Ronti Care Solutions Ltd

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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

This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to good governance.

This service scored 25 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Management practices demonstrated a critical lack of candour, evidenced by incomplete and unreliable data sharing with the inspectors. Oversight was severely hindered by a failure to present documentation requested during the inspection window. Key omissions that undermined regulatory confidence included clinical safety guidelines, internal performance reviews, and environmental risk assessments.

There was an evident lack of engagement regarding organisational culture and core values. Although regular staff meetings were conducted, reviewed documentation indicated that these sessions primarily served as an outlet for staff complaints, with a notable absence of management response or resolution. Concerns raised by care staff remained unaddressed without follow-up updates. Additionally, the provider failed to demonstrate that regular support or supervision sessions were utilised to share and reinforce the vision of the service with the workforce.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

There was a lack of transparency regarding external assessments used to check that home care packages were safe and appropriate for service users. Furthermore, the registered manager did not resolve the systemic compliance issues raised by external commissioners in January 2026. Because these issues were left unaddressed, external commissioners placed restrictions on the service.

The provider did not show that they understood the legal requirements of running a registered domiciliary care agency. They omitted essential updates to the CQC when required, which directly impacted the safety and governance of the service. This lack of awareness resulted in weak oversight from the registered manager and meant that internal audits of care logs and staff performance were ineffective. As a result, there was not enough evidence available during the inspection to prove the service was following regulatory standards.

Staff and service users did not feel they could speak up and that their voice would be heard. There was a clear lack of confidence that the registered manager would listen to or support care staff, meaning leadership did not establish a culture where staff felt comfortable actively raising concerns about care quality or working conditions. Instead of encouraging an open-door policy, the registered managers approach created an environment where staff felt hesitant to share feedback, meaning information regarding the daily running of the service was often withheld.

This lack of an open and safe culture was directly supported by feedback from the care team. Care staff shared comments such as, “Leadership attributes blame and imposes penalties rather than offering support for improvement” and “The negative impact of whistleblowing, leads to staff members suspecting one another.” These disclosures demonstrated that the registered manager did not build a culture where workers felt safe to speak out without fear of blame. Instead, this approach fostered suspicion and distrust among the team, which significantly reduced the likelihood of care staff reporting poor practice or safety risks.

Similarly, feedback from people using the service highlighted communication barriers and a lack of clarity regarding their rights. People shared comments such as, “I’m not sure of the complaints procedure” and “Whenever I need to speak to the office I can never get through, I can’t leave a message because their inbox is full.” These accounts showed that the service’s communication and phone systems were ineffective and poorly managed. Because people could not reliably contact the office or log an official complaint, the registered manager lacked a proper way to receive vital feedback. This directly increased the risk of home care issues or safety concerns going unresolved.

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The service lacked structured systems, policies, or processes to actively support, develop, and sustain an inclusive workforce. There was no evidence of established systems designed to promote equality of opportunity, embrace diversity, or ensure an inclusive workplace culture for all team members. This absence of formal equality and diversity initiatives meant the provider could not demonstrate a commitment to building a supportive environment that values different backgrounds and perspectives. Without these workforce structures, the service was unable to cultivate an inclusive organisational culture that reflected the diverse needs of the people using the service.

This deficit in workforce development is further compounded by a widespread lack of professional support, training, and development across the team. Mandatory training for both the management team and the care staff fell significantly short of required standards, leaving essential modules incomplete across the workforce. Furthermore, care staff did not receive the routine supervision or annual appraisals necessary to track professional performance, identify development needs, or ensure ongoing competency. The lack of active initiatives to promote staff wellbeing or recognise staff achievements further weakened workforce stability, leaving an under-equipped and unsupported team to deliver daily care.

Once staff member shared, “Within the company, it seems to be a matter of when you are needed, rather than how valuable you are” whilst another told us, “If the environment were truly positive, there would likely be opportunities for promotions. It appears there have been no promotions.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Deficiencies in internal quality assurance and risk management frameworks resulted in an ineffective governance structure that placed service users at increased avoidable risk. The providers internal auditing systems did not identify widespread operational concerns, undermining data quality and reducing CQC’s ability to rely on the information provided. This breakdown in oversight was further evidenced by the registered manager submitting inaccurate governance documents, including an incorrect 6-month quality report. Critically, the registered manager did not notify CQC of serious safeguarding issues, ongoing safety risks, and subsequent intervention measures already initiated by the local authority, resulting in a clear breach of regulatory requirements.

Weaknesses in quality monitoring mean that auditing tools consistently missed missing risk assessments, overdue care reviews, or generic, non-person-centred care plans. Because the registered manager did not routinely analyse daily care logs, clinical needs assessments, or safety incidents, the service could not identify recurring trends or take proactive steps to reduce practices that compromised safety. This lack of formal risk mitigation left care staff operating without essential guidance required to support people safely. Consequently, there was an absence of clear, vital instructions on how to manage high-risk physical and cognitive requirements, including people’s mobility needs, continence care, tissue viability, and specific cognitive support.

Ultimately, the absence of reliable records, robust quality monitoring, and assured recruitment practices meant the registered manager could not demonstrate that care was safe or aligned with assessed needs. Existing governance processes were not utilised to identify or correct these weaknesses. The service could not effectively drive continuous improvement. The combination of unmitigated clinical risks, training deficits, and inaccurate regulatory reporting created an unstable operating environment, directly compromising daily service delivery and the overall safety, quality, and long-term sustainability of the service.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

Despite clear expectations and ongoing guidance from the commissioning authority, the necessary steps to meet agreed improvement actions were not taken. This absence of proactive engagement and clear communication meant that known operational risks were not addressed in a coordinated or timely manner. Consequently, this detached approach led to persistent shortfalls across areas of service quality, safety, and overall governance, leaving existing system issues unresolved.

During our inspection, we found that the service did not routinely share information, solve problems jointly, or learn from external health and social care partners. Because the registered manager operated in isolation from the wider professional network, they missed out on community expertise, feedback, and industry learning. This lack of collaboration blocked service development and prevented the delivery of joined-up care, limiting the provider's ability to meet the changing needs of people they support.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The registered manager did not demonstrate an adequate understanding of continuous learning or how to implement sustainable improvements across the service. The overall governance and quality oversight frameworks were poorly managed, which meant that identified operational concerns and service shortfalls were not effectively addressed, resolved, or used to inform future practice. This reactive approach prevented the registered manager from establishing a culture of accountability and safeguarding against risk.

Furthermore, there were no processes in place for measuring, evaluating, or auditing outcomes and their direct impact on the people using the service. The lack of structured feedback and performance indicators meant the registered manager could not objectively assess whether the care provided was achieving positive results. Without these essential evaluation tools, the service operated without a clear benchmark for success, directly hindering its ability to drive meaningful development, learn from past mistakes, or guarantee safer outcomes.