Coronavirus (COVID-19) - care home outbreaks: root cause analysis - terms of reference

Terms of reference for a Review Group to collate and evaluate local level experiences and responses to the resurgence of COVID (wave 2) outbreaks within care homes.


To collate and evaluate local level experiences and responses to the resurgence of COVID (wave 2) outbreaks within care homes. To support learning and practice across the sector through the sharing of learning identified and approaches to improvement.

Review Group:

The group will comprise nominated individuals who are independent of the care homes, or associated Health Boards or Health and Social Care Partnerships.  Members of the team will bring expertise to the analysis and at least one member of the team must be experienced and trained in investigation review and root cause analysis.

Key roles

  • follow an adverse incident investigation process to identify any common themes and learning from recent care homes outbreaks
  • consider COVID outbreaks from August 2020 in care home settings identified to understand:
    • the factors that lead up to a COVID care home outbreak; and
    • if there are shared new characteristics across these.
  • understand the characteristics and risk factors of outbreaks in care homes and assess this against learning the first half of 2020. This approach will ensure appropriate clinical and operational guidance can be prepared for the sector
  • review feedback and information from local incident management teams and other data sources e.g. safety huddle tool across all KPI’s including workforce, DoPH weekly returns, care inspectorate data, SSSC data, Scottish Care data. Review timeline of events so far from IMT minutes and documents related to these care homes.
  • undertake interviews with local oversight teams and care homes
  • explore the hypothesis that that care homes that were not affected by COVID to June 2020 are more at risk this winter
  • review contributory factors, wider learning, and emerging national and international evidence and make recommendations to inform future practice and local arrangements during phase 2 of this pandemic that will support infection prevention and control across care homes
  • identify what further actions can be taken at local and national level to support care homes to deliver within this context

Guiding principle

Central to the operation of the Analysis Exercise is a partnership between the sector, agencies and others, dedicated to understanding the issues and challenges from COVID facing the care homes in winter 2020 and beyond.

Recommendations will be made for the benefit of residents of care homes, the workforce and families of residents in an independent and objective way.


The Analysis Exercise will be led by Professor Jacqui Reilly and David Crawford supported by Donna O’Boyle. The Reference Group will comprise of a group of named expert advisers that will not include individuals who have been previously been involved in assessing the IMT for any of these 4 care homes, will provide operational and delivery related guidance as required over the period.

Reference group




Ian Ramsay

CSWO Aberdeenshire Local Authority

Hazel Borland

NHS Board Nurse Director

Jennifer Champion

NHS Board Director of Public Health

Michelle Watt

General Practitioner

Joanna Macdonald

Chief Officer Argyll and Bute

David Marshall

Improvement Officer Care Inspectorate

Gareth Hammond

Regional Inspector, Care Inspectorate

Claire Pugh

Improvement Officer, Health Improvement Scotland


Joan Higgins

Senior Infection Prevention Control Nurse

Sarah Smith NHS 

NHS Lothian Chair of HCS



Nicola Dickie or Louise Wright or Claire Thomas – all COSLA

Partnership Side Rep


Donald Macaskill

Scottish Care

Philip Gillespie

Director of Workforces SSSC

Key roles of the Reference Group

  • advise the review group on key data that should be considered as part of the Root Cause Analysis
  • advise and support the review group throughout the fact-finding process, helping to formulate appropriate questions
  • provide feedback on key aspects of the Scottish Government clinical and practice guidance for care homes during the pandemic
  • provide feedback on the Scottish Government’s communication strategy


The team undertaking the Root and Cause Analysis Exercise will meet as frequently as required from 12 October to deliver conclusions and make recommendations for publication no later than the end of October. 

Data/information sources for review:  

  • information and data from Care Inspectorate e.g absence levels reported, dates and findings of last inspection, any reports of incidents (e-forms) or complaints during the previous 4/6 weeks.
  • information and outputs form local PAGS/IMT’s
  • last 4 – 6 reports from weekly DoPH returns
  • trend/KPI information from TURAS – Care Management safety huddle tool and compliance, staffing, occupancy, escalation, dependency.
  • information from discussion with oversight groups or Sitrep reports locally and SG
  • most recent DoN assurance visit findings and any recommendations
  • information on testing – any delays in returns with testing
  • interview information with care home managers and unions


  • adverse incident review report to be compiled by review team and shared with Health and Social Care Management Board, Directors and Cabinet Secretary
  • report conclusion and recommendations to be published. However it will be shared with and presented to NHS Boards and Health and Social Care Partnership oversight groups, care home providers, care home managers 1 day in advance of publication to ensure factual accuracy.
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