Coronavirus (COVID-19) care home outbreaks - root cause analysis: progress report November 2020 to September 2022

Track and report on progress on the recommendations set out in Coronavirus (COVID-19): care home outbreaks - root cause analysis (2020).


On the 12th of October 2020 the then Cabinet Secretary for Health and Sport, commissioned an independent review into the circumstances surrounding the occurrence and transmission of COVID-19 infection within four care homes in Scotland: Coronavirus (COVID-19) - Care Home Outbreaks: Root Cause Analysis' (RCA)[1].

The primary aim was to collate and evaluate local level experiences and responses to COVID-19 outbreaks within care homes and to identify learning and practice that would enhance support to improve care and outcomes.

The report found a number of contributory factors or root causes were present in at least two or more of the four care homes investigated in the review. Contributory factors are the influencing and causal factors that contributed to the outcomes which led to the initiation of this review; they are highlighted for their impact on systems, and they include: care home risk factors; leadership; training and education; inspection process; guidance and local adoption; visiting and carer concerns; built environment; and raising concerns. In summary the contributory factors or "root causes" were summarised as:

1) High community prevalence of COVID-19 in the region the care home is based in,

2) Care home size and occupancy,

3) Staff members who worked and who were asymptomatic but SARS-CoV-2 positive (unknowingly due to asymptomatic presentation was exacerbated by errors and delays to reporting screening results to care homes),

4) Staff members who worked in more than one place intra- and inter-organisations (staff, inclusive of nurses, carers and kitchen staff) not cohorted to floors/units, and continuing to work across these until outbreaks were confirmed (agency use, wider care home group staff use was high in some homes),

5) Missed opportunities to identify early warnings in safety huddle data and Directorate of Public Health (DPH -Presently reported as Care home assurance group: CHOG returns) reports (indicators included staffing data, single positive cases and self-reporting of these not accurate enough to identify risk. For example, 100% compliance with IPC and PPE self-reported, but this was found not to be accurate when on-site inspections were conducted),

6) Inadequate familiarity and adherence to infection prevention and control measures which may contribute to risk of transmission, delays to introducing additional transmission based precautions when a known case was suspected or identified,

7) Challenges to implementing infection control practices, including keeping up to date with latest guidance, specific care home built environment aspects and lack of expert advice of guidance in context, e.g. cleaning products,

8) Inadequate staff IPC measures to minimise staff to staff transmission. Situational awareness regarding risks in changing rooms, break rooms, smoking shelters, car sharing and socialising outside work with respect to social distancing,

9) Delayed recognition of cases in residents because of a low index of suspicion (not familiar with broader syndrome of COVID-19 in older people),

10) Delayed identification of cases, related to limited testing availability at the right time and turnaround time of the test, and difficulty identifying persons with COVID-19 based on signs and symptoms alone, asymptomatic/pre-symptomatic residents,

11) Underlying health conditions and advanced age of many long-term care facility residents and the shared location of residents in one facility places these persons at risk for severe morbidity and death. These homes had high levels of residents with dementia and receiving end of life care,

12) System relationships to support staffing in crisis. Larger care homes groups do not have well-established relationships with the NHS boards, the duty to establish these relationships lies with the NHS Board. Larger care home groups operate in more than one board area and may not have been fully informed or aware of the identified capacity and support available. There were indicators that there was high staff absence and fewer staff than the establishment identified as required at times for various reasons, this warrants further investigation,

13) The policy position of transferring people from hospital to community care without testing taking place to guide care.

Given the high number of contributory factors, the report noted that there is no single intervention that will prevent spread but instead there is a requirement for a multi-layered model of various individual controls in settings, system behaviours and factors/policies[2].

Overall, a series of 40 recommendations were made under 15 overarching headings. The RCA was carried out an early phase in the pandemic when the situation and understanding of COVID-19 was evolving rapidly. Many of the recommendations were therefore not static and naturally evolved as additional scientific and clinical knowledge emerged on the virus. In addition, other recommendations were not specifically related to the pandemic but were guided through of lens of providing high quality person centred care and support.

The recommendations were wide ranging and the responsibility for implementing and leading change lies with the Scottish Government (SG) and supporting agencies such as Public Health Scotland (PHS), Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) in National Services Scotland (NSS), the CI (CI), Scottish Social Services Council (SSSC), Health Boards (HBs), Health and Social Care Partnerships (HSCPs), Local Authorities (LAs) and care homes providers, managers and staff.

It should be noted that this report examines progress of the recommendations, since the publication of the RCA to the end of September 2022, on each overarching heading in turn and outlines what further progress must be taken. A "summary of further progress" is given in Appendix 1.

Where there has been significant progress since the end of September 2022 this is summarised in Appendix 2.



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