered provider stated the below actions would be discussed at a meeting on 14/04/2025 held by the service manager. All staff members will be issued with a copy of safe sleep and Fire safety policies. And further to the arranged meeting, the registered provider will request staff members to sign and date they understand and agree to issued policies. Alongside these actions, the registered provider stated the following measures were also taken by the service; (a) The service would complete a full centre fire drill on 15/04/2025. (b) The fire assembly point has been explained and identified through a picture to staff members. (c) Items blocking fire exits were removed and that all exits were clear as of 11/04/2025. (d) The registered provider reiterated to staff the importance of signing out children in real time. Through the CAPA response received on 29 May 2025, the registered provider stated monthly fire drills will take place. All fire exits will remain clear and the service will ensure this going forward. The registered provider stated they are willing to Liaise with Fire Officer and take on board any advice. A senior staff member has been appointed as the fire safety officer and will carry out fire safety checks of fire safety equipment and fire exits. A number of staff members have completed training on fire safety, and the remaining staff members will complete the training in the coming days. The service has liaised with the Fire Officer in Carlow. 2. The stackable beds are stored in the storage room and the manager has introduced checks to ensure that the floor beds are stored safely and that all fire exits are clear. Safe Sleep: 3. The registered provider provided a response to the Immediate Action Notice which stated the following measures were immediately implemented by the service; a. The importance of correct sleep checks to be carried out by Educators discussed at meeting 14 April 2025 b. Sleep checks will be filled out in real time and monitored by the service c. A thermometer was purchased on 14 April 2025 and put into the sleep room. 4. The registered provider stated that the staff member who is conducting sleep checks physically enters the room to observe children. 5. Bedding was checked thoroughly and removed if not appropriate. Regular check of bedding will take place and be replaced accordingly. 6. All footwear and unnecessary clothing will be removed for rest periods. A display has been put onto the notice board to remind staff to remove footwear and heavy clothing prior to sleep. Infection Control: 7. A display has been put onto the notice board to outline safe materials for the use on floor beds. 8. Correct bedding will be used on floor beds to include a sheet and blanket for each individual child. Regular check of bedding will take place and be replaced accordingly. 9. The service will use the emersion in summer months and heating in winter months switched on at 7.30am to provide a supply of warm water for hand washing. There will be an endless supply of warm water for handing washing. Water checks were added to the daily checklist. 10. Paper towels are supplied in all bathrooms and care rooms and it has been added to the daily risk assessment to ensure there is ample supply. 11. Nappy changing practices were discussed and all staff members understand the importance of adhering to nappy changing policies. Staff were all retrained on nappy changing practice. Nappy changing policy displayed in the area along with visual display. The service’s policy was also emailed to all staff for attention. The manager will carry out regular observation of nappy changes to ensure all steps are followed. 12. Manager will prioritise implementation of any Regulatory notices received from Tusla, Pobal, CCC etc. 13. The bin was replaced immediately. 14. One person has been assigned for cooking solely. An additional staff member was recruited to carry out cooking duties within the service. 15. There is a new foot operated bin in place. General Safety: 16. The service has re-vetted all staff and all re-vetting will be carried out in the specified timeframe going forward. 17. The wooden table was removed from the outdoor area. Broken equipment will be reported to management and will be replaced immediately. This was added to the daily risk assessment for the outdoor area. 18. The radiator cover was secured and poses no risk to children. All radiators were checked
Regulation 29 — Premises
- (e) 1. The nappy changing area was not suitable as it posed a risk of injury to the children and staff members. The nappy changing unit was in the staff sanitary area and located within a shower unit. The following was observed on the day of inspection; a. A shower hose and water dial were within reach when a child was lying on the nappy changing mat. b. Staff were observed to lift the children onto the nappy changing mat and manoeuvre the children between a tile intersection of the shower and a shelving unit onto the nappy changing unit. c. Staff were observed to stand on the raised frame of the shower tray when carrying out nappy changes. d. Nappy changing for some children was observed to take place on the floor of the sanitary area due to the absence of steps for children to access the nappy changing area. 2. Based on the age and stage of development of the children within the service, t he nappy changing facilities available did not support the needs of all children requiring a nappy change. Staff members were observed to carry out nappy changes for their group of children at set times during the day, and as required. At 12pm, a staff member identified a child aged 1 to 2 years required a nappy change. When the staff member went to the nappy changing area, the area was occupied with a staff member and child from another room. The staff member returned with the child to the nappy changing area on three occasions, however the nappy changing area remained occupied. This child remained unsettled until their nappy was changed at 12.25pm. There were inadequate facilities available to support the age and stage of the children
Provider's corrective action:
- 1. The changing area has been renovated. 2. A change in circumstance form was submitted to the Inspectorate on the 11 July 2025 outlining that the baby room ceased operation. This now reduces the pressure on the nappy changing area
Found compliant: Regulation 22, 25, 26.