The Care Quality Commission
  • Doctor
  • Independent doctor

Jacqui Mac Medispa

Overall: Good read more about inspection ratings

Rear of 41 Kirkgate, Silsden, Keighley, BD20 0AQ 07817 756360

Provided and run by:
Miss Jacqueline Katrina McGarry

All Inspections

22 March 2023

During a routine inspection

This service is rated as Good overall. (Previous inspection 27 July 2022 – Inadequate)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Jacqui Mac Aesthetics on 22 March 2023. We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was carried out to review the quality of care provided at the location and the breach of regulations identified at the inspection on 27 July 2022.

At the previous inspection in July 2022, we rated the provider as inadequate overall and inadequate for providing safe and well-led services. We rated the provider as requires improvement for providing effective services and good for providing caring and responsive services.

Following the inspection in July 2022, we told the provider to make improvements with regard to Regulation 12, Health and Social Care Act (HSCA) (Regulated Activities) (RA) Regulations 2014 Safe care and treatment and Regulation 17, HSCA (RA) Regulations 2014 Good governance. At this inspection we found the provider had responded to our concerns and made significant improvements following our last inspection.

The provider offers services to manage weight loss, the treatment of hyperhidrosis (excessive sweating) and Polydioxanone (PDO) thread lifts (non-surgical face lift). At the time of our first inspection the service was offering treatment for the management of hay fever; this has now ceased.

This service is registered with CQC under the HSCA 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC which relate to particular types of regulated activities and services, and these are set out in Schedule 1 and Schedule 2 of The HSCA 2008 (Regulated Activities) Regulations 2014.

Jacqui Mac Aesthetics also provides a range of non-surgical cosmetic interventions, for example, Botox, dermal fillers, vitamin injections and cheek contouring which are not within the CQC scope of registration. Therefore, we did not inspect or report on these services. Jacqui Mac Aesthetics is also registered with a national organisation of registered practitioners which review standards for non-surgical cosmetic treatments.

Feedback from patients on the provider’s website was positive and mirrored feedback from online reviews. Approximately 30 online patient reviews had been left within the last four months. The reviews were all exceptionally positive and described the provider and staff as informative, friendly, knowledgeable, and good at listening. All the reviews rated the service as five stars.

We saw that the provider responded kindly to all comments.

Our key findings were:

  • The provider had significantly improved record keeping at the clinic. We found that patient records were accurate, complete, and contemporaneous.
  • The provider ensured the proper and safe management of medicines at the clinic. We saw that medicines were stored correctly, and environmental and refrigerator temperatures were monitored in line with best practice.
  • The provider had established policies, systems and processes which operated effectively to assess, monitor and improve the quality and safety of care.
  • We found the consent policy which was in place at the clinic was up to date and followed by the staff team. Consent to treatment and the sharing of information with the patient’s GP was evidenced in the patient records. When appropriate, consultations were shared with the patient’s usual GP to support safe prescribing.
  • The processes which were in place for the management of infection, prevention and control kept people safe.
  • The provider had significantly improved the management of staff recruitment. A comprehensive overview of skills and mandatory training requirements was maintained.

The areas where the provider should make improvements are:

  • Continue with quality audits and the ongoing review of appropriate care and treatment to ensure that standards are maintained in line with best practice.
  • Record the discussion and decision to prescribe an ‘off label’ medicine when a licensed alternative medicine is available.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

27 July 2022

During a routine inspection

This service is rated as Inadequate overall.

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Inadequate

We carried out an announced comprehensive inspection at Jacqui Mac Aesthetics on 27 July 2022. This was the first inspection of this service. We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Act.

The provider offers services to manage weight loss, the treatment of hyperhidrosis (excessive sweating), Polydioxanone (PDO) thread lifts (non-surgical face lift) and at the time of our inspection was offering treatment for the management of hay fever, which the provider informed us has now ceased.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Jacqui Mac Aesthetics provides a range of non-surgical cosmetic interventions, for example, botox, dermal fillers and cheek contouring which are not within the CQC scope of registration. Therefore, we did not inspect or report on these services.

Feedback from patients on the provider’s website was limited, but very positive with two reviews left in the past 12 months.

Online patient reviews within the last 12 months were very positive. From 37 reviews, the provider scored an average of five stars. Patients described the provider as knowledgeable and professional and said they felt confident and reassured. The provider responded to all comments.

Our key findings were:

  • The provider failed to establish policies, systems and processes which operated effectively to assess, monitor and improve the quality and safety of care provided.
  • The provider failed to maintain an accurate, complete and contemporaneous record in respect of each service user.
  • The provider did not have a system in place to verify patient’s identity prior to making the decision to prescribe medicines.
  • The provider attended quarterly quality and safety meetings with other providers offering similar services.
  • The provider had failed to manage the safe recruitment of staff.
  • Feedback from patients was positive.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

You can see full details of the regulations not being met at the end of this report.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services