Inspection of 21 April 2026 — Inspection Report
Regulation 11 — Staffing levels
- (1) There were inadequate adults to meet the care needs of the eight children present during the Little Lions outdoor play time between 10:51 to 11:02. The inspector observed that three of the younger children were upset, two of whom were settling in. Three older children were observed engaging in rough play with the younger children. Both staff members were providing comfort to the children who were upset and the older children continued with rough play. At 11:02 the inspector asked a staff member if they needed help or could they move the children to another room. The staff member agreed and the inspector sought the assistance of the deputy manager. Following the inspector's intervention, two older children were then taken to join the Zebra room in the larger outdoor area, and the two staff then had 6 babies whom they were able to provide comfort to. At 11:07 the 6 children appeared content and settled, and they then transitioned back into the care room
Provider's corrective action:
- (1) The registered provider stated that the incident was reviewed immediately by management following the inspection. It was identified that, although the required adult-to-child ratio was maintained, the individual care needs of the children present at that time required additional staff support. Three new staff members, one specifically for the Little Lions room have been inducted. With the increased staffing levels, the service's floater is now more consistently available on the floor to provide additional support during busy periods, outdoor play, transitions, and settling-in times. As a preventive action staff have been reminded to continuously assess children's care and supervision needs and to seek additional support immediately when required. Procedures for outdoor play supervision and the grouping of children of different developmental stages have been reviewed. To further strengthen practice, staff have attended "Interactions with Under Twos" training course to enhance their skills in supporting the emotional wellbeing, development, and supervision needs of young children. Management will continue to monitor practice through regular supervision and room observations
Regulation 16 — Record in relation to pre-school service
- (j) Nine out of fourteen medication records dated between 09/01/2026 and 16/04/2026 were not fully completed. Details included a missing parental signature after administration of medication (on 5 records), prior parental consent was not obtained (on 4 records), and a second staff signature was not recorded (on 2 records). (k) The registered provider did not ensure that an accurate record in writing was kept in respect of accidents and incidents within the service. A total sample of 18 forms and did not contain all information required. The following was found; • 5 reports did not have parental signatures
Provider's corrective action:
- (j) The registered provider stated that following the inspection, a comprehensive review of all medication administration records was undertaken. Any missing information was identified and completed to ensure records are accurate, up to date, and fully compliant with the service's Medication Administration Policy and regulatory requirements. They confirmed that written parental consent for the administration of medication is obtained at the time of enrolment and is signed by the parent/guardian. This consent is maintained on the child's file. In addition to the signed enrolment consent, staff always contact the parent/guardian to obtain verbal consent immediately prior to administering any medication. The verbal consent obtained is documented in accordance with the Medication Administration Policy. As a preventive action they stated that staff have been reminded that the witness section of the medication administration form must be completed by a member of the management team following the administration of medication. All staff have completed refresher training on the Medication Administration Policy and Reporting Procedures, with particular emphasis on documentation requirements, consent procedures, and the accurate completion of medication records and our staff meeting. (j) The registered provider stated that following the inspection, all accident and incident records were reviewed, and any omissions identified were addressed to ensure that the documentation is complete, accurate, and compliant with the service's record-keeping requirements. As a preventive action they stated that all staff have undergone refresher training on the completion of accident and incident records, with particular emphasis on accurately completing all required sections and obtaining parental signatures on the day of the accident or incident. In addition, a new tracking system where it is logged into our app, so parents are aware they have an accident or incident form to sign on collection. Management will continue to monitor compliance through regular record audits
Regulation 23 — Safeguarding health, safety and welfare of child
- General Safety: 1. The hot water within the mixer taps at a number of hand wash sinks used by children was above the safe recommended temperature of 43°C as follows; • The children’s sinks in both toilets in the Zebra room were recorded at 47.3 – 49.1°C • The sink used for staff and children in the Little Lions sanitary area was recorded at 49.9°C to 51.9°C. It is acknowledged that the children, while using this sink, are supervised by staff. It is acknowledged that when brought to the attention of the persons in charge, the thermostat was adjusted; however, water temperatures remained above 43°C. 2. The inspectors observed cleaning chemicals and a bait box in low-level storage, which was accessible to children in the Tigers and Zebra rooms. This presented a risk of injury to the children. It is acknowledged that when brought to the attention of a manager, the items were removed from the storage area in the Tigers room. Infection Control: 3. A swing-top bin was present in the Zebra care room, and not a pedal-operated bin as required; this poses a cross-contamination risk
Provider's corrective action:
- Corrective & Preventive Action General Safety: 1. In the Zebra room Maintenance replaced the existing thermostat with a new thermostat control valve and adjusted the system to ensure that hot water temperatures at children's handwashing facilities do not exceed the recommended maximum temperature of 43°C. Staff in the Zebra Room have been reminded that water temperatures at children's handwashing facilities must not exceed 43°C. During routine water temperature checks, staff are required to immediately report any temperature reading above the recommended limit to management so that prompt corrective action can be taken. Ongoing monitoring and recording of water temperatures will continue to ensure compliance and maintain a safe environment for children. A new floor supervision form has been created to check all compliance on the floor such as water temperature are being checked by the management throughout the day. 2. Immediately following the inspection, all cleaning chemicals were removed from areas accessible to children and relocated to secure, locked storage. New safety latches were installed on storage units within the Tigers and Zebra rooms to prevent children from accessing any potentially hazardous items. As a preventive action A memo was sent to all staff reminding them of their responsibility to ensure that cleaning chemicals, pest control products, and any other hazardous substances are stored securely and remain inaccessible to children at all times. A sign has been created for the cupboards to remind staff that such items should not be kept there. A new maintenance officer has been appointed in the centres where staff can report issues to. The officer checks the rooms every Tuesday. The room and health and safety check are checked by the manager each day. Infection Control 3. The swing-top bin in the Zebra room was replaced with a hands-free pedal-operated bin to comply with infection prevention and control requirements and reduce the risk of cross-contamination. As a preventive action regular environmental health and safety checks will include verification that appropriate waste bins are in place and functioning correctly. Any non-compliant equipment identified during routine inspections will be reported and replaced immediately. Management will continue to monitor maintenance compliance with the floor supervision documents
Regulation 29 — Premises
- (d) Areas of wear and tear and chipped paint around hand-wash sinks and nappy changing area were observed as follows • At the hand-wash sink in the Zebra care room • At the hand wash sinks and the nappy changing area in the Zebra sanitary area • At the handwash sink in the Little Lions sanitary area
Provider's corrective action:
- (d) At the hand-wash sink in the Zebra care room a washable vinyl tile covering was installed around the sink area to protect the wall surface from water damage and facilitate effective cleaning in the room. Staff have been reminded to report any damaged surfaces or chipped paint immediately. Regular health and safety checks will be carried out to ensure repairs are completed in a timely manner
Found compliant: Regulation 9, 19, 25, 26, 28.