Inspection of 22 July 2025 — Inspection Report
Immediate action notice. An immediate action notice was issued to the registered provider on the 22nd July 2025 during the inspection in respect of Regulation 23, general safety and first aid. A response was received from the service on the 23rd July 2025 which sufficiently mitigated the risk identified.
Regulation 9 — Management and recruitment
- (a) (b) The registered providers had not sourced a reference from one staff member’s most recent employer. Another past employer reference was available, however it was not evident that this had been verified. (3) A review of documentation evidenced the registered provider had not taken the required steps as outlined in Regulation 9(2)(a)(b) to ensure that new recruits were suitable and competent before allowing them access to children, as detailed above
Provider's corrective action:
- The registered provider submitted the following response: Corrective and Preventive Action (2) (a) (b) (3) The service has yet to receive a written reference from the most recent employer of staff member despite contact being made, however the service did complete a reference check therefore two reference checks have been completed for this employee. Conditions have been made that no new staff members will be given a start date until all relevant information is provided to the service and checks carried out on the information received
Regulation 15 — Record of pre-school child
- (b) Two of the records reviewed did not detail the date on which the child had first attended the service. (h) Two of the records did not detail a record of immunisations received by the child. The records available for four other children of immunisations received were incomplete. The corrective and preventive actions submitted following the last inspection of the service on the 29th May 2023 did not prevent the re-occurrence of the non-compliance
Provider's corrective action:
- The registered providers submitted the following response: Corrective and Preventive Action All records mentioned were returned to the parents for correction. A check list has been added to the children’s record forms for parents to help make sure all correct information is added onto their child’s form
Regulation 19 — Health, welfare and development of child
- - A suitable rest area was not in place in the care rooms during the inspection to provide comfort for children to rest or take a break from activities if required
Provider's corrective action:
- The registered providers submitted the following response: Corrective and Preventive Action A suitable rest area was not evident on the day of inspection. A suitable rest area is provided now at all times for children to rest or take a break at any time throughout their day. Signs are in place at the rest areas to always have them be made available
Regulation 23 — Safeguarding health, safety and welfare of child
- General Safety: 1. The door in the Montessori room which led to the hallway entrance of the service was open when the inspectors arrived at the service and was unlocked during the morning of inspection and could be opened by a child. The door in the hallway to exit the service leading to a main road had a push release button on the wall to open it which was situated at a height which could be accessed by a child, posing a risk of a child exiting the service unsupervised. It is noted that children were supervised at all times in the Montessori room and following a request from the inspector on the day of inspection corrective actions were taken by the person in charge and the Montessori door was secured. 2. The wooden decking in place in part of the outdoor play area had worn away and eroded in parts exposing sharp splintered edges and rusted nails posing risk of injury to a child. 3. An electrical wire from an extension cord was hanging from a shelf to a low level socket in reach of the children in the Montessori room posing a risk of harm to a child. Infection Control: 4. A fabric cloth was in use on the day of inspection to clean down the shared nappy changing mat between changes posing a risk of cross contamination. 5. The bin in use in the outdoor play area for disposal of used nasal tissues was not pedal operated. Staff members were observed handling the bin lid holding soiled tissues during the inspection posing a risk of cross contamination. 6. There were no waterproof coverings on the five cot mattresses in use in the service posing a risk of cross contamination. Action submitted by the Registered Provider The registered providers submitted the following response:
Provider's corrective action:
- General Safety: 1. Works are to be carried out to move the push button higher out of children’s reach. Children are supervised at all times in Montessori and no child is allowed into the hallway alone. The door to the hallway will be immediately secured when person enters or exits the building. The placing of the release button higher will prevent the risk of children opening the door by themselves. 2. Wooden decking has been replaced with new decking. 3. The electrical wire has been covered by furniture and is no longer in reach of children. A more thorough daily risk assessment will be at the forefront to identity any issues going forward. Infection Control: 4. Paper towels are now used to clean the changing mat after use. A Sign is now in place in the bathroom area to address this issue. 5. A pedal bin in now provided in the outdoor area. 6. The service has ordered the waterproof coverings, and they are due for delivery
Regulation 24 — Checking in and out and record of attendance
- (b) Although a sheet of paper was available in the service which had documented the entry of some visitors, the record was not appropriately used to record the entry of external persons as follows: - The person in charge did not request the inspectors sign the record sheet on arrival to the service. - The sheet in place to record the entry of visitors had no records after January of 2025. The persons in charge confirmed that visitors had entered the service since January 2025, no records were maintained of these entries. (4) Documentation reviewed evidenced the record detailed above in paragraph (3) was not maintained as detailed above under (3)(b)
Provider's corrective action:
- The registered providers submitted the following response: Corrective and Preventive Action The service has purchased a visitor book which will make it easier to obtain and record previous and present visitors. No person is allowed no gain entry to the service without signing in on arrival. The purchase of the book will make it easier to record and keep evidence of visitors to the service. A sign is in place to show visitors this and to remind staff to be aware that this procedure must be followed
Regulation 25 — First aid
- An adult trained in First Aid Responder (FAR) training was not available in the service as no staff member employed held the required qualification, or any first aid qualification. An immediate action notice was issued to the service on the day of inspection
Provider's corrective action:
- The registered providers submitted the following response: Corrective and Preventive Action Contact was made to the tutor following the inspection and proof of First Aid Responder training was provided to the inspector following the immediate action notice. The service have been told this there is still a delay on certs being issued. The service will ask for written evidence of any training events undertaken
Found compliant: Regulation 11, 29.