Feeding UnTied Limited

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

This is the first assessment for this service. However, the service was inspected in 2019 under a different location, and this key question was rated as good. This meant that people were safe and protected from avoidable harm.

We reviewed all 8 quality statements for safe. This included, learning culture, safe systems, pathways and transitions, safeguarding, involving people to manage risk, safe environments, safe and effective staffing, infection prevention and control, and medicines optimisation. We found:

The service had a robust and well‑established process for recording incidents, ensuring they were documented accurately, reviewed promptly, and shared appropriately with the Association of Tongue-tie Practitioners (ATP) to promote learning and improve safety.

The registered manager was highly experienced with the right qualifications, skills, training, and experience. They had excellent knowledge of ensuring people were kept safe from avoidable harm and consistently provided high‑quality, appropriate care and treatment. The registered manager showed strong awareness of specific clinical risks and had received specialist training in the prevention and management of bleeding complications. The service had an efficient pathway to communicate with partners and escalate incidents.

The service thoroughly assessed and managed the risk of infection. People were protected from the risk of infection because the premises and equipment were kept clean and hygienic to an excellent standard.

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.

The registered manager understood the key risks associated with tongue‑tie assessments and frenulotomy. They recognised potential complications such as bleeding, infection, post‑procedure pain, and the possibility of re‑formation. The registered manager carried out thorough assessments to identify whether a baby’s feeding difficulties might be caused by other medical issues rather than tongue‑tie alone. Adverse events were reported externally to the Association of Tongue-tie Practitioners (ATP) to provide independent oversight and support shared learning. The registered manager understood the duty of candour. They were open and transparent and had processes in place to provide full explanations to families if things went wrong.

Systems and processes were in place to record and manage incidents. The service had a policy in place which outlined what incidents to report and how to report them. The policy was in date and had recently been reviewed.

The service had a pathway for sharing any incidents during a tongue-tie procedure to the ATP who would review these. The incidents included, heavy bleeding, infections post procedure, near misses, slips and falls and other clinical and non-clinical incidents. The registered manager is a member of the ATP and has attended events both in person and online. They also received relevant safety updates from the ATP.

The registered manager understood what incidents to report. There had been no serious incidents or adverse events in the service in the 12-month period prior to our assessment.

Safety risks were proactively identified and managed before safety events happened. For example, through the assessment process, the registered manager identified potential issues that would increase the risk of excessive bleeding and acted to reduce these risks. The registered manager ensured they remained fully informed about each baby’s health history, including any identified concerns, prior to delivering the tongue‑tie assessment or treatment.

The service had a process where learning from safety events could be discussed with a peer from another service. The registered manager had links with other local tongue tie practitioners as part of a regional group. This provided them with 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.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There was a robust referral and screening process. Risk assessments were carried out for each patient at the point of booking. This happened through a collaborative, joined-up approach to safety that involved the primary caregivers and other partners in their care. The registered manager reviewed the pre-assessment for each new referral to ensure the baby met the acceptance criteria. For example, they considered the age of the baby and reviewed any health conditions. Where there were any concerns, the registered manager called the primary caregivers to discuss and where appropriate, contacted other health professionals to gather additional information.

The provider had a system where appointments could be booked via the website, and information about available packages the service offered could be viewed. A booklet that provided information about the tongue-tie assessment, including the procedure and post-procedure care and feeding was available both on the website and at the service. This included detailed information of what a frenulotomy is, what to expect if the baby required a procedure, the post procedure care that caregivers should follow and breastfeeding advice.

The registered manager understood the risks involved in carrying out the frenulotomy procedure. The main risks were the risk of bleeding, infection and the baby having to undergo a re-division. There was a thorough health questionnaire for caregivers to complete before the assessment. This provided a medical history of both the baby, mother and relevant family medical history. During the first appointment, the registered manager undertook a comprehensive assessment and thorough physical examination, taking time to observe the baby’s feeding behaviours, review relevant medical history, and identify any factors that could influence the suitability or safety of a tongue‑tie procedure.

The screening and assessment process was thorough, helping to gather all the information needed to understand any potential risks and supporting safe, informed decision‑making about whether to proceed with the frenulotomy procedure. As part of the pre‑assessment, caregivers were asked to confirm whether the baby had received Vitamin K. Vitamin K reduces the risk deficiency bleeding, which could increase the chance of excessive bleeding after a frenulotomy.

The registered manager anticipated peoples needs following the procedure and had a process to support care. Emails and text messages were sent to caregivers explaining what to expect as their baby healed after the frenulotomy procedure on day 1, day 5, day 10 and day 14. An additional plan for a 3-month check-in text message was also forwarded as part of a post procedure check-up.

The service wrote to the GP and health visitor on the same day of the appointment, confirming that the frenulotomy procedure had been carried out with details of risk, any further information or suggested referrals. An emergency letter was also given to caregivers after the appointment. This was provided if there was ever a concern identified following the procedure and the service was closed.

The registered manager provided the opportunity for primary caregivers to ask questions and provide feedback throughout the appointment. For example, the registered manager listened to feedback about feeding techniques to support the assessment process. We saw evidence of a person‑centred approach following the frenulotomy procedure, with the registered manager taking time to listen to caregivers concerns and offering feeding support based on the family’s individual needs.

The registered manager updated the assessment details and frenulotomy procedure in the baby’s personal health record (red book). This meant all professionals involved in the care of the baby and family, such as midwives and health visitors, had details of the procedure and any advice given to support the baby to feed.

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 registered manager assessed the primary caregiver’s capacity to decide whether to proceed with the frenulotomy procedure. They explored the caregiver’s understanding of the associated risks and offered information in a variety of accessible formats to support informed decision‑making. People were supported to understand their rights, including their human rights and their rights under the Mental Capacity Act 2005 (MCA) and the Equality Act 2010.

The registered manager had completed safeguarding adult and children level 3 training. They understood how to identify potential abuse and neglect and could give examples of how to protect children and vulnerable adults, including those with protected characteristics under the Equality Act (2010).

There had been no safeguarding concerns identified or reported in the 12 months prior to our assessment. The registered manager had a good understanding of when to complete a safeguarding referral and how to escalate concerns. The registered manager could provide examples of when safeguarding concerns may happen at the service and how this would be managed.

There were systems, processes and practices to make sure people were protected from abuse and neglect. The service had a safeguarding adult and a safeguarding children policy in place, which had both been reviewed in June 2025. The policies included contact details of local safeguarding services for both adults and children. There was also a safeguarding babies and infants policy, which provided targeted guidance for protecting children specifically from 28 days to 1 year of age. This included risks, developmental needs, and safeguarding considerations relevant to this age group.

The registered manager had completed mental capacity training and demonstrated a good understanding of how to assess whether someone using the service could make their own decisions. They described how they would use simple language and adapt their communication when needed.

We scored the service as 4. The evidence showed an exceptional standard. The service always worked well with people to fully understand and manage risks by thinking holistically. They provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.

Caregivers were provided with clear and comprehensive information before booking and attending appointments. This included a detailed confirmation email containing practical information, preparation requirements, and a copy of the ‘Information for Parents’ booklet, which explained what to expect before, during, and after the procedure. This information was available on the website prior to booking.

Primary caregivers were informed about any risks that may occur during the procedure and how they would be acted upon during and after the procedure. Additional information was given regarding post procedure after care. For example, the registered manager talked about the risks of bleeding, alongside evidence‑based methods for stopping it, should this occur. Caregivers were given detailed, practical advice on how to reduce and manage bleeding at home, including the importance of allowing the baby to maintain regular tongue movement to reduce the risk of reformation.

Caregivers were provided with clear instructions on when and how to access further support if needed. One person told us that the registered manager provided clear and comprehensive aftercare advice, including detailed guidance on the healing process and the exercises that would support the baby’s recovery.

The registered manager carried out a swab count at the end of the frenulotomy and invited caregivers to take part. The swab count was undertaken to ensure swabs used to stem bleeding post procedure were not accidentally left in the baby’s mouth, which could cause a choking risk. The swabs counted were documented in the service records which provided an extra safety check and supported clear, open communication with families.

There was a balanced and proportionate approach to risk that supported people and respected the choices they made about their care. For example, if babies had not been given Vitamin K before the appointment, caregivers were informed about the increased possibility of bleeding. This information was shared with the caregivers before the appointment to support them to decide whether to proceed with the frenulotomy. The risk of not having the procedure was always weighed up with the presenting risks.

The provider had systems and processes to ensure risks were assessed and effectively managed. The registered manager reviewed questionnaires from caregivers before the appointment and involved them during the assessment. We saw evidence of caregivers being given the opportunity to ask questions and time to decide if they wanted the procedure to happen following the assessment made. We observed the registered manager communicating with the caregivers throughout the assessment, involving them in the decision-making process, including how conclusions were formed.

Risk assessments relating to the procedure were person‑centred and completed in partnership with the caregiver prior to treatment. This process helped the registered manager to gain an understanding of the baby’s individual needs, any potential risks, and the caregiver’s concerns. The assessment took into account the baby’s individual feeding history and any medical considerations specific to their needs.

Throughout the frenulotomy procedure, the registered manager ensured that the caregivers were kept informed of the different stages and involved them in the process. This included one of the parent’s inputting scores on the electronic tablet that was used to assess the function of the tongue. We were told by caregivers that this was part of the process they particularly valued, with one person saying that it made them feel “included” and “their voice mattered”.

When people communicated their needs, emotions or distress, the registered manager managed this in a positive way that to reduce distress. For example, the registered manager responded to signs that the baby was distressed in a calm and supportive manner, pausing the procedure until they were settled and reassuring the caregiver.

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 environment was spacious, clutter free and there was suitable storage space in the clinic. The assessment area was comfortable and relaxed where the registered manager undertook assessments and carried out post frenulotomy feeding support.

There was a disabled access toilet with baby changing facilities. Caregivers said that the environment was especially clean, calming, well organised and carefully arranged. One person said that this “exceeded” their expectations and they “appreciated the calm, quiet and intimate environment, which gave me confidence that my baby would be safely treated”.

The registered manager had appropriate environmental safety measures in place, which included routine servicing and safety checks for the air‑conditioning unit and the water cooler. The health and safety policy was updated in February 2026 and risk assessments had been undertaken, including infection control, flooding and electrical safety checks. A fire safety assessment had been carried out by an external company in January 2026, and a fire risk assessment had been updated by the registered manager in February 2026. The service had all necessary equipment such as fire extinguishers in place to reduce any fire risks, and we observed they had been safety checked and serviced. There had been recent Portable Appliance Testing (PAT) undertaken to ensure all electrical equipment was safe.

Access to the building was safe and secure. We observed the front door to the service did not have a security lock to prevent people from walking into the service unchallenged, which presented as a potential security risk when the registered manager was in a consultation. Immediately following our assessment, the provider installed a new security system which allowed visitors to gain entry via the use of an intercom system, ensuring greater security for people using the service.

Arrangements were in place to ensure clinical waste was safely disposed of. Clinical waste and sharps bins were in place, in good condition and not overfull. The external clinical waste bin was locked at all times. The service had contracts in place for waste collection.

Equipment such as the paediatric couch used to carry out the frenulotomy procedure was in good condition and safety checked. Consumable items including single use frenulotomy packs were sterile and sealed, in good condition and within the expiry date.

Processes were in place to continually check stock and expiry dates. The stock levels were checked by the registered manager daily and we observed equipment used for the procedure as being in-date and stored appropriately. There was a health and safety risk assessment in place that included potential hazards and who this could affect, with actions identified to control the risks.

Emergency equipment was in place. There was a contents list, and we observed that all equipment and consumable items to be accounted for and in date. The registered manager said that they checked stock levels daily to ensure that they did not run out of equipment.

We scored the service as 3. The evidence showed a good standard. The practitioner was qualified, skilled and experienced, who received effective support, supervision and development. The practitioner provided safe care that met people’s individual needs.

The registered manager had received training appropriate and relevant to their role. This included International Board Certified Lactation Consultant (IBCLC) recertification and Ankyloglossia / Frenulotomy Updated training. We saw this had been updated in line with the providers policy. The registered manager had in-date paediatric Basic Life Support (BSL) and Advanced Life Support (ALS) training.

The registered manager received the support they needed to deliver safe care. This included ongoing support from a local ATP network and yearly peer reviews and observations from other tongue-tie practitioners. This enabled the registered manager to develop their skills, seek support to improve and maintain their professional revalidation.

The Registered Manager is a sole Limited Company Director and clinician, therefore, did not employ any other staff. Where the registered manager was absent due to annual leave or ill health, no appointments were offered.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Clinic areas were exceptionally clean, well‑presented and had suitable and well-maintained furnishings, appropriate for the type of procedures carried out. All furnishings and surfaces were consistently clean and hygienic and the frenulotomy procedure was carried out on a full-sized wipeable clinic couch. A single use towel was also used for the procedure. The registered manager ensured that caregivers were thoroughly aware of how to prevent infections following the procedure.

The registered manager followed the infection control principles including the use of personal protective equipment (PPE) during the procedure. The frenulotomy procedure was undertaken in a clean and sterile environment, with the registered manager using LED lighting an apron, face mask, visor, gloves and a head torch. During the procedure, only single use surgical items were used.

The registered manager undertook daily cleaning and audits to identify infection prevention and control risks. Surfaces were cleaned in between appointments to maintain a clean and safe clinical environment. Equipment was wiped down with anti-bacterial wipes pre and post procedure. There was appropriate equipment available on site to ensure safe and effective management of any accidental spillage, including an easy access spill kit.

There was a carpet in the clinic room, which provided a more aesthetic and calming environment for consultations. The carpet had been removed from the clinical area where the frenulotomy procedure took place and replaced with medical grade non-slip flooring, to ensure it was compliant with IPC regulations. The registered manager renewed their Infection, Prevention and Control training in November 2025.

The registered manager had a structured process for reporting any Infections post frenulotomy to the Association of Tongue‑tie Practitioners (ATP).

Information about the risk of infection was shared appropriately with primary caregivers and relevant partners. There were processes in place to report any wound infections to the ATP who monitored this nationally. There had been no surgical site infections identified in the 12 months prior to our assessment. There was an in-date infection prevention and control policy. The clinic was divided into three areas. One area was designed for discussions before and after the procedure and there were two separate areas where the craniosacral and frenulotomy practices would take place.

Hand washing was carried out before and after each procedure. The registered manager asked that accompanying caregivers also washed their hands before and after the procedure. There was a separate clinical sink available for this.

The provider had a hand-washing policy. This was reviewed in July 2025 and was in line with national guidance. The registered manager communicated with caregivers around the importance of Infection Prevention and Control and how risks would be managed during the procedure.

Although the service did not use prescribed medications, there was baby paracetamol onsite for caregivers to administer if they felt this was needed. The registered manager maintained a stock of wound care supplies, including a gauze dressing, which helped control the bleeding.

The allergy status of the baby was recorded on the health questionnaire before the appointment and reviewed as part of the assessment process.