A review of documentation and discussion with the person in charge evidenced that one written reference from a past employer in respect of one adult had not been validated by the registered providers prior to the adult commencing in their role
Documentation reviewed evidenced that the procedures specified above under 9(2) had not been carried out prior to one adult commencing in their role in the service, as detailed above under regulation 9(2)
Provider's corrective action:
The staff member in question was on a work experience placement, and the second reference has been completed and validated. The file checklist will be reviewed and signed off by HR before an employee or work experience starts their role
The staff member in question was on a work experience placement, and the second reference has been completed and validated. The file checklist will be reviewed and signed off by HR before an employee or work experience starts their role
Regulation 20 — Facilities for rest and play
Appropriate rest facilities were not provided for all children under 2 years in Room 5. On the day of inspection, two children aged 1 year were observed on stackable beds. These beds were not fitted with firm, flat, waterproof and breathable mattresses. This may impact the safety and quality of sleep for children under 2 years
Provider's corrective action:
We have the beds available in our service fitted with the firm flat mattress, which were tested with both children but subsequently declined. The two children, aged 1 year and 8 months, have been offered the option to sleep on the beds fitted with firm, waterproof mattresses. All children under 2 years will be placed to sleep on beds fitted with firm, waterproof mattresses
Regulation 23 — Safeguarding health, safety and welfare of child
Administration of Medication: 1. Practices in place for children attending the service requiring medication were at variance with the service policy, posing a potential risk to the health and safety of children. Emergency medication available for one child was out of date posing a risk to the effective treatment of the child in an emergency. Safe Sleep: 2. Procedures and practices in place in relation to safe sleep for children using the cot room adjacent to Room 4 were inadequate and contrary to the service’s policy on safe sleep posing a potential risk to the health and safety of children as follows. a. Between 11:17 and 12:31 sleep checks were not consistently carried out every 10 minutes for a child aged 1 year who was sleeping in the cot room. Sleep checks were carried out at intervals of 15 minutes, 9 minutes, 14 minutes, 23 minutes, and 13 minutes. Between 11:55 and 12:31 sleep checks were not carried out every 10 minutes for a second child aged 1 year who was sleeping in the cot room. Sleep checks were carried out at intervals of 23 minutes, and 13 minutes. Staff in the room recorded sleep checks as taking place every 10 minutes during these times. b. At 11:55, a child aged 1 year, who was sleeping in the cot room was not sufficiently checked. A staff member was observed checking the child from the doorway of the cot room where an adequate assessment could not be completed. Action submitted by the Registered Provider
Provider's corrective action:
Administration of Medication: 1. The emergency medication has been replaced, and the service has now received the new medication for the child. This ensures that appropriate emergency medication is available and in date. To prevent delays in replacement, parents will now be reminded approximately 5 months in advance of expiry dates to allow sufficient time for renewal and supply of replacement medication. A new medication checklist has been created and displayed in the room including expiry dates and availability, and parents will now be reminded approximately 5 months in advance of expiry dates to allow sufficient time for renewal and supply of replacement medication. Safe Sleep: 2. The staff have been reminded that sleep checks must be conducted every 10 minutes and recorded accordingly. As a preventive measure, a timer will be set on the tablet to assist in ensuring sleep checks are conducted every 10 minutes
Immediate action notice. Following the submission of the second CAPA, a regulatory compliance meeting was held on 15 December 2025 with the registered provider and the person in charge to discuss unresolved non-compliance.
Regulation 9 — Management and recruitment
(a)(b) - Two written references were not available in respect of three adults, and a second reference was not available in respect of two adults employed to work in the service. - There was no evidence available to demonstrate that five written references in respect of four adults had been validated by the registered providers. (d) There was no police vetting available for three adults who lived outside the state for a period of longer than six months as an adult. Police vetting available for 10 adults employed had not been translated and therefore could not be interpreted
The registered providers did not take appropriate measures to ensure that all adults were suitable to work in an early years service prior to their commencement as follows. - There was no evidence to demonstrate that five references had been validated for four adults prior to the adults commencing employment as there were no dates recorded on the validation records. - Police vetting available for one adult was dated after the adult commenced employment. The adult commenced employment on 15 June 2025 and police vetting was obtained on 19 June 2025
Provider's corrective action:
(a)(b) Upon review, we have located the relevant written references, and these were in the staff files, but not in the specific location (the policy pocket) that was provided for inspection. We understand that the references should have been easily accessible and apologize for not having them in the requested location. We will review all staff files to ensure that references and all other required documentation are properly organized and stored in the policy pocket for ease of access during inspections and audits. We will validate all references by directly contacting the referees by phone to confirm the authenticity of the written references. Ensure that each reference is verified through a verbal conversation, not just email confirmation. Using our checklist for each new hire, which includes steps for phone-based reference verification. This checklist will be part of the recruitment file for each staff member, ensuring all steps are completed and documented. (d) Going forward, all police vetting documents will be filed correctly according to the file checklist available for inspection. The untranslated police vetting records have now been translated and filed. All police vetting records will be translated prior to an employee’s start date. This ensures that all necessary documentation is ready and compliant before they begin work
- The references were validated but the dates on the validation were not recorded, and this was an error due to human oversight during the process. We will reinforce the reference validation process with all relevant staff to ensure that dates of validation are properly recorded on all reference documentation moving forward. This will be part of a detailed checklist to ensure no information is overlooked in future. - No corrective and preventive actions were submitted regarding obtaining police vetting prior to adults commencing employment
Regulation 19 — Health, welfare and development of child
1. The registered providers did not ensure that suitable care practices were in place for all children in the service. Provision for children’s sleep requirements were inadequate to meet the needs of all children in Room 4 and were contrary to the service policy on safe sleep. One child, aged 9 months, was not provided with the opportunity to sleep when they displayed signs of tiredness. The inspector observed the child yawning, rubbing their eyes and crying. This child was observed to fall asleep in their highchair following their dinner. Although the adults acknowledged that the child was tired, the child was not placed to sleep in a timely manner. The sleep practices observed during the inspection do not meet the basic care needs of all children and are not in line with suitable child centred care practices. 2. The personal care needs of all children were not met in a timely manner in Rooms 4 and 5. Children were observed with mucus coming from their noses. Staff were observed engaging with the children but did not clean their noses
Provider's corrective action:
1. No corrective action submitted. We will continue to ensure all children’s sleep needs are met promptly, we have further emphasized the importance of placing children to sleep as soon as signs of tiredness are observed, without delay and our safe sleep policy has been re-shared with our staff. 2. We have reminded staff of the importance of regularly monitoring children for any signs of mucus coming from their noses. Staff have been retrained to ensure they clean children’s noses promptly when necessary and to be proactive in meeting the personal care needs of each child in a timely and compassionate manner. We have reminded staff to promptly clean children’s faces when needed, while being mindful of the child’s comfort
Regulation 23 — Safeguarding health, safety and welfare of child
Infection Control: 1. Some handwashing practices observed were inconsistent and at variance with the policy in place in the service posing a risk of the transmission of infection as follows. - In Room 5 a staff member was observed to clean a child’s nose but did not wash their hands following this. - Staff and children were observed lifting the lid of pedal bins to dispose of paper towel following hand washing. 2. Some nappy changing practices observed during the inspection were inadequate for infection control purposes and at variance with the service’s nappy changing procedure as follows. - Staff were observed handling the lid of the bin and redressing the children while wearing the same gloves used for nappy changing. - Staff did not consistently disinfect the changing mat following nappy changes. - Staff did not consistently wash their hands following nappy changing. - There was no requirement in the nappy changing procedure on display to remove and change used gloves to apply cream during nappy changing. 3. The children attending Room 8 were of an age where they explored toys with their mouths. During the inspection there was no attempt made to remove the toys when mouthed despite the room having a designated box for this purpose. The toys remained in use between the different children posing a risk of the transmission of infection. 4. In Room 8, children were observed drinking from each other’s beakers posing a risk of the transmission of infection. 5. In Room 8, soothers were not stored separately posing a risk of the transmission of infection. Action submitted by the Registered Provider
Provider's corrective action:
Infection Control: 1. We will continue to reinforce the importance of handwashing after any direct contact with a child’s bodily fluids. Staff have been reminded to wash their hands promptly in these situations to ensure proper hygiene practices are followed. We reinforced with staff the correct practice of using the pedal bins without touching the lid. We will continue to emphasize the importance of this practice in our staff meetings, as well as ensuring that staff consistently model proper behaviour. Regarding the children, we understand that they are still developing certain skills, including disposing of items without touching the bins. We will continue to support and guide children to use the pedal bin appropriately, considering their developmental stage, while ensuring that staff remain vigilant in helping them with these tasks. The handwashing policy has been re-shared with all staff, who have signed and acknowledged their commitment to implementing and reinforcing the policy in their daily practices. This will continue to be emphasized in staff meetings and during individual supervision to ensure consistent adherence to the procedure. We will continue to do regular spot checks to ensure the proper use of pedal bins are consistently followed. Any issues or deviations will be addressed immediately to maintain a safe and hygienic environment. 2. We take the infection control and hygiene procedures in our nappy changing process very seriously and strive to maintain high standards at all times. Staff are trained in our nappy changing procedure from day one and spot checks are done during the day. The practices observed during the inspection are not representative of our normal standards. In our daily operations, staff are expected to follow the nappy changing procedure outlined in our policy, which includes handling gloves, disinfecting changing mats, and washing hands consistently. These practices are regularly monitored during spot checks and they are typically followed without issue. The requirement to change gloves when applying cream is outlined in our Soiled Nappy Changing Policy, which is on display in each nappy changing room, alongside the wet nappy changing procedure. The Soiled Nappy Changing Policy includes the necessary steps for infection control, including the correct handling of gloves during nappy changes, and specifically addresses the need to change gloves before applying cream or handling any other items after changing a soiled nappy. 3. It is our practice to manage mouthing toys in accordance with our Mouthing Toys Policy, which includes the use of a designated box for toys that have been mouthed. During the inspection, the failure to remove mouthed toys from circulation was not in line with our usual practices and we have taken immediate steps to address this issue. We have already shared the Mouthing Toys Policy with all staff and they have signed and acknowledged their understanding and commitment to following the procedure. Staff will be reminded regularly during meetings, and our team leader and manager will monitor staff practices to ensure compliance throughout the day. 4. Each child’s beaker is labelled and sometimes children, particularly at a young age, may sometimes inadvertently share beakers. This is typically unintentional, but we recognize the importance of preventing this to avoid the potential transmission of infection. As part of the daily routine, staff will continue to gently remind children of the importance of drinking from their own beaker to prevent the spread of germs. 5. The soothers were placed in a clean bowl after being sterilized the evening before. All staff are fully aware that soothers should be stored in their original boxes to ensure proper hygiene and infection control. Unfortunately, this was an oversight on the day and we will ensure that it does not happen again moving forward. Staff were reminded that the soothers need to be placed in their original containers as they arrive to the room. This is being spot checked in the morning by the team leader and manager
Found compliant: Regulation 11, 16.
Inspection of 24 November 2023 — Inspection Report