R47 Response Accepted AI-assessed

ICM reports to CEO

Recommendation

Health Boards should ensure that the Infection Control Manager reports direct to the Chief Executive or, at least, to an executive board member.

Published Evidence Summary
The following publicly available evidence relates to this recommendation:
The Scottish Government accepted this recommendation in 2015, stating the Infection Control Manager (ICM) is accountable directly to the chief executive and the board, and Healthcare Improvement Scotland (HIS) IPC Standards (2022) Standard 1 addresses reporting structures for IPC. However, the QEUH Oversight Board found in 2021 that key IPC information was not escalated to senior management and the Board within NHS GGC, indicating that direct ICM reporting to the CEO/board was not effectively implemented in that health board (Scottish Government, 2015-06-18; Healthcare Improvement Scotland, 2022-05-01; Scottish Government Oversight Board, 2021-03-01).
How was this assessed?
Assessed by gemini-2.5-flash on 19 Mar 2026
Checked data held on this site (government responses, progress updates, independent evidence)
External sources searched: www.gov.uk, www.gov.scot, www.legislation.gov.uk, hansard.parliament.uk
This recommendation requires implementation across many organisations. The assessment reflects central policy response, not adoption in individual organisations.
Jurisdiction
Scotland
Response
Accepted
Accepted Scottish Government
18 Jun 2015

Section 2.2 of the Scottish Government's response explicitly states that the Infection Control Manager (ICM) is accountable directly to the chief executive and the board. Furthermore, the Scottish Government has been working with partners since 2014/15 to reinforce the stipulation that infection control managers have direct lines of communication and accountability to the board. This ensures a clear and direct reporting structure for the ICM.

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Published Evidence

Published assessments of implementation progress from inspectorates, select committees, official progress reports, and other sources. Check the source type badge to see whether each assessment is independent or government self-reported.

Good Progress
01 May 2022
Healthcare Improvement Scotland Other

HIS IPC Standards (2022) Standard 1 (Leadership and Governance) addresses reporting structures for IPC within health boards including requirements for board-level oversight.

View detailed findings

National standards provide framework for IPC reporting to senior leadership and boards.

HIS IPC Standards - Standard 1: Leadership and Go… View Source
limited_progress
01 Mar 2021
Scottish Government Oversight Board Other

QEUH Oversight Board found that within NHS GGC key IPC information was not escalated to senior management and the Board. DMA Canyon water reports were not escalated to relevant staff and senior managers despite Vale of Leven recommendation that ICM should report directly to CEO.

View detailed findings

IPC reporting failures at QEUH demonstrate that the recommendation for direct ICM reporting to CEO/board was not effectively implemented within NHS GGC.

QEUH/NHS GGC Oversight Board Final Report, March … View Source
Source
Report The Vale of Leven Hospital Inquiry Report 24 Nov 2014
Responsible Bodies
NHS Health Boards (Scotland) Primary
Recommendation age 11.3 yrs
Last formal update 3932 days ago