Other · Ofsted report
Kidstuff Day Nursery and Bottoms Up Baby Unit
Summary
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- Inspection date verified
4 May 2006
- Inspectorssingle source
Suman Willis
- Postcode verified
WD6 1TH
- Name on report verified
Kidstuff Day Nursery
- URN verified
EY254839
Deep dive
What this report says
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Tone of the report
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Reads more critically than most reports of this type.
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Strengths
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No standout praise found.
Concerns
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- The quality and standards of the care are inadequate - enforcement action. p.2
- The quality and standards of the nursery education are inadequate - special measures. p.2
- Nursery education The quality of nursery education is inadequate. p.5
- The leadership and management of the nursery education is inadequate. p.9
- Children are not always kind and respectful to others. p.6
Next steps
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- At the last inspection the provision were served with a number of enforcement notices and actions. p.9
- The registered person has devised a vetting procedure which ensures that all staff employed to work with children are suitable to do so. p.9
- Staff are booked to attend training in special educational needs and child protection. p.9
- However, children are still not supported in their care learning and play. p.9
- Strategies for managing behaviour is inconsistent and staff fail to intervene appropriately. p.9
- A registration system is not accurately maintained. p.9
- Procedures for carrying out risk assessments and fire drills are not used effectively to minimise risk to children. p.9
- Procedures for obtaining parents permission to administer medication and keep a record of accidents, signed by parents, is inconsistent. p.9
What the report dwells on
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Progress & outcomes9
“They have made limited progress.” p.9Communication & language7
“Staff interact with babies positively by lying with them and talking to them.” p.5
Anatomy of the report
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- Pages
- 11
- Words of findings
- 2,883
- longer than usual (typical 1049)
- Reading level
- Hard
- Flesch 48, typical 45
- Average sentence
- 16 words
- Next steps
- 8
- typical 5
- Hedged sentences
- 19%
- “some”, “not always”, “most”…
Where the words go
Full report text
Kidstuff Day Nursery
Inspection report for early years provision
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Kidstuff Day Nursery
Unique Reference Number EY254839 Inspection date 04 May 2006 Inspector Suman Willis / Hilary Preece
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Kidstuff Day Nursery
Setting Address 299 Shenley Road, Borehamwood, Herts, WD6 1TH
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Kidstuff Day Nursery
Telephone number 0208 953 0077 E-mail seps848471@aol.com Registered person The Borehamwood Nursery Ltd Type of inspection Integrated Type of care Full day care
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Kidstuff Day Nursery
This inspection was carried out under the provisions of Part XA of the Children Act 1989, as inserted by the Care Standards Act 2000
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ABOUT THIS INSPECTION
The purpose of this inspection is to assure government, parents and the public of the quality of childcare and, if applicable, of nursery education. The inspection was carried out under Part XA Children Act 1989 as introduced by the Care Standards Act 2000 and, where nursery education is provided, under Schedule 26 of the School Standards and Framework Act 1998. This report details the main strengths and any areas for improvement identified during the inspection. The judgements included in the report are made in relation to the outcomes for children set out in the Children Act 2004; the National Standards for under 8s day care and childminding; and, where nursery education is provided, the Curriculum guidance for the foundation stage. The report includes information on any complaints about the childcare provision which Ofsted has received since the last inspection or registration or 1 April 2004 whichever is the later.
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The key inspection judgements and what they mean
Outstanding: this aspect of the provision is of exceptionally high quality Good: this aspect of the provision is strong Satisfactory: this aspect of the provision is sound Inadequate: this aspect of the provision is not good enough For more information about early years inspections, please see the booklet Are you ready for your inspection? which is available from Ofsted's website: www.ofsted.gov.uk.
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THE QUALITY AND STANDARDS OF THE CARE AND NURSERY EDUCATION
On the basis of the evidence collected on this inspection:
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THE QUALITY AND STANDARDS OF THE CARE AND NURSERY EDUCATION
The quality and standards of the care are inadequate - enforcement action. The registered person does not meet the National Standards for under 8s day care and childminding.
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THE QUALITY AND STANDARDS OF THE CARE AND NURSERY EDUCATION
The quality and standards of the nursery education are inadequate - special measures.
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WHAT SORT OF SETTING IS IT?
Kidstuff Day Nursery and Bottoms Up Baby Unit opened in May 2003. It operates from a large property situated at the end of Borehamwood High Street. The building has been totally refurbished to a very high standard. The baby unit and toddler rooms are on the ground floor and have baby changing facilities close by. Children aged
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WHAT SORT OF SETTING IS IT?
This inspection was carried out under the provisions of Part XA of the Children Act 1989, as inserted by the Care Standards Act 2000 from 2 years old are cared for on the first floor along side the pre-school room. There is a secure outside play area with direct access to the park next door. The nursery is open throughout the year from 8:00 until 18:00 closing only for statutory Bank Holidays. Extended hours from 7:30am are an option. A maximum of 96 children may attend at any one time. There are currently 67 children aged from 3 months to 4 years on roll. Of these 18 children receive funding for nursery education. Children attend the nursery for various sessions as well as full time. The setting currently supports children with special educational needs and also supports a number of children who speak English as an additional language. The nursery currently employs 17 staff, including the nursery manager and the chef.
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WHAT SORT OF SETTING IS IT?
Some are qualified to NVQ level 3, of which 3 are studying towards a degree in early childhood studies. The nursery manager has a degree gained outside of the UK in early years teaching. Some nursery assistants having attained NVQ level 2.
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Helping children to be healthy
The provision is inadequate. Some children enjoy regular fresh air as they use the small paved outdoor area. Children in the pre-school have some opportunities for outside physical activity but this is not sufficiently planned to promote their physical development. They are able to run about the restricted outside play area and use some small equipment. However, ride-on toys and climbing apparatus are far too small for them and do not provide sufficient challenge for the older child to develop confidence and skills. Children have limited awareness of changes that happen to their bodies when they are active because staff do not explain why they may be out of breath or have a faster heart beat. Babies are taken out for walks maybe once or twice a week, therefore they do not receive regular fresh air. However, babies are developing their physical skills as they use a range of resources that help them to crawl, stand and
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Helping children to be healthy
climb. For example a baby enjoyed playing 'peek-a-boo' as he crawled through a small sturdy plastic tunnel. Therefore, there is an inconsistency throughout the nursery in promoting children's health and physical skills. Children generally stay healthy. All children are encouraged to wash their hands before and after meals, and younger children have their hands wiped with wet wipes. Pre-school children develop some awareness of staying healthy through planned and spontaneous activities. They talk about the importance of showering after swimming to remove the smell of chlorine from their bodies. Younger children walk around with noses un-wiped, and staff are unaware of the importance of maintaining good hygiene practice as they wipe dummies on their trousers and put them back in children's mouths. Therefore, the procedures for keeping children healthy and free from cross infection are inconsistent. Medication and accident records are completed, but not always signed by parents;
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Helping children to be healthy
This inspection was carried out under the provisions of Part XA of the Children Act 1989, as inserted by the Care Standards Act 2000 this compromises children's well-being. Accident and incident records are kept in individual rooms and there are many accidents recorded; however these are not monitored or reviewed in any way. Staff are unfamiliar with the differences between accidents and incidents, therefore they are unable to prevent or address any issues. Children are generally well nourished and have their dietary needs met. They are offered a balanced diet of meals and snacks that are cooked on the premises. Children are observed eating broccoli cheese, followed by peaches and cream. However, their understanding of the importance of eating a healthy diet is not promoted because staff do not reinforce the benefits of healthy foods during meal times. Children are offered a variety of biscuits during morning snack and they are
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Helping children to be healthy
not limited to the amount they could have. Younger children struggle as they eat peaches and cream and some children leave the table and wonder around covered in food without staff noticing. Consequently meal times are not treated as sociable occasions and there is not consistency in promoting healthy eating. Some children rest and sleep according to their individual needs, whilst other rooms organise a set sleep time after lunch. Children climb over bedding with outdoor shoes on while staff continue to prepare beds, therefore, outdoor grime is brought onto the beds that children are sleeping in.
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Protecting children from harm or neglect and helping them stay safe
The provision is inadequate. Children are generally kept secure. Visitors must ring a bell to enter the building and are requested to sign in and out of the premises. However, parents were observed letting in visitors without questioning, and staff were unaware. Therefore, security procedures are not explained to parents and staff are inconsistent in maintaining security to protect children. Within the nursery some children are able to leave rooms unsupervised by pushing open heavy doors and there have been many accidents reported of trapped fingers. Older children do receive some reinforcement of safety rules such as walking inside and lining up to go outside. However, staff are not consistent at promoting such rules. Children queue for lengthy periods and get bored, so they start pushing other children, hence there are a lot of accidents of bumped heads. Staff have introduced risk assessment procedures for carrying out checks both inside
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Protecting children from harm or neglect and helping them stay safe
and outside. However, staff are not consistent in carrying out these checks regularly and do not use their observational skills to minimise risks. Therefore, children's safety is compromised and the setting does not take effective steps to ensure that staff have a clear understanding of safety issues such as keeping floors uncluttered, so that toddlers can move around safely without tripping over. An emergency evacuation procedure has been drawn up; however, risks that have been identified, such as slippery stairs, have not been addressed. Consequently, children's safety is further at risk. Resources are not well maintained and do not offer challenge. In one room they are grubby and unimaginative, for example a play microwave is scribbled on and lies
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Protecting children from harm or neglect and helping them stay safe
This inspection was carried out under the provisions of Part XA of the Children Act 1989, as inserted by the Care Standards Act 2000 unused on top of a unit. Children are bored and play with chairs pulling them across the room, thus resources are compromising children's safety and do not support children's play. Children are generally protected by staff who are developing their knowledge of child protection issues. A written policy and procedure has been drawn up, however staff are unfamiliar with these. Subsequently children are not always protected because staff lack an understanding of how to record concerns such as pre-existing injuries. Therefore they are unable to monitor children's safety, and are putting themselves at risk of allegations of abuse.
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Helping children achieve well and enjoy what they do
The provision is inadequate. Children's individual needs are not met and their welfare is not promoted. Activities and play opportunities do not always help to develop children's emotional, physical, social and intellectual capabilities. Children in some rooms walk around aimlessly and are not engaged in activities. Poor organisation in rooms disregard children's needs as staff focus on their own groups and are not observant of all children, hence children are bored and display negative behaviour such as pushing, kicking and biting. In the baby room, resources are available to encourage children at their stage of development, for example soft toys and treasure baskets in the middle of the room. Staff interact with babies positively by lying with them and talking to them. In the 2-3 year old room some children are encouraged to join in and staff extend children's play as they construct train tracks. However this is inconsistent as some children are
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Helping children achieve well and enjoy what they do
bored quickly and charge around the room, and staff are not able to sustain their interest. Group times for this age group are often lengthy and children find it difficult to sit still. They also spend a long time waiting, for example at snack time or lining up to go out, therefore staff are inconsistent in their understanding of children's level of development. Staff in the 2-3 year old room have implemented planning and assessment, however resources are not appropriately used to promote areas of learning. For example teaching colours by mixing yellow colouring to water in a red trough, making, the water appear orange, so children lost interest very quickly and the learning intention was lost. Nursery education The quality of nursery education is inadequate. Children are making some progress in the six areas of learning but this is hindered by staff’s insecure knowledge and understanding of the principles of the Foundation Stage. Furthermore, the Registered
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Helping children achieve well and enjoy what they do
Person does not monitor the curriculum or provide the support that the staff need in order to develop their practice. Planning for activities has been developed to cover most aspects of the six areas of learning, and this now includes targets to help individual children progress. However,
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Helping children achieve well and enjoy what they do
This inspection was carried out under the provisions of Part XA of the Children Act 1989, as inserted by the Care Standards Act 2000 consideration is not given to planning the environment in order to promote children’s development and stimulate their interest. For example, there is no ‘writing area’ for children to practice their emergent writing, or opportunities for them to write during their play. Consideration is not given to planning the outdoor area as a learning environment, thus restricting children’s ability to explore and investigate and develop their physical skills. Children do not freely select and explore resources, therefore their independence is not promoted. Activities and resources are pre-selected by staff; these are often repetitive as resources are limited, hence children get bored. There is a system to assess children’s progress which is currently being reviewed. Presently, this is not effective as the assessments do not link to the early learning
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Helping children achieve well and enjoy what they do
goals for the Foundation Stage, meaning children’s achievements and progress are difficult to monitor. Some children engage in purposeful play and activities, especially when staff are there to support them. Their attitudes to learning are positive and they show an interest in what they do. They enjoy having pretend picnics and tea parties, or exploring the texture of paint on their fingers and hands. However, if staff are busy with their groups some children wander about without any focus, and behaviour deteriorates. This is common at tidy-up time when staff supervise those children who are keen to help, allowing others to run about and be disruptive. Children are not always kind and respectful to others. They still find it difficult to share and there are many incidents of children hurting each other which detract from their learning and enjoyment. Some children are confident communicators. They listen to stories and instructions
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Helping children achieve well and enjoy what they do
and join in with rhymes. They use language to express their thoughts, for example, a child explains she likes oranges because they are ‘squeezy’. Children are familiar with letters of the alphabet but do not have opportunities to hear the sounds these letters make. Staff are not aware of how to introduce activities, songs and rhymes to help children hear sounds and words. This prohibits children's early reading skills. Children use mathematical language in their play. They make ‘rectangular’ shaped gates out of Lego bricks and identify that cress seeds are small and beans are bigger. Children use numbers to count and recognise number symbols on flash cards. There are few opportunities to consolidate this learning and do simple calculations through practical activities, such as counting out cups at snack time. Children do not routinely use mathematical resources such as scales, sorting items and tape measures. Mathematical language such as bigger, smaller is also not used
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Helping children achieve well and enjoy what they do
by staff as they sit with a group of children building with bricks. Therefore, children's ability to learn mathematical language, concepts of quantity and simple calculations is limited. Children have some experience of creative media but this is often directed by adults. They use paint, dough and water play if it is set out for them but they cannot select their own creative resources. They use their imagination to act out familiar situations, such as role play in the home corner, but often need support to make this constructive. Children enjoy singing nursery rhymes, songs using musical instruments. Consequently children's ability to be creative and explore different materials is not promoted.
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Helping children achieve well and enjoy what they do
This inspection was carried out under the provisions of Part XA of the Children Act 1989, as inserted by the Care Standards Act 2000 Children learn about the living world. Some children are absorbed by a planting activity. They explore with interest the compost and water needed to grow cress seeds and compare them to previously planted beans. Children have few opportunities to investigate how things work because resources are limited or broken. Not all children are able to use technology effectively because the computer in the pre-school room still does not work. Some children are challenged through conversation about how a lava lamp works, and others explore the sound a toy drill makes when pressing the buttons.
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Helping children make a positive contribution
The provision is inadequate. Children learn about their community during walks within the local area and when they visit the park. They learn about the wider world through organised and planned topics and activities including festivals from around the world. An equal opportunity policy is now available for all staff and parents. However, staff are concerned that this is not implemented and some staff do not feel valued or respected. Therefore, children are cared for by some staff who feel undervalued and dis-respected, hence staff struggle to promote positive attitudes. Some children have been identified to have specific needs and there is a designated special needs co-ordinator in place, however she has not yet completed her training. Formal records for identifying specific needs are not maintained and staff are inconsistent in their recording of information to meet the needs of each individual children.
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Helping children make a positive contribution
Some positive steps have been taken to introduce more appropriate methods of managing behaviour in the pre-school in the form of workshops for staff. Some children are responding well to these methods. Unfortunately, training has not been offered to other staff and so behaviour remains a problem in other areas of the nursery. Children are not learning to manage their behaviour appropriately because they do not receive consistent support from staff. Some older children do have explained to them that its not nice to push their friend or snatch toys. However, children portray negative behaviour such as hitting and throwing toys, which are not observed by staff, hence they do not understand responsible behaviour and are not able to manage their own behaviour appropriately. Although staff in the pre-school room have covered training in behaviour management, they are still inconsistent in their approach. For example a member of staff pulled a child off a table without giving any
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Helping children make a positive contribution
explanations of why. Another staff member was heard shouting in a commanding manner at a child. Children as young as one year are observed hitting and pushing other children with no intervention from staff. Information about the children's day is shared with parents who receive details of food intake, nappy changes and sleep. A communication book has also been introduced, however this is not used consistently as staff feel that parents are not interested. Parents copies of the policies and procedures are left out in the reception area but the parents pack does not include any information about policies and
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Helping children make a positive contribution
This inspection was carried out under the provisions of Part XA of the Children Act 1989, as inserted by the Care Standards Act 2000 procedures. Parents can access the Ofsted inspection report from the internet, this is sometimes difficult as not all parents have access to the internet. Therefore, the nursery does not promote a positive partnership relationship. Staff are not supported by the proprietors in developing strong relationships as their decisions are often over-ridden as parents contact proprietors directly and make deals around childcare arrangements. Consequently staff feel undervalued and unsupported by the provision which impacts on the care they provide for the children. The partnership with parents of children who receive nursery education is inadequate. Parents receive brief information on the six areas of learning. However this is still not included in the parents information pack and parents of younger
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Helping children make a positive contribution
children are not made aware of what nursery education is. Parents get an overview of their children’s learning and experiences through well-presented notice boards displaying photos and information on topics. A home diary has been introduced to develop the sharing of information but staff say most parents prefer to discuss issues verbally each day. Parents do not have specific opportunities to be informed of their children’s progress but staff make themselves available to parents whenever required. Therefore, parents cannot fully participate in their children's learning. Children from a range of ethnic groups attend the setting and staff plan some activities to reflect a range of cultures and beliefs. However, there are few resources that promote diversity and help children identify features of themselves or their family life. Children are not developing a knowledge of right and wrong, and resources are
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Helping children make a positive contribution
not used appropriately to promote all areas of learning. Therefore, the provision does not foster children’s spiritual, moral, social and cultural development.
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Organisation
The organisation is inadequate. Overall the nursery is poorly organised and managed. Staff are still unaware of their roles and responsibilities. A general list of responsibilities for all nursery staff is displayed in each room. However there is no differentiation between nursery assistants, nursery nurses, room leaders and manager. Most staff do not have a contract of employment or a letter of acceptance. All arrangements are verbally agreed between new staff and the registered person. Although the overarching summary for each standard is now displayed in all rooms, staff are not familiar with the National Standards and the outcomes that Ofsted inspect against. Some staff are knowledgeable and experienced and are trying to establish a secure staff team. However, staff do not receive the necessary support such as supervision, monitoring and training. Staff are not appropriately deployed to ensure children's safety, welfare and
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Organisation
development. They are unable to observe children while carrying out small group activities, therefore children behave in a negative manner by running around and not engaging in activities. Children's safety is also put at risk as staff do not observe children wandering through into different rooms. Staff lack support from the registered person of keeping children safe, as they highlight areas of risk which are not addressed. Although staff ratios are maintained, staff turnover is very high,
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Organisation
This inspection was carried out under the provisions of Part XA of the Children Act 1989, as inserted by the Care Standards Act 2000 consequently it is becoming difficult for the nursery to continue to maintain adequate staff ratios. Therefore procedures to safeguard all the children are not in place. Poor organisation of time and routine impacts on children's care learning and play. Inappropriate lengths of time is spent in queues and during group time, hence children are bored. Resources and activities are inappropriately organised such as setting up a soft play obstacle course close to the construction area, hence disrupting both groups of children. Subsequently children's care learning and play is not promoted. The registered person has implemented all the required policies and procedures. However, staff are unfamiliar with the new policies and therefore, do not always implement the procedures accordingly. A system for recording children, staff and
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Organisation
visitors is now in place, although, this is not used consistently by all members of staff. There is an inconsistency of obtaining parents signature for medication administered. Therefore policies and procedures do not safeguard children effectively. The leadership and management of the nursery education is inadequate. Staff in the pre-school are trying hard to develop the curriculum and address weak areas. Some positive steps have been made since the last inspection but progress is hindered by the Registered Person’s lack of understanding of what is required. He is, therefore, unable to lead or support the manager and staff in order for them to make significant improvements to children’s learning and achievements. The provision does not meet the needs of all the children who attend.
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Improvements since the last inspection
At the last inspection the provision were served with a number of enforcement notices and actions. They have made limited progress. The registered person has devised a vetting procedure which ensures that all staff employed to work with children are suitable to do so. Staff are booked to attend training in special educational needs and child protection. However, children are still not supported in their care learning and play. Strategies for managing behaviour is inconsistent and staff fail to intervene appropriately. A registration system is not accurately maintained. Procedures for carrying out risk assessments and fire drills are not used effectively to minimise risk to children. Procedures for obtaining parents permission to administer medication and keep a record of accidents, signed by parents, is inconsistent. Equal opportunities policy is not understood by all staff. The complaints procedure is not fully understood, hence not appropriately implemented. Therefore,
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Improvements since the last inspection
the provision have been issued with further enforcement notices and actions.
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Complaints since the last inspection
Ofsted has received 6 complaints since the last inspection relating to the National Standards. A complaint was made to Ofsted in September 2004. Concerns were raised about
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Complaints since the last inspection
This inspection was carried out under the provisions of Part XA of the Children Act 1989, as inserted by the Care Standards Act 2000 staffing ratios and the impact on children's safety, and unvetted staff. There were also safety concerns around children's access to the stairs. Ofsted have investigated the complaint raised by conducting a visit to the provision. The provider was given 4 actions under National Standards 1:Suitability, 2:Organisation, 8:Food and drink & 12:Partnership with parents. Three recommendations were given under National Standards 6:Safety & 14:Documentation. Three further complaints were made to Ofsted in June and July 2005. Concerns were raised about staffing ratios and the appropriateness of activities provided at the provision. These concerns relate to National Standards 1:Suitability, 2:Organisation, 4:Physical Environment, 5:Equipment, 6:Safety, 8:Food & Drink, 11:Behaviour,
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Complaints since the last inspection
12:Working in partnership with parents & carers and standard 14:Documentation. Ofsted made an unannounced visit to the provision on 4th July 2005 and as a result set 5 actions. There were 4 under standard 2; to ensure that there is a named deputy on the premises at all times able to take charge in the absence of a manager, to ensure that ratios are maintained at all times, to ensure that there is an accurate system for recording children's times of arrival and departure on a daily basis and to provide an action plan which shows how staff are able to be clear about their roles, responsibilities and lines of communication within the nursery. Also 1 under standard 6; to ensure that the side areas outside are secure and clear of obstructions. A further 2 complaints were made to Ofsted in February 2006. Concerns related to Standard 11:Behaviour, and the management of this in the provision. Ofsted investigated these complaints on the 9 February 2006 during an inspection. The
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Complaints since the last inspection
following National Standards were investigated: National Standard 1:Suitable person, 2:Organisation, 3:Care, learning and play, 11:Behaviour management, 12:Working in partnership with parents and carers and 13:Child protection. Ofsted found that the provider was not meeting all of the National Standards; therefore a compliance letter has been issued for National Standard 1 and 3, with 4 actions to be completed in order to meet these standards. A further compliance notice has been issued under National Standard 11, with 7 actions to be completed in order to meet the standard. In addition to the compliance notices that were served, further actions were taken under the National Standards for the provider to meet, in order for the National Standards to be complied with. These were detailed in the inspection report that was published on the internet. Ofsted monitored the provisions progress to ensure that
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Complaints since the last inspection
these actions and compliances were met. The provision remains suitable for registration. The provider is required to keep a record of complaints made by parents, which they can see on request. The complaints record may contain complaints other than those made to Ofsted.
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THE QUALITY AND STANDARDS OF THE CARE AND NURSERY EDUCATION
On the basis of the evidence collected on this inspection:
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THE QUALITY AND STANDARDS OF THE CARE AND NURSERY EDUCATION
This inspection was carried out under the provisions of Part XA of the Children Act 1989, as inserted by the Care Standards Act 2000 The quality and standards of the care are inadequate - enforcement action. The registered person does not meet the National Standards for under 8s day care and childminding.
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THE QUALITY AND STANDARDS OF THE CARE AND NURSERY EDUCATION
The quality and standards of the nursery education are inadequate - special measures.
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The quality and standards of the care
Ofsted is taking enforcement action to safeguard the welfare of children.
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The quality and standards of the nursery education
The setting requires special measures to improve the provision for nursery education. The following urgent action is required: • ensure that planning allows children to make progress towards all the early learning goals for each area of learning, and monitor the effectiveness of the curriculum • plan the indoor and outdoor environment to provide stimulating resources and play opportunities that allow children to explore, experiment, plan and make decisions for themselves • develop children's early writing and reading skills through seeing adults writing for different purposes, experimenting with mark-making and linking sounds to letters • promote children's physical skills through planning opportunities that develop their confidence in movement and ensure equipment is sufficiently challenging The Department for Education and Skills and the local authority have been informed.
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The quality and standards of the nursery education
procedures set out in the leaflet Building better childcare: Compliments and concerns about inspectors' judgements which is available from Ofsted's website: www.ofsted.gov.uk
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The quality and standards of the nursery education
This inspection was carried out under the provisions of Part XA of the Children Act 1989, as inserted by the Care Standards Act 2000
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