Inspection of 10 March 2025 — Inspection Report
Regulation 9 — Management and recruitment
- (2)(d) One adult had a standard police certificate available rather than the required international child protection certificate (ICPC) which is a requirement for any staff member who has lived in the UK for 6 months or longer as an adult since October 2012 and who commenced working in an early years service after that date. Evidence was submitted to the Inspectorate by the registered providers that this staff member promptly applied for the required international child protection certificate within 2 days of the inspection
Provider's corrective action:
- The registered providers stated the following corrective actions and preventive actions have been carried out: Corrective Action (2)(d) The staff member in question applied for the required police vetting on 12/03/2025 and it was received on 17/04/2025. Preventive Action (2)(d) The employee in question had a standard UK police vetting certificate and the registered providers were unaware this document was not sufficient. The registered providers will ensure going forward that as advised the required ICPC is sought for any new staff that require UK vetting prior to them commencing employment
Regulation 23 — Safeguarding health, safety and welfare of child
- Infection control: 1. Some of the nappy changing practices observed during the inspection posed a risk of cross-infection as demonstrated in the following examples: ➢ Babies hands were not always washed after nappy changing. ➢ A staff member was observed to wear gloves for nappy changing but not to wash her hands before changing her gloves between each nappy change. This posed a risk of cross-contamination when removing the used gloves. ➢ Aprons were not worn for by staff members for all nappy changing procedures observed during the inspection. Aprons are required to protect staff members’ outer clothing from contamination. Safe sleep: 2. Inadequate space was left between 3 of the 9 cots in the sleep room. Spacing between these 3 cots was found to measure between 27cm and 30 cm which was less than the recommended distance of at least 50cm apart. This increased the risk of cross infection and also posed a risk that a child who was awake in one of these cots could make physical contact with another child in the neighbouring cot
Provider's corrective action:
- The registered providers stated the following corrective actions and preventive actions have been carried out: Corrective Action Infection Control: 1. The nappy changing policy was reviewed with all staff members at a staff meeting on 13/03/2025. All staff members read and signed to confirm they had reviewed and understand the policy. Safe Sleep: 2. The registered providers have updated the service’s policy and procedure for sleep time in the Baby Room and Toddler Room. The old procedure ensured that one additional cot was kept in the sleep room which was to be removed at sleep time and brought into the Toddler Room. This cot has now been taken out of the sleep room and is kept in a storage area to ensure the correct space between all cots in the sleep room can be maintained at all times throughout the day. Additional cots are then brought to the Toddler Room as required for sleep time. Preventive Action Infection Control: 1. Visual reminders have been placed in all nappy changing areas to ensure aprons are worn and correct hand washing practices are adhered to at all times. Management and Room Leaders will do spot checks to ensure correct nappy changing practices are being followed. Safe Sleep: 2. The safe sleep policy was reviewed with all staff members at a staff meeting on 13/03/2025. All staff members read and signed to confirm they had reviewed and understood the policy and new procedure. Management and Room Leaders will do spot checks to ensure the cots are maintained in the correct positions
Regulation 24 — Checking in and out and record of attendance
- (1) One child in the Toddler Room who arrived to the service at 8.43am on the day of inspection did not have their attendance recorded in the roll book until after 12.45pm. In discussion with the inspector some staff members reported that the roll book was used to confirm that all children had reached a designated safe place should an emergency occur. This posed a risk of the children not being counted in the event of an evacuation emergency or under the daily supervision routines. It is acknowledged that all children’s attendance in the service was also recorded on electronic tablet devices in each room and some other staff members reported using the tablet devices as opposed using the roll books to confirm all children were present during fire drills
Provider's corrective action:
- The registered provider stated the following corrective actions and preventive actions have been carried out: Corrective Action (1) The child in question had been signed in using the electronic app but not in the roll book. This was discussed at the service’s staff meeting on 13/03/2025 to ensure children are signed in on both the roll book and the electronic app and that both are brought with the staff member in the event of an emergency or fire drill etc. Preventive Action (1) Management and Room Leaders will do spot checks to ensure that all children have been signed in on both the electronic app and the roll book in the classrooms. Summary Comment The inspectors reviewed the corrective actions and preventive actions submitted by the registered providers following the inspection in relation to Regulation 24. Assurances given by the registered providers have been accepted and this will be reviewed at the next inspection
Regulation 25 — First aid
- (1) Based on a review of staff first aid qualifications, it was evident that a person who had undertaken first aid response (FAR) training was not available to the children attending the service at all times. For example, from 7.30am to 8.15am on the day of the inspection none of the staff members held in-date FAR training. It is acknowledged that, in advance of the inspection, the registered providers had booked for up to 8 staff members to attend FAR training on 05/04/2025, 12/04/2025 and 17/05/2025, as evidenced in email correspondence reviewed by the inspectors on the day of inspection
Provider's corrective action:
- The registered provider stated the following corrective actions and preventive actions have been carried out: Corrective Action (1) There are 4 staff members working at the service with in-date First Aid Responders (FAR) training (of whom 3 will expire in April 2026 and 1 will expire in September 2025). There are 10 other staff members with in-date paediatric first aid. The roster has been updated to ensure the 4 staff with FAR are working at times to ensure there is someone on site from 7.30am – 6.00pm. Preventive Action (1) Eight staff members are currently undergoing FAR training which will be completed on 17/05/2025. As per the inspection report this training had been booked prior to the inspection
Found compliant: Regulation 11, 19, 26, 28.