Inspection of 25 February 2026 — Inspection Report
Regulation 23 — Safeguarding health, safety and welfare of child
- General Safety: 1. On the day of inspection, the inspector gained access to the outdoor area of the service, through a door from the main building in which the service is located. While it is acknowledged that this door is a fire door, this unsecured access poses a risk to the safety of children and staff as it did not restrict unauthorised persons from gaining access to the premises. Infection Control: 2. Children’s hands in the baby room were not washed before being offered dinner and as these children were observed to self-feed and explore their meal with their hands. This practice poses a risk of cross contamination and infection. 3. On the day of inspection, three staff members were observed carrying out a nappy change. It is acknowledged that the services nappy changing procedure was located on the wall in the changing area. The following practice was observed which is not in line with the service’s own procedure: • Staff members were observed at 12:35 and 12:39 during nappy changes to apply cream and redress children wearing the same soiled glove from the nappy change. A fresh glove is required to be worn when applying cream during a nappy change to prevent cross contamination. • One adult did not effectively clean the changing mat after the nappy change and before the next adult and child used it. This practice poses a risk of cross contamination and infection for children and adults. 4. Pedal bins in the baby room, Preschool 2 and the sanitary accommodation area were broken with adults and children observed to lift the lid to dispose of waste on the day of inspection. This poses a risk to the health of the staff and children. Action submitted by the Registered Provider
Provider's corrective action:
- General Safety: 1. Immediate action was taken to address the identified non-compliance under Regulation 23. Contractors were engaged without delay, and an appropriate locking mechanism was installed on the fire exit door to eliminate the risk of unauthorised access to the premises. All educators were formally notified of this change and their responsibilities were reinforced to ensure that the fire exit door remains secured at all times, except in the event of an emergency evacuation. This was communicated through staff briefings and recorded accordingly. To prevent a reoccurrence of this non-compliance in the future, robust monitoring systems have been implemented to ensure ongoing compliance. The fire exit door is now included as a mandatory checkpoint within daily safety inspections through audits, with staff members required to verify and document that the door is secure. Management will carry out scheduled and unannounced audits of all entry and exit points to ensure adherence to safety procedures and to identify any potential risks proactively. Accountability has been assigned to designated staff members on each shift to oversee compliance, and this requirement has been incorporated into centre policies and staff responsibilities. Ongoing reminders and supervision will be provided to ensure consistent practice. Signage has been added to the garden to display no unauthorised entry. An Unauthorised Entry Risk Assessment was reviewed and updated relating to the fire access point in the garden. Infection Control: 2. Handwashing procedures are now clearly displayed and accessible in all care rooms and nappy changing areas to support consistent implementation. All educators were formally reminded of the required handwashing procedures and their responsibility to ensure these are adhered to at all times. Educators were specifically instructed to ensure that children wash their hands using running warm water and antibacterial soap at key times, including before and after meals, after toileting, after nappy changing, and following outdoor play. Managements have reinforced expectations through direct communication with staff, and responsibility for implementation has been clearly assigned. Initial spot checks have been conducted by the manager and deputy manager to verify compliance. To prevent this non-compliance from reoccurring in the future, ongoing monitoring systems have been implemented to ensure sustained compliance with infection control procedures. The manager and deputy manager will conduct regular unannounced spot checks to ensure that appropriate handwashing and nappy changing practices are consistently followed. Hand hygiene requirements have been embedded into daily practice and reinforced through regular staff briefings and team meetings, ensuring continued awareness and accountability among all staff members. Visual supports, including handwashing procedure displays, will remain in place across all relevant areas to promote consistent practice and support both staff and children in maintaining effective hygiene routines. Staff have been reminded of and reviewed the infection control policy. These measures ensure ongoing adherence to infection control standards and support the health, safety, and wellbeing of all children within the service. 3. All staff members were formally briefed on their roles and responsibilities in relation to nappy changing and cleaning procedures, with particular emphasis on infection prevention and control standards. Clear and appropriate signage has been installed in all relevant areas to support correct nappy changing and hygiene practices. Infection control policy was reviewed in detail with all staff members to ensure full understanding and compliance. This was reinforced through direct communication and staff acknowledgement of procedures. The infection control Risk Assessment was reviewed and updated and implemented across the Service. To prevent a reoccurrence of this non-compliance, structured monitoring systems have been implemented to ensure sustained compliance. The manager and deputy manager will carry out regular unannounced audits of nappy changing and cleaning practices to ensure procedures are being followed consistently. Infection control practices have been embedded into daily routines, with clear accountability assigned to staff on each shift to oversee adherence. Ongoing supervision, staff briefings, and team meetings will be used to reinforce expectations and maintain high standards of hygiene practice. These measures will ensure continued compliance with Regulation 23 and support the health, safety, and wellbeing of all children within the service. 4. All damaged bins were removed and replaced with appropriate, fully functional bins in all areas of the service. Clear signage has been installed on each bin to reinforce correct usage, including ensuring lids are securely replaced after use and that any faults or damage are reported promptly to management. Staff members have been informed of these requirements and their responsibility to maintain appropriate waste management practices in line with infection control procedures. Ongoing monitoring systems have been implemented to ensure that this non-compliance does not re- occur in the future. Management will carry regular and unannounced audits to assess bin condition, appropriate usage, and adherence to infection control standards. Daily room checks have been updated to include bin condition and functionality, with responsibility assigned to room leaders to ensure bins are clean, operational, and used correctly at all times. Any maintenance issues identified will be reported and addressed without delay to prevent recurrence
Found compliant: Regulation 9, 11, 16, 19, 25, 26, 28.