Inspection of 22 October 2025 — Inspection Report
Immediate action notice. An immediate action notice (IAN) was issued to the person in charge on the day of inspection in relation to a risk identified under
Regulation 9 — Management and recruitment
- (3) The registered provider did not ensure the following checks were carried out prior to six adults working in the service. • Documentary evidence available indicated written and verified references were not available for six adults. • Information was not available to ascertain whether one adult required International Police vetting
Provider's corrective action:
- 9 (3) All staff files were reviewed after the inspection. Written and verified references were obtained for the six adults, and additional information was provided for one adult confirming their requirements regarding Police vetting. A new staff checklist has been developed for use during the recruitment process, and no staff member will commence employment in the service until all required documents have been obtained. In addition, management will carry out a quarterly review of all staff files
Regulation 23 — Safeguarding health, safety and welfare of child
- General Safety: 1. An Immediate Action Notice (IAN) was issued as it was identified staff and managements knowledge regarding the medication requirements for a child was inconsistent. During discussions with staff the inspector was informed that one child had a serious allergy. Review of the child’s care plan evidenced the type of allergy the child presented with and symptoms of allergic reaction. No further documented details to support the child in the event of an allergic reaction were available. Review of the medication evidenced there was no prescribed medication with the child’s name in the service. Discussions with staff evidenced if the child had a reaction the staff would contact management, the child’s parents and use an auto adrenaline injector belonging to the service. On review this auto adrenaline injector had an expired in November 2024. Therefore, was out of date. Discussion with the person in charge evidenced the child had a signed letter form the parents dated 9 September 2025 stating they no longer have an allergy. This information was not communicated with staff. This posed significant risk to the child in the event of medication being administered that was not prescribed for their use. 2. Trailing cables from an air conditioning unit and a tv were observed in the Blue Pod and a trailing cable from a tv was observed in the Yellow Pod. The service was found to be non-compliant for trailing cables in the Blue Pod on the last inspection on 8 March 2023. The corrective and preventive actions submitted by the registered provider did not prevent the reoccurrence of the non-compliance. 3. The inspector observed that children’s lunches were not checked to ensure vegetables were halved. One child was found to have whole cherry tomatoes in their lunch box which posed a serious risk to the child’s safety. The inspector highlighted this with staff and the tomatoes were cut in half. Infection Control: 4. There was no single use paper towel available in one of the toilets used by the children. Children were observed using toilet roll to dry their hands following toileting. 5. There was no cover available on the toilet roll dispenser in the children’s bathroom in the Green Pod. Lack of appropriate hygiene equipment and supplies in children’s bathrooms poses a risk of the spread of infection. Action submitted by the Registered Provider
Provider's corrective action:
- General Safety: 1. Following the inspection, the child’s care plan was removed and the letter from the parents was stored on the child’s file. A staff meeting was held to clarify the child’s current medical status and ensure there was understanding across the team. The expired auto adrenaline injector which had been kept on site for training purposes was removed from the service. A full audit of all emergency medication was conducted to ensure that medication was in date. A new communication protocol has been introduced, requiring all medical updates from parents to be recorded immediately, signed, and shared with all relevant staff before being filed. In addition, all emergency medication will be checked and verified by management on a regular basis. Staff will receive documented briefings on any changes in children’s medical requirements and each room has a folder allocated for care plans along with a list of the medical requirements and allergies of all children in the service. 2. The air conditioning unit in the Blue pod was removed, and the television cables have been secured out of reach of children. A risk assessment for electrical equipment is carried out daily, and staff have been briefed on how to ensure cables are out of reach of children. 3. Following the inspection, management sent a message to all parents reminding them to ensure children’s lunches are appropriately prepared, including cutting vegetables in half. Staff will check to ensure children’s lunches are prepared safely, and management will continue to communicate with parents and carry out routine audits to ensure adherence to the lunchtime procedures. Infection Control: 4. Single use paper towels were immediately provided in all children’s toilets, and going forward staff will carry out daily checks to ensure paper towels are available. In addition, the importance of hand hygiene was discussed with the team at a staff meeting. 5. The cover of the toilet roll dispenser was attached securely, and staff were reminded to ensure all bathroom equipment is fully functional. Staff will carry out daily bathroom checks and have been instructed to notify management immediately of any equipment requiring attention
Regulation 27 — Supervision
- Children were not adequately supervised at all times during the inspection. It was observed during a transition from the care room to the hall, that one child was left behind in the classroom. Staff had taken the children down the stairs and completed a headcount at the bottom of the stairs when they realised one child was missing from the group. One of the staff members immediately returned to the room and found the child alone in the bathroom. Inadequate supervision of children poses a risk to their safety and wellbeing
Provider's corrective action:
- A full briefing was held with staff to reinforce the importance of maintaining constant supervision of children, especially during transitions. Headcounts are now completed before, during and after transitions to ensure all children are accounted for. Management has developed a new risk assessment for transitions to the hall and will carry out daily checks to ensure children are continuously supervised
Found compliant: Regulation 11, 16, 19.