Inspection of 17 November 2025 — Inspection Report
Immediate action notice. An Immediate Action Notice was issued on the day of inspection, 17 November 2025, under regulation 23 as a side gate with direct access into the service was not adequately secured to prevent unauthorised persons accessing the service.
Immediate action notice. The registered providers submitted a response on 18 November 2025 which was deemed to satisfactorily address this non-compliance.
Immediate action notice. Non-Compliance Information (1)(3) The registered providers did not notify the Agency in advance of implementing changes to the service’s registered details. The person in charge on the service’s registered details does not work in the service. The manager identified themselves as the person in charge and confirmed that they commenced in their position on 10 November 2025. It is acknowledged that a Change in Circumstance form was submitted in the afternoon of the day of inspection to address this issue, however, it was not submitted prior to the manager commencing in their role.
Regulation 9 — Management and recruitment
- Through a review of documentation and discussion with the area manager it was evident that the registered providers had not sourced a past employer reference for one new staff member from their most recent employer
Provider's corrective action:
- On review of the staff files, this staff member had already two written references available. A third reference has now been added and updated from their most recent employer and added to their staff files. This was carried out and updated on the 19th November 2025. Speak with HR and ensure staff files are checked in detail by management before start dates. Also for the person in charge to review staff files also as needed
Regulation 23 — Safeguarding health, safety and welfare of child
- General Safety: 1. An Immediate Action Notice was issued on 17 November 2025 as the potential risk of unauthorised persons gaining access to the premises was observed during the inspection. A gate at the front of the service was not adequately secured to prevent unauthorised access during the inspection. The registered providers submitted a response on 18 November 2025 which was deemed to satisfactorily address this non-compliance. Administration of Medication: 2. Practices in place for a child attending the service requiring medication posed a potential risk to the health and safety of the child. - It is acknowledged that an individual care plan was available for one child attending the Preschool 1 room who required emergency medication. However, this document was not adequately detailed as it did not state that a second autoinjector should be administered if the child’s condition did not improve within 5 minutes or to call an ambulance. This posed a risk to the timely treatment of the child in the event of an emergency. - A review of documentation evidenced that the care plan of a child who was present on inspection stated that they may require medication for mild allergic reactions which was not available during the inspection. The inspector asked staff if this medication was available, but staff were not aware of the requirement for this medication. This posed a safety risk of delaying appropriate medical attention if they became unwell. Action submitted by the Registered Provider
Provider's corrective action:
- General Safety: 1. Once this notice was issued on the 17th November and brought to our attention, the Area Manager contacted the Alarm company who came out to see the gate that evening. The area manager then received a text to say they had a cancellation so were able to come out on the 18th November and have a new maglock system fitted. Ensure all entrance gates have maglocks fitted in future to ensure no unauthorised person can gain access to the building. Administration of Medication:
- - Care Plans were available for all children needing them, one parent has since reviewed their care plan and updated it with the adequate details needed such as what to do in a severe allergic reaction to call emergency services. Ensure parents fill out care plans with as much detail as possible before start date. Also review care plans monthly and speak to parents in keeping communication opened and to allow for any changes with their doctor. - With the mild allergic reaction, the parent has provided us with medication in labelled bottle. The staff also have undergone retraining and took part in staff meeting/training night to refresh themselves on allergies in their care. Review care plans monthly and storage of medicine. Add this information into training nights also to keep staff fresh and aware of all allergies and the steps to follow in case of an emergency
Regulation not named in the report text
- (1)(3) The registered providers did not notify the Agency in advance of implementing changes to the service’s registered details. The person in charge on the service’s registered details does not work in the service. The manager identified themselves as the person in charge and confirmed that they commenced in their position on 10 November 2025. It is acknowledged that a Change in Circumstance form was submitted in the afternoon of the day of inspection to address this issue, however, it was not submitted prior to the manager commencing in their role. Acknowledgments The inspector wishes to acknowledge the cooperation of the person in charge, staff and children who were present on the day of the inspection
Found compliant: Regulation 11, 19, 25.