# Pugwash Bay LTD, Dundalk — inspection reports and findings

> Pugwash Bay LTD (Dundalk, Co. Louth): what Tusla inspections found — 3 published inspection(s), non-compliances and the provider's corrective actions.

## Pugwash Bay LTD

Full Day · 0 - 6 Years · Dundalk, Louth · Tusla ID **TU2015LH078** · Registered since 1 January 2026

An inspection records what inspectors saw **on one day**; services respond with corrective actions — [how to read this](/methodology.md).

#### Inspection of 11 March 2026 — Inspection Report

Full report (PDF, Tusla)

##### Regulation 9 — Management and recruitment

- The following files for the new staff that were presented for inspection did not have the following required documents available: (2)(d) Evidence of the required international police vetting was not available for 1 new staff member who had resided outside the Irish jurisdiction for a period of 6 months or more as an adult. (3) From the documentary evidence available for inspection, one new staff member had commenced working in the service prior to the required international police vetting being obtained. (4) Documentary evidence was not available to confirm that one new member of staff who works directly with the children held at least the minimum required level 5 childcare qualification on the National Framework of Childcare Qualifications or a qualification deemed equivalent. The non-compliances identified are recurring from the previous inspection that was carried out on 06/03/2025. The previous corrective and preventative actions submitted stated “A strict policy is in place to ensure that no staff member will commence work until official documentation confirming full qualification has been received and verified. This includes a certified letter or certificate explicitly stating that the individual is fully qualified and has successfully completed their training. A monthly internal audit will be carried out by the manager to ensure compliance with documentation requirements. A quarterly audit will be conducted by the area manager to provide an added layer of oversight and accountability”. These actions did not prevent the non-compliances reoccurring

- (2) (d) The staff member submitted an application for the required international police clearance immediately upon identification of the issue. Only manager and higher management will ensure staff members can’t commence work until all the correct documentation has been provided and signed off by both staff and Manager/Area Manager. Continuous audits to be completed on staff files to ensure all required vetting, including international police clearance where applicable, is obtained and verified prior to commencement of employment. (3) It was identified that the staff member had provided police clearance documentation; however, it did not meet the required standard. The staff member has now submitted an application for the correct international police clearance immediately. The service has strengthened its recruitment procedures to ensure that only valid and appropriate vetting documentation is accepted. A pre-employment verification process will be completed by management to confirm that all vetting meets Tusla requirements before a staff member begins work. Staff will not be permitted to commence employment until full compliance is confirmed. (4) A copy of the staff member’s diploma has been obtained and placed on file immediately. Only manager and higher management will ensure staff members can’t commence work until all the correct documentation has been provided and signed off by both staff and Manager/Area Manager. Continuous audits to be competed on staff files to ensure all required documentation is obtained and verified prior to commencement of employment. Continuous audits to be competed on staff files and ensure that at least level 5 certificate is on file while working directly with children

##### Regulation 16 — Record in relation to pre-school service

- (a) While 2 new members of staff had evidence of a curriculum vitae available, both of these were considered inadequate, for example, they did not detail employment records or educational records prior to 2024. And for one staff member, it could not be determined if international police vetting was required

- (a) Both staff members were requested to provide updated and comprehensive CVs immediately, including full employment and education history. Updated CVs have since been obtained and placed on file. The staff member in question has also confirmed via email to the Area Manager that they have not resided outside the Irish jurisdiction for a continuous period of 6 months or more in adulthood; therefore, international police vetting is not required in this case. This confirmation has been documented and retained on file. A standardised recruitment screening with be conducted in order check and include full employment and education history with no unexplained gaps. As part of the recruitment process, all CVs will be reviewed by management prior to employment to assess whether international police vetting is required, based on residency history. All supporting declarations (e.g., residency confirmation) will be documented and retained in personnel files to ensure full compliance with Tusla requirements. Regular file audits will be conducted to ensure ongoing compliance

##### Regulation 20 — Facilities for rest and play

- (1)(b) There were instances where sleep facilities were found to be inadequate, as demonstrated by the following: • In the sleep room off the Jelly Babies room, two of the cot mattresses were ill-fitting and had a foothold present in the cot. This is a potential safety hazard and was not identified by the staff carrying out the daily risk assessment of the sleep room

- (1) (b) The ill-fitting mattresses were removed from use immediately upon identification of the issue and replaced with appropriately fitted mattresses that meet safety standards. All cots in the sleep room were checked to ensure compliance. Staff were informed of the issue and reminded of the importance of ensuring all sleep equipment is safe and suitable. A comprehensive review of all sleep equipment has been conducted to ensure that all cots and mattresses are correctly fitted and compliant with safety standards. The daily risk assessment procedure has been strengthened to include a specific check of cot and mattress suitability. Staff have received refresher guidance on identifying potential sleep safety hazards, including ill- fitting mattresses. Management will carry out regular audits of sleep rooms to ensure ongoing compliance with Tusla requirements

##### Regulation 23 — Safeguarding health, safety and welfare of child

- The Inspectorate is not assured that adequate steps have been taken to ensure the health, safety and welfare of the pre-school children attending the service based on the following observations made during the inspection; General Safety: 1. One of the mattresses in the cot room, located off the Jelly Babies care room did not have the required safety standard label in place. 2. A low-level electrical lead, which was plugged into a wall socket, was accessible to a child in a cot in the small sleep room. This is a potential safety risk. 3. In the outdoor area, sharp edges from a broken chalkboard on the wall and 2 protruding nails on the wooden boat were accessible to the children playing. While no injury was observed, one child’s trousers were observed getting caught on the nails. These are a potential injury risk. 4. In the outdoor area, a gap was observed in the steel trim on the path. This is a potential trip or injury risk to a child playing in the area. 5. Sharp corners on units were present in the Little Buttons room. This is a recurring non-compliance where the registered provider outlined in their corrective and preventive action that “All sharp corners in the relevant areas have been safely covered to reduce the risk of injury”, which has been ineffective in preventing the non- compliance from recurring. 6. A plug for lights in the cosy area in the Rolo room had a protruding connection on the plug and a cord located at a low level, which poses a risk of injury to a child. Infection Control: The staff did not always take appropriate steps to prevent the spread of infection in the service. For example; 7. The following cross infection practices were observed during nappy changing. For example: a staff member in the Rolos room was observed to wear the same apron for 6 nappy changes and the children's hands were not washed following nappy changing. In the Little Buttons room, the staff member kept the gloves on that were used to change the child’s nappy, sprayed the nappy changing mat, reached for a paper towel to dry the mat and also helped the child reach for a paper towel to dry their hands, all while wearing the gloves from the nappy changing process. These practices are not in accordance with the service’s nappy changing policy. 8. Hand washing was not observed being carried out when the children from the Jelly Babies room returned from outside play. This is a cross-contamination risk as the children were observed to return to play with the toys and the sensory tray containing edible rice puffs and wheat crumbs. 9. Some perishable food items were observed inappropriately stored in a box in the Jelly Babies room rather than in a refrigerator. In addition, a bottle of milk that one child was observed to drink from in the Skittles Room was stored in their bag in the care room rather than the refrigerator. 10. The nappy bin observed in use in the sanitary area off the Jelly Babies room was unsuitable. The lid did not close and therefore did not provide a sealed bin as required. In addition, the children in the Rolo and Little Buttons room were observed to lift the lid of pedal-operated bins with their hands when disposing of paper hand towels following handwashing practises. The staff in the Little Buttons room were observed on two occasions to lift the lid of the pedal-operated bin for the disposal of nappies. The 11. In the Rolo room, one child was observed to wear a dress-up costume and take some stickers they were playing with into the nappy changing area with them. Both the dress-up costume and stickers were taken back to the play area by the child following their nappy change. This is a cross-infection risk

- Corrective & Preventive Action General Safety: 1. The non-compliant mattress was removed immediately and replaced with a new mattress that meets the required safety standards and includes the appropriate labelling. All sleep equipment has been reviewed to ensure compliance with safety standards and appropriate labelling. Regular equipment audits will be conducted by management to ensure ongoing compliance with Tusla requirements. 2. The low-level electrical lead was removed immediately, and cable covers were installed to eliminate access to electrical hazards. A full environmental safety check will be conducted to identify and eliminate accessible electrical hazards. Staff have been verbally reminded to include electrical safety checks in daily risk assessments. Ongoing monitoring and regular safety Checks and Hazards Identification Audit will be conducted to ensure compliance with Tusla standards. 3. The broken chalkboard was removed immediately. The identified hazards, including protruding nails, were addressed to eliminate risk to children. A comprehensive inspection of the outdoor area has been completed to identify and rectify any additional hazards. A routine outdoor safety checklist has been scheduled daily. Staff have been reminded to report and act on hazards promptly. Regular maintenance checks will be carried out to ensure continued compliance with Tusla requirements. 4. Maintenance staff addressed the hazard immediately by fitting a metal piece to securely cover the gap. All outdoor surfaces have been reviewed to identify potential trip hazards. The manager will ensure that the maintenance log is used daily to ensure timely repair of identified issues. Regular inspections will be conducted to ensure that outdoor play areas remain safe and compliant with Tusla standards. 5. Safety corner covers were installed immediately on all low-level units to reduce the risk of injury. A more robust approach has been implemented to ensure all sharp edges are consistently covered and maintained. All rooms have been re-assessed for similar risks. Management will carry out frequent spot-checks to ensure corner protectors remain securely in place. The effectiveness of control measures will be reviewed regularly to prevent recurrence and ensure compliance with Tusla requirements. 6. The lights and associated plug were removed immediately to eliminate the hazard. All electrical equipment within children’s reach has been reviewed and removed or made safe as appropriate. Daily safety checks and periodic audits will ensure continued compliance with Tusla standards. Infection Control: 7. Infection control training was delivered to all staff during a staff training day on 02/04/2026, with a focus on correct nappy changing procedures, appropriate use of PPE, and hand hygiene practices. Additional Nappy Changing training focusing just on this specific area has been booked for all staff. The nappy changing procedure has been reinforced with all staff, including clear step-by-step guidance in line with best practice. Ongoing supervision and spot checks will be carried out by management to ensure adherence to procedures. Infection control will be a standing item on staff meeting agendas, and regular refresher training will be scheduled to ensure continued compliance with Tusla requirements. 8. Infection control training was provided on 02/04/2026, and the importance of handwashing after outdoor play was reinforced at a subsequent staff meeting. A clear handwashing routine has been discussed, requiring all children to wash their hands after outdoor play. Staff have been assigned the responsibility to supervise and ensure compliance. Visual reminders have been introduced where appropriate, and management will monitor adherence through regular observations to ensure compliance with Tusla standards. 9. Staff were immediately reminded of the correct procedures for storing perishable food items and milk bottles, ensuring all such items are stored in appropriate refrigerated conditions. Food storage procedures have been reinforced with all staff. Regular checks will be carried out to ensure compliance with safe food storage practices. Clear guidance has been reissued regarding the handling and storage of children’s food and bottles, and compliance will be monitored through routine supervision in line with Tusla requirements. 10. A new, appropriate pedal-operated nappy bin with a fully functioning sealed lid was purchased and put into use immediately. Infection control procedures, including correct waste disposal practices, were reinforced during the staff training day using practical scenarios. All waste disposal equipment has been reviewed to ensure suitability and proper functioning. Staff have been instructed on the correct use of pedal bins to avoid hand contact. Ongoing monitoring and refresher training will be implemented to ensure adherence to infection control procedures and compliance with Tusla standards. 11. Staff were immediately reminded to ensure that no toys or play items are brought into nappy changing areas and to supervise children closely during transitions to prevent such occurrences. This was also discussed with staff during the Staff Training Day on 02.04.2026. Clear procedures have been reinforced to ensure that nappy changing areas remain strictly separate from play items. Staff supervision during nappy changing routines has been strengthened. Regular reminders and monitoring will be implemented to ensure adherence to infection control practices and compliance with Tusla requirements

Found compliant: Regulation 11, 19, 25, 29.

#### Inspection of 6 March 2025 — Inspection Report

Full report (PDF, Tusla)

##### Regulation 9 — Management and recruitment

- The following documents were not available and were not in place prior to the staff member commencing in the service;
- 1. One student did not have a 2nd written and validated reference available for inspection. 2. Insufficient documentary evidence was available to indicate that 3 written references were appropriately validated (d) Documentary evidence of the required international police vetting was not available for one student and one staff member who had resided outside the Irish jurisdiction for a period of 6 months or more as an adult. (3) The required documents relating to written and validated references were not complete prior to 2 students and 1 staff member commencing in the service. (4) From the documentary evidence reviewed there was insufficient evidence to demonstrate that 2 members of staff, who work directly with the pre-school children held at least the minimum required level 5 Childcare Qualification or a qualification deemed equivalent by the Minister

- (2)(a) Second references for the individual were obtained and verified on 07.03.2025. References for the relevant staff member have been added to the Tusla staff folder. A vetting checklist will be carried out for all new staff and students to ensure that all required documents (including two verified references and police clearance) are tracked and followed up promptly. The designated person responsible for recruitment and vetting will review the file before any staff or student commences placement to confirm all documents are in place. Monthly audit checklist will be carried out for all staff to ensure everything is in the file. This be followed by quarterly audit done by area manager. (d) Police clearance has now been received for the student in question. The staff member, whose police clearance was outstanding, has submitted a new application to ensure compliance. Regular internal audits of staff files will be conducted on a monthly basis to prevent any future oversight. (3) To address the identified non-compliances, references for one staff member and two students have been obtained, verified, and securely filed in accordance with regulatory requirements. Prior to any staff or student commencing placement, the manager will ensure that all required documentation, including references and the completed student placement application form, is collected and verified. A monthly internal audit will be carried out by the manager to ensure compliance with documentation requirements. A quarterly audit will be conducted by the area manager to provide an added layer of oversight and accountability. (4) Additional documentation confirming the qualifications of one staff member has been obtained and filed appropriately. We have now received the results from the second staff member. Additionally, their qualification is included on the DCYA list of approved qualifications. A strict policy is in place to ensure that no staff member will commence work until official documentation confirming full qualification has been received and verified. This includes a certified letter or certificate explicitly stating that the individual is fully qualified and has successfully completed their training

##### Regulation 19 — Health, welfare and development of child

- 1. In the Little Button’s Room, transition periods were generally chaotic and noisy. For example, when the children were getting ready for their dinner the noise levels in the room increased and at one stage 3 different members of staff were observed to ask the same child had they washed their hands within a few seconds of each other. Additionally, when the children were getting ready for bed and the room was being prepared for sleep time this transition was protracted and took from 11.57am – 12.27pm until all children were eventually lying down on their mattresses to sleep. During this period the room was chaotic for example; some children were observed running around, climbing on mattresses as they were being set up and going to get toys, while staff assisted children with getting settled and comforted a child who was upset

- s The manager has collaborated with the staff in the room in question to develop and implement a new routine aimed at improving structure and consistency. A designated task sheet has been introduced to clearly assign responsibilities to each staff member, supporting a smoother daily transition and improved workflow. The supervisor has been appointed to support the team during sleep time, providing additional oversight and assistance with preparation and transition activities. Monthly staff room meetings have been scheduled to review progress, address any emerging challenges, and ensure continued improvement. Daily check-in by management is being conducted to monitor routines, provide support, and maintain consistent communication with room staff

##### Regulation 20 — Facilities for rest and play

- 1. The soft/rest area within the Rolo’s room was inadequate as the rest area was considered too small and consisted of 2 child size chairs, a bathmat on the floor and 3 cushions for the 17 preschool children in attendance
- In the large outdoor area, the following hazards were identified: 1. There was a broken plastic toy pram in the area which was a potential injury hazard. 2. In the area directly outside the Skittles Room there was a piece of one of the metal drain covers missing which was a potential trip hazard. 3. The concrete around the manhole outside the Skittles Room was cracked and chipped away, this was a trip hazard

- 1. The soft/rest area within the Rolos room has been improved. A new rug and additional cushions have been added to enhance comfort and ensure the area meets the needs of the children using it. The curriculum is now being planned with a specific focus on ensuring that all defined areas within the room are appropriately set up. This includes providing adequate resources and equipment to support the developmental needs of the children and accommodate the number of children present in the room
- 1. A broken plastic toy pram was identified and has been removed from the premises to eliminate risk of injury. 2. The missing piece of the outdoor drain has been reported to the maintenance to ensure safety and prevent tripping hazards we have temporary obstructed the area. 3. The concrete surrounding the manhole outside the Skittles room has been repaired to eliminate uneven surfaces and potential safety risks. The manager will now conduct daily morning safety checks of the outdoor garden area. Any hazards identified will be immediately removed or reported, with the maintenance person contacted without delay to ensure timely resolution of any safety concerns

##### Regulation 23 — Safeguarding health, safety and welfare of child

- The registered provider did not ensure that all reasonable measures were taken to safeguard the health, safety and welfare of a preschool child in relation to the following: General Safety: 1. A number of sharp corners on low-level storage units were exposed in both The Rolos and Little Buttons care rooms. This is a potential injury risk. 2. The corners of the floor mats in the Marshmallow and Little Buttons Room were curling up and potential trip hazards. Infection Control: 3. There was an infection control risk observed due to the lack of appropriate sanitary and washing facilities servicing the Jelly baby’s room. A lidded bucket was being used to hold the contents of a potty for a child who was being toilet trained. This bucket wasn’t immediately emptied after use and was held on at least 2 occasions. The staff reported that the contents of the bucket were then transferred to the staff sanitary area on the other side of the building to be emptied. 4. Four out of 8 cots in the Sleep Room were in an unhygienic condition. Large cobwebs were observed extending over the latts and base of the cots. 5. When the Little Buttons Room was being set up for sleep time, the staff member was observed to place the children’s individual sheets and blankets on the sleep mats and then to stack the sleep mats on top of each other. This is a cross-contamination risk. In addition, a few different children were observed to climb and lie on the mats when they were being placed out on the floor

- Corrective & Preventive Actions General Safety 1. All sharp corners in the relevant areas have been safely covered to reduce the risk of injury. 2. Two new rugs have been purchased and placed in the rooms to improve safety and comfort for the children. The manager will carry out daily morning safety checks in all rooms to identify and address any potential hazards, including exposed corners or inadequate soft furnishings. This will ensure a consistently safe environment for the children. Infection Control 3. The child has been moved to a room with toilet facilities, as a space became available in an older group. Staff have been reminded of maintaining hygiene and adhering to infection control protocols. The Infection Control Policy has been circulated to all staff members. 4. The cots room and the cots have been cleaned immediately. The manager has implemented a new cleaning checklist and routine for the cleaner, which includes daily cleaning of the cot room. Daily checks during sleep time are now carried out by the manager or supervisor to monitor hygiene and general room standards. 5. The involved staff member was spoken to by the manager regarding the importance of following hygiene protocols, specifically relating to infection control. he children

##### Regulation 29 — Premises

- (c) 1. A strong odour was evident in a number of areas in the service indicating that the ventilation may be inadequate e.g. in the nappy changing area off the Smarties Room and the toilet area off the Rolos Room. (d) 2. Some areas of the premises were in a state of disrepair as evidenced by the following observations; Large brown stains were observed on the ceiling and pillar of the nappy changing area off the Smarties Room. Paint was observed chipping off the walls in the sanitary area off the Rolos Room. This is a recurring non-compliance from the last inspection which was carried out on 25/06/2024. As a corrective action, the registered provider stated that measures were put in place to investigate and repair the matter and to ensure it did not reoccur. However, the remedial and preventive measures outlined were inadequate as the non-compliance was evident at this inspection. 3. Some of the sanitary areas on the premises were in an unhygienic condition. For example; large accumulations of dust were observed in the toilet and lobby areas off the Rolos Room and ingrained dirt was on the floor at the sink of the toilet area. Large cobwebs were observed extending over the walls and the ceiling of the nappy changing area off The Jelly Babies room. The extractor fan covers in the toilet area of the Rolos room and the nappy changing area of the Smarties room were caked with dust and dirt. Black staining was observed behind the sink in the Marshmallow room and the paint on the wooden plinth was beginning to peel. 4. The top of one of the tables in the Marshmallow Room was chipped and in disrepair. 5. Shelving units in some of the rooms were in a state of disrepair as the veneer on the bottom of the units was peeling /hanging off

- s 1. All ventilation systems throughout the premises have been thoroughly checked and confirmed to be in full working order. Any dust or blockage issues were addressed immediately to ensure proper airflow and compliance with health and safety standards. The manager will now conduct monthly ventilation checks as part of the site’s routine maintenance schedule. Any issues identified will be addressed promptly to ensure continued compliance and a healthy environment for children and staff. 2. The walls of the Smarties Room and the nappy changing room have been cleaned, and necessary areas have been freshly painted to maintain hygiene and appearance. The sanitary area in the Rolos Room has also been cleaned and refreshed. 3. The toilet and lobby areas were immediately cleaned, and all cobwebs throughout the building were removed. The wooden plinth in the Marshmallow Room has also been repainted to improve cleanliness and visual condition. The manager will conduct weekly spot checks of walls across all rooms, as part of the ongoing maintenance and cleanliness audit to ensure walls are clean and well-maintained. A new cleaning checklist and routine has been implemented for the cleaner to follow daily. In addition, management is exploring the option of hiring an additional cleaning staff member to support daily cleaning duties and ensure a consistently high standard is maintained. 4. A corner protector has been installed on the top of the table in the Marshmallow Room to eliminate risk of injury. The manager will perform weekly spot checks of all room corners to ensure corner protectors remain in place and in good condition, and that corners are free from damage or buildup. 5. Shelving units have been covered with connecting paper to enhance cleanliness and safety. The manager will also carry out weekly checks on shelving units as part of regular maintenance reviews to ensure protective coverings remain intact and hygienic

Found compliant: Regulation 11, 16.

#### Inspection of 25 June 2024 — Inspection Report

Full report (PDF, Tusla)

**Immediate action notice.** • While an unannounced inspection was scheduled for this service, the registered provider had submitted notification of an incident which required assessment at inspection. • An immediate action notice was issued to the acting service manager on the day of inspection in relation to an elevated ambient temperature in the Little Buttons Room when it was converted to a sleep room. The room temperature was recorded as 25.5°C at 13:11 hrs which exceeds the recommend safe sleep room temperature of 18-22°C for children over 1 year of age. The service manager provided written assurances of appropriate immediate actions undertaken in the service to control the risk to children within 24 hours of the inspection. This inspection was unannounced and focused on the area of governance/ health, welfare and development of child/ safety/ premises and facilities. The inspection may also focus on other areas as required. The inspection focused on an examination of compliance under regulations 9, 11, 16, 19, 23, 25, and 31; however, on inspection additional non-compliances which posed a risk were identified under

##### Regulation 9 — Management and recruitment

- 1. One new staff member present in the service during the inspection did not have two written and validated references available for inspection. One written reference available for one staff member was not appropriately validated. (d) 2. One new member of staff who had resided in a 2nd country outside the Irish jurisdiction for a period of greater than six months, did not have documentary evidence of the required international police vetting available for inspection. (4) One adult who was observed working with the preschool children did not have the required official translation of their qualification available for inspection, to determine that it meets the required minimum level 5 childcare qualification. (7) On review of new staff files there was no documentary evidence available for 2 staff members to indicate that staff induction had been completed on commencing employment in the service

- The registered provider stated that the following actions had been taken to address the non-compliances
- 1. Obtained the required written references and completed verifications. Introduced a new pre-employment checklist to ensure all required documents, including references are collected and validated before a new staff member begins working. (d) 2. Obtained the required international police vetting documentation for the staff member in question. Verified the authenticity of the international police vetting document. Ensured the international police vetting documentation is included in the staff member's personnel file and made available for future inspections. Reviewed the recruitment policy to make sure that international police vetting for any staff member who has resided in a second country outside the Irish jurisdiction for a period greater than six month is obtained. Introduced a new pre-employment checklist to ensure all required documents, including international police vetting, are collected and validated before a new staff member begins working. Share with the managers the updated policy and checklist procedures to ensure compliance with international vetting requirements. Schedule regular audits of staff files to ensure all required international police vetting documentation is on file and validated
- Verified the qualifications of the adult in question to ensure they meet the required minimum level 5 childcare qualification and obtained an official result of the qualifications. Ensured the obtained document is added to the individual's personnel file. Informed the manager about the importance of having official translations of their qualifications. Updated the recruitment policy to include a mandatory requirement for official translations of qualifications/actual results for all staff and shared the updated policy with the managers. Ensured that all current staff have their qualifications officially translated. Implemented a regular audit schedule to ensure all staff qualifications are up-to-date and meet regulatory requirements. Designated a compliance officer/manager to oversee the qualification verification process during recruitment and regular audits. Developed a standardized procedure for maintaining and updating staff qualification records. Use a digital record-keeping system to track the status of each staff member’s qualifications and translations. Reviewed the policy and procedure annually to ensure they remain effective and compliant with regulatory standards
- Conducted a review to confirm that the two staff members in question have completed their induction training. Documented the completion of their induction training by having the staff members and their supervisors sign an induction completion form and added these forms to the respective staff files. Cross-checked with the induction training records to ensure that all mandatory components of the induction were covered. Updated the induction policy to include a clear requirement that all induction training must be documented immediately upon completion. Specified the forms and documentation that must be completed and filed for each new staff member. Ensured the checklist is signed by both the new staff member and their manger upon completion and filed in the staff member’s personnel file. Trained all managers on the updated induction process and the importance of maintaining proper documentation. Implemented a regular audit schedule to review staff files for compliance with induction documentation requirements. Designated a compliance officer/manager to oversee the induction process and ensure all documentation is completed and filed appropriately. Use a digital system to track induction training and completion for all staff. Review and update the induction process annually based on feedback and audit results to ensure ongoing compliance and effectiveness

##### Regulation 16 — Record in relation to pre-school service

- (1)(a) A curriculum vitae was not available for inspection for 1 member of staff and 1 maintenance contractor to confirm the qualification, experience or the requirement of international police vetting if applicable. (k) The accident and incident form relating to the recent Notification of Incident submission in the service was reviewed. This form was found to be incomplete as it did not contain a parental signature to indicate that the parents had been informed about the incident. In addition, two books containing accident and incident forms for the service were also reviewed. A number of these accident and incident forms were incomplete. For example, some forms did not contain a manager’s signature to confirm that they had reviewed the incidents, and some forms did not have a parent signature indicating that the parents had been informed about the incident. This is at variance with the procedures outlined in the services Accidents and Incidents policy

- The registered provider stated that the following actions had been taken to address the non-compliances. (1)(a) Obtained the CVs for one staff member and the maintenance contracted person. Determine if international police vetting is required for these staff members, based on their work history and qualifications. Added the obtained CVs to the respective staff members' personnel files. Included a checklist for managers to confirm that all required documents, including CVs and police vetting, are in place before the employment start date. Developed a standardized hiring checklist that includes all mandatory documentation such as CVs, qualification verification and police vetting requirements. Ensure this checklist is completed and signed off by manger before a new employee's first day. Conduct refresher training sessions periodically to reinforce the importance of complete and verified documentation. Implemented a regular audit schedule to review staff files for compliance with documentation requirements, including the presence of CVs. Designated a compliance officer/manager to oversee the hiring process and ensure all required documentation is collected and filed appropriately. Utilized a digital system to track and store all required hiring documentation, including CVs and vetting reports. Review and update the hiring process annually based on feedback and audit results to ensure ongoing compliance and effectiveness. (k) Reviewed the specific incident forms that lacked parental signatures and follow up with the parents to obtain their signatures. Ensure that the manager reviews and signs the incident forms that lacked managerial signatures. Conduct a thorough review of all current accident and incident books to identify and rectify any other incomplete forms. Review the policy for documenting accidents and incidents to explicitly require signatures from both parents and managers. Reviewed accident and incident form that includes clearly marked sections for parent and manager signatures. Sent the reviewed policy to all staff and highlight the importance of completing all sections of the accident and incident forms. Conduct refresher training sessions regularly to reinforce these requirements. Implement a regular audit schedule to review accident and incident forms for completeness, including the presence of all required signatures. Designate a compliance officer/manger to oversee the review process and ensure adherence to documentation standards. Ensured staff are aware of promptly informing parents about any incidents involving their children, using follow- up calls or meetings to ensure parents are aware and have signed the necessary documentation. Utilize a digital system to track and store accident and incident reports, making it easier to identify incomplete forms and follow up accordingly through the service electronic application. Ensured that electronic copies are securely stored and easily retrievable for inspections. Regularly review and update the accident and incident reporting process based on feedback and audit results to ensure ongoing compliance and effectiveness

##### Regulation 19 — Health, welfare and development of child

- The Inspectorate is not assured that each child’s learning, development, and well -being is being facilitated within the daily life of the service in relation to the following: 1. In the Jelly Babies Room, one child who was displaying obvious sign s of tiredness was not put down to sleep in a timely manner. For example; at 11:35am one child was crying and observed putting their head down on a staff members knee and closing their eyes . This staff member was heard saying “you’re tired …? And then proceeded to say to the 2nd staff member present in the room “I’ll put … down” to which the second staff member replied ” no…we’ll try to keep ….up. Its only 10 or 15 minutes to dinner … and you’ll sleep much better on a full belly”. This child was placed in the highchair for dinner and was crying and refused to eat dinner and then closed their eyes. This child was eventually put down to sleep at 12:08. 2. No dinner was reserved for the child detailed above when they got up from their sleep. When questioned the staff present stated that “no… didn’t get dinner …don’t know where … dinner went…must have got confused. but…got 2 yoghurts, a bottle and rice puffs”. This is not adequate as a dinner for a child aged 1 year 6 months. 3. One staff member was observed to use negative language, a sharp tone and direct ed the children when they were getting ready for sleep time after dinner. For example: “do not do that” “….sit up in your chair” “….now cosy corner…..cosy corner now” “….its night night time we are not playing with toys its night night time”. 4. In the Little Buttons Room the door to the toilet used by the children in this room remained open and therefore the children using the toilet could be seen from the care room. This does not maintain the privacy and dignity of the child during toileting

- s The registered provider stated that the following actions had been taken to address the non-compliances
- Ensured the children are given the opportunity to sleep as soon as tiredness is observed. Assessed the current room environment and staff routines to identify why the child's tiredness was not promptly addressed. Held an immediate meeting with the two staff in question and we retrained them. Reinforced the importance of responding promptly to signs of tiredness in children. Reviewed the policy on a maximum response time from when signs of tiredness are observed to when the child is put down to sleep. Discussed with staff the importance of recognizing signs of tiredness and the updated nap-time policy. All staff has been retrained on the policy. Implemented routine checks where a designated staff member monitors children for signs of tiredness and ensured they are put down to sleep promptly. Assessed the sleep environment in the Jelly Babies room to make it conducive for children to rest comfortably and promptly when needed. Ensured that cots and sleeping mats are readily available and easily accessible. Encouraged parents on a daily basis to share their child’s sleep patterns and preferences to better inform staff. Implemented a regular review process where the effectiveness of the nap-time policy is assessed, and any incidents of delayed response are analysed. Designated a staff member to oversee the implementation of the nap-time policy and ensure compliance. Regularly review and update the nap-time policy and procedures based on feedback and monitoring results to ensure ongoing compliance and effectiveness
- Held an immediate meeting with the two staff to discuss the incident. Identified the reasons why the child's meal was not reserved and address any misunderstandings or gaps in procedure. Document the incident, including the actions taken to resolve it. Reviewed the meal policy to ensure that meals are reserved for all children who are sleeping during mealtime. Clearly define the roles and responsibilities of staff members in reserving and serving meals to sleeping children upon waking. Discussed with all staff the updated meal policy and the importance of ensuring all children receive their meals, even if they are sleeping during scheduled mealtimes. Highlighted the importance of proper communication and coordination among staff to ensure meal reservations are made. Staff are asked to use a checklist or log to track which children are asleep and need meals reserved. Implemented routine checks to ensure all children’s meals are appropriately reserved and served after they wake up. Encourage parents to share any specific dietary needs or preferences their children may have. Implemented a regular review process to assess the effectiveness of the meal reservation procedure and identify any incidents of non-compliance. Conduct periodic audits to ensure all staff are adhering to the updated policy and procedures. Regularly review and update the meal policy and procedures based on feedback and audit results to ensure ongoing compliance and effectiveness
- Addressed the behaviour directly with the staff member involved, emphasizing the importance of using positive language and a gentle tone with children. Provided immediate feedback to the staff member on appropriate communication techniques. Documented the incident, including details of the behaviour observed and the immediate corrective actions taken. Manager/deputy manager to observe the staff member’s interactions with children to ensure compliance with appropriate communication practices. Reviewed the communication and behaviour management policy to include clear guidelines on the use of positive language and tone when interacting with children. Outlined specific consequences for staff who do not adhere to these guidelines. Sent out a behaviour management policy for all staff including positive communication techniques and behaviour management strategies. Search for potential additional training on emotional intelligence and conflict resolution. Implemented a regular observation schedule where manager or designated staff monitor interactions between staff and children to ensure compliance with positive communication practices. Encouraged staff to self-reflect and seek support if they feel challenged in managing behaviour positively. Provide mentoring and support for staff members who may struggle with implementing positive communication techniques. Pair experienced staff with new or less experienced staff to provide guidance and modelling of appropriate behaviour. Regularly review the effectiveness of the communication and behaviour management policy through staff feedback, parent feedback, and incident reports. Update training programs and policies based on the review findings to ensure ongoing improvement and compliance
- Ensured the toilet door is closed immediately to maintain the privacy of the child currently using the toilet. Communicate with the staff in the Little Buttons room about the importance of maintaining the privacy and dignity of children during toileting. Assessed the physical layout of the room and toilet area to identify any potential modifications needed to ensure privacy. Documented the incident, including the immediate steps taken to resolve the issue. Clearly state that toilet doors must be closed when in use and provide guidelines for staff to discreetly monitor children’s safety without compromising privacy. Reviewed the privacy policy, emphasizing the importance of maintaining children’s privacy during toileting. Implemented routine checks to ensure that the toilet door is always closed when in use. Designated a staff member to monitor and ensure compliance with the privacy policy during regular intervals. Educate children about the importance of privacy during toileting in an age-appropriate manner. Implemented a regular review process to assess the effectiveness of the privacy measures and ensure compliance. Conduct periodic audits and gather feedback from staff, parents, and children to identify areas for improvement. Regularly review and update the privacy policy and procedures based on feedback and audit results to ensure ongoing compliance and effectiveness

##### Regulation 23 — Safeguarding health, safety and welfare of child

- The registered provider did not ensure that all reasonable measures were taken to safeguard the health, safety and welfare of a preschool child in relation to the following: General Safety: 1. When the Little Buttons room was converted to a Sleep room at 13:11, the room temperature was recorded at 25.5 oC which exceeded the recommended safe sleep room temperature of 18-22 oC for children over 1 year of age. It is acknowledged that some remedial actions were taken in an attempt to reduce the room temperature with fans running and the windows opened, however this did not reduce the temperature to within the acceptable range. An immediate action notice was issued in respect of this safety concern to which an accepted response was received. 2. A bottle of cleaning spray was stored on the worktops in the Skittles Room and Little Buttons Room and was potentially accessible to the preschool children. It is acknowledged that the bottle in the Little Buttons Room was moved to a higher shelf out of the reach of children at approximately 11:38am. 3. A free standing, unsecured wooden microwave was accessible to the children attending the Skittles Room and 2 unsecured metal microwaves were in the outdoor area. This is a potential impact hazard if pulled by a preschool child. 4. Sharp unprotected corners were exposed on the concrete windowsills and paved steps in the outdoor play areas. These are a potential injury hazard. This was also acknowledged as a concern by the area manager. 5. The brown shelving unit in the Skittles Room and blue table in the Smarties Room had sharp unprotected corners exposed which is a potential injury hazard. Additionally, the risk assessment document on display in the Smarties Room dated 24/06/2024 detailed that “all tables and chairs in good condition”

- General Safety: The registered provider stated that the following actions had been taken to address the non-compliances. 1. Confirmed that the temperature in the Little Buttons room is brought within the recommended range (18- 22°C) by taking additional measures beyond using fans and opening windows and purchased big air conditioning units. Documented the immediate actions taken to reduce the room temperature and ensure children's safety. Informed Tusla of the additional immediate actions taken to address the non-compliance and ensure children's safety. Updated the facility’s temperature monitoring and control policy to include specific procedures for ensuring sleep room temperatures remain within the recommended range. Awaiting the air conditioning units control systems to be installed in the rooms and sleep room to maintain the recommended temperature range. Ensured that the current air conditioning equipment is regularly maintained and monitored for effectiveness. Implemented a routine temperature monitoring schedule, with checks conducted multiple times a day, especially before converting the room for sleep. Educated staff on the importance of maintaining the recommended temperature range for children’s safety and comfort. Encourage parents to provide feedback on their child’s comfort and any concerns they may have regarding room temperature. Regularly review temperature logs and staff feedback. Review policies and procedures based on review findings to ensure ongoing compliance and effectiveness. 2. Moved the bottle of cleaning spray in the Skittles room to a secure location immediately, ensuring it is out of reach of children. Verified that the bottle in the Little Buttons room is securely stored on a higher shelf, out of children's reach. Conducted a thorough inspection of all rooms to ensure no other hazardous materials are accessible to children. Sent out a memo with the immediate actions taken to secure the cleaning sprays and any other hazardous materials. Reviewed the safety and storage policy including specific guidelines for the storage of cleaning supplies and other hazardous materials. Clearly stated that all such materials must be stored in locked cabinets or designated high shelves out of the reach of children. Sent out memo to all staff, emphasizing the importance of securing hazardous materials. Implement routine checks to ensure that all cleaning supplies and hazardous materials are properly stored. Designated a manager to conduct daily checks and record compliance with the storage policy. Highlighted the importance to report any incidents or observations of improperly stored hazardous materials. Ensure that any reported incidents are promptly addressed and documented. Regularly review feedback and inspection reports to identify trends and areas for improvement. Update policies and procedures based on feedback and review findings to ensure ongoing compliance and effectiveness. 3. The two metal microwaves in the outdoor area have been secured. The wooden microwave in the Skittles room area have been secured. Conducted a thorough safety inspection of all areas to identify and address any additional unsecured items that could pose similar hazards. Ensured that all potentially hazardous items are either secured properly or removed from accessible areas. Implemented a schedule for regular safety audits of all rooms and outdoor areas to ensure all equipment and furnishings are secure. Designated a staff member responsible for conducting these audits and maintaining records of findings and actions taken. Discussed with all staff about the safety protocols, including the importance of securing potentially hazardous items and regular checks for compliance. Conduct refresher training sessions quarterly to ensure ongoing awareness and adherence to safety standards. Introduced a procedure for environmental risk assessments to be conducted monthly, focusing on identifying and mitigating potential hazards. Clearly communicated safety expectations and procedures to all staff, including the importance of reporting potential hazards immediately. Ensure transparency and build trust by regularly updating parents on safety improvements and protocols. 4. This issue was identified and added to our maintenance list prior to the inspection, indicating that the registered provider had acknowledged the hazard. It is now prioritized for repair, and protective measures have been ordered and will be installed on the affected areas immediately after delivery. The maintenance team has been instructed to ensure all sharp corners are adequately covered and secured to prevent any potential injuries. The registered provider is waiting for the rubber materials to be delivered. In the meantime, staff has been asked to keep a closer eye on the children playing close to the areas.To prevent similar issues in the future, the registered provider is implementing a more rigorous inspection and maintenance schedule for the outdoor play area. Regular checks will be conducted to identify and address potential hazards promptly. Additionally, staff will be trained to report any safety concerns immediately so they can be addressed without delay. This task has been added to managers daily and weekly checklist. 5. Installed corner protectors on the brown shelving unit in the Skittle room. The blue table in the Smarties room has been replaced with a new table. Conducted a thorough inspection of all furniture in both rooms to identify and address any other potential hazards. Updated the risk assessment document for the Smarties room to accurately reflect the current condition of the tables and chairs. Displayed the revised risk assessment document prominently in the Smarties room. Discussed with staff the importance of carrying out the room risk assessment properly before the children come to the service in the morning. Implemented a schedule for regular inspections of all rooms to ensure furniture and equipment are in safe condition. Assigned a designated staff member to carry out these inspections and document any findings and actions taken. Discussed with all staff the importance of identifying and reporting potential hazards, including issues with furniture and equipment. Fostered open communication among staff regarding safety concerns and encourage the immediate reporting of any identified hazards. Regularly remind staff of the importance of accurate risk assessments and immediate updates when conditions change

##### Regulation 29 — Premises

- (d) 1. Large brown stains were evident on the ceiling of the sanitary area and paint was chipping of the walls in a number of areas in the sanitary area of the Smarties Room. 2. The sanitary accommodation used by the children attending the Little Buttons and Skittles Rooms had accumulations of dust and black dirt around the skirting and woodwork. In addition, the sink pedestal in the Skittles sanitary accommodation was in a state of disrepair with paintwork peeling and chipped

- (d) 1. Investigated the source of the brown stains on the ceiling to determine if there is a leak or other underlying issue. Cleaned and repainted the stained areas of the ceiling to ensure a clean and sanitary appearance. Repainted the affected walls with durable, moisture-resistant paint suitable for sanitary areas. Implemented a schedule for regular maintenance checks of all sanitary areas to identify and address issues such as stains, leaks, and chipping paint promptly. Assigned a designated staff member to conduct these checks and maintain a log of findings and actions taken. Ensure any signs of water damage or deterioration are reported immediately and addressed promptly. Remind staff on identifying early signs of wear and tear, moisture damage, and other issues that could affect the sanitary condition of the facility. Encouraged prompt reporting of any concerns to the maintenance team for quick resolution. Scheduled regular preventive maintenance and repairs to ensure the facility remains in good condition. Implemented enhanced cleaning protocols to maintain the cleanliness and appearance of sanitary areas. Use appropriate cleaning agents that do not damage paint or other surfaces while ensuring hygiene standards are met. 2. Conducted a thorough cleaning of the sanitary accommodation in both the Little Buttons and Skittles rooms, focusing on the skirting and woodwork areas to remove all dust and dirt. Used appropriate cleaning agents to ensure all surfaces are sanitized and free from contaminants. Assessed the condition of the sink pedestal in the Skittles room sanitary accommodation. Repaired the sink pedestal as necessary to ensure it is in good condition and free from chipped paint. Cleaning staff will be retrained. Implemented a regular cleaning schedule for all sanitary accommodations to ensure they remain clean and free from dust and dirt. Assigned specific staff members responsible for daily, weekly, and monthly cleaning tasks, with detailed checklists to ensure thoroughness. Established a protocol for routine maintenance checks of all sanitary accommodations, focusing on the condition of fixtures, fittings, and surfaces. Discussed with staff the maintenance checks, noting any areas that need attention and actions taken to address them. Included instructions on how to identify and report any maintenance issues promptly. Scheduled regular inspections by manager to ensure cleaning and maintenance standards are being met. Document inspection findings and follow up on any areas requiring attention. Encourage open communication among staff regarding any issues or concerns related to the cleanliness and maintenance of sanitary accommodations. Establish a clear process for reporting and addressing maintenance issues promptly

##### Regulation not named in the report text

- The registered provider did not notify the agency of a change of designated person in charge

- s (1) The registered provider stated that the following actions have been carried out. • Notified Tusla immediately about the change of the designated person in charge. • Updated all internal records to reflect the new designated person in charge. • Ensured the new designated person's details are accurately recorded in all relevant documentation and systems. • Ensured everyone is aware of the new contact details and responsibilities. • Developed and implemented a policy that outlines the procedure for notifying the Tusla of any changes in the designated person in charge. • Include clear steps and timelines for notification. • Share the policy with all relevant staff on the new policy and procedures. • Ensure that staff understand the importance of timely notification and the steps involved. • Schedule regular reviews of the designated person in charge status as part of internal audits. • Ensuring that any changes are identified promptly and notifications are made without delay

Found compliant: Regulation 11, 25, 31.

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Página: https://creche-inspection-reports.pages.dev/creche/pugwash-bay-ltd-dundalk-3/
Fonte: Tusla Early Years Inspectorate
Recolha: 2026-09-11