Inspection of 28 April 2026 — Inspection Report
Immediate action notice. registered provider must demonstrate how they have rectified the non-compliance and will prevent any non - compliance from re occurring. The Corrective Action and Preventive Action plan (CAPA) will be used to inform decisions about compliance with regulatory requirements. Where the registered provider fails to meet the statutory requirements an escalation process may be commenced.
Regulation 23 — Safeguarding health, safety and welfare of child
- Fire Safety: 1. A referral was made to the fire officer with reference to two doors in use as fire doors; the entrance door to the care room door had no lit signage and no thumb turn lock or push bar mechanism. The second door, identified as the main fire exit door in use by the service, was secured with a key lock and a night latch both posing a safety risk to the children and adults if the children and adults had to evacuate the service quickly in the event of an emergency. General Safety: The following non-compliances posed a general safety risk to the children; 2. Two gates in the outdoor play areas were accessible by unauthorised adults. 3. A mark making board in the outdoor play area had a broken frame with splinters accessible by the children. 4. The lock on the adult toilet door was broken and the area was accessible by the children. 5. Cleaning agents were accessible in an unlocked cupboard under the sink. Infection Control: 6. Contrary to the service’s nappy changing policy an unclean changing mat was observed in the children’s sanitary area. In conversation, a staff member stated that children were changed on the mat on the floor, posing a risk of infection. 7. Contrary to the service’s nappy changing policy no disposable aprons were available in the event a child required nappy changing, which may pose a risk of cross infection. 8. There were three full wheelie bins positioned in the rear outdoor play area which were accessible by the children, posing a potential risk of cross contamination. Action submitted by the Registered Provider
Provider's corrective action:
- Fire Safety: 1. The registered provider stated that they are awaiting a response from the fire officer. General Safety: 2. Secure devices were fitted to both the large metal gate at the front of the service and the gate at the rear of the service on 29/04/2026 to ensure the safety of the children. A risk assessment will be carried out by staff prior to children playing in the outdoor areas to ensure that no unauthorised adults can enter the area while the children are on the premises. 3. The damaged mark making board has been removed from the area. 4. A secure device has been fitted to the adult toilet to ensure that the children cannot access the area. Staff will check to ensure that the door remains secured while the children are present in the service. 5. Cleaning agents have been removed and stored in a secure cupboard out of reach of the children. Infection Control: 6. A new changing unit and nappy changing mat are now in use. 7. Single use disposable aprons are now in place in the sanitary area for use by the adults, if required. Staff will ensure that a new apron is put on prior to each child being changed in order to prevent cross contamination. 8. The wheelie bins were moved into the shed which is secured and inaccessible to the children. They have been added to the daily risk assessment which will be checked by staff prior to the children being allowed in the area
Found compliant: Regulation 9, 11, 19, 25, 26, 28.