Regulation 23 — Safeguarding health, safety and welfare of child
General Safety: 1. The nappy changing unit which was fixed to the wall in the ground floor sanitary accommodation of number 16 was not suitable for the age range of the children who used it. The unit was recommended for the use of infants under the age of 12 months and the children who used the unit ranged in age from 11 months to over two years old. This posed a potential risk of becoming unsecured or unstable causing a risk of injury. 2. The soft close mechanism on the door to the Water Lily room was not operating correctly, causing it to slam closed. This posed a potential risk of injury to children. It is acknowledged that the registered provider submitted evidence the day after the inspection that this had been addressed. 3. Although it is acknowledged the service maintained a record of all accidents and incidents within the service; of the 20 records reviewed, seven did not record the date that the parents were informed of an incident. This posed a potential risk around the timely communication for the appropriate care of a child following an incident. Infection Control: 4. Dirty bed linen was observed on a cot which was not changed prior to a child sleeping on it. This increased the potential risk of infection. Safe Sleep: 5. An ill-fitting sheet was in use on a cot which a child was observed to sleep in. The sheet was too large for the cot and there was a potential risk the child could be tangled in the bedding. Fire Safety: 6. The positioning of the cots in Lily Lodge cot room restricted access leading to one of the two emergency exits. This posed a potential risk for the safe evacuation in the case of an emergency. This was identified as a non- compliance on the last inspection in February 2025, and while it is acknowledged the cots were repositioned leaving a wider gap, the gap available still partially restricted access through the fire exit. Action submitted by the Registered Provider
Provider's corrective action:
General Safety: 1. The changing unit was replaced with a unit suitable for the age range. The service report that a review process for all equipment has been implemented, and staff have been instructed to report any concerns regarding equipment suitability. 2. The defective soft-close door mechanism in the Water Lily Room was repaired immediately following the inspection. The mechanism has been fully adjusted and tested to ensure the door now closes in a controlled and safe manner. The service report that a check is now included on a monthly safety check of all internal doors to confirm that soft-close mechanisms are functioning correctly. 3. The relevant files were updated and the service report that procedures have been strengthened to ensure full compliance with record-keeping requirements. Staff were informed to ensure that all accident and incident forms are fully completed. The service report that a monthly audit of records has been introduced by management to monitor compliance. Infection Control: 4. The bed linen identified during the inspection was removed and replaced immediately to ensure the cot was clean and suitable for use. The service report that infection control procedures have been reinforced with all staff with a daily checklist introduced to confirm that all sleep areas meet hygiene standards. Regular spot checks will be carried out by management to ensure ongoing compliance. Safe Sleep: 5. The ill-fitting sheet identified during the inspection was removed immediately and replaced with an appropriately sized, well-fitted sheet suitable for the cot. A clear protocol has been implemented requiring staff to check that all sheets are correctly fitted before each use which was added to the staff checklist. Fire Safety: 6. The cots in the Lily Lodge cot room were repositioned immediately following the inspection to ensure a clear and unobstructed pathway to the emergency exit. The service report that daily visual checks are now carried out to confirm that evacuation routes are unobstructed. Regular fire safety checks and drills will also include verification of clear exit access
Found compliant: Regulation 9, 11, 16, 21, 25.
Inspection of 19 February 2025 — Inspection Report
Immediate action notice. An Immediate Action Notice was issued to the registered provider on the 19 February 2025 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 on the 19 February 2025. See body of report for details.
Regulation 9 — Management and recruitment
(2) (d) Police vetting was not available for one staff member in respect of one country that they had lived in other than Ireland for a period longer than 6 months as an adult. (3) A review of documentation available showed that garda vetting declarations for one staff member had not been considered prior to the commencement of their employment. This posed a potential risk to the children
Provider's corrective action:
(2) (d) A police vetting disclosure has been added to the staff file of one adult. A review of all staff files has been conducted to ensure that no other employees have gaps in their vetting records. A checklist has been created to verify vetting compliance before issuing employment contracts with ongoing audits conducted every six months to maintain compliance. (3) Management have introduced a policy to ensure that no new employee can begin working until their garda vetting has been reviewed and approved
Regulation 19 — Health, welfare and development of child
1. Drinks were not visible or accessible to the children in the Froglet room on the day of the inspection. Beakers were observed to be stored in a high, closed press, restricting access to a drink if children were thirsty. 2. Children in the Froglet room did not have access to table and chairs throughout the day except at mealtimes. The low-level table and chairs were stored in a separate part of the care room, restricting the children’s access to sit down and take part in tabletop activities if they so wished
Provider's corrective action:
1. Beakers for drinking water have been relocated to an easily accessible area to ensure children have unrestricted access to drinks throughout the day. Staff have been advised to ensure beakers to be left at child level. 2. The low-level tables and chairs are now accessible within the care room to allow children to engage in tabletop activities as desired. A room layout has been developed to ensure that essential resources remain accessible to children at all times. Regular monitoring of room arrangements will be conducted to prevent recurrence
Regulation 23 — Safeguarding health, safety and welfare of child
General Safety: 1. A care room that was potentially accessible to the children contained hazardous items such as saws, a drill, exposed wiring and other hazardous building equipment. These posed a potential risk of injury to a child. It is acknowledged that the care room was undergoing repair following recent damage in a storm and that the door to the care room was locked at approximately 2.50pm, restricting access by children. An Immediate Action Notice was issued to the service in respect of this non-compliance. 2. On the day of the inspection, the following potential trip hazards were observed: o Part of a staircase had a plastic protective covering laid on several steps. It is acknowledged this plastic protective covering was in place due to ongoing repairs in a care room. o Five floor mats were stored at the top of a staircase. It is acknowledged that the mats were moved when the inspector brought this to the attention of the staff. 3. A box containing wiring, which was mounted on the wall of a care room, was not secure. This posed a potential risk of injury to a child. 4. There was no window restrictor on a window in a care room located on the first floor of the service, posing a risk of injury. Additionally, a wire that borders the window frame was broken and exposed. It is acknowledged that the registered provider confirmed that these wires were not live. 5. Tangled wire lights, a notice board and a shelf were unstably propped against the wall in an unlocked storeroom, which posed a risk of injury if a child were to gain access. Additionally, the handle of the storeroom door was broken, which posed a potential risk of a child becoming locked inside. 6. A shelf in a hallway of the service was broken, which posed a potential risk of injury. It is acknowledged that this was removed when brought to the attention of the staff. Infection Control: 7. There was no dispensed toilet roll in sanitary accommodation used by the children in the Hoppers room. This posed a risk of cross contamination and repeated touch to surfaces. Safe Sleep: 8. The temperature in Lily Lodge cot room was not maintained between 18°C - 22°C. A temperature of 24.8°C was recorded by the inspector at 12:12pm while children aged 1 – 2 years slept. Fire Safety: 9. Children’s attendance records were not maintained in a contemporaneous manner: o Children who were moved to another room were observed to be recorded as being present in two rooms. o One child who arrived in the service at 10:35am had not been signed in to the attendance record in a timely manner. The child was still not signed in 02:48pm. This reduced the effective evacuation of the children in the event of an emergency. 10. The emergency exit in the Ribbit Room was partially obstructed from the outside on the day of inspection. It is acknowledged that this was obstruction was removed during the inspection. 11. The space between two cots in Lily Lodge cot room measured 34.5cm, limiting the free floor space leading to an emergency exit. This posed a potential risk for safe evacuation in case of an emergency. Action submitted by the Registered Provider
Provider's corrective action:
General Safety: 1. The care room containing hazardous materials has been fully secured, and all unsafe items have been removed. A comprehensive safety check is now conducted weekly to identify and address hazards promptly. 2. Trip hazards identified have been removed. A comprehensive safety check is now conducted weekly to identify and address hazards promptly. 3. The insecure wall-mounted wiring box has been repaired and secured. A comprehensive safety check is now conducted weekly to identify and address hazards promptly. 4. A window restrictor has been installed on the first-floor window, and the broken (non-live) wire has been taken away. A comprehensive safety check is now conducted weekly to identify and address hazards promptly. 5. Items propped against the storeroom wall have been secured, and the storeroom door handle has been fixed. A comprehensive safety check is now conducted weekly to identify and address hazards promptly. 6. The shelf in the hallway has been put back up securely. A comprehensive safety check is now conducted weekly to identify and address hazards promptly. Infection Control: 7. Toilet roll dispensers have been installed in all sanitary accommodations used by children. Daily hygiene checks have been implemented to ensure all sanitary areas are fully stocked and compliant with hygiene standards. Safe Sleep: 8. A new air conditioning unit has been installed which keeps the cot room at the correct temperature at all times. Temperature control is always monitored and documented on daily room temperature sheets Fire Safety: 9. Attendance records have been updated to reflect accurate real-time sign-in/sign-out procedures. Staff have been trained on accurate attendance recording procedures during a staff meeting. 10. The emergency exit in the Ribbit Room has been cleared of all obstructions and staff have been advised to ensure clear pathways for emergency evacuation. 11. The spacing between cots in Lily Lodge have been adjusted to ensure clear pathways for emergency evacuation. Staff have been advised to ensure clear pathways for emergency evacuation
Found compliant: Regulation 11, 24, 27, 28.
Inspection of 19 September 2024 — Change in Circumstance