R47 Response Accepted

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 published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response explicitly stated that the ICM is accountable directly to the chief executive and the board. The HAI Standards require this direct reporting line, ensuring IPC concerns reach the highest level of governance without being filtered through intermediate management.
- Healthcare Improvement Scotland monitors whether this direct reporting line is in place through its inspection programme.
Sources
How was this evidence gathered?
Evidence searched by Claude (Anthropic) on 10 Apr 2026
Checked data held on this site (government responses, progress updates, independent evidence)
This recommendation applies across many organisations. The evidence above reflects central policy activity; adoption in individual organisations may vary.
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 progress from inspectorates, select committees, official progress reports, and other sources. Source type badge indicates 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
Inquiry Vale of Leven Inquiry
Report The Vale of Leven Hospital Inquiry Report 24 Nov 2014
View Source
Responsible Bodies
NHS Health Boards (Scotland) Primary
Themes & Tags
Weak Government Accountability & Scrutiny Quality and safety oversight Management Governance
Recommendation age 11.5 yrs
Last formal update 4000 days ago