Inspection of 25 November 2025 — Inspection Report
Regulation 9 — Management and recruitment
- • One staff member did not have 2 written and validated references available for inspection. • Two staff members did not have a 2nd written and validated reference. • The second reference for one staff member was not validated. (d) There was not an officially translated copy of the international police vetting for 1 staff member available for inspection
Provider's corrective action:
- To ensure full compliance with Regulation (2)(a) the registered provider will ensure that all staff have two written and validated references on file at all times. Following the inspection, all missing and unvalidated references have been obtained and validated and all staff files are now fully compliant. Compliance will be monitored using a staff file checklist and through quarterly audits of personnel files to ensure ongoing adherence. The registered provider will ensure a staff recruitment and personnel file checklist is used for all staff to confirm that two written and validated references are in place. No staff member will commence employment until both references have been received and validated. I will review and sign off on all staff files prior to commencement and will complete quarterly audits of personnel files to ensure ongoing compliance. (d) To ensure full compliance with staffing requirements, the provider will ensure that officially translated copies of international police vetting are obtained and retained on file for any staff member where vetting is issued in a language other than English. Following the inspection, an officially translated copy of the international police vetting for the staff member identified has been obtained and is now available for inspection. The registered provider will ensure that officially translated copies of all international police vetting documents are obtained and placed on staff files where vetting is issued in a language other than English. No staff member will commence employment until the translated vetting is received. A staff recruitment checklist will be used to verify compliance, and the registered provider will complete quarterly audits of personnel files to ensure ongoing adherence
Regulation 19 — Health, welfare and development of child
- 1. The children’s drink cups were stored in kitchen areas off the rooms and not readily accessible within the care rooms to the children should they require a drink. 2. In the Baby Room the defined Home Corner which was readily accessed by multiple children was poorly resourced with supporting equipment. The kitchen equipment available consisted of a pizza cutter, 1 plate and 1 wooden cup. There was also a basin in the sink. This does not adequately support the 13 children who were present play experiences and also led to minor disagreements between children over the 1 cup and plate
Provider's corrective action:
- 1. To ensure children have continuous and independent access to drinking water within the care rooms, all children’s drink bottles will be stored in the room at a child-friendly height and remain accessible throughout the day. Following the inspection, a child-height table has been purchased and placed in the room, and all children’s water bottles are clearly labelled and readily accessible at all times. The registered provider will ensure that children’s drinking water is available within each care room at all times and stored at a child-friendly height. Staff will complete daily room checks to confirm water bottles are accessible and labelled. This requirement will be reinforced during staff supervision and team meetings, and room layouts will be reviewed regularly to ensure children can independently access drinking water throughout the day. 2. To ensure the Home Corner in the Baby Room adequately supports the play and developmental needs of all children, the area will be fully resourced with sufficient, age-appropriate play equipment to meet the needs of the group. Following the inspection, additional Home Corner resources have been purchased and introduced, including multiple plates, cups, kitchen utensils and role-play items, ensuring there are sufficient materials to support shared play and reduce conflict among the 13 children. The registered provider will ensure that the Home Corner in the Baby Room is consistently well resourced with sufficient, age-appropriate equipment to meet the needs of all children using the area. Regular room and resource checks will be completed to monitor quantity and condition of equipment, and resources will be reviewed and replenished in line with the number of children attending. Staff will observe play to identify emerging needs and will report any resource gaps promptly to ensure timely replacement or addition
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 pre-school child attending the service and that the environment of the service is safe as specified below: General Safety: 1. In the Baby Room skin cream and powder belonging to 1 child was stored in their bag within the care room on a low-level peg which was potentially accessible to the children. This is a health and safety risk. 2. The room temperature in the Preschool Room was recorded at 23.2o C at 11.45am which exceeds the room temperature of 18 – 22o C. This went unnoticed by staff and when questioned they confirmed to the inspector there was no thermometer in the room. Infection Control: 3. In the Baby Room during 1 round of nappy changes a staff member was observed to not change their apron between each nappy change. This is an infection control risk. 4. Not all toys which some of the children placed in their mouths during play were removed to the “dribble box” for cleaning before being put back into toy boxes in the care room. This is an infection control risk. Safe Sleep: 5. Room temperatures in the sleep rooms exceeded the recommended safe sleep room temperatures of 16 – 20 o C. For example, in the Toddler sleep room at 2pm the large room temperature was recorded at 21.9o C and the small room was 22.4o C. At 14.05 in the sleep room off the Baby Room the room temperature was recorded at 21.9 o C. This elevated temperature went unnoticed by staff until brought to their attention by the inspectors when the windows and doors were then opened. This is a health and safety risk. 6. Some staff were not recording the correct sleep room temperatures on the sleep log in both sleep rooms for example in the Baby Room sleep room the room temperature was being recorded on the electronic sleep log at the electronic application setting of 19.9 o C instead of the actual room temperature e.g. 21.9 o C. This is a health and safety risk. 7. In the small sleep room there was no separate thermometer to check the room temperature. This was also confirmed by two staff
Provider's corrective action:
- Corrective & Preventive Action General Safety: 1. All personal care items such as skin creams and powders will be stored securely in a locked medical storage facility and kept out of children’s reach at all times. Following the inspection, arrangements have been made to remove all such items from children’s bags and low-level storage, and they will be stored immediately in a designated locked medical storage unit within the service. The registered provider will ensure that all personal care items, including creams and powders, are stored in a designated locked medical storage facility and kept out of children’s reach at all times. Staff have been informed of this requirement and will no longer store such items in children’s bags or low-level areas. Daily room checks will be completed to confirm safe storage, and this practice will be reinforced through staff supervision and team meetings. 2. To ensure a safe and comfortable environment for children, the room temperature in the Preschool Room will be maintained within the recommended range of 18–22°C at all times. Following the inspection, a room thermometer has been installed in the Preschool Room, and staff have been informed of acceptable temperature ranges and actions to take if temperatures exceed these limits. Procedures are now in place for staff to monitor and record room temperatures daily and to take immediate action, such as adjusting heating or ventilation. The registered provider will ensure that a thermometer is present in the Preschool Room at all times and that staff monitor and record room temperatures daily to ensure they remain within the recommended range of 18–22°C. Staff will be trained on the actions to take if temperatures fall outside this range, including adjusting heating or ventilation and reporting concerns immediately. Compliance will be reviewed through daily room checks, staff supervision, and regular management oversight to ensure consistent adherence. Infection Control: 3. To ensure effective infection control practices, staff will change aprons between each nappy change in line with the service’s infection control policy. Following the inspection, the staff member was reminded of correct nappy-changing procedures, and additional disposable aprons have been made readily available at the nappy changing area. All staff have been re-briefed on infection control procedures, and adherence will be monitored through daily supervision and periodic practice observations to ensure ongoing compliance. The registered provider will ensure that clear infection control procedures are followed during all nappy changes, including the use of a new disposable apron for each child. Disposable aprons will be consistently stocked and accessible at nappy changing areas. Infection control practices will be reinforced through staff training, supervision, regular practice observations, and compliance will be monitored through daily oversight and ongoing management checks. 4. All toys mouthed by children will be removed immediately to the designated dribble box for cleaning and disinfecting before being returned to use. Following the inspection, staff were reminded of the toy- cleaning procedure, and the use and location of the dribble box was reinforced within the care room. Staff have been re-briefed on infection control practices, and compliance will be monitored through daily room checks and ongoing supervision to ensure procedures are consistently followed. The registered provider will ensure that all toys mouthed by children are removed immediately to the dribble box for cleaning and disinfecting before being returned to use. Staff will receive ongoing reminders and supervision regarding this procedure, and dribble boxes will be clearly labelled and easily accessible in care rooms. Compliance will be monitored through daily room checks, practice observations, and regular staff supervision to ensure consistent adherence to infection control procedures. Safe Sleep: 5. To ensure children’s safety during rest periods, all sleep room temperatures will be maintained within the recommended safe range of 16–20°C at all times. Following the inspection, thermometers were installed in all sleep rooms, and staff were immediately instructed to monitor room temperatures during sleep times. When temperatures exceed the safe range, staff will take prompt corrective action, including opening windows and doors or adjusting heating, to restore appropriate conditions. Ensure that thermometers are present and visible in all sleep rooms and that staff check and record room temperatures before and during sleep times to ensure they remain within the recommended range of 16– 20°C. Staff will be trained on safe sleep temperature guidance and the actions required if temperatures exceed limits, including ventilation and heating adjustments. Compliance will be monitored through daily checks, staff supervision, and regular management oversight to ensure consistent adherence. 6. To ensure children’s safety during rest periods, actual sleep room temperatures will be accurately measured and recorded on sleep logs at each sleep period. Following the inspection, staff were instructed to record temperatures directly from the room thermometers and additional guidance was provided on correct temperature recording procedures. Staff have been retrained on safe sleep temperature requirements and management will review sleep logs daily to ensure accuracy and compliance. Ensure that staff record sleep room temperatures directly from the room thermometers at each sleep period. Clear guidance on this procedure will be included in staff training and reinforced during supervision. Daily management checks of sleep logs will be completed to verify accuracy, and any discrepancies will be addressed immediately. Ongoing compliance will be supported through regular audits, staff supervision, and refresher training to ensure consistent and accurate practice. 7. To ensure children’s safety during rest periods, each sleep room will have its own dedicated thermometer to allow accurate monitoring of room temperatures at all times. Following the inspection, a separate thermometer has been installed in the small sleep room, and staff have been informed of its location and the requirement to monitor and record room temperatures during sleep times. Ensure that each sleep room has a dedicated, clearly visible thermometer in place at all times. Staff will be reminded to check and record room temperatures during each sleep period, and this will be verified through daily checks of sleep logs. The presence and condition of thermometers will be included in regular room safety checks, and compliance will be reinforced through staff supervision and ongoing management oversight
Found compliant: Regulation 11.