Regulation 19 — Health, welfare and development of child
Care practice was observed which may negatively impact the health and wellbeing of the children in attendance as follows: • At 11:17am a child attending the ECCE room had a soiled nappy and required changing. A staff member attempted on three occasions to change the child’s nappy, however the only nappy changing area available in the service was occupied by the Playgroup room. The child remained in the soiled nappy playing outdoors until 11:39am when the changing area became available and they were changed
Provider's corrective action:
A new nappy changing unit was ordered for the ECCE room, this will prevent children from the ECCE room waiting for the changing room to become available
Regulation 23 — Safeguarding health, safety and welfare of child
Infection Control: Some observations were deemed inadequate for infection control purposes and posed a risk of cross contamination as follows; • The nappy changing mat in the designated nappy changing area was torn. • The nappy changing mat in the designated nappy changing area had a build-up of dirt on its edges. • There was a build up of dirt and dead insects accumulated around the bin area in the hallway between the two classrooms, this poses a safety risk as the area was accessible to children. Action submitted by the Registered Provider
Provider's corrective action:
Infection Control: 1. The torn nappy changing mat has been removed and replaced. 2. The staff have been reminded to disinfect the changing are after each use. 3. The bin and brush have been removed from the hallway
Regulation 29 — Premises
(e) On the day of inspection there were sixteen children present requiring nappy changes between the two rooms and only one nappy changing unit available, as a result children were left waiting to have soiled nappies changed as detailed above under Regulation 19. One nappy changing unit is required for every eleven children attending a pre-school service
Provider's corrective action:
A new nappy changing unit has been installed in the service, this will prevent children from the ECCE room waiting for the changing room to become available
Immediate action notice. On 19 April 2024, an Immediate Action Notice was issued to the registered provider. Concerns were identified as an immediate and significant risk or is likely to be a risk to the safety of the children attending the service which is contrary to the requirement of
Regulation 8 — Notification of change in circumstances
(1) The registered provider failed to notify the Agency in writing of a change of person in charge. The registered provider failed to notify the Agency in writing of a change of person in charge on previous inspections dated 25 April 2022,4&5 October 2022 and 29 March 2023. Since the inspection dated 25 April 2022, the service has been non-compliant on this regulation and has had five new people in charge. The registered provider was informed on each occasion of the requirement to notify the Agency in writing of this change. Despite assurances given during the corrective action and preventative action process, the registered provider has failed to do so
Provider's corrective action:
The registered provider is taking on the role of person in charge. Should a new person be appointed as the person in charge in the future, this person will not take the role until a change of circumstances has been submitted. In order to be compliant going forward, the registered provider has outlined procedures to follow – 1 Interview. 2 Garda Clearance. 3 Check both references. 4 Offer job. 5 submit change of circumstances
Regulation 9 — Management and recruitment
(a) Two references were not signed by the person who validated them in respect of two adults
A new Garda vetting disclosure was not sought for one adult who had left the service and returned after a period of months. 17 & 18 April 2024
On two different occasions during the inspection, the registered provider was not present in the service, The inspectors asked each staff member who was in charge, and each mentioned a different member of staff. The person who is registered as the designated person in charge has not been in the service for over a month. This was non-compliant on previous inspections dated 25 April 2022,4&5 October 2022 and 29 March 2023. (2) (a&b) Two members of staff joined the service since the last inspection (22 January 2024). One validated reference from either a past employer or a source other than a past employer was not available for either staff member. (4) On 19 April 2024, an Immediate Action Notice was issued to the registered provider as the registered provider did not ensure that each employee working directly with pre-school children held the required qualification. On 16 April 2024, through discussion with staff and review of the records in the service, it was confirmed that one adult was caring for 5 children between 2-3 years and 6 children over 3 years between 4- 6pm. There was no evidence that this adult held an award in Early Childhood Care and Education at Level 5 on the National Framework for Qualifications, or a qualification deemed by the Minister to be equivalent. (7)(a) On discussion with a new staff member regarding their induction into the service, the staff member confirmed they had read the policies but has not signed to confirm they had read them which is contrary to the induction policy of the service. On 17 & 18 April 2024, further non-compliances were found which need to be addressed. These include Regulation 9 (1)(c), (2) (a&b), (4), (7)(a)
Provider's corrective action:
The corrective action and the preventative action response submitted on 23 February and 18 March 2024 by the registered provider was insufficient and did not meet regulatory compliance. The inadequate response triggered a CAPA review inspection on 17 & 18 April 2024 to ascertain if the registered provider could meet compliance through review of the records onsite. The registered provider submitted an additional CAPA response on 23 May 2024. (1) (c) No corrective action or preventative action submitted to address the non-compliances identified. (2) (a) & (b) One staff member is waiting on their previous employer for a reference. This staff member will not be in the service until they receive their second reference. Two references will be given in before new staff start. (4) The service has changed to a sessional service, sufficient staffing will maintain ratios. With going sessional staff rotas will reflect qualifications and if the service does not have adequate staff the registered provider will not allow children on to the premises. (7) (a) A signature will be sought after new staff have read the policies and procedures. This will be kept in the staff file and will be put on the staff file check list
Regulation 11 — Staffing levels
16 April 2024 (2) The minimum ratio of adults to children was not maintained. On discussion with staff and review of the records, it was confirmed that two adults in the Bees room were caring for 14 children aged between 2-3 years until 1.30pm. The Bees room and the Butterfly room combine together at 1.30pm. One adult was caring for 5 children between 2-3 years and 6 children over 3 years from 1.30 – 6pm. 17 April 2024 Two adults were caring for 13 children between 2-3 years until 1.30pm in the Bees room. Between 2pm -3.10pm two staff were caring for 5 children between 2-3 years and 8 children over 3 years. After 3.10pm, one adult was caring for 5 children between 2-3 years and 2 children over 3 years. Children who attend either parttime or fulltime require 1 adult to every 6 children aged 2-3 years and 1 adult to every 8 children aged 3-5 years. This regulation was previously non- compliant on previous inspections dated 25 April 2022,4&5 October 2022, 29 November 2022. The regulatory requirements have not been met
Provider's corrective action:
A new member of staff has started and will be working to 5pm every day. No preventative action was submitted
Regulation 15 — Record of pre-school child
(b) The date on which six children first attended the service was not recorded. (g) The name, address and telephone number of each child’s general practitioner (GP) was not recorded on eleven forms. This was a non-compliance on the last inspection 21 September 2023, despite assurances from the registered provider during the corrective action and preventative action process that this would be rectified
Provider's corrective action:
The corrective action and the preventative action response submitted on 23 February and 18 March 2024 by the registered provider was insufficient and did not meet regulatory compliance. The inadequate response triggered a CAPA review inspection on 17 & 18 April 2024 to ascertain if the registered provider could meet compliance through review of the records onsite
Regulation 16 — Record in relation to pre-school service
22 January 2024 (i) The staff roster did not accurately reflect who was present on the day of inspection. The staff roster available was dated 13-17 November 2023. 17 April 2024 (i) The staff roster did not accurately reflect who was present on the day of inspection despite assurances during this corrective action and preventative action inspection that this would be available and accurate. 18 April 2024 (i) No staff roster was available to inspect. A staff roster is required to ensure that a registered provider can demonstrate that sufficient staff will be in place to care for children who are attending the service. This regulation was non-compliant on previous inspection dated 4&5 October 2022, 29 November 2022 and 29 March 2023
Provider's corrective action:
The corrective action and the preventative action response submitted on 23 February and 18 March 2024 by the registered provider was insufficient and did not meet regulatory compliance. The inadequate response triggered a CAPA review inspection on 17 & 18 April 2024 to ascertain if the registered provider could meet compliance through review of the records onsite. CAPA response submitted on 23 May 2024. Staff will be working the same hours every week. Rotas will be changed if a staff member is out. Rotas will be changed to reflect if a staff is absent to make sure there is adequate staff on the day. If the service is short-staffed children will not be allowed in to keep in ratio. Staff rotas are available in the ECCE room on the notice board. Management will be responsible every morning to ensure the rota is changed to reflect staff absence
Regulation 23 — Safeguarding health, safety and welfare of child
General Safety: 1. On 17 April 2024, fifty-three accident and incident records were inspected/ reviewed since the last inspection dated 22/1/2024. Forty-seven of these records were/ detailed injuries caused from one child to another. 2. Attendance records were not recorded accurately. Details of children’s attendance was not accurately recorded as evidenced below: On 16 April 2024, the records confirmed that one child was not recorded as having left the premises. On 17 April 2024, it was evident that one child was not recorded on any attendance record on the premises since 4 April 2024. This child was added to the attendance record at 3.10pm when the registered provider was made aware of this. On 17 April 2024, eleven children were not recorded as having left the premises at 2.20pm. At 3.10 pm one child remained not recorded as having left the premises despite leaving at approximately 1.30pm. Inaccurate attendance records pose a significant risk to children in the event of an emergency evacuation. 3. There was no registration form available for one child present in the service on either day of the inspection. This posed a significant risk to the child as important information would not be available in the event of an emergency. The service would not be able to access this child’s preschool record in the event of an emergency. 4. Two fire doors were propped open at different times of the day during the inspection. Fire doors should be closed at all times in order to prevent fire and harmful fumes spreading to other areas of the building. Action submitted by the Registered Provider
Provider's corrective action:
General Safety: (1) No corrective action or preventative action submitted. (2) Children's attendance will be recorded by one staff member. So going forward one staff member in each room will be responsible for signing the children in and out. Attendance records will be printed out on the Friday for the following week. It will be checked before giving it to staff to make sure all the children are on it. Staff have been told to record the time they come in and go home as soon as they have come in or left the building. (3) Registration forms for each child are now back in the application form folders. Children's folders will be checked on a regular basis to make sure all the files are correctly placed in the correct folders. After use they will be put back into their files. (4) Going forward staff have been told not to prop open any doors. Signs have been put up on the fire doors to remind staff to keep them closed
Immediate action notice. On 19 April 2024, an Immediate Action Notice was issued to the registered provider. Concerns were identified as an immediate and significant risk or is likely to be a risk to the safety of the children attending the service which is contrary to the requirement of
Regulation 8 — Notification of change in circumstances
(1) The registered provider failed to notify the Agency in writing of a change of person in charge. The registered provider failed to notify the Agency in writing of a change of person in charge on previous inspections dated 25 April 2022,4&5 October 2022 and 29 March 2023. Since the inspection dated 25 April 2022, the service has been non-compliant on this regulation and has had five new people in charge. The registered provider was informed on each occasion of the requirement to notify the Agency in writing of this change. Despite assurances given during the corrective action and preventative action process, the registered provider has failed to do so
Provider's corrective action:
The registered provider is taking on the role of person in charge. Should a new person be appointed as the person in charge in the future, this person will not take the role until a change of circumstances has been submitted. In order to be compliant going forward, the registered provider has outlined procedures to follow – 1 Interview. 2 Garda Clearance. 3 Check both references. 4 Offer job. 5 submit change of circumstances
Regulation 9 — Management and recruitment
(a) Two references were not signed by the person who validated them in respect of two adults
A new Garda vetting disclosure was not sought for one adult who had left the service and returned after a period of months. 17 & 18 April 2024
On two different occasions during the inspection, the registered provider was not present in the service, The inspectors asked each staff member who was in charge, and each mentioned a different member of staff. The person who is registered as the designated person in charge has not been in the service for over a month. This was non-compliant on previous inspections dated 25 April 2022,4&5 October 2022 and 29 March 2023. (2) (a&b) Two members of staff joined the service since the last inspection (22 January 2024). One validated reference from either a past employer or a source other than a past employer was not available for either staff member. (4) On 19 April 2024, an Immediate Action Notice was issued to the registered provider as the registered provider did not ensure that each employee working directly with pre-school children held the required qualification. On 16 April 2024, through discussion with staff and review of the records in the service, it was confirmed that one adult was caring for 5 children between 2-3 years and 6 children over 3 years between 4- 6pm. There was no evidence that this adult held an award in Early Childhood Care and Education at Level 5 on the National Framework for Qualifications, or a qualification deemed by the Minister to be equivalent. (7)(a) On discussion with a new staff member regarding their induction into the service, the staff member confirmed they had read the policies but has not signed to confirm they had read them which is contrary to the induction policy of the service. On 17 & 18 April 2024, further non-compliances were found which need to be addressed. These include Regulation 9 (1)(c), (2) (a&b), (4), (7)(a)
Provider's corrective action:
The corrective action and the preventative action response submitted on 23 February and 18 March 2024 by the registered provider was insufficient and did not meet regulatory compliance. The inadequate response triggered a CAPA review inspection on 17 & 18 April 2024 to ascertain if the registered provider could meet compliance through review of the records onsite. The registered provider submitted an additional CAPA response on 23 May 2024. (1) (c) No corrective action or preventative action submitted to address the non-compliances identified. (2) (a) & (b) One staff member is waiting on their previous employer for a reference. This staff member will not be in the service until they receive their second reference. Two references will be given in before new staff start. (4) The service has changed to a sessional service, sufficient staffing will maintain ratios. With going sessional staff rotas will reflect qualifications and if the service does not have adequate staff the registered provider will not allow children on to the premises. (7) (a) A signature will be sought after new staff have read the policies and procedures. This will be kept in the staff file and will be put on the staff file check list
Regulation 11 — Staffing levels
16 April 2024 (2) The minimum ratio of adults to children was not maintained. On discussion with staff and review of the records, it was confirmed that two adults in the Bees room were caring for 14 children aged between 2-3 years until 1.30pm. The Bees room and the Butterfly room combine together at 1.30pm. One adult was caring for 5 children between 2-3 years and 6 children over 3 years from 1.30 – 6pm. 17 April 2024 Two adults were caring for 13 children between 2-3 years until 1.30pm in the Bees room. Between 2pm -3.10pm two staff were caring for 5 children between 2-3 years and 8 children over 3 years. After 3.10pm, one adult was caring for 5 children between 2-3 years and 2 children over 3 years. Children who attend either parttime or fulltime require 1 adult to every 6 children aged 2-3 years and 1 adult to every 8 children aged 3-5 years. This regulation was previously non- compliant on previous inspections dated 25 April 2022,4&5 October 2022, 29 November 2022. The regulatory requirements have not been met
Provider's corrective action:
A new member of staff has started and will be working to 5pm every day. No preventative action was submitted
Regulation 15 — Record of pre-school child
(b) The date on which six children first attended the service was not recorded. (g) The name, address and telephone number of each child’s general practitioner (GP) was not recorded on eleven forms. This was a non-compliance on the last inspection 21 September 2023, despite assurances from the registered provider during the corrective action and preventative action process that this would be rectified
Provider's corrective action:
The corrective action and the preventative action response submitted on 23 February and 18 March 2024 by the registered provider was insufficient and did not meet regulatory compliance. The inadequate response triggered a CAPA review inspection on 17 & 18 April 2024 to ascertain if the registered provider could meet compliance through review of the records onsite
Regulation 16 — Record in relation to pre-school service
22 January 2024 (i) The staff roster did not accurately reflect who was present on the day of inspection. The staff roster available was dated 13-17 November 2023. 17 April 2024 (i) The staff roster did not accurately reflect who was present on the day of inspection despite assurances during this corrective action and preventative action inspection that this would be available and accurate. 18 April 2024 (i) No staff roster was available to inspect. A staff roster is required to ensure that a registered provider can demonstrate that sufficient staff will be in place to care for children who are attending the service. This regulation was non-compliant on previous inspection dated 4&5 October 2022, 29 November 2022 and 29 March 2023
Provider's corrective action:
The corrective action and the preventative action response submitted on 23 February and 18 March 2024 by the registered provider was insufficient and did not meet regulatory compliance. The inadequate response triggered a CAPA review inspection on 17 & 18 April 2024 to ascertain if the registered provider could meet compliance through review of the records onsite. CAPA response submitted on 23 May 2024. Staff will be working the same hours every week. Rotas will be changed if a staff member is out. Rotas will be changed to reflect if a staff is absent to make sure there is adequate staff on the day. If the service is short-staffed children will not be allowed in to keep in ratio. Staff rotas are available in the ECCE room on the notice board. Management will be responsible every morning to ensure the rota is changed to reflect staff absence
Regulation 23 — Safeguarding health, safety and welfare of child
General Safety: 1. On 17 April 2024, fifty-three accident and incident records were inspected/ reviewed since the last inspection dated 22/1/2024. Forty-seven of these records were/ detailed injuries caused from one child to another. 2. Attendance records were not recorded accurately. Details of children’s attendance was not accurately recorded as evidenced below: On 16 April 2024, the records confirmed that one child was not recorded as having left the premises. On 17 April 2024, it was evident that one child was not recorded on any attendance record on the premises since 4 April 2024. This child was added to the attendance record at 3.10pm when the registered provider was made aware of this. On 17 April 2024, eleven children were not recorded as having left the premises at 2.20pm. At 3.10 pm one child remained not recorded as having left the premises despite leaving at approximately 1.30pm. Inaccurate attendance records pose a significant risk to children in the event of an emergency evacuation. 3. There was no registration form available for one child present in the service on either day of the inspection. This posed a significant risk to the child as important information would not be available in the event of an emergency. The service would not be able to access this child’s preschool record in the event of an emergency. 4. Two fire doors were propped open at different times of the day during the inspection. Fire doors should be closed at all times in order to prevent fire and harmful fumes spreading to other areas of the building. Action submitted by the Registered Provider
Provider's corrective action:
General Safety: (1) No corrective action or preventative action submitted. (2) Children's attendance will be recorded by one staff member. So going forward one staff member in each room will be responsible for signing the children in and out. Attendance records will be printed out on the Friday for the following week. It will be checked before giving it to staff to make sure all the children are on it. Staff have been told to record the time they come in and go home as soon as they have come in or left the building. (3) Registration forms for each child are now back in the application form folders. Children's folders will be checked on a regular basis to make sure all the files are correctly placed in the correct folders. After use they will be put back into their files. (4) Going forward staff have been told not to prop open any doors. Signs have been put up on the fire doors to remind staff to keep them closed