Ronti Care Solutions Ltd

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate.

This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of legal regulation in relation to people’s safe care and treatment, staffing and fit and proper persons employed.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The service lacked a process to review and analyse accidents and incidents. Events were not thoroughly investigated, which prevented the registered manager from identifying root causes or implementing lessons learned to prevent reoccurrence. Because there was no effective way to learn from mistakes, service users with complex needs were left exposed to preventable risks and harm.

While some reviews took place after incidents occurred, this process was inconsistent. These checks did not look closely at how the events happened, and the registered manager did not put robust action plans in place to fix the underlying issues. Furthermore, because these findings were not shared with the wider team, staff missed critical opportunities to improve care and make the service safer.

The service culture did not prioritise safety improvements driven by openness and honesty. For example, staff meeting minutes contained no evidence of shared learning, and incident reviews or safety concerns were entirely excluded from team discussions. Consequently, staff were denied the opportunity to understand what went wrong, creating an environment where systemic errors could reoccur without correction.

The registered manager lacked an effective system to share lessons learned or support staff development following incidents and safety concerns. Staff supervisions were irregular, and annual performance appraisals were omitted or incomplete. Consequently, the service operated without a robust mechanism to drive continuous improvement, directly compromising the safety of service users with complex support needs.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

There was a lack of evidence that care and support were planned or organised alongside service users, their relatives, or local communities to ensure continuity of care. Although the provider delivered care commissioned by the local authority, significant concerns had been raised regarding the overall quality and safety of the service.

People’s needs were not fully understood, care plans were left unreviewed, and staff did not escalate risks as required. For example, while 1 persons’ health diagnosis was noted, the care plan lacked critical information on how the condition directly impacted them and which external professionals were involved. Furthermore, because up-to-date care plans were not maintained, accurate information sharing was compromised. This risk was worsened because copies of current care records were not kept in service users' homes, preventing external professionals from working together safely. A relative shared, “I emailed the agency to ask for a revised care plan, they made me feel like it was a bit of an issue” whilst a person told us, “I’m not aware of any reviews. I joined this agency so long ago.”

Additionally, the registered manager could not explain or clarify the inconsistencies in the number of people supported by the service.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Care plans did not contain suitable or sufficient risk assessments to protect people from abuse, neglect, or preventable harm. The reviewed documentation lacked the detail needed to support individuals safely, completely overlooking known complex needs such as mobility and catheter care. Consequently, daily logs consistently highlighted elevated safety risks and unmet needs without any corresponding mitigation plans or formal oversight.

These documented issues occurred alongside significant managerial oversight. The registered manager stated that no safeguarding concerns, incidents, accidents, or complaints had occurred, leaving the service unable to demonstrate safe event management. However, physical evidence directly contradicted this claim, proving that incidents, including missed care calls, had occurred and placed people at immediate risk of harm. Despite these logged events, the registered manager did not investigate the issues, mitigate future risks, or regularly review safe care practices. This left care staff without safe, consistent written instructions and guidance, increasing the risk of unsafe care and avoidable harm. One relative told us, “On a few occasions there have been no-shows” whilst another shared, “This agency doesn’t have an app or a way to check on their website to see if the staff have turned up, therefore I’m not confident with what’s happening.”

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People’s risks were not consistently identified, assessed, or managed to mitigate the risk of harm. A review of 5 care records revealed the absence of robust, individualised assessments or management plans for specific risks. These unaddressed areas included skin integrity, falls, choking, catheter care and self-neglect, representing a systemic gap in the service's risk management framework.

Individuals identified as being at an increased risk of falls lacked effective management plans for staff to follow. The provider did not produce necessary guidance for safe repositioning or moving and handling operations, leaving care plans outdated and unreflective of current care needs. For example, 1 person explicitly declined to use the specific equipment provided for safe transfers. Despite this, the use of mechanical equipment remained detailed throughout their active care plan, and the registered manager provided no alternative guidance to enable staff to complete transfers safely.

Furthermore, the core care plan sections did not link or integrate primary clinical diagnoses into daily delivery instructions. This fragmented approach meant care staff lacked immediate, clear guidance within the specific care sections required to deliver safe care. Omitting the clear communication of peoples’ health, care, and medical conditions directly exposed people to inappropriate treatment, unmanaged clinical deterioration, and avoidable harm.

This lack of information was particularly evident regarding cognitive support. The only written instruction regarding cognitive impairment and confusion across the reviewed records was a brief directive for staff to "reassure" the person. The registered manager provided no further strategies to address complex behaviour’s, communication barriers, or escalating confusion. This lack of appropriate information increased risks to peoples’ health, safety, and psychological wellbeing, leaving staff to deliver care without essential clinical oversight.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The provider did not establish or maintain environmental and equipment risk assessments to ensure safety where the care was being provided. A review of the service's oversight documentation revealed a total absence of environmental risk assessments designed to identify and mitigate physical hazards within people's own homes. Furthermore, there were no equipment risk assessments in place to ensure that assistive devices and moving and handling tools used during visits were safe, well-maintained, and fit for purpose. This lack of essential safety documentation meant the registered manager could not demonstrate that care was delivered in a safe environment, leaving both service users and staff exposed to unmanaged hazards and equipment-related risks.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The service did not maintain robust recruitment and vetting processes to ensure staff were safe to work with vulnerable individuals. A review of staff recruitment files revealed gaps in mandatory pre-employment checks. Specifically, the provider did not identify unverified professional references, unaddressed employment histories, or missing criminal record checks for oversea employees. Because these critical background checks were not thoroughly completed or validated prior to staff employment, the registered manager could not demonstrate that staff recruitment met essential safety and suitability standards.

Furthermore, staff training and skills validation were not consistently managed to ensure effective care delivery. Most care staff had incomplete mandatory training, leaving staff without current knowledge in safety areas. Crucially, the registered manager did not complete or record practical competency assessments for high-risk tasks, specifically medicines administration and moving and handling. This lack of up-to-date instruction and verified competency meant staff were employed to deliver care without documented proof of their skills, significantly increasing the risk of medication errors, unsafe transfers, and avoidable harm to service users. A relative told us, “Some are skilled, but some need more training” whilst another commented, “I had to go to [relative] at two in the morning recently just to wash [relative] down. I think that sometimes these carers just make my life a little bit more difficult at times” and a person commented, “When they first started using the hoist they got confused, I had to tell them what to do but now they seem to have got the hang of it.”

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Feedback from relatives indicated that staff did not consistently follow safe infection prevention and control practices during home visits. Relatives expressed frustration regarding poor hygiene standards and a lack of attention to basic cleanliness, with 1 relative stating, “I’m getting frustrated with having to clean up after the carers.” Concerns were also raised regarding a lack of care when handling waste, as another relative noted, “Some of these carers are just so lazy that they won’t even put the toilet seat up when they’re emptying out the commode.”

Crucially, witnessed practices demonstrated that staff did not always understand or implement effective cross-contamination barriers. One relative shared a significant safety concern, explaining, “I once noticed that the carer had put on gloves to wash [name], but [care staff] didn’t change the gloves when they went into the kitchen straight after. So, [care staff] was making food and tea with contaminated gloves.” These accounts indicate that staff were not consistently applying safe personal protective equipment (PPE) protocols or maintaining hygienic practices, directly increasing the risk of cross-contamination and infectious spread within people's homes.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

The service did not maintain safe or robust systems for medicines management and administration. A review of the service's documentation during the inspection revealed that management could not evidence any completed competency checks for staff administering medicines. Furthermore, the registered manager was unable to provide an up-to-date medicines policy to guide staff on safe practices. The Medication Administration Record (MAR) sheets provided, lacked basic identifying details, including the names of the service users. The clarity of the records was further compromised by the inclusion of outdated information regarding disused medicines, making the documentation difficult to follow. These combined issues meant the registered manager could not demonstrate that medicines were being handled, tracked, or administered safely and in accordance with prescribed guidance.