Child Day Care Centres Unannounced Inspection

Transcription

1 Department of Health and Social Care Rheynn Slaynt as Kiarail y Theay Child Day Care Centres Unannounced Inspection Registration and Inspection Unit Department of Social Care 4 th Floor Markwell House Market Street Douglas Isle of Man IM1 2RZ Establishment: Beehive Kindergarten Under the Regulation of Care Act 2013 Time: 9.30AM Date: 16 MARCH 2015

2 FACILITY INFORMATION Name of Facility: Tel No: (01624) Beehive Kindergarten Mobile: (07624) Registration No: ROCA/P/008B Address: Beehive Kindergarten Hillberry Road Onchan Isle Of Man address: Registered person/company: Person in charge: Beeline Nurseries Limited Mrs Alice Oakes Date of last registration certificate: 8/02/14 Registration Details: Type of Establishment: 74 children in total of which no more than 12 are to be aged between 1 and 2 years. Full Day Care and Out of School Care Days open: Holidays: Monday - Friday Bank Holidays (except senior race day).days in-between Christmas and New Year No. of children at the time of inspection: 61 No. of staff present at time of inspection: 9 Person in charge at time of inspection: Name of Inspector(s): Mrs M Nation Jenny Percival & Becci Rea 2

3 CONTENTS Facility Information Introduction to Report/Inspection Visits Brief Description of Facility Part 1: Summary of Inspection What the service does well What has improved since the last inspection What they could do better What the plans are for the next 12 months Relationship between staff and children Part 2: Inspection Methods & Outcomes Inspection methods used. Observation Document reading Questionnaires Talk to staff Tour of Premises Feedback Part 3: Requirements and Recommendations Compliance with Previous Requirements Good Practice Recommendations from Previous Inspections Compliance with Conditions of Registration Requirements identified during this Inspection Good Practice Recommendations from this Inspection Part 4: Provider s Response 3

4 The purpose of the inspection is: INTRODUCTION TO REPORT AND INSPECTION to satisfy the Department that services are being provided to an acceptable standard and children are being cared for appropriately; to provide reassurance for parents; to establish that children are safe and take part in activities that contribute to their development and learning; to confirm that the provision is consistent with the information held on the register held by the Department and that the registered person is compliant with their conditions of registration; to raise standards and promote high quality in the provision of care and learning. When making judgements, inspectors have regard as to how well the provider meets the Child Day Care Centres Standards, produced by the Department, August Service providers are required, as part of their conditions of registration, to comply fully with the standards. This document summarises the inspection findings. The inspection outcomes relate to the Minimum Standards (MS) for Child Day Care Centres. The report also identifies strengths and areas for improvement and follows the format of the standards. The numbering shown corresponds to that of the standards. Care providers are expected to comply fully with the Minimum Standards. The Minimum Standards will form the basis for judgements by the Department regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the MS and the numbering shown in the report corresponds to that of the standards. The report will show the following: Inspection methods used Outcome and evidence Compliance with the Required actions on the part of the provider Recommended good practice Summary of the Outcomes Provider s response and proposed action plan to address outcomes INSPECTION VISITS Inspections will be undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Regulation of Care Act This report is based on the outcomes of the specified inspection dates and will be known as an open report and will be made readily accessible to the public. 4

5 Registered Number of Children: CONDITIONS OF REGISTRATION 74 Children in total and of those 74 (seventy four), no more than 62 (sixty two) are to be aged 2 years or above and no more than 12 (twelve) are to be between the ages of 1 and 2 years. (Under Section 65 & 107(1-4) of the Regulation of Care Act 2013). All registered providers of Child Day Care must comply with their conditions of registration as stated on the certificate of registration issued by the Department of Social Care. BRIEF DESCRIPTION OF THE SERVICES PROVIDED This Kindergarten offers facilities which are all on ground floor level and a large, secure outside play area. The facilities have been adapted to offer care for the under two year olds including separate play areas and a sleep room. The Kindergarten provides cooked meals and there is a well equipped kitchen. The Beeline Nurseries also operate two further nurseries, one of which, Kindergarten Shelleig, is situated on the same site as the Beehive Kindergarten and offers care for children aged two years and above on the first floor and for children aged under two years on the ground floor. The children aged two years and above share the facilities of both nurseries. Children aged 18 months and under first attend the Kindergarten Shelleig and then move on to the Beehive Kindergarten Baby Wing. Descriptors of performance against standards Inspection reports will describe how a service has performed in each of the standards inspected. Compliance statements by inspectors will follow the framework as set out below. Not compliant Compliance could not be demonstrated by the date of the inspection. This will result in a requirement or recommendation being made Partially compliant Compliance could not be demonstrated by the date of the inspection. Appropriate systems for regular monitoring, review and revision were not yet in place. However, the service could demonstrate acknowledgement of this and a convincing plan for full compliance. In most situations this will result in requirements/recommendations being made Substantially compliant Arrangements for compliance were demonstrated during the inspection yet some criteria were not yet in place. In most situations this will result in recommendations being made. Compliant Arrangements for compliance were demonstrated during the inspection. There are appropriate systems in place for regular monitoring, review and any necessary revisions to be undertaken. In most situations this will result in an area of good practice being identified and comment being made. Not assessed 5

6 Assessment could not be carried out during the inspection due to certain factors not being available. Open Reporting As of February 2014 all inspection reports will be available on the Registration and Inspection Units Website and accessible for all to read. PART 1 SUMMARY OF INSPECTION This is an overview of what the inspector found at the time of inspection and the purpose of this inspection was to check the service s level of compliance with the standards as set out in Part 2. This inspection was undertaken on the basis of a risk assessment carried out by the inspector. At this time this service was assessed as being low. Areas of good practice The following are comments from the parents of children that attend the kindergarten; There are always bright and colourful displays to greet you on entering the nursery The staff are always cheerful and welcoming I ve been taking my children for the last 19 years and I cannot fault the nursery education of the staff. The nursery is a joy to have in my children s life Love that they have the garden and all activity along with it The children feel welcome, almost family like setting. Great garden My happy youngster has come on so much since starting at the Beehive and I m pleased with his progress The fabulous garden is a definite asset Quality improvements subsequent to the previous inspection All the requirements from the previous inspection had been completed, with the exception of one which has been brought forward to this report. The plans for the next 12 months To complete the requirements from this report and work to meet the revised standards of August 2014 for Child Day Care Centres. Relationship between staff and children The staff were observed to integrate with the children in an appropriate manner. The children were supervised at all times and given the opportunity to play with their peers or play alongside the staff. The children appeared to be happy and when they were upset were reassured quickly by the staff. 6

7 PART 2 INSPECTION METHODS & FINDINGS The following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling/observation: Displayed documents Inspection Questionnaire Records Meals Activities Medicine Administration Hygiene Practices Other (specify) Individual discussion with children Group discussion with staff Individual discussion with staff Discussion with management Discussion with parents Tour of Premises Document reading The following pages summarise the outcomes and evidence from this inspection, together with the extent to which the Child Day Care Centres Standards have been met. Child Day Care Centres Standards These standards intend to: Provide a framework to protect children. Contribute to providing reassurance for parents about what they can expect from the day care provider. Ensure that services meet acceptable standards. Ensure that service providers are aware of the standards their services are expected to meet. Ensure that services provided are within an established legislative framework. Ensure that services provided are subject to continuous improvement. The standards fall into 16 subject areas and the following pages summarise the key findings and evidence from the inspection. 7

8 Standard 1 Suitable Person Expected outcomes: Adults providing day care, looking after children or having unsupervised access to them are suitable to do so. Training and qualification requirements are met. All requirements were not met during this inspection. Outcome SUBSTANTIALLY COMPLIANT The responsible must ensure that all relevant checks completed have been recorded including the outcome. All staff must have their DBS (disclosure and barring servicepolice check) renewed at a minimum of every 3 years. Where possible the staff should sign up for portability. The registered persons are the only persons living on the premises and as they are included in the staff team, their DBS checks will be completed. The proposed registered manager had a relevant qualification but is currently on maternity leave. Therefore there was a suitable experienced and qualified person to take charge in her absence. Standard 2 Organisation The registered person meets required adult: child ratios, ensures that training and qualifications requirements are met and organises space and resources to meet the children s needs effectively. All requirements were not met during this inspection. Outcome SUBSTANTIALLY COMPLIANT The staffing team were deployed effectively on the day of the inspection. There were sufficient staff working in each of the areas, but there were no written plans displayed of this or the activities they were carrying out with the children. The statement of purpose was displayed in the entrance hall. The children were allocated to a specific staffing group which enabled them to build relationships but interact with the staff within that team. There was a written induction procedure and record for staff, but this needed to be completed thoroughly and any training needs identified. Within the newly implemented standards there is a requirement for there to be a registered manager. This person has the role of what at present is called the person in charge. This person is required to undertake a QCF Level 5 Diploma in Leadership for Children s Care, Learning and Development (Management) or equivalent. From 1 st April 2019, there is an expectation that managers seeking registration will have gained or are in the process of gaining this qualification. The staff that had undertaken their Foundation Child Care Course with The Children 8

9 Centre must complete further training if they want to achieve a full level 3 diploma in Child Care. There has always to be a minimum of 50% of the staff team on duty with a relevant care qualification. Any unqualified staff must not work unsupervised. There was a register for recording the attendance of both staff and children on a daily basis. Regulation of Care Act 2013, Part 2 (37) and Part 3 (9) of Care Services Standard 3 Care, Learning and Play Expected outcomes: The registered person meets children s individual needs and promotes their welfare. They plan and provide activities and play opportunities to develop children s emotional, physical, social and intellectual capabilities. All requirements were not met during this inspection. Outcome COMPLIANT The nursery followed a balanced curriculum that promoted the children s overall development and well-being. Planning sheets were available but they did not show deployment of staff or the learning intentions/goals for each activity. This was discussed with the management team at the end of the inspection and with the staff during the inspection. Including more information on the planning would ensure the staff team are aware of the focus of the activities they are providing and ensure effective planning for the next step of development. The staff team were carrying out observations on the children and the inspector was able to see them recorded in the children s records. The children s activity rooms were displayed with children s art work and themed friezes. Plenty of children s toys were available to play with and easily accessible for children to choose which enabled them to make choices. There was a daily routine which included outside play. The kindergarten benefitted from a large open planned outside play area. This consisted of areas for wet play, climbing, story time and space to use outside toys such as trikes. Children were observed to use this area in small groups and were not all out together. Standard 4 Physical Environment The premises are safe, secure and suitable for their purpose. They provide adequate space in an appropriate location, are welcoming to children and offer access to the necessary facilities for a range of activities which promote their development. All requirements were not met during this inspection. 9

10 Outcome SUBSTANTIALLY COMPLIANT The premises were welcoming for both children and staff. The entrance hall provided a large open area for parents to arrive with their child and hand over to the staff. There was an information board on the wall for parents to view that provided details of policies and services provided. There was also children s art work displayed. There were five activity rooms for the children aged 2 years and above, and separate rooms for the children aged between 18 and 24 months. All rooms were well lit and adequately ventilated. They were in a suitable state of repair and decoration. Each of the rooms had displayed children s art work on the walls and mobiles. The rooms were clean and the staff wiped tables down prior to being used for snack and lunch time. All the rooms need to be maintained at a minimum of 18 c. On the day of the inspection, all with the exception of one were below this. The rooms were set out to enable the children to move freely between the furniture. There were dedicated rooms or areas for sleep that were provided with appropriate sleeping arrangements. The staff had an area they could go to eat their lunch and facilities to place their personal belongings. The kitchen was large and equipped with enough equipment to enable the cook to provide cooked meals and snacks throughout the day. The laundry facilities were separated from the children s areas. There was a large outside play area to the rear of the premises that was easily accessed from the kindergarten. This area had a summer house equipped with a suitable indoor crafts/ play area. There was also a toilet and wash hand basin installed. Standard 5 Equipment Furniture, equipment and resources (including toys) are provided which are appropriate for their purpose and help to create an accessible and stimulating environment. They are of suitable design and condition, well maintained and conform to safety standards. All requirements were met during this inspection. Outcome: COMPLAINT There were sufficient toys and play materials that were age appropriate for children being cared for. Suitable equipment such as tables and chairs were available and were child size. Standard 6 Safety The registered person takes positive steps to promote safety within the setting and on outings and ensures proper precautions are taken to prevent accidents. All requirements were not met during this inspection. 10

11 Outcome SUBSTANTIALLY COMPLIANT The registered persons had taken steps to minimise the risk of hazards to staff, children and visitors. Risk assessments had been completed but require to be reviewed and a completion date recorded. Radiator surface temperatures and water temperatures accessible to children were below the required maximum of 43 c. Hazardous substances were locked away and made inaccessible to the children. Electric sockets had covers placed in them and there were no trailing wires. All portable appliance s such as the kitchen equipment had been portable appliance tested (PAT) annually, with the exception of one item. The premises were locked and parents/ visitors would have to ring the doorbell to gain entry. The registered persons had installed a new security system since the last inspection. This enabled the staff to view any visitors through a viewing intercom/ camera. This was observed during the inspection. There was a fire log book that contained the tests completed on the fire alarms and emergency lighting. These were being completed on a weekly and monthly basis respectfully. There was public and employers liability insurance which met with the criteria for standard The outside play area had a fenced perimeter and bolted gate. The nursery had a mini bus to transport the children. There was appropriate insurance cover that was valid and driver s licences checked. Standard 7 Health The registered person promotes the good health of children and takes positive steps to prevent the spread of infection and appropriate measures when they are ill. All requirements were not met during this inspection. Outcome SUBSTANTIALLY COMPLIANT The premises and equipment were clean. Areas were cleaned throughout the day, such as tables and changing mats. Children were supervised when using the toilet and the staff ensured that the children washed their hands. The nursery provided wet wipes and nappies, but parents provided their own creams. The nursery was on the Department of Environment and Fisheries and Agriculture list for registered provider of food handling. There was a written record of the fridge temperature being taken, however these were not dated or consistent. To meet with regulations relating to food safety and hygiene, the cook must keep a written record of all ingredients used in the meals and incorporate the 14 allergens. 11

12 There were records for the administration of medication and authorised signature from parents for the staff to give their child the medicine and again to acknowledge when it had been given. Training is required to be given to all staff regarding any identified medical condition from a qualified health professional. There were sufficient first aid kits and trained staff in first aid. Any accidents had been recorded and again signed by the parents to acknowledge that they had been informed. The kindergarten operated an exclusion policy for any child identified with an infectious illness. There was a no smoking policy. Standard 8 Food and Drink Children are provided with regular drinks and food in adequate quantities for their needs. Food and drink is properly prepared, healthy & nutritious and complies with dietary and religious requirements. All requirements were met during this inspection. Outcome COMPLIANT The nursery provided a cooked meal at the premises for the children. The details of the menu were displayed in the entrance hall. Parents had been requested to supply information about any dietary requirements their child had. The tables had been cleaned and the children s hands washed prior to eating their lunch. Standard 9 Equal Opportunities The registered person and staff actively promote equality of opportunity and antidiscriminatory practice for all children. All requirements were met during this inspection. Outcome COMPLAINT There was an equal opportunities policy. The children being cared for ranged from 18 months and above. All the children had been provided with opportunities to play and build relationships with the staff. Each child had a file that recorded their individual needs enabling the staff to provide an appropriate level of care. This information had been provided by their parents. Job 12

13 vacancies had been advertised and a recruitment process implemented. Standard 10 Special needs (including special educational needs and disabilities) The registered person is aware that some children may have special needs and is proactive in ensuring that appropriate action can be taken when such a child is identified or admitted to the provision. Steps are taken to promote the welfare and development of the child within the setting, in partnership with the parents and other relevant parties within a multi-agency structure. All requirements were not met during this inspection. Outcome SUBSTANTIALLY COMPLIANT : The provider must make themselves aware of the Codes of Practice for the Identification and Assessment of Special Needs. There was a policy in place for special needs. Children had been identified with additional medical requirements and the parents had completed information to inform the staff of these needs. The staff must be fully trained by a suitable qualified practitioner in the specific requirements to meet these needs. The premises were all based on the ground floor which would allow access for prams or wheel chairs. The outside play area attached to the rear of the premises was accessible via patio doors allowing easy access to this area. Standard 11 Behaviour Adults caring for children in the provision are able to manage a wide range of children s behaviour in a way which promotes their welfare and development. All requirements were met during this inspection. Outcome COMPLIANT Children s behaviour was managed in a way that promoted their welfare and development. There was a written policy regarding behaviour management and the staff were observed to act in an appropriate manner. Expectations of children s behaviour were in accordance with the child s age and development stage of understanding. Standard 12 Working in partnership with parents and carers The registered person and staff work in partnership with parents to meet the needs of 13

14 the children, both individually and as a group. Information is shared. All requirements were met during this inspection. Outcome COMPLIANT Parents had been provided with written information about the services provided prior to making a decision to enrol their child at the Kindergarten. The statement of purpose was on display and the policies and procedures included a policy regarding care, learning and play, parent s access to records and confidentiality. The written complaints policy was on display which had included how to contact the registration and inspection unit. Parents and staff had the opportunity to exchange information with each when delivering and collecting the child. The kindergarten also have a social media (facebook) page, photographs of children s activities and details of outings were placed. This page also provided parents with guidance regarding any contagious or infectious illness s. Standard 13 Safeguarding The registered person complies with the safeguarding procedures approved by the Isle of Man Protecting Children s Board and ensures that all adults working and looking after children in the provision are able to put the procedures into practice. All requirements were not met during this inspection. Outcome SUBSTANTIALLY COMPLIANT There was a safe guarding policy, which needs to identify the different persons to contact id there were any concerns. The person in charge and responsible person gave a verbal account of the procedure they would undertake if they had any concerns. Although the staff had completed safe guarding training, it is now a requirement that the training is renewed every three years as a minimum. There were other polices that supported this standard including, confidentiality, use of mobile phones, taking of photographs, lone working, intimate care of children. There were some that still require to be completed. The children were able to interact with an identified staffing groom for their age group. This enabled them to build relationships but not be at risk of grooming. The person in charge was supernumery and part of that person s daily activity is to supervise during toileting and nappy changing routines. The staff completed a record for the changing of nappies which included the name of the person completing this task. 14

15 Standard 14 Documentation Records, policies and procedures which are required for the efficient and safe management of the provision, and to promote the welfare, care and learning of children are maintained. Records about individual children are shared with the child s parent. All requirements were not met during this inspection. Outcome SUBSTANTIALLY COMPLIANT There was a record of information for each child on the register. The records contained information required to ensure the individual needs were recorded and met. There was some additional information required to be added to the forms and completed. Other records being completed included; accidents, exclusion due to an infectious illness, administration of medication, safeguarding concerns and persons living on the premises. There was an accurate system for recording the attendance of staff, this included the arrival and departure times. The children s register needs to include the arrival and departure times of the child. The children s register did include the child s date of birth. The service had registered with the Data Protection Office as information was stored on the computer. Policies and procedures were written that supported the services provided by the kindergarten. These included; confidentiality, behaviour management, exclusion of children who are infectious, safe arrival and departures, missing child, failure to collect, complaints, special needs, equal opportunities, induction and training, safeguarding, health and safety, fire safety, outings, medication administration, parents access to records, intimate and personal care, hazardous substances, and care, learning and play. Regulation of Care Act 2013 Annexe A Babies/children under 2 A suitable standard of care is promoted for children under the age of two years. All requirements were not met during this inspection. Outcome SUBSTANTIALLY COMPLIANT Children aged between 18 and 24 months were being cared for in separate rooms to the older children. The equipment, furniture and toys were suitable for the age group. 50% of the staff had a relevant child care qualification. There was a written plan of activities displayed however it was not relevant to this age group. The staffing group had been consistent providing the children to develop relationships. Meals were provided by the Kindergarten and a record was provided for parents of their child s intake. 15

16 Regulation of Care Act 2013, Annexe B Overnight Care A suitable standard of care is provided for the children who are cared for overnight. All requirements were met / not met during this inspection. Outcome NOT ASSESSED The service does not provide overnight care. 16

17 REQUIREMENTS AND RECOMMENDATIONS COMPLIANCE WITH PREVIOUS REQUIREMENTS Identified below are requirements made at previous inspections under the Regulation of Care Act 2013 and the Child Day Care Centre Standards and progress to date No. Refer to Standard/ regulation Reg 5 Requirement/date for compliance Rooms must be maintained at the recommended minimum of 18 c. IMMEDIATE The seal around the edging of the kitchen flooring must be repaired. TO BE COMPLETED BY 28/02/14 The door frame and window sills need attention and appropriate action taken due to the paint chipping. TO BE COMPLETED BY 28/02/14 The box of carrier bags in one of the children s bathrooms to be made inaccessible. IMMEDIATE The bin in one of the children s bathrooms needs a lid. IMMEDIATE The registered person must ensure that the premises have sufficient security measures to prevent access by unauthorised persons. AXTION TO BE COMPLETED BY 10 MARCH A statement of purpose to be written. TO BE COMPLETED BY 17 MARCH Action Plan by Provider Recommendations from Previous Inspections Met/Not Met Not Met Met Met Met Met Met Met No. Standard Requirements 1 12 RECOMMENDATIONS A policy written regarding the use of media websites. Action Plan by Provider Comment Not Actioned 17

18 No Requirements/Recommendations from this Inspection ROCA/P/0008B It is a requirement under the conditions of registration that Child Day Care Centres Standards are met. Any additional recommendations are made with regard to recognised principles which underpin good practice and high standards within child day care provision. Therefore the registered person should act upon these recommendations. Requirements Identified During This Inspection Identified below are areas addressed in the main body of the report which indicate non-compliance with the Regulation of Care Act 2013 and the Child Day Care Centres minimum standards. The requirements should be complied with within the given time scales. Standard/ Regulation & Annex A & & Requirements and Timescales Room temperatures must not go below a minimum of 18 c. IMMEDIATE Any portable appliance equipment must be PAT tested on an annual basis. IMMEDIATE Written plans of the deployment of staff and their activities with children must be displayed. IMMEDIATE The risk assessments need to be reviewed and the date recorded. BY 13/04/15 All staff must have a DBS check completed at a minimum of every 3 years. Where possible the staff should sign up for portability. PROCESS TO COMMENCE IMMEDIATELY All staff must have an awareness of, and any relevant training regarding any child s identified medical condition. IMMEDIATE Ensure that the safe guarding policy clearly states who must be contacted about any concerns. IMMEDIATE There must be a written policy regarding access to the service by non- staff members. BY 13/04/15 Staff induction records must be completed. Details of Action taken (or to be taken) by Registered Person 18

19 No ROCA/P/0008B Requirements Identified During This Inspection Identified below are areas addressed in the main body of the report which indicate non-compliance with the Regulation of Care Act 2013 and the Child Day Care Centres minimum standards. The requirements should be complied with within the given time scales. Standard/ Regulation Requirements and Timescales IMMEDIATE Details of Action taken (or to be taken) by Registered Person The staff records need to ensure that all checks had been completed and recorded. This includes; DBS results Health declaration outcome Certificate numbers included IMMEDIATE The children s records must include; Recent photograph of the child Any social, emotional or behavioural needs First language and any other languages used BY 8/05/15 The temperature of the fridge is required to be taken and recorded on a daily basis. IMMEDIATE A written record of all ingredients used in the meals and incorporate the 14 allergens. IMMEDIATE ACTION Staff training in safe guarding children to be renewed at least every 3 years. IMMEDIATE ACTION The daily attendance record to include the arrival and departure times of children. IMMEDIATE Recommendations from this inspection from research or evidence-based practice No. Standard Recommendation and Timescales None Details of Action taken (or to be taken) by Registered Person 19

20 The Registration and Inspection Unit must be provided with confirmation in writing of the intentions of the registered manager/provider as regards the above requirements/recommendations. To facilitate this process please complete and the above sections beside each recommendation/requirement providing details of action taken (or to be taken) by the registered person with timescale for each. Please return the completed requirements/recommendations sections of this report to the Registration and Inspection Unit by 29/05/15. The inspector would like to thank those present for their co-operation with this inspection. If you would like to discuss any of the issues mentioned in this report please do not hesitate to contact the Registration and Inspection Unit. Inspector: Jenny Percival Date: 20/05/15 20

21 Provider s comments/response To: Registration and Inspection, Department of Health and Social Care, 4 th Floor Markwell House, Market Street. Douglas. IM1 2RZ From: Mrs & Mr Welch I/we have read the Annual Inspection report (21 pages in total including this page) for the inspection carried out on 16/03/15 at Beehive Kindergarten. The Provider s comments and response to this report are as follows: I /we confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I/we agree to comply with the requirements/recommendations within the timescales as stated in this report. I am/we are returning the requirements/recommendations sections duly completed with comments. or I/we am/are unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above dates (s) for the following reasons: Any further comments regarding this report Signed Signed Signed Date Date Date Please return this page and those pages with your comments beside each recommendation/requirement. Please use Tahoma and font 11 when completing your action plan before returning. Action plan/provider s response noted and approved by Inspector: Date: Signature/Initial: 21

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