D-Restricted Ltd

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this key question under its current registration. However, the key question was previously rated under a different registration as good. We assessed all 6 quality statements for this key question, and it has been rated as good.

This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

The registered manager made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. The service planned and delivered people’s care and treatment with them. They worked well across teams and services to support people. Caregivers were empowered to manage their health and wellbeing. Care and treatment was monitored and outcomes were consistently positive. The service explained to people what their rights around consent were, making sure they fully understood them.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

We scored the service as 3. The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Up‑to‑date clinical guidance, specialist training, observational and listening skills were used to carry out a personalised, holistic and comprehensive tongue tie assessment. The service had a current tongue tie policy which reflected guidance and used wider training in infant feeding and lactation to strengthen the quality of the assessment.

Assessments were holistic, thorough and personalised, ensuring care reflected each infant’s feeding needs, health and birth history, and family circumstances. Prior to the first appointment, caregivers completed an online pre‑assessment covering medical, surgical, pregnancy, birth and feeding histories. Any identified risks or complications were proactively followed up by the RM before the face‑to‑face assessment; all 14 records reviewed showed this was consistently completed. At the initial appointment, the RM reviewed the pre‑assessment, explored health concerns, carried out an intra‑oral examination and observed feeding before and after the procedure. A nationally recognised assessment tool was used. The Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) was used to assess tongue‑tie severity and exclude other causes of feeding difficulties. This information informed an individualised care plan. Caregivers consistently reported feeling listened to, understood and confident in the assessment process.

We observed 2 assessments and found they were comprehensive and personalised to the infant and caregiver’s needs. They were carried out in line with best practice and the providers tongue tie and associated policies. The RM took time to assess feeding ability and examine tongue anatomy. Caregivers were supported to talk openly about their experiences, allowing the RM to develop a clear and accurate understanding of the infant’s needs and the caregiver’s priorities. They explored factors such as birth history, weight trends, maternal comfort, feeding frequency, latch quality and any wider health or emotional considerations that could influence feeding challenges.

We reviewed 14 records, all of which were fully completed in line with policy and best practice. Each record included the documented use of evidence‑based assessment tools and a HATLFF score to confirm the presence, type, and severity of the tongue tie. Details of the procedure, along with post‑procedure assessments of feeding ability and maternal pain, were documented and pictures were also retained in records.

Assessments included input from partner organisations when there was a clinical need. The RM also gathered information from other services when the assessment identified additional needs, health concerns, or risks. For example, from health visitors and midwives to support infant feeding and weight gain.

Tongue function, feeding ability and caregiver reported pain were reassessed after the frenulotomy. Caregivers were given time to feed their infant so the effectiveness of the procedure could be observed. We saw the RM check feeding and tongue function post‑procedure and take photographs to demonstrate and document the outcome.

The assessment considered both the infant’s needs and those of the primary caregiver to ensure safe and effective management during and after the procedure. Caregivers were fully included in identifying any unmet needs or support required to feed their infant post‑division. Feeding was assessed through observation, using an evidence‑based tool. The RM provided tailored advice on positioning and technique to support infant feeding and caregiver comfort. The assessment also considered the caregiver’s physical, emotional and mental wellbeing. For breastfeeding caregivers, pain levels were assessed using a maternal pain score before and throughout feeding, and reassessed post‑procedure to determine improvement. This enabled the RM to tailor support, offer reassurance and signpost to additional services where needed.

The RM used a collaborative approach alongside to work alongside caregivers to assess their needs. Following assessment, they discussed the findings in a clear and balanced way. This ensured caregivers had the information they needed to make fully informed choices about next steps.

Care needs were routinely reviewed, and ongoing care was personalised and holistic. The RM provided a 6‑week follow‑up package that included regular check‑ins, tailored advice and access to a dedicated tongue tie support group. All caregivers we spoke with praised the high level of follow‑up support and the RM’s consistent, personalised guidance.

We scored the service as 3. The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Infants and caregivers received care, treatment, and support that was evidence-based and in line with good practice standards. Clinical guidelines and pathways were based on national recommendations, including National Institute for Health and Care Excellence (NICE) guidance on the division of ankyloglossia (2005). The tongue tie and bleeding management policy was based on the clinical advice produced by the Association of Tongue Tie Practitioners (ATP).

Policies were subject to regular review to ensure they reflected current guidance and emerging best practice. The RM had established processes to check compliance with tongue‑tie and frenulotomy guidelines.

Caregivers were informed about good practice relevant to their care and were involved in decisions about treatment. We observed the RM clearly explaining tongue anatomy, feeding techniques and the frenulotomy procedure, including accurate information about risks to support informed decision‑making. Best practice guidance was used to explain how to optimise tongue function and support wound healing, and caregivers were provided with personalised information leaflets.

Nutrition and hydration needs were met in line with current guidance. A full feeding assessment was completed before deciding on a frenulotomy, including review of feeding history, feeding methods and positioning. Guidance was given to improve feeding post frenulotomy procedure.

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

The service had access to all the information needed to assess, plan and deliver safe care. Caregivers were asked to bring the personal child health record (PCHR), also known as the ‘red book’ to the appointment. This provided key background details and updates from other professionals to ensure a joined-up approach to assessment and care planning was taken. The online pre‑assessment questionnaire also captured key information from a multidisciplinary perspective. With consent from caregivers’ key information from the PCHR was saved in the patient record. This helped the RM complete the assessment and provide ongoing care.

The RM documented the tongue tie assessment and frenulotomy outcome in the infant’s PCHR so other professionals had up‑to‑date information about this. A letter was sent to the infant’s GP detailing the outcome of the assessment, procedure and any required follow‑up that was required. Of the 14 records we reviewed, all showed that the PCHR had been updated and the GP notified. This meant the caregivers did not need to explain the outcome to other professionals as they had already been fully updated by the RM.

The RM worked closely with other services to coordinate care and improve outcomes. The service had established links with midwives, health visitors, general practitioners and independent complementary therapists to support holistic care for infants and caregivers. Clear referral pathways were in place for specialist services. We reviewed multiple examples where the RM identified concerns, took immediate action and made timely referrals. This included researching specialist services where required to make a direct referral. As part of our assessment, we spoke to key stakeholders who provided positive feedback about multi-disciplinary working.

Pathways were available to refer infants and caregivers to NHS and independent providers, including general practitioners, paediatricians, health visitors, midwives and specialists in infant feeding and for therapies such as cranial massage and osteopathy.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

Caregivers were supported and empowered to manage their own health, care and wellbeing because the RM understood their individual needs and preferences. During appointments, caregivers received clear, personalised, guidance and encouragement to improve feeding techniques post frenulotomy and were invited to a weekly peer support group with other caregivers who had similar experiences. Caregivers told us they felt encouraged, emotionally supported and well guided both during and after the appointment.

The service focused on early identification of risks and preventing deterioration. For example, caregivers were given advice on improving their infants tongue motility to avoid the likelihood of complications and improve feeding outcomes. Caregivers could also access guidance and exercises to support healing through the providers online portal.

Where wider needs were identified, the RM signposted caregivers to other relevant services, to ensure infants and families received the right support.

Caregivers were involved in ongoing review and monitoring of their infant’s health and feeding ability post frenulotomy. A self-assessment tool enabled caregivers to reassess their infant post procedure, with the RM using this information to tailor ongoing advice and referral where needed. The RM regularly checked feeding progress, healing and any concerns raised.

We scored the service as 4. The evidence showed an exceptional standard. The service monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of people themselves.

The service had effective systems to monitor outcomes and benchmark performance.

Performance was effectively monitored, evaluated and benchmarked against national performance. An electronic case management system enabled the RM to track monthly outcomes, including assessments and procedures carried out, complications, re divisions, infection rates, maternal pain scores and feeding ability. Key risk indicators were measured and submitted to the ATP, allowing performance to be compared nationally.

Data provided by the service showed consistently positive outcomes for infants and caregivers in relation to both risk and quality indicators measured. For example, outcome data showed the service performed better than national averages in relation to redivision rates, excessive bleeds and surgical site infections. In 2025, the service re‑division rate was 1.18%, compared with the national ATP rate of 2%. No excessive bleeds, complications or surgical site infections were reported in the 12 months before our assessment, compared with a national complication rate of 0.18%. This reflected the RM approach in providing preventive advice and guidance around risk to reduce post procedure complications.

Quality indicators were assessed and monitored demonstrating if frenulotomy had a significant impact on long term outcomes for the infant and caregiver. Pain and feeding tools were used to assess effectiveness. They were completed before and immediately after the procedure, and then 6 weeks after. Data for 2025 showed significant improvement in these scores following frenulotomy. Before the frenulotomy, 23% of caregivers who breast fed reported severe pain and 33% moderate pain. Following the procedure, 77% reported no pain and 20% mild pain. This demonstrated an immediate impact in the infant’s ability to feed and a significant reduction in the caregiver’s pain score. Breastfeeding caregivers confirmed immediate and continued improvement in comfort and technique following frenulotomy.

Feeding ability was measured immediately after the procedure and again at 6 weeks. In 2025, 82% of caregivers reported immediate improvement in feeding ability, and of the 31 caregivers who completed the 6‑week assessment, all reported a vast or optimal improvement.

The RM regularly collected feedback from caregivers following the procedure, enabling them to measure qualitative outcomes which we observed were consistently positive. Online reviews from the previous 12 months showed 100% of respondents rated the service 5 out of 5 stars. Thirty-seven positive feedback notifications were received by the Care Quality Commission over the same period, providing strong evidence of consistently good outcomes. Furthermore, all 9 caregivers we spoke with said the procedure met their expectations and feeding had improved.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

The service had an up‑to‑date consent policy that reflected current legislation and best practice. It set out clear guidance for consent in line with the service provided. It included considerations for same‑sex and adoptive parents, and for people with sensory, communication or language needs. The RM had a good understanding of the policy and had completed training in consent and mental capacity.

The RM understood the importance of ensuring caregivers fully understood what they were consenting to before care or treatment was provided. Caregivers were provided with relevant information to make informed decisions. It was provided in a way caregivers could understand and gave them appropriate support and time to make decisions. During the assessment, we observed the RM explain the procedure and risks clearly.

Caregivers told us they understood their rights around consent. They told us the RM provided clear, detailed information to support informed decision‑making. An electronic consent form was completed during the appointment, covering consent for the procedure, sharing of information, taking photographs and storing records electronically. Where an interpreter was used, the form confirmed they had relayed all relevant information. Consent was clearly recorded in all 14 records we reviewed. We observed the RM seeking verbal consent throughout the appointment, such as before handling the infant or physically supporting caregivers with feeding technique.

The RM understood the legal framework and requirements of the Mental Capacity Act 2005 for consent and knew how to seek professional advice if needed or if they had concerns about a person capacity to consent. The RM was clear about how they would liaise with midwives, health visitors or general practitioners if concerns about capacity arose.

Parental responsibility was confirmed before proceeding. The RM checked the PCHR and birth history to verify the caregiver’s legal authority. For infants in foster care or going through adoption processes, they obtained consent from social workers and requested copies of relevant documentation prior to treatment. The RM would not proceed without this confirmation. We found appropriate checks were carried out in all 14 records we reviewed.