A review of the new Lister Surgicentre, which has been dogged by patient delays, has heavily criticised the management for a lack of staff and proper training - warning legal action will be taken if improvements are not made.

The independent health watchdog the Care Quality Commission published its latest report on the privately-run routine surgery unit today showing it had failed to meet standards in four out of five areas of inspection.

Inspectors who made an unnanounced visit on February 9 listed a series of failures including a lack of evidence that significant risks such as inadequate staffing levels and theatre efficiency were being addressed.

The CQC said procedures were not in place to escalate problems to a senior level.

“This meant that significant risks to people’s welfare that had been identified within the service had not been appropriately assessed and managed through the Lister Surgicentre’s governance arrangements,” the report said.

Senior management at centre operators Clinicenta blamed difficulties in managing and maintaining staff on the retention of employment conditions for East and North Herts NHS Trust staff seconded to the centre, which had resulted in gaps in theatre staffing and recruitment.

Other issues raised by the CQC included medical records not being shared with the NHS, a lack of appropriate levels of staffing to meet patients’ health and safety needs and a lack of training to frontline staff to meet patient welfare needs.

Andrea Gordon, CQC deputy director of operations said the law dictates standards everyone should be able to expect.

“Providers have a duty to ensure they are compliant,” she added. “This warning sends a clear message that the owner of Lister Surgicentre needs to address this issue or face further consequences.

“Our inspectors will return in the near future and if we find that the required progress is not made we won’t hesitate to use our legal powers to protect the people who use this service.”

A spokesman for Clinicenta said patients can be reassured that the company is compliant with the standard for care and welfare of people using the service, adding: “We acknowledge that we need to improve in other areas and in particular in keeping documentary evidence of how we monitor the quality of the service. Since the inspection in February we have made significant improvements and remain committed to working with NHS Hertfordshire to deliver services to patients”.

The CQC report highlighted patient comments that staff were “very kind and helpful” and treated them with respect.