Immediate action notice. Immediate Action Notice - Part VI – Safety
Immediate action notice. Regulation 23: An Immediate Action Notice was issued to the registered providers on 13 March 2024 due to the significant risk posed in relation to safety. A response was received from the registered provider s on 14 March 2024 outlining actions taken to address the risk. These are documented under regulation 23 in the report.
Immediate action notice. Non-Compliance Information The registered providers did not notify the Agency of a change that was made to the person in charge of the service on 11 March 2024. Corrective & Preventive Action submitted by the Registered Provider Corrective and Preventive Action
Regulation 9 — Management and recruitment
(7)(a) Through review of records and discussions with staff and the registered providers it was evident that staff had not received appropriate supervision and were not provided with appropriate information and training in relation to the service’s policies and procedures as outlined below. It is acknowledged that three of the staff members had only commenced employment in February and March 2024. • There were no records available relating to staff supervision. The registered provider told inspectors that no supervision meetings had been carried out in the past few years and that eight staff members had not had any supervision meetings. This was at variance with the service’s Staff Supervision policy which stated that all staff members must have regular supervision, the session is recorded, and the record kept in the staff member’s file. • Through discussion with staff and management it was evident that staff did not have sufficient information regarding the services’ policies and procedures to ensure the safety and wellbeing of all children. A record held by the service which indicated that staff had read the service’s policies and procedures had been completed by only three of the eleven staff members. • Through conversation with staff and management it was evident that staff had not received adequate induction training to ensure the safety and wellbeing of all children. The registered provider told inspectors that the service did not have an induction training programme or any record of staff inductions. This was at variance with the services Staff Training policy which stated that every staff member will be provided with an induction training programme and the induction will be recorded on the induction record form
Provider's corrective action:
• Supervision sessions scheduled for all staff, starting on 24 April to be conducted every 6 months as per the service policy. The manager will oversee these sessions, and a comprehensive record of each meeting will be maintained. • All staff, including new hires, review and sign off on the service’s policies and procedures. This documentation is recorded and stored in each staff member’s file. • Presentation given by the manager upon induction training. Monitoring systems enhanced to flag lapses in supervision or training, ensuring compliance with service policies. Checklists used during the onboarding process. • External auditor engagement to review training and supervision records annually. First audit carried out 17 April. • Yearly supervision and training calendar to be circulated to ensure staff are aware of upcoming sessions. Regular updates and reminders included
Regulation 15 — Record of pre-school child
(f) There was insufficient detail recorded about the illness, allergies or special care or attention that may be required in relation to four of the five children. Three of the children were still registered to attend the service
Provider's corrective action:
The service contacted parents of the children to obtain comprehensive details regarding their illnesses, allergies, and any special care requirements. These records were updated 13 and 14 March. Health care plans will be reviewed and updated regularly in consultation with the children’s parents or guardians and healthcare providers. An external auditor will be engaged to periodically review the service’s health record keeping practices. The focus will be to assess the accuracy, completeness, and compliance of the service health documentation processes. The first audit took place on 17 April
Regulation 19 — Health, welfare and development of child
(1)(b) The inspection focused on the measures taken by the registered providers to include children with food allergies in the service. The registered providers told the inspectors that the service recently terminated a child’s place due to their food allergy. They stated that the main meal is provided by a catering company and that although a separate meal was provided for the child, the catering company could not provide an absolute guarantee that there would be no cross contamination. It was not evident that any measures had been considered to accommodate the child’s needs prior to the decision to terminate their place. It was not evident that the parents were consulted prior to the decision. This was at variance with the services’ Inclusion policy which stated that the service will work in consultation with the staff, the parents/guardians of the child and other professionals and/or agencies to determine additional resources required to meet the functional and developmental needs of the child and to determine the suitability of the service in meeting these needs
Provider's corrective action:
Management will revise the services Inclusion policy to incorporate specific protocols for managing food allergies, which will include mandatory consultation with parents. To ensure the service adheres to its policy on inclusion, regular audits will be conducted. These audits will assess how well the service accommodates children with special needs, including those with food allergies. The audits commenced 17 April
Regulation 23 — Safeguarding health, safety and welfare of child
The inspection focused on measures taken by the service to safeguard children with a known illness or allergy. It was not evident that the registered providers had taken reasonable measures to provide emergency treatment or care to the children. Through review of records and discussions with staff, it was evident that a child had been given a meal containing foods the child had a known allergy to, which resulted in the child requiring emergency treatment. The service had not appropriately identified the risks that lead to the incident and appropriate measures had not been put in place to prevent a similar incident. Inspectors identified ongoing risks including insufficient recording of information in relation to known illnesses/allergies, absence of care plans and deficiencies in communicating information about children’s illnesses/allergies/medication requirements with staff. On inspection, one staff member was unaware that a child in her care had an underlying medical condition or may require emergency medication. An Immediate Action Notice was issued to the registered providers on 13 March 2024 due to the significant risk posed. Action submitted by the Registered Provider
Provider's corrective action:
• Parents were contacted to obtain the details needed regarding their children’s illnesses and allergies. These records were updated 13 and 14 March. • Individual health care plans were developed and updated for each child. These plans have been formulated in collaboration with healthcare professionals and the children’s parents or guardians. These will be reviewed regularly. When updated, staff are asked to read and sign again, to ensure they have a full understating of each child’s condition. • Health care plans are available in the children’s rooms and have been signed by all staff members. • The allergy and food requirements list has been updated with the new information provided by the parents. This is reviewed in a monthly basis, or more regularly if the situation requires it. This list is available in all rooms, including the kitchen and office. • As part of the induction program, staff are introduced to the children’s specific needs regarding allergies, illnesses, or special food requirements and where to find individual health care plans, emergency medicine, etc. This takes place on the staff members first day. • All staff will undergo training in food allergy management, cross-contamination prevention, and emergency procedures related to allergic reactions
Regulation 31 — Notification of incidents
(d) The registered providers did not notify the Agency in writing of an incident that occurred in the service resulting in a child attending hospital for immediate medical treatment
Provider's corrective action:
Corrective & Preventive Action The service will review and clarify incident reporting requirements to ensure all staff understand when it is necessary to escalate reporting to the agency. This review can help prevent misunderstandings and ensure compliance with regulatory requirements. This review will be completed by the 3 May 2024. Management will develop a clear incident reporting protocol that outlines the steps and criteria for notifying the Agency about any incidents. This protocol will be included in the staff handbook and reinforced during regular training sessions
Regulation 32 — Complaints
(2)(b) The registered providers did not ensure that a recent complaint made to the service was dealt with in accordance with the service’s Complaints policy. The policy stated that on receipt of a complaint, the Manager will meet with the staff member and keep an accurate and detailed account of what was discussed. The registered providers told the inspectors that there were no records kept of any meetings held in relation to the complaint
Provider's corrective action:
(2)(b) The service introduced a new system to track and document all aspects of a complaint from its receipt to resolution. The service is using this form in the review meeting to ensure all discussion points, decisions, and actions are recorded accurately. Management will conduct comprehensive training sessions for all staff, emphasizing the importance of following the Complaints policy and using the new tracking form correctly. This will ensure everyone understands their responsibilities and the steps involved in documenting complaints. Management will periodically review the Complaints policy to ensure it remains effective and relevant. Management will increase oversight in the complaint handling process. This will include routine checks of the complaint logs and the new forms used for documenting complaints to ensure compliance with the policy
Regulation not named in the report text
The registered providers did not notify the Agency of a change that was made to the person in charge of the service on 11 March 2024
Provider's corrective action:
The registered provider notified the Agency of the change to the person in charge following the inspection. To ensure compliance, the service will initiate annual audits of processes and compliance status. These audits will be conducted by an external auditor to ensure impartiality. The first audit took place on 3 May 2024
(2)(a) & (b) It was not evident that references had been appropriately considered for three staff members. Five of the references provided for these staff members did not have a record of verification. This regulation was non- compliant on previous inspections dated 6 March 2018, 18 October 2019, and 21 October 2020. The actions subsequently submitted by the registered providers had not been effective in preventing the recurrence. (c) A Garda vetting disclosure was not available for one staff member who had commenced working in the service on 2 January 2024 contrary to the National Vetting Bureau (Children and Vulnerable Persons) Act 2012. This regulation was non-compliant on previous inspections dated 18 October 2019 and 21 October 2020. The actions subsequently submitted by the registered providers had not been effective in preventing the recurrence. An Immediate Action notice was issued on 16 January 2024 due to the risk posed. The registered providers submitted a response on 17 January 2024 which included the outstanding Garda vetting dated 16 January 2024. (d) International police vetting was not available for one staff member who had lived in another state as an adult for more than six months. This regulation was non-compliant on previous inspections dated 18 October 2019 and 21 October 2020. The actions subsequently submitted by the registered providers had not been effective in preventing the recurrence. (3) It was not evident that the procedures outlined under regulation 9 (2)(c) had been carried out prior to the employment of three adults (not including the adult referred to under regulation 9 (2)(c) above). The dates recorded on the Garda vetting disclosures were later than the dates the adults commenced working in the service as follows: Adult 1 - Start date: 14 December 2023. Garda vetting date: 3 January 2024 Adult 2 - Start date: 1 November 2023. Garda vetting date: 6 November 2023 Adult 3 – Start date: 2 January 2024. Garda vetting date: 3 January 2024 (4) There were no records to evidence that two of the adults working directly with children held awards in Early Childhood Care and Education at a minimum Level 5 on the National Framework of Qualifications or a qualification deemed by the Minister to be equivalent. This was non-compliant on previous inspections dated 6 March 2018, 18 October 2019, 21 October 2020 and the most recent inspection dated 26 July 2021. The actions submitted by the registered providers following those inspections had not been effective in addressing the non- compliance
Provider's corrective action:
An experienced centre manager has been hired to help manage all aspects of regulation 9. A memo was sent to management regarding the recruitment process and requirements. A staff checklist has been implemented including "mandatory before start date" to remind hiring manager that a particular document must be obtained before staff starts at the service. The company has drawn up a comprehensive plan involving 13 activities to be carried out by quarter three of 2024 including mock inspections, webinars, audits, staff training, etc. 9 (2) (a) & (b) All references with verification information are now available. Management will use validation forms that contain details of the verification check. New stamps were ordered to help hiring manager notice any potentially unverified reference letters. Management have conducted a meeting with the hiring manager to emphasise the importance of collecting and verifying references. Shall there be changes to recruitment process or change of hiring manager, management will organize a similar meeting to reflect the changes. (c) The outstanding Garda Vetting document was sent to the inspectorate on 17 January 2024. (d) The outstanding police vetting document was sent to the inspectorate on 17 January 2024. 9(4) One staff member has been re-assigned to an administrative role and will commence study for the full award on 5 of January 2024. The second staff member no longer works in the service. Two new staff will commence on 6 March 2024. The service has two directors that are working with children full time to maintain the required ratio of adults to children in the meantime
Regulation 19 — Health, welfare and development of child
(1)(a) The children attending the Wobbler room were not provided with adequate opportunities for play, learning and development. Play was mainly adult-led with a lack of opportunities for child-led play. The supporting equipment for a play kitchen were stored out of reach of the children. A child who approached the kitchen was directed away by staff towards the adult-led activity. The children were placed in chairs which restricted their movement during one of the adult-led activities. The staff told the inspector that the children had not been to the outside area since they started working in the service on 2 January 2024. This was contrary to the routine displayed which had two allocated outdoor times daily and the service’s outdoor policy which stated children play outdoors daily. Providing appropriate play opportunities is necessary for children’s learning, development, and wellbeing. This regulation was non-compliant on previous inspections dated 6 March 2018, 18 October 2019, and the most recent inspection dated 26 July 2021. The actions subsequently submitted by the registered providers had not been effective in addressing the non-compliance. It is acknowledged that the registered provider who was present on the inspection agreed to participate in the Better Start National Early Years Quality Development Initiative for support in meeting the regulatory requirement
Provider's corrective action:
Management conducted a review and revision of the current activity program, placing a greater emphasis on child-led play. Equipment has been made more accessible and engaging for children. An application has been submitted by the service to the Better Start National Early Years Quality Development Initiative. Regular training programs will be implemented focusing on the importance of child-led play and how to effectively incorporate it into daily activities. Management will institute regular reviews and updates. The outdoor policy was reviewed and distributed among staff to highlight the importance of bringing children outdoors at least once a day. A service- wide curriculum officer was assigned and is clearly identified on the staff roster. Monthly meetings will be scheduled to allow for planning and reflection
Regulation 23 — Safeguarding health, safety and welfare of child
All reasonable measures had not been taken to safeguard the children from harm as outlined below. General Safety: 1. Inspectors observed unsecured, looped blind cords in Pre-school rooms 1 and 2, posing a risk of strangulation if accessed by a child. This was non-compliant on previous inspections dated 6 March 2018, 18 October 2019, 21 October 2020 and the most recent inspection 26 July 2021. The actions submitted by the registered providers following those inspections had not been effective in addressing the non-compliance. 2. The doors between the Toddler room and kitchen were open throughout the inspection. This posed a risk of children accessing the hazards within, which included cleaning products and cooking equipment. Fire Safety: 3. The exit leading from the cot room onto the outdoor area was partially blocked with a cot when children were sleeping. This posed a risk to the timely evacuation of children in the event of a fire. 4. The emergency exit at the base of the stairs was secured with a latch which the inspectors observed to be difficult to open. This could impede the timely evacuation of children in the event of a fire. It is acknowledged that the deputy person in charge informed the inspectors that a new push-bar door had been sourced and was due to be installed. 5. Fire doors were wedged open throughout the premises rendering them ineffective in the event of a fire. 6. There were no emergency exit signs available to indicate the escape routes in the event of a fire. Infection Control: 7. Appropriate handwashing was not carried out for children attending the Toddler room after nappy changing. The inspector observed that the adult changing children’s nappies did not wash their hands after seven changes and did not wash the children’s hands after six. The service’s nappy changing procedure did not state that children’s hands must be washed after nappy changes. This was non-compliant on previous inspections dated 21 October 2020 and the most recent inspection dated 26 July 2021 and posed a risk of spreading infection within the service. The actions submitted by the registered providers following those inspections had not been effective in addressing the non-compliance. 8. Perishable foods brought from home by the children attending Preschool rooms 1 and 2 for lunch were not stored below 5OC as required. The foods were stored at room temperature posing a risk of foodborne illness. Action submitted by the Registered Provider
Provider's corrective action:
General Safety: 1. The service ordered new cordless roller blinds. New blinds will be installed by 24 of February 2024. Until then, old blinds are properly secured. 2. The doors connecting the Toddler room to the kitchen are now kept closed. To reinforce this protocol, safety signs have been installed on these doors. Management will remind staff that all areas deemed hazardous need to be always secured and made inaccessible to children. Regular training sessions in safety protocols will be conducted and reminders will be communicated to staff. Fire Safety: 3. The service has cleared the area in front of the doors to ensure unobstructed access. A safety sign has been installed. The service will conduct regular checks to ensure that evacuation routes always remain clear. Management will introduce a daily checklist for staff to ensure compliance with safety protocols, including the maintenance of clear evacuation routes. A message was sent to all staff member to remind them about the importance of Fire Doors. This will be sent each time a door is observed to be blocked. 4. The latch has been replaced with a new 'push to open' bar mechanism. Regular inspections and maintenance of the door will be scheduled. 5. All wedges have been removed from fire doors across the facility. A comprehensive fire safety review of the premises has been completed. A strict policy has been implemented prohibiting the wedging of fire doors under any circumstances. Regular fire safety training sessions for staff will be conducted. These sessions will cover the importance of fire safety protocols, the proper use of fire safety equipment, and procedures to follow in the event of a fire. 6. On 29 January, emergency exit signs were installed. Management will regularly review and maintain all signage, including emergency exit signs. This will involve periodic checks to ensure that all signs are clearly visible, in good condition, and accurately reflect the current layout and safety protocols of the facility. Infection Control: 7. Management have reinforced the importance of handwashing post-nappy change with all staff members. The 'nappy changing routine' poster has been moved to a prominent position in each of the toilets. Management will conduct regular training sessions with a particular emphasis on handwashing techniques and the correct procedures for nappy changing. Management will introduce a handwashing policy with clear guidelines for staff. 8. The service has acquired a new fridge for the pre-school room. Management have undertaken a comprehensive review of the food safety policy. A poster stating "KEEP FOOD IN FRIDGE ALL THE TIME" has been prominently displayed on the fridge. Management will conduct regular training sessions for staff on food safety and hygiene practices. To ensure adherence to food storage guidelines, daily checks will be implemented
Regulation 26 — Fire safety measures
(4) Notices of the procedures to be followed in the event of a fire were not displayed. This posed a risk to the safety of the children in the event of a fire
Provider's corrective action:
New maps and procedures outlining clear instructions are now on display in each room. Bi-annual audits will be conducted to ensure all safety notices, including fire evacuation procedures, are prominently displayed, up-to- date, and compliant with current regulations. These audits should be documented, with reports highlighting compliance status and any corrective actions taken
Regulation 29 — Premises
The Toddler room and adjoining corridor used by the children were not adequately ventilated. The inspectors observed a damp odour in the Toddler room and condensation droplets falling from the ceiling window. They observed black patches which appeared to be mould surrounding the ceiling windows in the corridor and Toddler room and on a corner of the wall and ceiling in the corridor
Provider's corrective action:
The service used professional services to remove the existing mould. A professional assessment of the entire building was conducted. The assessment concluded that to effectively manage the humidity levels, particularly in the corridor where mould was visible, an additional radiator is necessary. This installation, scheduled for 17 February 2024, will play a significant role in preventing mould reoccurrence. Management will implement a regular maintenance schedule which will include routine checks for ventilation efficiency and any signs of mould