Bedford Road

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.

This is the first assessment for this newly registered service. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 61 (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 had a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. However, following the change of provider, there were some inconsistencies in how the provider communicated and embedded its vision and values. Some relatives told us communication had been poor, indicating that the provider needed to strengthen its engagement with people and their communities.

Overall, people experienced good, person-centred care from a team of committed, experienced and established staff. Feedback from relatives confirmed this. However, some relatives were concerned about the provider’s lack of engagement and slow communication, resulting in frustration and uncertainty. This indicated that the provider needed to do more to communicate its vision and strategy and promote trust and understanding among people using the service and their relatives.

Following the assessment, the provider informed us that it had taken steps to improve communication and engagement with relatives. We will check this at the next assessment.

The provider had capable, compassionate and inclusive leadership. However, although a registered manager was in post with formal responsibility for managing the service, the provider did not ensure the registered manager had adequate oversight of the service. The registered manager was based at another service and had limited involvement in the management of Bedford Road. This meant there was limited effective management of the service as the registered manager could not fulfill all their roles and regulatory responsibilities around being accountable for the quality and safety of the service.

However, a new manager was in the process of registering and was supported by the deputy manager and regional manager. This provided some mitigation, as there were clearer management arrangements to support the day-to-day running of the service. However, this required to be further embedded within the service to ensure effective day to day management of the service was maintained. Relatives and staff spoke positively about the deputy manager, whose longstanding presence provided stability and reassurance during multiple organisational changes.

The provider fostered a positive culture where staff felt they could speak up and their voice would be heard.There were different channels, including one-to-one discussions with line managers, team meetings and informal conversations, where staff could raise concerns and share their views. A staff member told us, “I always speak if I see something that's not right. The good thing is they listen to me as well.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The management team spoke to us about the resources the organisation made available to staff, including access to wellbeing champions and an open-door policy. Staff reported fair treatment, flexibility and suitable opportunities to discuss their personal circumstances. A staff member told us, “Our [new] manager is definitely flexible for us.”

The provider had governance arrangements in place, but these were not yet fully embedded or consistently effective. Quality assurance processes did not always identify concerns, including some environmental, infection prevention and control, and record-keeping issues found during our assessment. The management team was aware of some shortfalls and was taking action to address them, but further work was needed to ensure governance systems consistently identified and addressed risks and areas for improvement.

The provider Certitude Limited Trading took over the responsibility for the service in December 2025 following a short transition with limited handover from the previous provider. Existing staff adapted to the changes and provided continuity and stability for people, while the new provider assessed the service, identified issues and began improvement works. Following the transition, the provider established management support arrangements for the deputy manager to oversee day-to-day operations and monitor progress against improvement actions.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Records showed the service worked with health and social care professionals to ensure people received appropriate care and support. Staff maintained regular contact with people’s relatives and representatives. This ongoing communication supported the service to respond to people’s individual needs effectively and in a timely manner.

While the provider demonstrated a commitment to learning and improvement, it was too early to say if their improvement and development plan for the service will be embedded and sustained over time and if continuous learning will be an ongoing feature of the service.

Following the change in provider, the new provider carried out a full audit of the service, identifying several areas for improvement and related actions. They developed a comprehensive action plan to monitor progress and drive improvements across the service. While some actions had been completed, others remained in progress. However, our assessment identified several areas where improvement was still needed, which the action plan recorded as completed. For example, environmental risk assessments and reviews of people’s care records were recorded as complete, although we found concerns in these areas. This showed that, while some improvements had been made since the last inspection and following the change in provider, further work was needed to ensure improvements were fully embedded and accurately monitored.