(2) The required ratios were not maintained in two of the care rooms during the afternoon, as follows: • At 12.34pm, the Toddler room was staffed with one adult, who was caring for seven children, aged 2 to 3 years. The ratio requirement for this age range is one adult to every six children. The two students present were not included in the adult to child ratio. • At 1.40pm, there were 20 children aged 3 to 4 ½ years attending Pre-school 2, in the care of 2 adults. As these children were attending full day care, the required ration is one adult to every eight children. Non-compliance in relation to adult child ratios was also noted at the time of the previous inspection on 12 June 2025
Provider's corrective action:
The written reply outlined that a staff member returned to the Toddler room after the ratio count had taken place and that there are currently three staff members based in Pre-school 2
Regulation 23 — Safeguarding health, safety and welfare of child
Infection control: 1. Warm running water was not available at any of the wash hand basins across the service, which did not support effective handwashing. Recorded water temperatures ranged from 12.20C to 15.60C. 2. In Pre-school 1, the perishable foods for the children’s first snack were not refrigerated. These foods were observed to be stored in the children’s bags, which were located outside the door of the care room. This posed a risk of food spoilage. 3. During a nappy change in the Baby room, the inspector observed that the child’s hands were not washed after the nappy change. This posed a risk of cross infection. Action submitted by the Registered Provider
Provider's corrective action:
Infection control: 1. In her written reply, the registered provider stated that the boiler must be topped up with pellets, in order to ensure that the water is maintained at the correct temperature. This will be carried out throughout the day. A record sheet will be put in place, as a reminder to staff to top up the pellets. 2. The children’s lunches will be stored in the fridge, in the kitchen. The lunches will be placed in the fridge when the children arrive and at lunch time, all children will go to the kitchen to retrieve their lunch boxes. 3. The registered provider spoke to all staff to remind them to wash the children’s hands after nappy changes and to observe the children washing their hands, after using the toilet. As a preventive measure, staff will be reminded to wash the children’s hands
Regulation 29 — Premises
(d) 1. In the Pre-school 2 sanitary facility, dirt and debris were visible on the floor beside the skirting board, in one of the toilet cubicles. There was also a black speckled residue on the skirting board and on the ceiling leading up to the skylight window. Non-compliance in relation to residue was also found in the same sanitary facility, at the previous inspection. 2. A malodour was evident in the sanitary facility adjoining Pre-school 2, despite two windows being open. 3. Evidence that effective cleaning had taken place in the Baby room nappy changing area, was not available. It was acknowledged that cleaning records were available and signed, however, there was a build-up of debris along the edges of the nappy changing unit and the extractor fan had a build-up of dust
Provider's corrective action:
(d) 1. The CAPA response stated that this skirting board has been cleaned and repainted. The sky light has also been painted. Going forward, staff will ensure that the sky light is not opened during bad weather, in order to help prevent the area from getting wet and causing black spots. 2. The malodour was no longer apparent when the toilets were flushed. Going forward, all toilets will be flushed before children enter the room. 3. The changing area has been cleaned and the vent has been taken down and cleaned. The registered provider spoke to the staff about making sure that all of the changing area is cleaned. The registered provider also directed staff to check the vents regularly, in order to ensure that they are clean. Going forward, the changing mat will be removed and the changing table will be cleaned and the mat will be cleaned in between nappy changes. The vents will be checked regularly, to ensure that they are clean
Found compliant: Regulation 9, 10, 16, 19, 24, 25.
Regulation 10 — Policies, procedures etc. of pre-school service
1. The policies listed below did not meet the necessary requirements: • The statement of purpose and function did not set out the number of children that could be catered for at the service. • The behaviour management policy did not specify that the procedures for the protection and welfare of children were managed in line with the service’s safeguarding statement. While the policy stated that all staff members would be provided with support to deal with stressful situations arising from dealing with challenging behaviour, it did not outline the specific supports offered to staff. It was also noted that reference was made to the staff supervision policy, which was unavailable. The behaviour management policy referenced a staff supervision policy that was not available. 2. The registered provider did not have the following policies as required by legislation: • Recruitment • Risk management • Staff training • Supervision of staff
Provider's corrective action:
• The service’s statement of purpose and function was amended to include the number of children that the service can cater for. • The service’s behaviour management policy was amended to include that the procedures for the protection and welfare of children were managed in line with the service’s safeguarding statement. • The following policies were submitted, recruitment, risk management and staff training
Regulation 11 — Staffing levels
(2) The ratios were not maintained in line with regulation in Preschool Room 2 in the afternoon as 20 children were present in the care of 2 adults. The required ratio is 1 adult to every 8 children. Not operating in line with minimum ratio requirements could impact the wellbeing of children and affect staff members ability to meet the individual needs of each child
Provider's corrective action:
The written reply stated that additional hours have been allocated to a staff member to ensure correct adult child ratios
Regulation 16 — Record in relation to pre-school service
(k) From a sample of 10 accident and incident records from September 2024 to February 2025, it was noted that 2 of the records had not been signed or dated by the children’s parents or guardians. This posed a risk that parents or guardians may be unaware of accidents or incidents that involved their children
Provider's corrective action:
The written reply stated that all accident and incident forms had been signed and processes had been put in place to ensure that the forms are signed the day of the incident or accident
Regulation 19 — Health, welfare and development of child
(1)(a) Basic needs: 1. In Preschool 1 and 2, children’s needs for rest and relaxation were not always met as observed in the following examples: • A designated rest area was unavailable to meet the children’s need for rest and relaxation in Preschool 1. During discussion, the registered provider outlined that the sofa previously available in this room was now only brought into the room when needed, or when requested by the children. However, a clearly identifiable space for children to rest is required to be available at all times. • During free play periods, the rest facilities in Preschool 2 room were unable to accommodate children who required rest at this time. In the afternoon one child had become visibly upset as the child sized couch within the room was unavailable for use and the staff within the room were unable to respond to the needs of the child in a timely way. The inspector heard the child communicating their need to rest to a staff member who tried to get additional soft furnishings but was unable to do so. 2. On the day of the inspection, the children in the Baby room were not provided with the opportunity to engage in outdoor play. This did not meet the children’s need for mobility and a change of environment, while attending full day care. A staff member in this room advised that the children would not be going outside, as the ground was wet. However, it was noted that a sheltered area was available in the outdoor play area. 3. In Preschool 2 room, inadequate support was offered to children with toileting. The inspector observed that one child was not being supervised while toileting and required support and had become visibly upset. The inspector had to alert a staff member that a child required support; the staff member then attended promptly to the care needs of the child. Programme of activities 4. In Preschool 2 room, the inspector observed activities that did not support children’s active participation, resulting in frustration for the children. The staff member laid out puzzles and connectors on two sperate tables for the children to engage with. However, there was limited space, and materials available, for example, there were only eight puzzles available. The inspector did not observe alternative materials or solutions being offered to the children to support children with turn taking. The impact of this was observed as children became frustrated, crying and shouting at times
Provider's corrective action:
The written reply stated that additional couches had been added to Preschool 1 and 2. It was also stated that children from the Baby room would go outdoors daily and that children would be supported further with toileting by asking each child if they need help as they enter and exit the toilet
Regulation 23 — Safeguarding health, safety and welfare of child
General safety: 1. The service did not have a child protection and welfare policy available as stated in the child safeguarding statement. This posed a risk as it was unclear if staff were aware of what procedures are to be followed if there is a child protection concern within the service. Staff who spoke with inspectors were aware that the registered provider was the designated liaison person, and staff had completed the Children First e- learning training. 2. The outdoor area was cluttered with equipment and materials which posed a trip hazard. This also reduced the amount of space that children had to run around and play with scooters, bikes and other ride on toys. Infection control: 3. The children in the Baby room did not wash their hands before eating their morning snack. This increased the risk of cross infection and was also at variance with the service’s hand hygiene policy, which outlined that staff encourage children to wash their hands before eating. 4. During the same meal break in the Baby room, some of the children were observed to eat snacks such as raisins and sandwiches directly from the table, as no crockery was provided. This posed a risk of cross infection. Action submitted by the Registered Provider
Provider's corrective action:
General safety: A copy of the child protection and welfare policy was submitted and the service stated that it could not be located at the time of inspection. The service stated that the outdoor equipment was now being stored in the shed and taken out as needed. Infection control: The service stated that all staff were reminded again of the handwashing policy. Placemats have now been provided when children are eating snack
Regulation 29 — Premises
(d) 1. The toilet area adjacent to Preschool 2, one of the toilets was missing a toilet seat and this posed a potential safety risk to the children. 2. The toilet area adjacent to Preschool 2 had a residue on the ceiling and the wall behind the toilet in the cubicle located on the right-hand side. This posed a potential health risk to the children
Provider's corrective action:
The service stated that the toilet seat in Preschool 2 was now repaired and that the residue had been removed from the toilet and the area had been painted
Regulation 32 — Complaints
(3)(a) The service did not have any records of how the complaint was dealt with and therefore it could not be determined if the service adhered to their complaints policy. Not following the services policy on the management of complaints may lead to a complaint not being fully addressed by the service
Provider's corrective action:
The service stated that all complaints are stored in the office and dealt with according to the service’s complaints policy
The minimum ratio of adults to children was not met in the morning and during part of the afternoon. This posed a risk that an adequate number of adults may not be available to meet the children’s needs. In the morning, it was recorded that a total of 6 adults were available to 41 children, where 7 adults were required: Room Name and Age Range of Children Number of Children Present Number of Adults Present Baby Room 8 - 16 months (2 aged under 1 year 7 aged over 1 year) 9 2 Toddler Room 1 ½ - 2 ½ years (1 aged under 2 years 10 aged over 2 years) 11 2 Pre-school 1 2 - 4 ½ years 21 2 (7 aged under 3 years 14 aged over 3 years) When ratios were noted between 1.07pm and 1.14pm, there was a total of 5 adults working directly with 37 children, where 6 adults were needed to meet the minimum requirements. During this period, the rooms were staffed as follows: Room Name and Age Range of Children Number of Children Present Number of Adults Present Baby Room - including 5 children from the Toddler room 11 months - 3 years (1 aged under 1 year 5 aged 1 – 2 years 5 aged 2 – 3 years) 11 2 Toddler Room 2 – 3 years 4 1 Pre-school 1 2 - 4 ½ years (8 aged under 3 years 14 aged over 3 years) 22 2
Provider's corrective action:
The written reply stated that one staff member had been on leave and that since she has returned, there is enough staff to cover. The adult child ratio will be maintained
Regulation 23 — Safeguarding health, safety and welfare of child
General Safety: 1. Safe storage of medication was not ensured, which increased the risk of a child accidently ingesting said medication. One of the children had been prescribed an inhaler and said inhaler was kept in the child’s bag, which was stored on a shelf at child height. It was also noted that the expiry date on said medication had passed. This posed an additional risk that expired medication, which may be unsafe to use, could be administered to a child. Infection Control: 2. Warm running water was unavailable the wash hand basins in the sanitary facilities adjoining the Baby, Toddler and Preschool 1 rooms and at the wash hand basin in the staff sanitary facility. Recorded water temperature readings ranged from 21.40C to 22.80C. Cold water temperatures may impede effective handwashing. 3. Six of the eight available cot mattresses were not waterproof or fitted with waterproof mattress protectors, as required to reduce the risk of cross infection. One of the six cot mattresses was not fitted with any mattress protector. 4. In the following sanitary areas, hygienic hand drying was not ensured, which increased the risk of cross infection: the Toddler room sanitary facility and nappy changing area, the Preschool 1 sanitary facility and the staff toilet facility. As loose rolls of paper towelling were in use, this required each person to handle the roll of towelling after they had washed their hands, while their hands remained wet. This was also found at the previous inspection on 8 May 2023. The CAPA response at the time stated that the paper rolls had been removed and the paper towels from the dispenser would be used going forward. However, this was only found in practice in the nappy changing room adjoining the Baby room and remained an issue in the other sanitary areas. 5. Foldable green mats in the outdoor play area were not maintained in a clean condition, which increased the risk of cross infection. The mats, which had been discarded on the ground were dirty, wet and torn. Action submitted by the Registered Provider
Provider's corrective action:
General Safety: 1. The reply stated that all parents have been informed that medication must be handed to staff, and not placed in the children’s bags. All medication will be kept in the fridge or on shelves, out of children’s reach, at all times. Any medication out of date will not be permitted on the premises. Infection Control: 2. The registered provider outlined that extra pellets were required for the boiler at the time of inspection. Going forward, water temperatures will be checked throughout the day and pellets will be toped up to ensure that warm water is available. 3. Waterproof mattress protectors have been purchased for all mattresses. As a preventive measure, mattresses will be checked to ensure that all have waterproof protectors. 4. The written reply stated that a delivery of paper towels for the paper towel dispensers, was awaited at the time of inspection. An alternative company has since installed new paper towel dispensers. Going forward, staff will ensure that all paper towel dispensers are stocked at all times and will contact the company before running out of stock. 5. The mats have been disposed of. All equipment both indoors and outdoors will be checked on a weekly basis
Regulation 29 — Premises
(d) The electric hand dryer in the staff sanitary facility was not functioning. (e) There was inadequate drainage at the wash hand basin in the Baby room nappy changing area and at the wash hand basin in the staff sanitary facility. Water from these taps was observed to accumulate and pool in the basins
Provider's corrective action:
(d) The written reply outlined that the hand dryer is no longer in use, paper towels are used instead. (e) A drain unblocker has been used on the wash hand basins. All sinks will be checked to ensure that the water is flowing freely
Found compliant: Regulation 9, 10, 16, 19, 25, 28.