Inspection of 4 March 2026 — Inspection Report
Regulation 9 — Management and recruitment
- (2) (a) (b) (d) One staff member did not have the required International Child Protection Certificate available. It is acknowledged a basic disclosure was available for the staff member. One adult employed on the Community employment scheme did not have the following on file, • Identification • CV • References on file from previous employer or reputable source. • It could not be established if one adult required international police vetting due to no CV available
Provider's corrective action:
- (1) The staff member was instructed to apply for the International Child Protection Certificate urgently. Introduced a strict pre-employment check: no staff member can begin regulated work without valid certification. Assigned responsibility to a designated staff member (e.g. Safeguarding Officer/HR) to monitor compliance. Set up automated reminders for certificate renewal and outstanding applications. Updated the organisations safeguarding policy to reinforce mandatory certification requirements. Conducted staff awareness/training sessions on safeguarding compliance and documentation. (2) The required documents were in place and on file. However, the file was not clearly labelled (missing name tab), which led to it being overlooked during the check. The correct file was located and verified, confirming compliance. The file was immediately labelled correctly with the staff member’s name. All staff files were reviewed to ensure proper labelling and organisation
Regulation 23 — Safeguarding health, safety and welfare of child
- General Safety: (1) In the baby room, it was noted that a fridge used to store anti-febrile medication. The medication was accessible to the preschool children, as no lock was on the fridge to restrict access. (2) A large sorting toy in the toddler room was broken and resulted in a shaper steel piece being exposed. This could cause injury to the preschool child. (3) The designated sleep room in the wobbler room was being used to store toys, child size furniture, and child size kitchen. Storage of these teams in the sleep room can distract the children when they are trying to sleep. Infection Control: (4) On the day of inspection, after nappy changing, the hands of the babies were observed to be not consistently washed, posing a risk of cross contamination. Gloves and aprons were observed not to be removed after disposing of an unclean nappy, and prior to moving onto the next care activity of placing on a clean nappy, followed with redressing the child. This could lead to a risk of cross infection. (5) Older Children did not routinely wash their hands after activities, before food or when they came back to room from playing outside. (6) A substantial accumulation of dust had formed on the mechanical ventilation fan in the nappy changing area and there was a strong malodor present in the room. Action submitted by the Registered Provider
Provider's corrective action:
- General Safety: (1) The medication was immediately removed and secured to prevent child access. Access to the fridge was restricted straight away. All medicines were immediately removed from the baby room fridge. Medications were relocated to a fridge in the staffroom, which is inaccessible to children. Access to medication is now restricted to authorised staff only. Staff were reminded of correct medication storage procedures (2) The toy was removed immediately from the room upon discovery. It was disposed of the next day into a skip. The area was checked for any loose or hazardous parts. Staff were informed of the issue and reminded to report damaged equipment promptly. The incident was recorded and reported to management. Introduced regular toy and equipment safety checks in all rooms. Implemented a system where damaged toys are removed immediately and reported. Maintained a log of equipment checks and replacements. Ensured only age-appropriate, safe, and well-maintained toys are accessible to children. Assigned responsibility to a designated staff member i.e.: room leader, for routine safety inspections. (3) Established that the sleep room is to be used for rest only, with no storage of toys or equipment. Introduced regular room checks to ensure the sleep environment remains appropriate. Updated room-use guidance to ensure clear separation between play and rest areas. Provided staff guidance/training on creating and maintaining a suitable sleep environment. Assigned responsibility to a designated staff member i.e.: room leader, to monitor room setup daily. Infection Control: (4) Staff were immediately reminded of correct nappy changing and hygiene procedures. Clear guidance was reinforced. A demonstration of proper procedure was provided where necessary. Increased supervision and monitoring of nappy changing routines was implemented. The incident was recorded and reported to management Introduced/refreshed infection control and hygiene training for all staff. Displayed step-by-step nappy changing procedures in changing areas. Implemented regular hygiene audits and spot checks. Ensured adequate supplies of gloves, aprons, and handwashing materials are always available. Assigned responsibility to a designated staff room leader to monitor compliance daily. (5) Staff were reminded immediately of the importance of promoting hand hygiene at key times (after activities and around mealtimes). Children were supported and encouraged to wash hands routinely throughout the day. Handwashing routines were reintroduced and embedded into daily transitions (e.g. before meals, after play). (6) The ventilation fan was cleaned immediately to remove dust accumulation. The nappy changing area was deep cleaned and sanitised. The source of the malodour was identified and addressed. Staff were reminded of cleaning responsibilities and hygiene standards. Implemented regular deep cleaning of nappy changing areas. Added routine environmental hygiene checks to daily/weekly checklists. Ensured clear allocation of cleaning responsibilities to staff. Established monitoring and sign-off procedures for cleaning tasks
Regulation 25 — First aid
- (2) (a)(b) While first aid kits were present on site, there was no evidence that regular inventory checks of their contents had been completed, as a result a lot of the contents in the first aid box had expired. The absence of these checks could lead to expired or missing items being relied on in the event of an emergency, therefore delaying or compromising the required first aid response to the child
Provider's corrective action:
- (1) All first aid kits were immediately checked and restocked, removing expired items. Expired items were safely disposed of and replaced with current stock. Staff were reminded of the importance of regular checks and monitoring of first aid supplies. The issue was recorded and reported to management. All first aid kits were immediately checked and restocked, removing expired items. Expired items were safely disposed of and replaced with current stock. Staff were reminded of the importance of regular checks and monitoring of first aid supplies
Regulation 26 — Fire safety measures
- The records for the smoke detection system indicated the last service occurred on 06 December 2024. This is not in line with the services requirements, which indicates that the system should be services annually
Provider's corrective action:
- (1) Although the service has been carried out, the service certificate has not yet been received due to required panel updates. Which have been carried out today the 02/04/2026. Implemented a tracking system for all service certificates to ensure documentation is received promptly. Assigned a designated staff member in the office to follow up with contractors on outstanding certificates. Scheduled verification checks to confirm all future services are documented with certificates immediately. Ensured all staff are aware of compliance requirements and the importance of keeping records up to date
Found compliant: Regulation 11, 16, 19.