D-Restricted Ltd

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• 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

We looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this key question under its current registration. However, the key questions was previously rated under a different registration as good. We assessed 7 quality statements for this key question, and it has been rated as good.

This meant people were safe and protected from avoidable harm.

The service had a proactive and positive culture of safety, based on openness and complete honesty. The service worked collaboratively to establish and maintain safe systems of care. Safety was well managed and monitored. The service worked well with caregivers to fully understand what being safe meant to them and how to achieve that. Risks were fully understood and manged holistically in a way which met caregivers individual needs. Environmental risks were identified and controlled well. Infection risks were thoroughly assessed and proactively mitigated. The registered manager was qualified, skilled and experienced to carry out the surgical procedure.

We have not awarded this service a score for Safe.

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

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Systems and processes were in place to record and manage incidents. The adverse event and near miss policy and procedure reflected national guidance. Incidents and complaints were recorded on a register, and workplace accidents were recorded in an accident book. An incident form was completed to report, investigate and document any learning and actions from patient safety incidents. All incidents classified as an adverse event were reported to the Association of Tongue Tie Practitioners (ATP). For example, incidents when an infant had bled significantly post frenulotomy and required treatment, re-divisions of the tongue tie, and wound infections were submitted to the ATP. The service collected data for monitoring and for learning.

The service worked with other providers to ensure frenulotomy procedures were safely carried out to avoid serious incidents from occurring. Safety risks were proactively identified and managed before safety events happened. For example, through the assessment process, the RM identified potential issues that would increase the risk of excessive bleeding and acted to reduce these risks.

There were processes to ensure incidents and complaints were appropriately investigated and reported. The RM knew what incidents to report and how to report them. From 1 March 2025 to 28 February 2026, there had not been any incidents reported, including adverse events, never events or complaints. Prior to this timeframe we observed incidents had been reported. For example, in February 2025, a post procedure wound bleed was reported and investigated, though no harm was found.

Learning from incidents was shared with others. Patient safety events that happened elsewhere were also used for learning and development. The RM had links with other local tongue tie practitioners as part of a regional group. This provided the RM opportunities to share learning and learn from others when something went wrong. They also received relevant safety updates from the ATP to inform their practice.

Changes had been made as a result of learning. For example, the RM implemented a preventative measure to reduce the risk of an excessive bleed by using gauze and sterile water. This was learning shared by the ATP following an incident that had occurred elsewhere. The provider had also updated their bleeding guidelines in response to this learning. During our assessment we observed sterile water and gauze was readily available and used during procedures we observed.

The RM understood the duty of candour. They described how they were open and honest and would involve primary caregivers in any investigation, and provided a full explanation and apology whenever necessary.

The RM could seek professional support through the ATP following an incident. We saw the adverse event reporting form included an option to request a de-brief following submission of incidents.

People were encouraged and supported to raise concerns, they felt confident that they would be treated with compassion and understanding. Caregivers told us they felt comfortable to contact the RM to raise any concerns. They were provided with information about how to raise a concern and opportunities to feedback and seek advice post procedure.

There was a culture of continuous learning that was driven by the needs of the people who used the service.

We scored the service as 4. The evidence showed an exceptional standard. The service always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. Safety and continuity of care was a priority throughout the infant and caregivers’ treatment journey. This happened through a collaborative, joined-up approach to safety that involved them as well as the RM and other partners in their care.

There was a comprehensive referral and screening process that ensured all essential information about the infant and primary caregiver was used to determine if their needs could be safely met. All 14 records we reviewed contained a pre-assessment and evidence the RM followed up with caregivers when needed to ensure safe and appropriate progression to the full assessment and frenulotomy if this was needed.

Assessments were holistic, collaborative and tailored to individual need. We observed 2 assessments where the RM clarified pre assessment information, completed full birth and health histories and involved caregivers throughout the feeding observation and physical examination. For breastfeeding families, pain related to feeding was assessed, and an evidence-based tool was used to determine tongue tie severity. Caregivers were supported to understand findings and treatment decisions at each stage.

Risks were proactively identified and effectively managed. The RM worked closely with caregivers and partner healthcare professionals to mitigate risks before proceeding with treatment. For example, when infants were under weight, the service postponed frenulotomy and coordinated support with health visitors and paediatricians to enable safe weight gain. Caregivers described receiving sustained support, including refund of treatment fees when procedures were deferred for safety reasons.

There were clear, individualised treatment pathways, comprising assessment, frenulotomy, and a tailored 6-week post procedure support programme. The RM provided caregivers and infants with a personalised feeding plan, access to a comprehensive online resource, face to face follow up if required and responsive telephone support. All caregivers we spoke to were highly positive about the continuity, consistency and reassurance provided throughout.

The service demonstrated effective partnership working to support safe transitions. Risk assessments were completed where concerns were identified, and written confirmation was sought from other healthcare professionals, when required, that frenulotomy was safe to be carried out. This included specialist assurance for premature infants or infants with other health conditions. The RM ensured accurate, timely information sharing by updating personal child health records and providing same day summaries to GPs. Caregivers were also given clear emergency guidance for use outside service hours.

Communication between services was exceptionally strong. Records showed regular professional involvement, positive external feedback and proactive escalation of concerns. Caregivers described the RM as going, “above and beyond” to engage other healthcare professionals, including identifying previously undiagnosed conditions and making timely referrals.

The service had clear transfer‑out procedures for emergencies. For example, bleeding and infant resuscitation guidelines provided clear instructions on how to respond in an emergency and who to contact. The RM demonstrated strong awareness of escalation pathways and described these confidently during the inspection.

The views of people using the service and partners were listened to and acted upon. Caregivers told us they felt heard, and we observed the RM taking time to listen and provide tailored advice and support. The service’s online portal included a direct messaging function that gave caregivers immediate access to the RM. We saw evidence of timely and responsive communication via email and text, both before and after the frenulotomy procedure.

The RM strengthened safety across the wider system by inviting NHS and other healthcare colleagues to observe practice. This supported shared learning, consistent pathways and improved knowledge of tongue tie management within the local system. Partner services spoke positively about this collaborative approach and its impact on timely and safe care.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The service had safeguarding systems, policies, and practices to protect adults and children from abuse and neglect. Safeguarding children and adult policies were reviewed in January 2026 and underwent a full review every 2 years, with annual checks for legislative updates. The policies aligned with current legislation and best practice and covered all forms of abuse and neglect, including domestic abuse, female genital mutilation and child trafficking. Clear governance arrangements, escalation pathways and training supported a strong safeguarding culture. Local safeguarding processes for all areas served were included for quick reference, and the RM knew how to seek advice and support when needed.

Safeguarding was included on the service’s risk register with mitigation actions aligned to policy. A safeguarding register was maintained to record concerns and referrals made to local safeguarding teams.

The RM demonstrated good safeguarding knowledge and took immediate action to keep people safe from abuse and neglect. Level 3 safeguarding adult and children safeguarding training had been completed with yearly updates, the training included preventing radicalisation training. The RM was highly skilled in recognising signs of abuse and neglect, including through behavioural changes, unexplained markings, and concerns about attachment. They could clearly describe how to protect people from harassment and discrimination, including those with protected characteristics under the Equality Act. There were processes to ensure professional safeguarding advice could be obtained through local safeguarding teams. The RM was confident raising safeguarding issues with caregivers and understood how to escalate concerns.

The assessment process was holistic and inclusive, enabling the RM to identify any potential safeguarding risks. The pre‑assessment form included questions about the infant’s child protection status, details of any named social workers, and explained that the provider might need to contact them. It also gathered relevant information about caregivers’ health and behaviours, including alcohol use. During the appointment, the RM took a full birth and feeding history and carried out a physical examination and observation of interactions, helping to build a comprehensive picture of any safeguarding concerns.

There was a commitment to taking immediate action to keep people safe from abuse and neglect, including working collaboratively with partner organisations. The service demonstrated they had acted when a safeguarding concern had been identified. From 1 February 2025 to 31 January 2026, 2 safeguarding concerns had been appropriately recorded on the safeguarding register and escalated to multi agency safeguarding hubs. Caregivers were asked to bring the personal child health record (PCHR) to the first appointment, enabling the RM to check for existing safeguarding information and to document the tongue tie assessment and procedure for other professionals involved in the infant’s care.

People were supported to understand safeguarding, what being safe meant to them, and how to raise concerns. The RM built positive, trusting relationships and often provided support beyond the appointment when additional help was needed. For example, they identified and supported caregivers experiencing postnatal depression, offering time, reassurance and appropriate signposting or referrals. They listened carefully to concerns and took early action to prevent issues from escalating into potential neglect. Several caregivers described the RM as, “a life saver” and going “above and beyond”.

Safeguarding systems, processes and practices gave assurance the provider upheld patients’ human rights and protected them from discrimination. People were supported to understand their rights, including their human rights, rights under the Mental Capacity Act 2005 (MCA) and the Equality Act 2010. For example, the RM assessed the primary caregiver’s capacity to decide whether proceed with frenulotomy. They checked the caregivers understanding of the presenting risks and provided multiple ways of providing information to support their understanding. Furthermore, the RM ensured the procedure was in the best interest of the infant by carrying out an evidenced based assessment beforehand. When the RM did not consider frenulotomy was in the best interest of the infant, they did not proceed with the procedure. Instead, they worked in partnership with the caregivers to improve feeding techniques.

We scored the service as 4. There was a strong awareness of the risks to people across their care journeys. Risks were assessed holistically and reviewed throughout the care pathway. Pre‑assessment health questionnaires captured infant, parental and family medical history, and risk information was reviewed together with caregivers at the appointment. We saw this consistently applied across all 14 records reviewed.

The service demonstrated highly effective risk management, supported by strong involvement of caregivers at every stage. Post‑procedure complication and infection rates were consistently low, indicating robust systems to anticipate, reduce and manage risk.

Caregivers were fully informed, listened to and actively involved in decisions about their infant’s care. Clear, accessible information about benefits, risks and limitations of frenulotomy was provided from the point of booking and reinforced during the assessment. Information was available in multiple formats through an online portal and discussed in detail during appointments. A well-structured consent checklist ensured risks were explained consistently. We observed 2 assessments where the RM discussed the risks associated with frenulotomy, the likelihood of them occurring, and how risks could be mitigated. They used national data to support these conversations. Caregivers spoke positively about the clarity and quality of information provided.

Risk management was preventative and proactive. The provider ensured policies were evidence‑based and clinical guidance reflected up to date national best practice. The RM clearly explained how immediate and post‑procedure risks would be managed and provided practical guidance for home care, including when and how to seek further support. For example, they provided practical advice including oral hygiene to reduce the risk of infection and tongue exercises to improve tongue motility and improve feeding ability. Caregivers told us this input gave them confidence to recognise and respond to risks such as bleeding, infection, and re‑attachment.

Care was personalised and proportionate to individual risk. When infants had not received vitamin K prophylaxis, caregivers were informed of the increased bleeding risk in advance and supported to make informed choices. Vitamin K prophylaxis is a supplement that is given to newborn babies to prevent a rare but serious bleeding disorder called vitamin K deficiency bleeding. An individual risk assessment was completed for each infant, and risks of proceeding were balanced against risks of delaying treatment. Records demonstrated these risks were clearly documented and actively managed.

Caregivers were supported to participate in the risk assessment at every stage. The RM used a personalised approach to explore each family’s feeding goals, their concerns and any wider factors that may influence risk such as prematurity, medical conditions, complex feeding challenges or parental anxiety.

The RM promoted open dialogue and shared decision‑making. Caregivers were encouraged to ask questions and express concerns. Conversations were supported by demonstrations, visual aids and step‑by‑step explanations. Risk was revisited throughout assessment, feeding observation and aftercare planning, to enable caregivers to recognise early signs of concern and take timely action. Caregivers consistently told us they felt involved, informed and confident in managing risks.

There were robust systems to identify and respond to clinical deterioration. The resuscitation policies reflected the most up to date Resuscitation Council UK (RCUK) Resuscitation Guidelines 2025. The RM had completed annual adult, paediatric and newborn resuscitation training. Emergency prompts and guidance were visible in the clinic to support staff to respond to a life-threatening event.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The clinic environment was designed in line with national guidance to meet the needs of infants and caregivers. Facilities were spacious, clean and uncluttered. Clinical equipment was stored securely, including in lockable cupboards, and the layout supported safe assessment, feeding and frenulotomy procedures.

The clinic room enabled safe, calm and dignified care. The frenulotomy was carried out on a raised, wipe‑clean surface. The surface was sturdy, flat and accessible from 2 sides. This ensured the safety of infant throughout the procedure. Comfortable seating and space were provided for the assessment and post‑procedure feeding and support. There was a toilet for caregivers and infant changing facilities.

Equipment used for care and treatment was appropriate, well maintained and safely managed. The RM used single use sterile rounded scissor packs to carry out the frenulotomy procedure. Everything needed to perform the procedure was included in the sterile packs. The packs were stored safely to prevent damage and protect the sterility of the instrumentation. The packs we checked were in good condition and within the stated expiry date. The service maintained an effective tracking system, recording serial numbers and photographs of equipment in records to enable rapid identification of equipment used if required. Swabs used to stem bleeding were counted and documented in records to ensure there was no risk of a swab being misplaced in an infant’s mouth.

There were effective systems to monitor the safety and upkeep of the premises. These included up‑to‑date health and safety policies, environmental risk assessments and daily and monthly safety checks. The registered manager demonstrated strong oversight of environmental and operational risks and how these were mitigated.

Fire safety arrangements were comprehensive and regularly monitored. Electrical testing, an external fire safety assessment and a fire risk assessment had been completed, and evacuation plans were clearly displayed. Fire safety equipment was checked and serviced, alarms were tested weekly, and the registered manager had completed fire safety and warden training.

Emergency equipment was readily accessible, complete and well maintained. An emergency bag contained appropriate airway and bleeding management equipment, guidance and an escalation process. Monthly checks were completed and documented, including expiry dates to ensure the timely purchase of replacement consumables.

The clinic was secure and protected from unauthorised access. Entry was controlled via locked doors and a bell system. Caregivers were met on arrival by the registered manager. CCTV covered the front and rear access points to the building. The registered manager had a personal safety alarm, to provide additional reassurance during lone working. The alarm notified a designated person that the registered manager required their immediate support.

We scored the service as 3. The evidence showed a good standard. The RM was qualified, skilled and experienced to carry out frenulotomy procedures. Appropriate support and professional development was provided from national networks and included ongoing training and supervision alongside other practitioners. The RM was accessible to meet service demand, with contingency arrangements to cover periods of absence.

The RM met fit and proper person requirements. They held relevant professional qualifications, including registration as a general nurse with a Qualification in Specialty (QiS) in neonatal care. They completed an assessed advanced clinical skills course in tongue tie management in 2014, with annual updates maintained, enabling them to safely perform frenulotomy procedures for infants up to 12 months. An enhanced disclosure and barring service check was completed annually in line with policy. Caregivers consistently described the RM as knowledgeable and confident.

Mandatory training in key skills was sourced through an external accredited health and social care training provider. A system was in place to alert the RM when training was due for renewal. The RM had completed and was up to date with all mandatory training requirements, including paediatric, newborn and adult resuscitation training. Training on recognising and responding to people with mental health and learning disabilities had been completed.

The RM invested in continuous professional development. They were an International Board-Certified Lactation Consultant (IBCLC). This qualification supported their skills and ability to perform an holistic assessment of feeding ability in conjunction with the tongue tie assessment. They remained up to date with mandatory training and their recertification requirements.

The RM received appropriate support to deliver safe care. This included ongoing involvement in the local ATP network and annual supervision. Through this network they took part in reciprocal arrangements for observational peer reviews with other tongue tie practitioners. These arrangements helped them maintain and develop their skills, access professional support and meet revalidation requirements.

The RM flexed their availability to meet the demand for the service. This ensured they could respond quickly to new referrals and offer ongoing support post frenulotomy.

Contingency plans were embedded to maintain safety during periods of absence. The service did not accept new referrals during these times, and an informal reciprocal arrangement with other local practitioners enabled emergency follow up for existing patients if required. The service directed new enquiries to the ATP website to access alternative providers where needed.

We scored the service as 4. The evidence showed an exceptional standard. The service thoroughly assessed and managed the risk of infection. They always quickly detected and controlled the risk of it spreading and had robust systems to share concerns with appropriate agencies promptly.

The service had an effective approach to assessing and managing the risk of infection, aligned with national guidance. There was an up-to-date infection, prevention and control (IPC) policy that was reviewed annually. The policy reflected current legislation and best practice. There were separate policies for managing bodily fluid spillages and preventing legionella. The RM completed annual IPC and hand‑hygiene training. The RM had an excellent knowledge of IPC risks associated with frenulotomy and was able to describe how the risks were mitigated.

People were protected from the risk of infection because the premises and equipment were kept clean, hygienic and tidy. Caregivers consistently described the clinic as ‘very clean’ and ‘spotless’. The environment included hospital grade flooring and wipe clean furnishings to support effective cleaning. The RM disinfected equipment before and after use and used appropriate cleaning products, alongside bodily fluid spill kits.

Rigorous cleaning and monitoring protocols were enforced. Daily and weekly cleaning schedules were fully completed. The schedules included daily cleaning tasks as well as a weekly deep clean. Regular environmental audits were consistently completed. Legionella controls were effective, with documented monthly water temperature checks and weekly tap flushing.

The RM adhered to IPC principles, including compliant handwashing and the use of personal protective equipment (PPE). They used aseptic non touch technique for frenulotomy and used appropriate personal protective equipment, including sterile gloves and aprons. Only single use instruments and dressings were used. PPE was accessible for clinic and home visits, and we observed it being used in line with national guidance. The RM complied with uniform and bare below the elbow requirements and maintained high standards of personal hand hygiene.

There was a handwashing sink in the clinic room. Hand sanitising gel was readily available for use by the RM and caregivers. Information about effective handwashing was displayed at handwashing sinks in the clinic. The RM washed and sanitised their hands before and after procedures. Caregivers were asked to wash their hands and encouraged to use hand gel. Nail varnish and jewellery were not worn which enabled effective hand decontamination.

Equipment used to support assessments was clean. A mobile phone sanitiser using ultraviolet light was used to disinfect the device before taking photographs of infants’ mouths before and after the frenulotomy. This was used alongside antibacterial wipes.

Clinical waste and sharps were managed safely and in line with policy. Sharps and waste segregation were appropriately managed. Bins were correctly labelled, stored securely and in good condition. Waste disposal contracts ensured regular and safe collection of waste. The RM was liscenced to transport clinical waste safely when providing outreach care.

The RM shared information about the risk of infection. During assessments, caregivers were advised how to minimise infection risks such as avoiding contact with the wound or objects entering the infant’s mouth and were offered 6 weeks of follow‑up support with encouragement to report any concerns.

The service monitored infection outcomes effectively. No surgical site infections were reported in the 12 months prior to our assessment. The service maintained a robust sterile pack tracking system, recording serial numbers and photographs in clinical records to enable prompt investigation if required.

We did not look at Medicines optimisation during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.