C.A.S.P.E.R. Day Care of Children Cults Primary School Community Education Centre Earlswell Road Aberdeen AB15 9RG Telephone:

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1 C.A.S.P.E.R. Day Care of Children Cults Primary School Community Education Centre Earlswell Road Aberdeen AB15 9RG Telephone: Inspected by: Fiona Thompson James West Type of inspection: Unannounced Inspection completed on: 20 March 2013

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 7 3 The inspection 19 4 Other information 36 5 Summary of grades 39 6 Inspection and grading history 39 Service provided by: Aberdeen City Council Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Fiona Thompson Telephone enquiries@careinspectorate.com C.A.S.P.E.R., page 2 of 41

3 Summary This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change after this inspection following other regulatory activity. For example, if we have to take enforcement action to make the service improve, or if we investigate and agree with a complaint someone makes about the service. We gave the service these grades Quality of Care and Support 3 Adequate Quality of Environment 2 Weak Quality of Staffing 3 Adequate Quality of Management and Leadership 2 Weak What the service does well Staff provide a relaxed and welcoming atmosphere. Staff have developed good relationships with children and their families. What the service could do better Better systems must be put in place for infection prevention and control. Care plans and medication records need to be regularly updated to ensure they reflect the current needs of children. Quality assurance systems must be developed to improve the quality of service provided. Systems must be developed to monitor staff practice and provider appropriate support for all staff. What the service has done since the last inspection Detailed care plans are now in place for all children requiring a care plan. As a result staff have developed their knowledge of each child and are providing care as detailed in their plan. Medication records now provide clear information and medication is available in the service for all children requiring medication. Conclusion Some improvements have been made since the last inspection. However, the service must make significant improvements as detailed in the requirements and recommendations within this report. C.A.S.P.E.R., page 3 of 41

4 Who did this inspection Fiona Thompson James West C.A.S.P.E.R., page 4 of 41

5 1 About the service we inspected The service is a daycare of children service. It is currently registered to care for a maximum of 60 primary school aged children after school, on in-service days and in the school holidays. It is also registered to care for up to 40 children in the breakfast club. The service is based within Cults Primary School in the city of Aberdeen. The service has sole use of the main room and can also use the gym, dining hall and outdoor area. The Care Inspectorate regulates care services in Scotland. Prior to 1 April 2011, this function was carried out by the Care Commission. Information in relation to all care services is available on our website at This service was previously registered with the Care Commission and transferred its registration to the Care Inspectorate on 1 April Requirements and Recommendations If we are concerned about some aspect of a service, or think it could do more to improve its service, we may make a recommendation or requirement. A recommendation is a statement that sets out actions the care service provider should take to improve or develop the quality of the service based on best practice or the National Care Standards. A requirement is a statement which sets out what is required of a care service to comply with the Public Services Reform (Scotland) Act 2010 ("the Act") and secondary legislation made under the Act, or a condition of registration. Where there are breaches of Regulations, Orders or conditions, a requirement may be made. Requirements are legally enforceable at the discretion of the Care Inspectorate. Based on the findings of this inspection this service has been awarded the following grades: C.A.S.P.E.R., page 5 of 41

6 Quality of Care and Support - Grade 3 - Adequate Quality of Environment - Grade 2 - Weak Quality of Staffing - Grade 3 - Adequate Quality of Management and Leadership - Grade 2 - Weak Inspection report continued This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change following other regulatory activity. You can find the most up-to-date grades for this service by visiting our website or by calling us on or visiting one of our offices. C.A.S.P.E.R., page 6 of 41

7 2 How we inspected this service The level of inspection we carried out In this service we carried out a high intensity inspection. We carry out these inspections where we have assessed the service may need a more intense inspection. What we did during the inspection We wrote this report after an unannounced inspection that took place on 19 March 2013 at the breakfast and after school sessions. Feedback was given to the management team on 20 March As requested the provider completed and sent us a self assessment form and an annual return. We issued 30 questionnaires to parents and carers of children using the nursery. Eight questionnaires were returned to us before the inspection. In this inspection we gathered evidence from various sources, including the relevant sections of policies, procedures, records and other documents: observing how staff work evidence form the service's most recent self assessment children's records child protection policy medication records first aid box staff training records whistle-blowing policy complaints policy risk assessments action plan monitoring records minutes of staff meetings one to one supervision records records of emergency evacuations parent questionnaires children questionnaires examining equipment and the environment discussions with various people including: C.A.S.P.E.R., page 7 of 41

8 - the Childcare Development Officer - the manager - staff - children - parents and carers of children using the service Inspection report continued Grading the service against quality themes and statements We inspect and grade elements of care that we call 'quality themes'. For example, one of the quality themes we might look at is 'Quality of care and support'. Under each quality theme are 'quality statements' which describe what a service should be doing well for that theme. We grade how the service performs against the quality themes and statements. Details of what we found are in Section 3: The inspection Inspection Focus Areas (IFAs) In any year we may decide on specific aspects of care to focus on during our inspections. These are extra checks we make on top of all the normal ones we make during inspection. We do this to gather information about the quality of these aspects of care on a national basis. Where we have examined an inspection focus area we will clearly identify it under the relevant quality statement. Fire safety issues We do not regulate fire safety. Local fire and rescue services are responsible for checking services. However, where significant fire safety issues become apparent, we will alert the relevant fire and rescue services so they may consider what action to take. You can find out more about care services' responsibilities for fire safety at C.A.S.P.E.R., page 8 of 41

9 What the service has done to meet any requirements we made at our last inspection The requirement The provider must ensure all references to the complaints procedure contain correct information. This is in order to comply with: Scottish Statutory Instrument 2011/210 Regulation 18. Timescale: Within 1 week of receipt of this report. What the service did to meet the requirement This requirement had not been met, further information can be found in quality theme 1, statement 1. The requirement is: Not Met The requirement The provider must ensure the child protection policy is updated to include clearer guidance for staff. All information regarding child protection procedures must be clear, accurate and reflect the current management structure. This is in order to comply with: Scottish Statutory Instrument 2011/210 Regulation 4 (1) (a). Timescale: Within 1 week of receipt of this report. What the service did to meet the requirement The child protection policy had been updated. The requirement is: Met The requirement In order to meet the health and welfare needs of children the provider must ensure an appropriate first aid box is on the premises. In order to achieve this the provider must ensure regular checks of the first box are undertaken and recorded. The check must include ensuring: C.A.S.P.E.R., page 9 of 41

10 all the necessary items are in the first aid box; all items are in date; items that require to be discarded if opened are discarded; and all items are suitable for the age of children attending the service. This is in order to comply with: Scottish Statutory Instrument 2011/210 Regulation 4 (1) (a). Timescale: Within 1 week of receipt of this report. What the service did to meet the requirement Regular checks were undertaken on the first box and as a result the first aid box was well stocked with appropriate items that were in date. The requirement is: Met The requirement The provider must ensure written permission is obtained from parents for children to leave the service unaccompanied. Before a child leaves the service unaccompanied an assessment of the risks must be undertaken to ascertain if it is appropriate for the child to leave unaccompanied. This is in order to comply with: Scottish Statutory Instrument 2011/210 Regulation 4 (1) (a). Timescale: Within 24 hours of receipt of this report. What the service did to meet the requirement Written permission was now in place for all children leaving the service unaccompanied. However, risk assessments had not been undertaken to ascertain if it was appropriate for children to leave the service unaccompanied. A new requirement has been made in this inspection report, further information can be found in quality theme 2, statement 2. The requirement is: Met The requirement The provider must ensure suitable arrangements are in place to protect children from sunburn. C.A.S.P.E.R., page 10 of 41

11 This is in order to comply with: Scottish Statutory Instrument 2011/210 Regulation 4 (1) (a). Timescale: Within 48 hours of receipt of this report. What the service did to meet the requirement Sun cream was now available in the service. However, no written permissions were in place for children to apply the sun cream. Further information can be found in quality theme 1, statement 3. The requirement is: Not Met The requirement The provider must develop appropriate procedures for ensuring prevention and control of infection. A written policy must be developed detailing the infection control procedures for staff to follow. This is in order to comply with: Scottish Statutory Instrument 2011/210 Regulation 4 (1) (d). Timescale: Within 48 hours of receipt of this report. What the service did to meet the requirement This requirement had not been addressed. Further information can be found in quality theme 2, statement 2. The requirement is: Not Met The requirement The provider must ensure appropriate risk assessments are in place detailing all the hazards and appropriate control measures. To achieve this the provider must: a) ensure all staff receive training in assessing and managing risks b) undertake risk assessments of all areas of the premises, outdoor areas, outings and higher risk activities. The risk assessments must: take account of the needs of individual children take account of the age and stage of development of all children identify all the potential hazards C.A.S.P.E.R., page 11 of 41

12 identify appropriate control measures to minimise the risks to children The provider must then ensure the risk assessments are implemented in the service. This is in order to comply with: Scottish Statutory Instrument 2011/210 Regulation 4 (1) (a). Timescale: a) within 3 months of receipt of this report, b) to start within 2 weeks of receipt of this and to be completed no later than within 3 months of receipt of this report. What the service did to meet the requirement This requirement had not been addressed. Further information can be found in quality theme 2, statement 2. The requirement is: Not Met Inspection report continued The requirement The provider must review the current emergency arrangements. The review must include ensuring: a) all emergency equipment is fitted in line with the manufacturer's guidance; b) all children are familiar with emergency evacuations by carrying out regular emergency evacuations on different days of the week; c) children's emergency contact details are stored in the correct manner so as they are available in the event of an emergency; d) a clear record is kept of the areas in use by children at the time of emergency evacuations; and e) the emergency evacuation policy reflects the practice in the service. This is in order to comply with: Scottish Statutory Instrument 2011/210 Regulation 4 (1) (a). Timescale: a-d) within 1 week of receipt of this report, e) within 3 weeks of receipt of this report. What the service did to meet the requirement C.A.S.P.E.R., page 12 of 41

13 Some improvements were noted in relation to this requirement. Emergency equipment was properly fitted and children's emergency contact details were stored so as they were easily available in the event of a fire. However, the other elements of this requirement had not been addressed. A new requirement has been stated in this report, further information can be found in quality theme 2, statement 2. The requirement is: Met Inspection report continued The requirement The provider must implement an effective quality assurance system to ensure children's safety and improve outcomes for children in the service. In order to achieve this the provider must: develop and implement a rigorous quality assurance programme; ensure policies, procedure and records are properly kept and implemented in the service; put effective systems in place for identifying and monitoring the development needs of staff; involve staff in the systematic evaluation of their work and the work of the service; put clear plans in place for maintaining and improving the service; and ensure the management team effectively monitors the work of each member of staff and the service as a whole. This is in order to comply with: Scottish Statutory Instrument 2011/210 Regulation 3, Regulation 4(1) (a) and Regulation 15 (b). Reference: National Care Standards for Early Education and Childcare up to the age of 16. Standard 5. Quality of experience. Standard 12. Confidence in staff. Standard 13. Improving the service. Standard 14. Well-managed service. Timescale: To start within 2 weeks of receipt of this report. What the service did to meet the requirement Some limited improvements were noted in relation to this requirement. For example, the management team were undertaking some monitoring in the playrooms. However, these improvements were in the very early stages and were not yet C.A.S.P.E.R., page 13 of 41

14 impacting sufficiently on making the required improvements. Not all elements of the requirement had been addressed. Further information can be found in quality theme 4, statement 4. The requirement is: Not Met Inspection report continued The requirement The provider must ensure all persons employed in the service receive appropriate training for the work they are to perform. In order to achieve this the provider must: a) effectively monitor the quality of work of each member of staff; b) carry out a training needs analysis for all staff employed in the service; and c) provide training appropriate for the work staff are to perform. This is in order to comply with: Scottish Statutory Instrument 2011/210 Regulation 7 (2) (c) and Regulation 15 (b) (i). Timescale: a) within 1 week of receipt of this report, b) within 4 weeks of receipt of this report and c) to start within 6 weeks of receipt of this report. What the service did to meet the requirement Some limited improvements were noted in relation to this requirement. For example, staff had attended some training. However, these improvements were in the very early stages and were not yet impacting sufficiently on making the required improvements. Not all elements of the requirement had been addressed. Further information can be found in quality theme 4, statement 4. The requirement is: Not Met The requirement The service provider must ensure a record is kept of the qualifications and training for all staff employed in the service. This is in order to comply with: Scottish Statutory Instrument 2002/114 Regulation 19 (2) (a). Timescale: Within 1 month of receipt of this report. What the service did to meet the requirement This requirement had not been addressed, further information can be found in quality C.A.S.P.E.R., page 14 of 41

15 theme 4, statement 4. The requirement is: Not Met The requirement The provider must ensure a member of staff employed at practitioner level or above is present in the service at all times. This is in order to comply with: Scottish Statutory Instrument 2011/210 Regulation 4 (1) (a) and Regulation 15 (a). Timescale: Within 24 hours of receipt of this report. What the service did to meet the requirement We found a member of staff employed at practitioner level or above was always present in the service. The requirement is: Met The requirement The provider must ensure the whistle blowing policy is updated to include all the necessary information. The provider must ensure staff have a good understanding of the whistle blowing procedure to follow in the event of any concerns. This is in order to comply with: Scottish Statutory Instrument 2011/210 Regulation 4 (1) (a) and Regulation 15 (b) (i). Timescale: Within 4 weeks of receipt of this report. What the service did to meet the requirement This requirement had not been addressed, further information can be found in quality theme 4, statement 4. The requirement is: Not Met C.A.S.P.E.R., page 15 of 41

16 What the service has done to meet any recommendations we made at our last inspection 1. The provider should continue to develop a range of method for involving children and their families in assessing and improving the service. Reference: National Care Standards for early education and childcare up to the age of 16. Standard Improving the service. Standard Well-managed service. Some progress had been made towards this recommendation, for example questionnaires had recently been issued to seek parents' view on the service. Further information can be found in quality theme 1, statement The provider should develop a participation strategy to outline how children and their families can expect to be involved in the service. Reference: National Care Standards for early education and childcare up to the age of 16. Standard Improving the service. The service had not developed a participation strategy. Inspection report continued 3. A review should be undertaken of the current snack arrangements. The review should include: children's involvement in preparing snack; staff interaction with children during snack; and the arrangements for children being escorted to the main play room after they have finished snack. Following the review improvements should be implemented in the service to ensure children receive a quality experience both during and immediately after snack. Reference: National Care Standards for Early Education and Childcare up to the age of 16. Standard 3. Health and Wellbeing. Standard 4. Engaging with Children. This recommendation had not been addressed, further information can be found in quality theme 1, statement The provider should develop the range of activities on offer to ensure all children are suitably challenged and motivated. Reference: National Care Standards for Early Education and Childcare up to the age of 16. Standard 5. Quality of experience. C.A.S.P.E.R., page 16 of 41

17 This recommendation had not been addressed. Further information can be found in quality theme 1, statement The provider should review the use of the rooms and space available to ensure that at all times there is sufficient space for children to play. Reference: National Care Standards for Early Education and Childcare up to the age of 16. Standard 2. A safe environment. We found better use was being made of the space available. During the inspection good use was made of the gym hall. This meant there was sufficient space available in the main playroom for children choosing to do quieter activities. 6. The service provider should ensure that information for children and their families is clear, accurate and easily accessible. Reference: National Care Standards for Early Education and Childcare up to the age of 16. Standard Well-managed service. This recommendation had not been addressed. Further information can be found in quality theme 1, statement 1. The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. The service submitted a self assessment before the inspection. Strengths and areas for improvement were identified. The self assessment could be further developed to provide a more accurate reflection of the level the service is performing at and the developments needed in the service. Taking the views of people using the care service into account All children we spoke with told us they liked the staff and would feel confident to discuss any concerns with the staff. Most children told us they enjoyed attending the C.A.S.P.E.R., page 17 of 41

18 club and liked the range of activities provided. Some older children told us they were sometimes bored and sometimes there was not enough for them to do. Taking carers' views into account We sent out 30 Care Standard Questionnaires and eight were completed and returned to us before the inspection. These indicated that on the whole parents were pleased with the service provided. When asked about the overall quality of care their child received at the service: two parents indicated they were very satisfied; and six parent indicated they were satisfied. Parents spoken with found staff helpful and approachable. Most parents told us they felt their child enjoyed attending the club. C.A.S.P.E.R., page 18 of 41

19 3 The inspection We looked at how the service performs against the following quality themes and statements. Here are the details of what we found. Quality Theme 1: Quality of Care and Support Grade awarded for this theme: 3 - Adequate Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the care and support provided by the service. Service strengths The service had developed adequate opportunities for children and parents/carers to give feedback and make suggestions for improving the service. A range of information was provided for parents. The notice boards provided additional information for parents including the aims of the service and the complaints policy. The policy folder was available in the playroom for parents to view. Newsletters covering a number of Aberdeen City Council services were issued to parents. Parents were provided with some opportunities to give their views about the service. Questionnaires had recently been issued to seek parents' views on the service. The questionnaires asked parents to grade the service and also asked open questions to encourage parents to make suggestions. The questionnaires had been collated and the results displayed on the notice board. One parent had commented that the toilets were often messy so the manager had asked staff to regularly check the toilets and record the checks. Comment slips were available for parents to make suggestions and give feedback about the club. During the inspection we saw staff exchanging information with parents, this included general information about the service as well as specific information about their child. Seven of the eight parents returning the Care Standards questionnaires responded positively to the statement "The service has involved me and my child in developing the service, for example asking for ideas and feedback". C.A.S.P.E.R., page 19 of 41

20 Children were also provided with opportunities to give their views about the club. Staff used mind mapping to gather and record children's ideas about different aspect of the service. We saw children had been asked for their ideas for snack and activities to do in the gym hall. Children told us they were able to choose from a variety of activities. Some toys were stored in the playroom and children helped themselves to these throughout the sessions. Additional toys and games were stored in a large store cupboard. Children were given the choice of playing in the main play room or going to the gym to do activities. Areas for improvement The results of the parent questionnaires had been shared with parents. However, the changes made as a result of the responses to the questionnaires had not been shared with parents. (See Recommendation 1). Children had completed questionnaires about the service. These questionnaires asked closed questions that did not encourage children to give their ideas and suggestions for developing the service. (See Recommendation 1). Mind mapping had been done to seek children's ideas. We advised the service these could be done more frequently and where children's ideas were implemented these should be evidenced on the mind maps. (See Recommendation 1). At the last two inspections a requirement had been made to ensure all references to the complaints policy contained the correct procedure to follow. The complaints policy displayed on the notice board did not include the correct procedure. (See Requirement 1). At the last inspection we identified the information booklet include a number of inaccurate statements as well as information that differed from the policies of the service. The service was no longer issuing the information booklet but had not developed a new booklet to ensure parents were provided with accurate and easily accessible information. We found some parents spoken with were not aware that the service had a complaints procedure and a child protection policy. (See Recommendation 2). Grade awarded for this statement: 3 - Adequate Number of requirements: 1 Number of recommendations: 2 C.A.S.P.E.R., page 20 of 41

21 Requirements 1. The provider must ensure all references to the complaints procedure contain correct information. This is in order to comply with Scottish Statutory Instrument 2011/210 Regulation 18. Timescale: Within 1 week of receipt of this report. Recommendations 1. The provider should continue to develop a range of methods for involving children and their families in assessing and improving the service. Reference: National Care Standards for early education and childcare up to the age of 16. Standard Improving the service. Standard Wellmanaged service. 2. The service provider should ensure that information for children and their families is clear, accurate and easily accessible. Reference: National Care Standards for early education and childcare up to the age of 16. Standard Well-managed service. Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths At this inspection we found the service was adequate at meeting the health and wellbeing needs of children. Since the last inspection care plans had been developed, where appropriate. These provided detailed information on the needs of each child and clearly described how staff would meet each child's needs. Staff talked confidently about the needs of children and how they met individual children's needs. We saw staff following the information in the care plans. Since the last inspection the medication policy had been developed and now included more detailed information. This meant clear information was provided for parents and staff. Medication was now available in the service for all children requiring long term medication. Detailed information had been obtained for children requiring long term medication as well as information on the procedure to follow if the medication was not effective. At the last inspection a requirement had been made to ensure an appropriate first aid C.A.S.P.E.R., page 21 of 41

22 box was on the premises. The first aid box had been reviewed and monthly checks were now undertaken and recorded. As a result all items in the first aid box were appropriate and in date. Snacks appeared healthy and children told us they enjoyed the snacks. Children served their own snack and were able to choose from a range of fruits. There was some interaction between staff and children at snack time. At the last two inspections a recommendation had been made for a review to be undertaken of the use of the rooms and space available to ensure there is sufficient space for the children to play. We found better use was being made of the space available. During the inspection staff made good use of the gym hall and as a result there was sufficient space in the main playroom for children wanting to do quieter activities. Since the last inspection the child protection policy had been updated and now included clearer information for staff on the procedure to follow in the event of any child protection concerns. Staff spoken with had a good understanding of child protection issues and were confident with the procedure to follow in the event of any concerns. All staff had attended child protection training. Areas for improvement Inspection report continued The care plan policy stated all care plans would be reviewed termly. However, some care plans had not been reviewed for over six months. Care plans must be reviewed at least every six months to ensure the plans reflect the current needs of the children. (See Requirement 1). The medication policy stated children's medication needs would be reviewed termly. However, some medication forms had not been reviewed for over six months. This meant information could be out of date. The medication policy stated a daily audit would be undertaken of the medication on the premises, however, this was not being done. The medication box was difficult to open. We had previously advised the serviced to address this so as medication could be easily accessed in the event of an emergency. (See Requirement 2). A requirement had been made at the last inspection to ensure suitable arrangements were in place to protect children against sunburn. Sun cream was now available in the service for use when children did not have their own sun cream. However, parental permission was not in place for children to use this sun cream. (See Requirement 3). During the inspection we saw the children having breakfast and snack. At the morning session we did not see staff making sure all children that needed breakfast, had been offered breakfast. Breakfast time appeared quite disorganised with children eating breakfast amongst the toys. There was quite limited interaction between staff C.A.S.P.E.R., page 22 of 41

23 and children at snack time. During feedback we discussed how snack time could be reviewed to ensure more staff were interacting with the children during snack. Children were spilt into two groups for snack. The management team told us they were looking at how the changeover between the two groups could be better organised. (See Recommendation 1). A recommendation was made at the last inspection to develop the range of activities on offer to ensure all children are suitably challenged and motivated. We found the breakfast club appeared disorganised with limited interesting and challenging activities on offer, particularly for the older boys. As a result some of the older children appeared uninterested and their behaviour became disruptive. Most parents spoken with thought their children enjoyed the activities provided. However, one parent commented "There's not enough thought going into activities to stimulate them and encourage new kids to join the club". The younger children spoken with all enjoyed attending the club and liked the activities provided. However, some of the older children told us they were sometimes bored and when they could not play outside there was not enough to do. (See Recommendation 2). Grade awarded for this statement: 3 - Adequate Number of requirements: 3 Number of recommendations: 2 Requirements Inspection report continued 1. The provider must put in place and implement effective systems for the review and update of personal plans for those children attending the service with additional support needs. The systems must ensure that a review will take place: when requested by the child or their parent/carer; when there is a significant change in a child's health, welfare or safety needs; and at least every six months. This is in order to comply with Scottish Statutory Instrument 2011/210 Regulation 4 (1) (a) and Regulation 5 (2). Timescale: Within 3 weeks of receipt of this report. 2. The provider must: a) put in place and implement effective systems for the review and update of medication forms. The system must ensure a review will take place: C.A.S.P.E.R., page 23 of 41

24 when requested by the child or their parent/carer; when there is a significant change in a child's health, welfare or safety needs; and at least every six months. b) ensure a daily audit is undertaken of the medication on the premises. c) ensure medication can be easily accessed in the event of an emergency. This is in order to comply with Scottish Statutory Instrument 2011/210 Regulation 4 (1) (a) and Regulation 5 (2). Timescale: Within 3 weeks of receipt of this report. 3. The provider must ensure suitable arrangements are in place to protect children from sunburn. This is in order to comply with Scottish Statutory Instrument 2011/210 Regulation 4 (1) (a). Timescale: Within 3 weeks of receipt of this report. Recommendations Inspection report continued 1. A review should be undertaken of the current breakfast and snack arrangements. The review should include: developing systems to ensure all children that require breakfast are offered breakfast ensuring there is a designated area for children to eat their breakfast * children's involvement in preparing snack; * staff interaction with children during snack; and * the arrangements for children being escorted to the main play room after they have finished snack. Following the review improvements should be implemented in the service to ensure children receive a quality experience during breakfast and snack. Reference: National Care Standards for early education and childcare up to the age of 16. Standard 3. Health and Wellbeing. Standard 4. Engaging with children. C.A.S.P.E.R., page 24 of 41

25 Quality Theme 2: Quality of Environment Grade awarded for this theme: 2 - Weak Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the environment within the service. Service strengths Information in relation to this quality statement has been included in quality theme 1, statement 1. Areas for improvement See quality theme 1, statement 1. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Statement 2 We make sure that the environment is safe and service users are protected. Service strengths At this inspection we found the performance of the service was weak in relation to this statement. Following a requirement made at the last inspection the fire blanket was now securely attached to the wall. This meant in an emergency situation staff could easily access the fire blanket. Emergency contact details for parents were now stored in the box file staff took with them in the event of evacuation. In line with best practice, paper towels and liquid soap was available in the service for the children to use. Areas for improvement There were a limited number of risk assessments in place. We found these contained basic information and did not reflect all the hazards in the service. Risk assessments were not in place for a number of key areas such as the outdoor area and trip hazards. (See Requirement 1). C.A.S.P.E.R., page 25 of 41

26 Following a requirement made at the last inspection parental permissions were in place for children to leave the service unaccompanied. However, no risk assessments had been undertaken to ascertain if it was appropriate for individual children to leave the service unaccompanied. (See Requirement 1). A requirement had been made at the last inspection to ensure all children were familiar with emergency evacuations by carrying out regular emergency evacuation practices on different days of the week. Two emergency evacuation practices had been carried out on Tuesdays at the breakfast club. This meant children not attending the breakfast club on a Tuesday would not be familiar with the procedure. (See Requirement 2). In both the main toilet and disabled toilet there was a toilet brush loose on the floor. The toilet brush in the disabled toilet was dirty with what appeared to be faeces. The disabled toilet was used for changing children. The changing mat was torn which meant it could not be properly cleaned. There was no mat for staff to kneel on whilst changing nappies to reduce the risk of spreading infection. Staff told us all the items required to change a child were in a box in the disabled toilet, however, no disposables aprons were in the box. A sledge was stored in the disabled toilet. Items stored in a toilet cubicle are open to airborne contamination. (See Requirement 3). Children did not wash their hands before or after eating breakfast. Children were also eating breakfast whilst playing with toys which meant toys could easily become contaminated. Before snack a member of staff stood outside the toilets to ensure children washed their hands. However, staff did not undertake checks of children washing their hands. As a result all the children we saw did not use any soap to wash their hands. (See Requirement 3). The disposable gloves in both first aid kits were stored loose. This meant they were open to contamination. (See requirement 3). The infection control policy gave very limited guidance for staff on the correct procedures to follow to ensure the prevention and control of infection. A requirement had been made at the last three inspections to develop a written policy detailing the infection control procedures within the service. This had not been addressed. A clear written procedure would support staff to implement effective infection control procedures. (See Requirement 3). The disabled toilet used for the personal care of children was very cold. This meant it would be unpleasant for children to be changed in this area. No temperature checks were undertaken in this area. (See Requirement 4). The manager had introduced toilet checks following a comment made by a parent about the toilets often being messy. Staff were supposed to check the toilets regularly C.A.S.P.E.R., page 26 of 41

27 and record these checks on the check list. However, we noted on most occasions the toilets were only checked once after school and this was often at the beginning of the session. In order for the system to be effective, regular checks would need to be undertaken throughout the session. (See Recommendation 1). The cleaning records were not being accurately completed. For example, the records showed the fridge in the playroom was last cleaned in February, however, staff told us this was cleaned each week. (See Requirement 5). Grade awarded for this statement: 2 - Weak Number of requirements: 5 Number of recommendations: 1 Requirements Inspection report continued 1. The provider must ensure appropriate risk assessments are in place detailing all the hazards and appropriate control measures. To achieve this the provider must: a) ensure all staff receive training in assessing and managing risks b) undertake risk assessments of all areas of the premises, outdoor areas, outings and higher risk activities. The risk assessments must: take account of the needs of individual children take account of the age and stage of development of all children identify all the potential hazards identify appropriate control measures to minimise the risks to children The provider must then ensure the risk assessments are implemented in the service. This is in order to comply with Scottish Statutory Instrument 2011/210 Regulation 4 (1) (a). Timescale: a) within 3 months of receipt of this report, b) to start within 2 weeks of receipt of this and to be completed no later than within 3 months of receipt of this report. 2. The provider must put effective systems in place to ensure all children are familiar with the emergency evacuation procedure. This is in order to comply with Scottish Statutory Instrument 2011/210 Regulation 4 (1) (a). Timescale: Within 1 month of receipt of this report. C.A.S.P.E.R., page 27 of 41

28 3. The provider must ensure appropriate procedures are implemented for the prevention and control of infection. This must include developing the written policy to provide clear guidance for staff on the infection prevention and control measures. This is in order to comply with Scottish Statutory Instrument 2011/210 Regulation 4 (1) (d). Timescale: Within 1 week of receipt of this report. 4. The provider must make the necessary improvements to ensure the temperature in all the areas where children are cared for is maintained at an appropriate level. This is in order to comply with Scottish Statutory Instrument 2011/210 Regulation 4 (1) (a) and Regulation 10 (2) (c). Timescale: Within 1 week of receipt of this report. 5. The provider must ensure a record is kept of any maintenance that is carried out of the toys and equipment used in the service. This is in order to comply with Scottish Statutory Instrument 2002/114 Regulation 19 (3) (e). Timescale: Within 1 week of receipt of this report. Recommendations Inspection report continued 1. The manager and staff should ensure regular checks of the toilets are undertaken and recorded throughout the session. Reference: National Care Standards for early education and childcare up to the age of 16. Standard 2. A safe environment. C.A.S.P.E.R., page 28 of 41

29 Quality Theme 3: Quality of Staffing Grade awarded for this theme: 3 - Adequate Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service strengths Information in relation to this quality statement has been included in quality theme 1, statement 1. Areas for improvement See quality theme 1, statement 1. Grade awarded for this statement: 3 - Adequate Number of recommendations: 0 Number of requirements: 0 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths At this inspection we found the performance of the service was adequate in relation to this statement. On the whole staff interacted well with the children and appeared genuinely interested in the children. We saw staff taking time to ask children about their home life and outside interests. Staff had developed good relationships with parents and made time to talk with parents at the start and end of the sessions. Parents spoken with told us they found staff helpful and approachable. Staff had attended a variety of training, including child protection. A programme of core training was planned for all staff. All staff were either qualified or working towards a qualification. All staff that were required to be were registered with the Scottish Social Services Council (SSSC). The remaining staff were in the process of registering with the SSSC. C.A.S.P.E.R., page 29 of 41

30 Children appeared confident to approach staff. Children told us they liked the staff and found them nice and friendly. Children also told us they would be confident to speak to staff if they had any worries or concerns. Areas for improvement Staff would benefit from additional training to address some of the areas for improvement identified in this report. A full training needs analysis had not been completed for staff. This would support the management team to identify staff strengths and areas for development. Further information about this can be found in quality theme 4, statement 4. Some staff would benefit from clearer direction on their roles and responsibilities. For example, during the inspection clear direction was not given to staff on their roles at the breakfast club. As a result the breakfast club session appeared disorganised with some of the children becoming disruptive. Some of the training staff had attended was not recorded in the training records each member of staff kept. The management team were in the process of recording the core training staff had attended but this did not include all the training undertaken by staff. The provider is required to keep a record of all training undertaken by staff. Further information can be found in quality theme 4, statement 4. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Inspection report continued C.A.S.P.E.R., page 30 of 41

31 Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 2 - Weak Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the management and leadership of the service. Service strengths Information in relation to this quality statement has been included in quality theme 1, statement 1. Areas for improvement See quality theme 1, statement 1. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Statement 4 We use quality assurance systems and processes which involve service users, carers, staff and stakeholders to assess the quality of service we provide Service strengths The service was in the early stages of developing and implementing quality assurance systems involving staff, parents, children and stakeholders. As a result we found the level of performance was weak in relation to this statement. Regular staff meetings were held and records of these meetings were kept. Staff told us the staff meetings had been used to discuss the improvements needed in the service. Management and staff had daily discussions before the after school club sessions started. They used this opportunity to share ideas and discuss any issues. One to one supervision sessions were now in place for all staff. Staff told us they found the supervision sessions helpful. The provider's quality assurance team had started to visit the service. We found these visits provided useful guidance and direction to support the service to make improvements. C.A.S.P.E.R., page 31 of 41

32 Areas for improvement Inspection report continued Some monitoring had been undertaken by the management team. However, there was no clear purpose identified for the monitoring and as a result the monitoring records were very general and did not focus on specific issues. Many of the monitoring records did not identify the strengths and areas for development needed to make improvements in the service. There was no record that the monitoring was shared with staff and no action points developed to support improvements in the service. (See Requirement 1). The weekly staff meetings did not include a review of the previous week's meeting. As a result issues identified were not followed up to ensure they had been fully addressed. (See Requirement 1). An action plan was in place, however, this did not appear to be service specific and did not focus on the issues in the service. There was no evidence the action plan was reviewed and as a result it was not clear what progress had been made towards achieving the actions. A clear action plan focussed on the specific areas for improvement required in the service that would support the management team and staff to drive forward the improvements needed in the service. (See Requirement 1). The new manager had recently restarted one to one supervision sessions with staff. These were in the early stages of development and we suggested these could be further developed to involve staff in the evaluation of their work and to support staff to embed new practices in the service. This would support staff to make the required improvements in the service. A full training needs analysis had not been undertaken for staff. This would be useful to support staff to develop their knowledge and skills and in turn make improvements in the service. (See Requirement 1 and Requirement 2). At the last two inspections a requirement had been made to ensure accurate records were kept of staff training. This requirement had not been met. Some staff training records were not up to date. (See Requirement 3). A change of manager form for the new manager had not been submitted to the Care Inspectorate as required. (See Requirement 4). At the last inspection a requirement was made to update the whistle blowing policy to include all the necessary information and to ensure staff had a good understanding of the procedure to follow in the event of any concerns. Although the policy referred to the Care Inspectorate it did not direct staff to contact any other outside agencies, for example Social Work or the Police. Staff spoken with did not demonstrate a good understanding of the agencies they could contact in the event of any concerns. (See Requirement 5). C.A.S.P.E.R., page 32 of 41