Immediate action notice. The inspection focused on a review of regulations which were found to be non-compliant on the last inspection of the service on the 6th March 2024, and the subsequent corrective and preventive actions submitted following the inspection to address the non-compliances. The registered provider made an application to increase the maximum number of children in attendance in the service from 75 to 80, with the proposed increase being facilitated within the existing five care rooms available. The proposed increase was assessed as part of the inspection process. The requirement has been met to accommodate 80 children at any one time, based on the children attending on a full day care basis, and subject to the floor space requirements being met for the ages of children in attendance.
No non-compliance recorded in this report.
Found compliant: Regulation 9, 11, 16, 19, 23, 25, 30.
Immediate action notice. This was a planned focused inspection however; additional Regulations were assessed following the receipt of information which was furnished to the Early Years Inspectorate on the 26th February 2024. An Immediate Action Notice was issued on the 7th March 2024 in respect of
Regulation 9 — Management and recruitment
Three adults who were employed to work directly with the preschool children did not have a major award in Early Childhood Care and Education at a minimum Level 5 on the National Framework of Qualifications
(a) (b) The registered provider did not demonstrate that they had taken all reasonable measures to ensure that all employees were appropriately supervised and provided with appropriate information and training to safeguard the health, safety and welfare of children attending the service and to comply with the regulations as follows: • The inspectors were not assured that all employees were provided with the appropriate information or training in relation to the policies of the service. For example, a staff member who commenced working in the service on the 4th March 2024 was asked by the inspectors if they had read and understood the policies and procedures of the service. The staff member did not understand the question in relation to the policies and procedures as English was not their first language. The inspector used an online translation tool to ask the same question in the staff member’s native language. Following the translation, the staff member then confirmed that they had read the policies and procedures in English. • The recruitment and training manager was present on both days of inspection however on the first day of inspection was observed working directly with children. Therefore, they were unable to carry out induction training with a new staff member which they said they were in the service to do on the first day of inspection. • Senior staff members stated they had training records available indicating staff had completed training as per service policy however this was not evident in practice over the course of the inspection as detailed under Regulation 19
Provider's corrective action:
(4) Three staff members have been replaced within the centre until their certificate comes through. All three staff are waiting on their completed certificate from the college. Staff will not be present until their certificate is issued
On the day of the inspection, the area manager had all training files present for the inspectors to view. All staff members had signed off on the policies and procedures which are translated into their native language - On site training has been provided in their native language. The recruitment manager was present on the day as she was carrying out on the spot training within the centre. This type of training is carried out by the manager taking over the room and the staff members observing. All training records were present on the day of the inspection, inspectors refused to go through these. All staff members were inducted into their roles and training has been carried out every week. This involves evening training, weekend training and on the spot room training
Regulation 11 — Staffing levels
The registered providers did not ensure that there were always an adequate number of adults working directly with the children. Inspectors observed this to have a significant impact on the care of the children. Examples of this included: Inspectors observed the person in charge moving constantly between rooms to maintain ratios and help staff. Eleven staff members told inspectors that if they require assistance in their rooms, they contact the person in charge. Inspectors observed that the person in charge was required in the care rooms on a daily basis to maintain minimum ratios and to cover breaks between 11am and 2pm. Staff told inspectors that would have to call other care rooms until someone became available. This posed a risk to the care, welfare and safety of children and staff if no one was available to assist in the event of an emergency. On the second day of inspection in the Wobbler room, a senior staff member who was required in the room to maintain ratios was observed phoning another care room looking for the person in charge to take one of the children to the cot room for their nap. The person in charge was not present in that care room. Inspectors observed that a domestic staff member was directed to locate the person in charge to assist them. However, the person in charge could not assist as she was unable to leave the room that she was in as it was observed that she was part of ratio there. The unavailability of additional staff to assist in care rooms negatively impacted the care and welfare of the children in the service as in this instance the child could not be taken for their nap, as minimum ratios could not be maintained at that time if the senior staff member left the room
Provider's corrective action:
We explained to the inspectors that the person in charge in all our services are included in the floor covers. This happens within all our services. All our cover staff and person in charge move between rooms between 11am to 2pm to cover nappy changes and staff breaks. We have phones within all our rooms so that the staff can call for help. We had four staff floating on the day of the inspection. We have been actively recruiting to provide more support for the centre (additional staff). We have recruited a further two staff members to date to commence within the centre
Regulation 16 — Record in relation to pre-school service
(h) It is acknowledged that details of most of the children’s attendance records were recorded on an electronic application. However, a child attending the Wobbler room left the service at 10.22am and was not signed out until 10.48am when it was brought to the staff members attention by the inspector. This impacted the safe evacuation of all children in the event of an emergency. (i) Inspectors reviewed the roster for the week commencing 26th of February and the 4th March 2024. An additional three members of staff from Head Office were present on the first day of inspection. On the second day of inspection a fourth member of staff from Head Office was also present but was not observed working directly with the children. Inspectors also observed that the senior staff did not know the children’s names or routines which demonstrated a lack of familiarity with the children which impacted on their care if senior staff were not aware of their needs. A member of staff told inspectors that they don’t have time to play with children due to inadequate staffing. The rosters reviewed by inspectors were inaccurate and did not reflect staff present in the service, examples include: • One staff member from head office who was rostered to work for the week was not present on the first day of inspection but was on the second day. • A senior staff member who was not on the roster for the week beginning the 4th March was present on both days of inspection and arrived following the inspector’s arrival on the first day of inspection. • Another senior member of staff from head office was rostered for the full week beginning the 4th March 2024 from 10.30am – 6.30pm in the service. This staff member told an inspector that she had not been present in the service on Monday of that week. • A staff roster for the previous week beginning 26th February 2024 was reviewed by the inspectors. Two senior staff members had been rostered every day from 10.30am to 6.30pm. Staff members confirmed one senior staff member had been present on two days of the roster despite being rostered for the full week from 10.30am – 6.30pm and they had not seen the other staff member at all the previous week. • The third senior staff member was rostered to work Monday 26th February 2024 from 9.30am – 6.30pm and Friday 1st March 2024 from 9.30am to 6.30pm. Twelve staff members told the inspectors they had not seen this senior staff member present in the service at all during the week of 26th February 2024. • The additional three senior members of staff from head office who do not usually work in the service were observed carrying out the primary care duties in the Baby, Wobbler and Toddler rooms and were also required to maintain ratio in theses rooms. Inspectors observed these staff comforting children who were upset, nappy changing, preparing care rooms for sleep, putting children to sleep and carrying out sleep checks. • Through discussion with staff, it was evident that the area managers that were rostered on week 4th March 2024 were not always present. Therefore, it was not possible to ascertain if ratios were maintained at all times as the rosters presented to inspectors was not an accurate reflection of the total staffing complement
Provider's corrective action:
(h) We will ensure staff sign children in and out in a timely manner. We have retrained staff on the on importance of a live register. Staff have been retrained on carrying out information on the tablets. (i) We have ensured that the roster is live each day. The manager will readjust the roster when needed by 9.30 each morning. Onsite and weekend training is constantly being carried out to ensure staff are aware of each child’s needs. This has been sent out in communication during a managers meeting to ensure the rosters are live and accurate each day. The Training manager carries out on site and weekend training on all aspects of the individual child’s needs
Regulation 19 — Health, welfare and development of child
The inspectors were not assured that staff working directly with the children had sufficient knowledge of the regulatory requirements or the policies and procedures of the service to meet the needs of the children as detailed below: 1. On a number of occasions, it was evident that the staff could not understand questions asked by the inspectors or directions from senior staff members. This impacted on the care the children received. For example: • On the inspectors arrival to the service, the area manager stated that the English of some staff working in the service was not very good and inspectors may have some issues when communicating with staff. The area manager told inspectors that they have to use an online translation tool to communicate with staff. It was evident that some staff struggled to understand the questions the inspectors were asking. Inspectors made several attempts to rephrase and re- word questions so that staff members understood them. Despite this, inspectors could not gather the information required through discussions with staff given their limited ability to converse in the English language. For example, on one occasion the inspector asked what time the children had woken from their sleep. The inspector observed that the staff member who was covering a lunch break in the room had to translate the question in their native language for the staff member who was based in the room. This posed a risk of children’s basic care needs not being met if staff did not understand the children. • On one occasion, a senior member of staff asked a staff member to give a spoon to a child to encourage him to self-feed. Inspectors observed the staff member did not understand the instruction and the senior member of staff gave the spoon to the staff member. As soon as the senior staff member left the room the staff member took the spoon from the child and placed it in the sink. As a result of the lack of understanding of the instruction the child was not afforded the opportunity to self-feed. • A senior staff member directed a staff member to clean a child’s nose. She had to repeat the instruction a number of times before the staff member carried out the request. • Inspectors found that staff could not communicate the basic care needs of children to them. Through discussions staff could not answer questions such as: What time do children go home?, What time is sleep?, What time is dinner? What time did a child arrive to the service and how long a child slept for? Inspectors observed that a colleague of the staff member had to translate the questions in their native language. Therefore, inspectors were not assured that the care needs of children were met given that communication in the language spoken by the inspectors with staff was so limited. 2. Inspectors observed that some staff were unable to provide appropriate and suitable care to children as follows: • In the Wobbler room children were observed to pinch and hit one another in front of a staff member. The staff member did not react or attempt to comfor t the child that was hurt . A senior member of staff intervened and comforted the upset child whilst the staff member based in the care room did not intervene. • On both days of inspection there was adequate staff in the in the Wobbler room. However, adults were observed to be unable to provide appropriate care in a child centred manner to children. Children were observed to be upset and crying at the same time. Staff members were observed picking up children briefly to comfort them and then having to put them down again to comfort other children who were upset. During these times, the other staff members in the room were observed carrying out nappy changes and cleaning duties in the room rather than comforting the children who were visibly upset. 3. The registered provider did not ensure there was an adequate provision of food and drinks for some of the children in attendance on the days of inspection as follows: • Information given to the inspectors in relation to food provision was contradictory. In one room during the first day of inspection, a number of children were looking for more food when a staff member told them there was no more food. A senior manager disagreed with the staff member and said there was more food. The staff member told the inspector that they normally do not offer extra food. • A child who had asked for more food was observed to take another child’s bowl from them and begin to eat their food. The inspector had to intervene and tell the staff what had happened. • In the Wobbler room, on the second day of inspection, a child was observed asking for more food and pointing to the counter after the morning snack at 11.31am. A senior staff member offered water which the child refused. The child was then picked up by another staff member who said there was no more food available. The next scheduled meal in the service was dinner which takes place at 2.30pm. This practice posed a potential risk of a child being hungry and is not in line with child centred care practices. 4. The inspectors observed that the service designated sleep times of children in the Wobbler and Toddler rooms were adult led to meet service needs rather than to meet the sleep needs of children attending the service as follows: • In the Toddler room children were placed to sleep at 11.50am. The children did not appear to be tired but the person in charge told the inspector that they all were tired. A number of children observed by inspectors were off their beds and heard saying “no sleep” whilst taking off their blankets. The person in charge instructed the staff member to bring 4 children to the garden at 12.15pm. A further 4 children also got out of their beds and were brought to the garden. At 12.35pm 4 children were asleep and 9 were in the garden. The designated sleep time was not observed to meet the needs of the children on both days of inspection. • The inspector observed that three children in the Wobbler room who were displaying signs of tiredness including crying and rubbing their eyes were not placed to sleep in a timely manner on the first day of inspection. Although staff acknowledged that the children were tired and made attempts to comfort them when they were upset, the first child who displayed signs of tiredness at 11.05am was not placed to sleep until approximately 12.25pm. A senior member of staff who was bringing children to the cot room for their sleep was heard to state that this child’s cot was not ready yet. This was due to the fact that the mattress needed to be disinfected and a new sheet put on the mattress as the cots in use by the children in Wobbler room are shared with the children attending the Baby room. The other two children were placed to sleep approximately 50 minutes after they first displayed signs of tiredness. The sleep practices observed during the inspection do not meet the basic care needs of children and are not in line with suitable child centred care practices. 5. A child was due to receive an antibiotic at two times specified by the parents, 11.30am and 3.30pm. At 1.42pm a senior member of staff noticed that the 11.30am dose had not been given. They immediately gave the medicine to the child. Therefore, the second dose of medication scheduled for 3.30pm had to be delayed to 5.45pm. The senior staff member confirmed that the parents were advised of this delay when they collected the child. This posed a risk of ineffective treatment as the specific timing instructions prescribed by a medical practitioner were not followed. 6. The room environments in the Toddler and Wobbler rooms required further development to cater for the number of children attending and to encourage intellectual and emotional development. There were 14 children attending the Toddler room. There were two small shelving units containing construction materials and puzzles, whose pieces were mixed up, a small kitchen area and some books. The Wobbler room had two shelving units with vehicles, balls and blocks. A small kitchen and a play tunnel and tent and a felt display were also available. Fifteen children attended this room on the busiest day. 7. The program of activities were observed to be adult led in a number of care rooms . Staff were observed spending little time on an activity before quickly moving on which prevented the children engaging in the activity. In the Baby room children were happy playing with the felt display and animals when the staff member told them they were going to play with the kitchen now. As some children could not walk the staff member carried them over to the kitchen area and the children began to cry. This practice resulted in children being upset as observed by inspectors and was not child centred
Provider's corrective action:
Contradiction on this in relation to staff not understanding English - Then in other parts the staff were questioned and did understand. Area manager explained that the staff were trained in native languages. 2., 3., 4. All staff have been retrained. We train staff on the spot. We train staff in their native language. We have retrained staff on hygiene. We have retrained staff on positive behaviour and policies. We have retrained staff on how to handle different situations within the room, offering more food if a child still appears to be hungry, safe sleep policy. What signs to watch out for when children are tired and allowing them to sleep when needed. 5. Staff have been retrained on the administration of medication. 6. We were informed that the rooms were just about equipped but would need more over time. All rooms have been rearranged and more equipment has been bought. 7. We have carried out training on children’s interests. Training has taken place in relation to Aistear and activities for children. We have now hired a training and development manager who will ensure all the non-compliances mentioned are looked at and in turn this will present them from happening again
Regulation 23 — Safeguarding health, safety and welfare of child
General Safety: 1. The service was not secured to prevent unauthorised access. A door leading from the underground carpark to the premises where the service is located, was not adequately secured and was unlocked. It was possible to enter the premises via a platform lift from the underground carpark. This presented several risks to the children’s safety and created a risk of an unauthorised person entering the premises. An Immediate Action Notice was issued to the provide in respect of the above non-compliance on the 7th March 2024 to mitigate the risk. A response was received on the 11th March 2024 from the registered provider, this was deemed to adequately address the non-compliance. 2. A senior staff member was observed to tilt a cot on its side so that it was balanced on two legs in order to rock a child to sleep in the cot room. This practice posed a risk of injury to the child as the cot was unstable on two legs as observed by the inspectors. 3. A play kitchen door was observed to be coming off its hinges leaving a gap which could cause a child to pinch their fingers when playing with it. The play kitchen had been removed from the care room on the second day of inspection and was observed in the office with the hinge repaired. Infection Control: 4. The nappy changing procedures were ineffective in relation to infection prevention and control and contrary to the service’s nappy changing procedure as follows: • Of the six nappy changes observed no staff member washed their hands prior to the change, this is at variance with the nappy changing policy which was available on the wall of the nappy changing area. • Three nappy changes were observed in the Baby room. The children’s hands were not washed following any of these changes which is at variance with the nappy changing policy and posed a risk of cross contamination. 5. Staff were observed carrying out three nappy changes while children had a soother in their mouth. One nappy change was completed while a child held a blanket in the Wobbler room despite signage being in place reminding staff not to do so. This posed a risk of cross contamination. 6. The bin in the Toddler nappy changing area was observed to be overflowing preventing the lid from closing. Staff were observed lifting the lid and placing soiled nappies on top of the existing waste. It is acknowledged that an ancillary member of staff changed the bin shortly after. 7. Staff were not aware that children were taking each other’s cups and drinking from them. In the baby room a child was observed taking another child’s cup and drinking from it. This happened on two occasions before staff noticed. In the Wobbler room a child was observed taking cups belonging to 2 other children and drinking from them. Staff did not intervene. This posed a risk of cross contamination. Action submitted by the Registered Provider
Provider's corrective action:
The wind coming into the service prevented the door from closing. This was fixed straight away. Email sent out to families and staff. We have now put a spot check note of checking the exits and entry zones of the centre
We have retained staff on the sleep policy to ensure this does not happen again. Training notes for sleep - signed off
We have live maintenance reports - so anything which breaks within the centre is fixed immediately. (this had been on the list to get repaired). Our maintenance staff member is available each day. Infection Control:
All staff have been retrained on the nappy policy to ensure it is carried out correctly. Training notes on nappy changing are attached
Meeting carried out with all staff members and we have discussed soother use. Staff know how important it is to only allow soother use while children are resting or sleeping
This point was discussed with the inspectors at the handover meeting. The bins were changed just after the changes were complete. Domestic and staff have been informed to change the bins more regularly
Staff have been retrained in reg 23 and the important of hygiene within the rooms. Supervision has also been discussed and the importance of ensuring children do not share each other’s cups. The importance of hygiene discussed with staff
Regulation 25 — First aid
A person trained in First Aid Responder was not available to the children at all times. The person in charge was the only person available to children who had received the appropriate training. The person in charge was rostered to work from 7.25am to 4.25pm, Monday to Friday. There was no person available to the children with the required FAR training from 4.25pm to 6.30pm daily. This posed as a significant risk to the care, safety and welfare of children in the event of an emergency. The person in charge stated that a second member of staff who had been trained in FAR had left the service at the beginning of February. An Immediate Action Notice was issued to the registered provider in respect of the above non-compliance on the 7th March 2024 to mitigate the risk. A response was received from the registered provider on the 11th March 2024 which addressed the findings contained within the Immediate Action Notice
Provider's corrective action:
We discussed with the inspectors we had three staff members available who were trained on FAR. We lost two staff members, and they left without warning which left only one staff trained in FAR. We immediately put another staff member on the course when they left. We sent in evidence that the second staff member was waiting on their FAR cert