Immediate action notice. An Immediate Action Notice was issued to the registered provider on the day of the inspection under Regulation 23, in relation to a non-compliance identified under Regulation 23. A response was received from the registered provider which mitigated the risk identified. See body of report for details.
Regulation 9 — Management and recruitment
(3) A review of available records demonstrated one staff member had commenced employment within the service prior to the appropriate consideration of references
Provider's corrective action:
As soon as the written reference was received it was verified, validated and documented in the staff member’s file. The documentation was available on the day of inspection. For any person who holds a role within the service written references will be obtained and verified before their commencement
Regulation 16 — Record in relation to pre-school service
(k) The registered provider did not ensure a full record in writing was maintained for accidents and incidents. This posed a potential risk of miscommunication impacting the appropriate care of children after an injury. A sample of 7 records were reviewed dated since the last inspection. Five records were observed incomplete and did not include a parent’s signature confirming they had been informed of the incident. This non-compliance was observed on the previous inspection in May 2025. The preventive action has not been maintained in line with the information provided to the inspectorate following the last inspection
Provider's corrective action:
Following the previous inspection, continuous reminders are being sent to all parents to approve any pending accident and incident records. These reminders were presented to the inspector on the day of inspection. However, to ensure that parents sign, the service has also introduced a dedicated recording book where parents sign to confirm that they have been notified of any incident or pending incident report awaiting their approval. These measures aim to ensure that all accident and incident records are complete, accurate, and appropriately acknowledged by parents. The person in charge will continue to ensure that parents receive regular reminders regarding any pending incidents
Regulation 23 — Safeguarding health, safety and welfare of child
General Safety: 1. Radiator temperatures in the sanitary area had a surface temperature that exceed 50℃ were accessible to children and posed a significant risk to children’s safety. The following was observed: • The radiator in the sanitary hallway had a surface temperature of 53.1℃. • The radiator in the sanitary area used by the Jasmine room had a surface temperature of 51.9℃. An immediate action notice was issued. 2. The radiator accessible to children in the sanitary area used by the sunflower room had a surface temperature of 48.3℃ and posed a potential risk of injury to children. 3. The door at the rear of the Sunflower classroom was observed propped open as children played in the room although it is acknowledged there was a high level of supervision in the room at the time this practice could potentially pose a safety risk to children. Action submitted by the Registered Provider
Provider's corrective action:
General Safety: 1. The issue with the radiators was promptly reported to the community centre management. The radiators have been fully shielded with radiator covers. Regular monitoring of radiator surface temperatures will continue, particularly during periods of increased heating use, to ensure they remain within safe limits. All radiators accessible to children will remain covered at all times. 2. A safety cover was installed on the radiator in the Sunflower Room sanitary area, which had recorded a surface temperature of 48.3℃. This corrective action was completed within 24 hours to eliminate any potential risk to the children. Radiator surface temperatures in the Sunflower Room sanitary area will be continued to be routinely monitored, particularly during periods of increased heating use. All radiators accessible to children will remain fitted with safety covers to ensure that no radiator poses a potential safety risk to children in the future. 3. Staff members were reminded at the post inspection meeting that the fire safety door must remain closed at all times while children are in attendance. The importance of adhering strictly to all fire safety procedures was re-emphasised and reinforced with the team. The person in charge and the room leader will continue to continue to carry out routine checks throughout the day to confirm that all fire safety doors remain closed while children are present. Any issues identified will be addressed promptly to maintain a safe environment
Immediate action notice. An immediate action notice was issued to the registered provider on 12th May 2025 in relation to concerns identified under Regulation 23, Safeguarding the Health, Welfare and Development of child. A response which adequately addressed the concern was received on 13th May 2025.
Regulation 11 — Staffing levels
(1) The registered provider did not ensure an adequate number of adults were working directly with the children throughout the morning of the inspection. The staff available were unable to respond adequately to the care needs of the children and provide adequate supervision. This is detailed under the non-compliance section of Regulation 19
Provider's corrective action:
(1) On the morning of the inspection adult child ratios were fully in line with requirements. We also acknowledge that, during the inspection, some of the children were experiencing sensory overload, which resulted in moments of dysregulation. To ensure consistent high-quality care and supervision, we will continue with the high-quality training, we have in place for our staff. We have a contingency plan in place to provide extra support during staff transitions, such as deploying senior staff members to assist as needed. Regular reviews of staff capacity and workload are conducted to identify and address any gaps proactively, maintaining compliance with regulatory adult-to-child ratios and supporting the wellbeing of both children and staff
Regulation 16 — Record in relation to pre-school service
(j) The registered provider did not ensure a full record in writing was maintained for the administration of medication. This posed a potential risk of miscommunication impacting the safe administration of medication. A sample of 8 records were reviewed and 7 were observed incomplete. • Three records did not include a parent’s signature confirming they had been informed of the administration or the signature of the staff member who witnessed the administration of medication. • Four records did not include the full details of the child who received the medication. (k) The registered provider did not ensure a full record in writing was maintained for accidents and incidents. This posed a potential risk of miscommunication impacting the appropriate care of children after an injury. sample of 10 records were reviewed and 7 were observed incomplete. • Six records did not include a parent’s signature confirming they had been informed of the incident. • One record did not include a parent’s signature or the mangers signature. This is not in line with service policy
Provider's corrective action:
(j) The administration of medication procedure is fully embedded in daily practice and is included in our daily checklist for the person in charge to review at the end of each day. Medication administration is included in our daily checklist and reviewed by the person in charge. Completed forms are reviewed and signed off each day by the room leader or manager to confirm accuracy and completeness. (k) To ensure continued accuracy and clear communication, the person in charge will continue to remind parents of the importance of reviewing and signing their child’s incident report upon receipt. In addition to notifications through an online system, staff inform parents verbally at collection time if any incidents or accidents have occurred and remind them that the completed report is available for their review and confirmation. The practice of completing reports promptly and notifying parents immediately is well embedded in daily procedures
Regulation 19 — Health, welfare and development of child
Basic Needs: 1. Children’s needs were not met during a transition for toileting which was poorly managed leading to upset and frustration for children. • Both classrooms were brought to the sanitary area following playtime in the hall. This resulted in the children queuing in narrow hallway waiting to access the sanitary facilities. • A child was observed to enter the storage room and needed to be removed by a staff member. • Children were observed pushing their peers repeatedly as they waited. • Despite staff being present the experience was loud and disorganised for the children resulting in children showing discomfort and frustration by behaviours such as crying or placing their fingers in their ears. Care practices and transitions should be managed effectively in a supportive manner to meet children’s needs and to reduce negative experiences. This practice is not in line with service policy that advises children will be supported to remove themselves from situations where they are feeling frustration and staff will support creating conditions that minimises conflict between children. 2. Children’s needs were not met during mealtime in the Jasmine room. The mealtime was not a relaxed and enjoyable experience for the children present. The following was observed: • Children were observed to take and eat their peer’s food unnoticed by staff which led to frustration for a child. • Children were positioned at furniture that was not suitably sized for their comfort as it reached chest and neck height. It is acknowledged that one staff member was sitting with a child who required support during this time and was therefore unable to support the needs of the other children and attempted to give direction to a second staff member who needed instruction. 3. The registered provider did not ensure that varied and sufficient food was available for children attending full time care. • A child who did not like the main meal was not offered a suitable alternative meal but was instead given a bread-based snack. • A second child who did not eat the main meal had a bread type snack from home that was repeatedly taken by their peers. This is not in line with the Food and Nutrition Standards for hot meal provision which outlines that every hot meal should contain a number of specific food groups. It is acknowledged that some children may have food preferences however the availability and presence of a suitable alternative hot meal can encourage children’s healthy eating habits. Programme of activities: 4. The programme of activities in the Jasmine room was poorly managed and did not actively engage the children. This was evidenced by the following: • Children who did not wish to take part in graduation preparation or circle time did not have an alternative activity made available to them. • Following mealtime there was no activity set up for the children to engage with as they waited to be brought for sleep or for those who remained awake. • There was no evidence of a displayed routine in the room as guidance for staff or children. Alternative activities prepared in advance in line with an age-appropriate routine can provide engagement for all children. It is acknowledged that a staff member attempted to provide some activities however they were regularly disrupted by to attending to individual children’s needs or to provide guidance to another staff member
Provider's corrective action:
1. To manage this effectively, we have a daily toileting schedule that follows outdoor playtime. This schedule is designed to prevent overcrowding and ensure the safety and well-being of all children during transitions. Staff members have completed refresher training focused on supporting smooth transitions and fostering positive, supportive interactions, in line with our service policies. Supervision in transition areas remains active to promptly address any unsafe behaviour and support children showing signs of distress. Regular refresher training on effective transition management and positive interactions, will continue to be provided to all staff in line with service policy. 2. The table in the Jasmine Room is an adjustable type and has been re-adjusted to better support children's comfort and independence during activities and mealtimes. To prevent discomfort and support children’s independence, the adjustable furniture in the Jasmine room will be regularly checked and re-adjusted as needed. Staffing ratios and supervision levels during mealtimes will continue to be reviewed and support provided as needed. 3. We will continue to ensure that a varied and sufficient menu is provided, including suitable alternative hot meals for children who do not eat the main meal. Staff have been instructed to follow a clear procedure for offering an alternative hot meal, rather than fruit or bread-based snacks. This procedure will be followed consistently, regardless of whether the child accepts the alternative meal, to ensure compliance with nutritional standards and promote healthy eating habits. Ongoing monitoring to ensure staff consistently adhere to the procedure, promoting compliance with nutritional standards and supporting healthy eating habits. 4. Staff have been reminded of the importance to always put up the daily schedule, especially on mornings when the room needs to be set up after being cleared the previous day or over the weekend. Staff also receive ongoing support and training to plan inclusive activities with appropriate alternatives, ensuring that quiet and engaging options are consistently available for all children after mealtimes. To make sure this step is never missed, it has now been added to the morning checklist for the person in charge to verify each day
Regulation 23 — Safeguarding health, safety and welfare of child
General Safety: 1. Water temperature in a sanitary area used by the children was not thermostatically controlled and exceed 50℃ posing a potential risk of scalding. At 11.06am the water temperature of the sink in the sanitary area was 53.3℃. An immediate action notice was issued. 2. Children were observed playing in the community centre hall on the day of inspection. The hall door was a swing door which led into the community centre reception and main exit door leading to the car park. The hall door was not observed to be secure on the day posing a potential risk of a child exiting unsupervised. 3. A storage room located by the sanitary area contained cleaning agents stored on low level shelving was observed with the door open making the room accessible. A child was observed entering this room on the day of inspection. This posed a potential risk of accidental poisoning. 4. Football nets present in the hall posed a potential risk of injury. A child was observed to climb behind the nets resulting in their foot becoming stuck in the netting. 5. Children in the Jasmine room were observed to eat their peers’ lunch from home this went unnoticed by staff. This posed a potential risk in the event of an allergy. Infection Control: 6. Children in the Jasmine room were not supported to wash their hands prior to dinner which posed an infection control risk. Safe Sleep: 7. The recommended ambient sleep temperature between 18-22℃ was not maintained in a room were children over one year old were sleeping. At 1.54pm the temperature in the room was recorded at 23.3℃ posing a potential risk to children’s safety. Fire Safety: 8. Staff in the Jasmine room did not bring the attendance record to the community centre hall during the children’s play time. This posed a potential risk of hindering safe evacuation of the premises in the event of an emergency. Action submitted by the Registered Provider
Provider's corrective action:
General Safety: 1. The water temperature in the affected sanitary area was immediately addressed as a priority. A thermostatic mixing valve was installed to regulate the temperature safely. Temperature checks remain part of our daily health and safety checklist and will continue to be conducted to ensure the water temperature remains within safe limits. Staff will carry out these checks daily and promptly report any irregularities to prevent recurrence. 2. Staff members are assigned to be stationed at the door during all hall activities to maintain active supervision and ensure the door remains secure at all times. Clear responsibilities have been assigned for door monitoring, and regular reminders will be given during staff meetings. Ongoing spot checks by the person in charge will ensure the door remains secure and supervision is consistently maintained. 3. The storage room is kept locked at all times, with no exceptions. A clear sign has been placed on the door to remind staff of this requirement. All staff will receive periodic reminders about the importance of keeping the storage room locked. Regular spot checks will be carried out by the person in charge to ensure the door remains secured. Also, responsibilities around storage room security have been clearly outlined in staff training to reinforce safe practices. 4. Supervision during hall activities continues to be actively reinforced, with staff consistently monitoring all areas to ensure children do not access or misuse equipment. To prevent future safety risks during hall time, staff have been assigned clear supervision zones to ensure full visibility of all areas and equipment. A pre-use hall inspection is in place before each session to identify and remove any unsuitable or unsafe equipment. Ongoing staff training will reinforce safe equipment use and supervision protocols, ensuring children can play safely and confidently. 5. Staff members are actively supervising the children during mealtimes to prevent food sharing, thereby reducing the risk of allergic reactions. This supervision protocol is consistently reinforced on a daily basis to ensure the health and safety of all children. Visual reminders highlighting food allergies and staff supervision responsibilities are clearly displayed in the classrooms to support ongoing awareness and vigilance. Infection Control: 6. As part of our ongoing commitment to children’s health and wellbeing, staff actively support and supervise children’s handwashing routines before mealtimes to help reduce the risk of infection. To help prevent lapses in hygiene practices, visual cues and handwashing posters are displayed in the classroom and sanitary areas to reinforce the routine for both children and staff. Additionally, handwashing is included in regular room audits to ensure it remains a consistent and embedded part of daily practice. Safe Sleep: 7. A safe air conditioner is available for use when necessary to support appropriate temperature regulation in the sleep room. Room temperature is regularly recorded during sleep times and is monitored as part of the daily health and safety checklist to ensure the environment remains within the recommended range, maintaining a safe and comfortable space for all children. A temperature monitoring log is maintained and reviewed daily by the person in charge to promptly identify and address any deviations. Fire Safety: 8. As part of our established safety procedures, staff consistently bring the attendance record when moving children to different areas, including the hall. To reinforce this routine, it remains part of our daily checklist, and the person in charge continues to verify compliance through regular safety checks to maintain consistency and best practice. A visual reminder is placed at the room exit to prompt staff to take the attendance record before leaving with the children. To further support this safety measure, regular spot checks will be carried out by the person in charge to ensure ongoing compliance with this established protocol
1. The registered provider did not ensure that the Designated Liaison Person completed their role and function in line with the services Child Protection policy regarding two instances noted during a review of Regulation 32. 2. Conversations with staff and a review of available documents demonstrated that the service did not act in line with their policy regarding the supervision and training of two new staff while on their probationary period. For example, service policy states they will conduct fortnightly reviews during the first 2-4 months of a staff’s employment however there was no evidence to show these reviews had been completed
Provider's corrective action:
1. Corrective action: The registered provider ensures that the Designated Liaison Person (DLP) carries out their responsibilities in accordance with the service’s Child Protection policy. It is acknowledged during the transition of our files there was an oversight regarding the two instances. Preventive action: A continuous review of the process involved in transferring of files to our online filing system to ensure all records are accurately transferred and easily accessible on request. The child safety statement has been updated and further training has been given to the DLP. 2. Corrective action: We have reviewed and reinforced the service's policy on staff supervision and training with the person in charge to ensure a clear understanding, with particular emphasis on the importance of conducting regular reviews during the probationary period. A tracking system has been implemented to ensure these reviews are completed on time. The Regional Manager (RM) is responsible for overseeing the completion of probationary reviews, ensuring that they are scheduled, conducted, and documented in a timely manner, and in accordance with the service’s policy. Preventive action: To ensure that in the event of any technical difficulties, a contingency plan is in place to quickly retrieve records from alternative sources, to ensure transparency and compliance during inspections. We will continue to regularly review and update our online filing system to guarantee that all necessary records are consistently uploaded and accessible. The person in charge will ensure that they oversee the ongoing file transfer process and ensure that all records are available within the online system at all times. The person in charge will also ensure that records are properly categorized and easy to retrieve during inspections
Regulation 19 — Health, welfare and development of child
1. A child was observed to have removed their skirt and wear a top and tights at 12.21pm this went unnoticed by staff until the inspector brought it to their attention. Staff did not act after being informed of the child’s partial clothing as the child was observed to remain without bottoms at 1.54pm. Ensuring the children are appropriately dressed supports the comfort and dignity of the child. 2. Transitions were observed to be poorly managed in the Marigold room with ineffective strategies used leading to upset and frustration for children. The following was observed: • A staff member was observed to repeatedly use the same language to request a child to a complete a task in an exasperated and monotone voice leading to frustration and shouting from a child. • Staff were observed to begin an approach to support a child’s transition, but then walk away mid interaction. For example, beginning a countdown and then walking away or resuming conversation. • A staff member was observed to lean over children while standing who either sat or lay on the floor during interactions for transitions and did not join children at their level. • During group transitions to the toilet children were observed to push and hit one another unnoticed by staff. • Staff were observed to prioritise cleaning practices while children displayed frustration during transitions such as hurting peers or running away across the room. • A child who was crying after a transition to the sanitary area had three staff members interact with them for brief intervals but with no follow through on their interaction to address the upset and provide consistency and comfort. Care practices around transitions should be managed effectively in a supportive manner in order to reduce negative experiences for children. 3. A child was observed with a crusted nasal discharge between 10.00am-11.17am. Timely nasal hygiene practices support the overall comfort of the children
Provider's corrective action:
1. Corrective action: Management has re-emphasised to staff members to pay closer attention to children's clothing throughout the day, ensuring they remain appropriately dressed at all times. The person in charge has established an immediate response protocol to promptly assist and re-dress any child found without appropriate clothing or removing their clothes. Staff members have been retrained on the importance of maintaining children's dignity and comfort by ensuring they are dressed appropriately at all times, as part of their overall well-being. Preventive action: Staff will continue maintain the safety, dignity of the children without compromise. The service will continue to foster an environment where children feel comfortable expressing their preferences regarding clothing, at the same time empowering them to make decisions within appropriate boundaries. The service will continue to engage parents in discussions regarding clothing preferences to ensure alignment between home and school, fostering mutual understanding and respect for the child’s choices. 2. Corrective action: Staff members have been reminded of the importance of using positive, encouraging, and varied communication, including visual aids when engaging with children to ensure that children feel supported and motivated. Preventive action: The service will continue to provide targeted training on how to support interaction with children and transitions, focusing on the use of positive, calm language, visuals, and consistent approaches that are adaptable to each child’s individual needs. The person in charge to support staff during transitions. Visuals aids to be used during transitions throughout the day. 3. Corrective action: Management have stressed the importance of regular hygiene checks with staff to ensure that all children are attended to promptly. This included an established routine to monitor and address nasal hygiene as part of our daily care practices. Preventive action: Staff members must consistently implement the existing schedule for nasal hygiene checks throughout the day (e.g., after meals, during playtime, before naps). Staff members must do a random quick check on all the children, and regularly use the soft tissues provided by the service for children’s nose, where necessary. Staff members to continue to teach the children self-care skills, and where possible, encourage them to use tissues to wipe their nose, where required
Regulation 23 — Safeguarding health, safety and welfare of child
General Safety: 1. A child’s lunch included whole grapes which were not sliced and posed a choking hazard. 2. The middle cubicle in the large sanitary area had a damaged toilet seat observed to be used by children which was unstable and moved and posed a risk of injury. This was a non-compliance on the last inspection the corrective and preventive action had not been sustained. 3. Two large goals in the hall were folded away leaving metal bars with pieces facing upwards were unstable and observed to be walked on by a child and posed a risk of injury. Infection Control: 4. On the day of the inspection a child’s lunch containing perishable food item was stored in their bag and not refrigerated. Perishable food must be stored in a refrigerator or cool place at temperatures between 0-5°C as there is a risk of contamination. 5. Bed linen was not stored in effective way for infection control. Bed linen was observed to be stored in a range of bags including nonsealable card bags and staff were observed to place multiple pieces of bed linen into one bag. Action submitted by the Registered Provider
Provider's corrective action:
General Safety: 1. Corrective action: Staff members have been reminded to closely monitor meals and snacks, ensuring that all grapes and similar foods are appropriately sliced or prepared to minimize choking risks. Additionally, we have reiterated to parents the importance of sending foods that are appropriately prepared to reduce the risk of choking. Preventive action: Staff to continue to check children’s lunches on arrival to ensure that all grapes and other food that can cause choking hazards are sliced or appropriately prepared before being served. 2. Corrective action: The damaged toilet seat was replaced immediately. Preventive action: The person in charge and a second designated staff member will ensure that they conduct a thorough inspection of all sanitary areas, checking for any signs of wear or instability in toilets, seats, and other fixtures. A frequent, quick check will be conducted at intervals daily to ensure that no issues such as instability or damage arise unexpectedly. Any unexpected damage arising must be reported to the management immediately for repairs or replacement to be made without any delay. 3. Corrective action: This has been promptly brought to the attention of the community centre manager on the same day. The removal of the goal posts has since been reviewed, and it has been agreed that the goal posts are safe to remain in the hall, allowing children to play football if they wish, as they pose no danger to their safety. Preventive action: We will continue to implement regular safety checks and ensure that all equipment is properly secured and monitored before any activities involving children take place. Infection Control: 4. Corrective action: Children’s lunch boxes are to be kept in the fridge as soon as they arrive. This is added in the classroom risk assessment. Preventive action: Each class been assigned a designated staff member who must check children’s lunch boxes upon arrival to ensure that perishable items are properly stored in the refrigerator immediately. The person in charge has designed a visual aid for meal storage which serves as a continuous reminder for staff to prevent any instances of oversight. An ongoing staff training on food safety practices is in place. 5. Corrective action: The service have implemented updated procedures to ensure that bed linen is stored properly in sealable bags only. Each child’s bag is now clearly labelled for easy identification to prevent any cross-contamination. Preventive action: Ziplock bags will be stored permanently at the centre. Blankets and bed linens will be placed directly into these bags on arrival and stored in a closed container to maintain hygiene. Regular staff training on infection control practices will continue to be provided
Regulation 32 — Complaints
(2)(a)(b) A review of documentation and conversation with the service manager and director of education in relation to five complaints showed that the service had not followed their policy in relation to the action taken and recording of a number of complaints. The following was observed; 1. A record of the outcome and action taken in relation to one complaint regarding a staff member from April 2023 was not provided to the inspectors on the day. 2. A second complaint regarding a staff member from March 2023 was not recorded in the complaints folder and was only brought to the attention of the inspectors during the feedback meeting when discussing the complaint referred to in point 1. A letter to the staff member following the complaints process was reviewed
Provider's corrective action:
Corrective Action All relevant documentation including outcome of complaints are available for review at the centre. Preventive Action An ongoing review of filing system and the process for retrieving records to ensure all documents are both accurately transferred and accessible at all times. Summary Comment The inspector has reviewed the actions taken and evidence submitted. This will be reviewed on next inspection