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

Findings of the rapid review of COVID-19 outbreaks in four care homes, including a list of recommendations based on risk factors that were found to be common in at least two of the homes.

Executive Summary

Background and summary

The Cabinet Secretary for Health and Sport commissioned this review into the circumstances surrounding the occurrence and transmission of COVID-19 infection within four care homes in Scotland. 

The Terms of Reference required the establishment of high-level recommendations to support quality improvement in the safe management of care for residents within care homes across Scotland.

The establishment, and process, of this review has taken place within an extraordinary set of circumstances and a timeframe in which events that led to this review are continuous and ongoing; most importantly the context for the review is set against a backdrop of the current world-wide COVID-19 pandemic. 

The context and conditions of measures to limit the spread of the virus in Scotland have been examined in the light of care homes' experiences, to provide meaningful insight into the nature of any systems defects which may have had an impact on the management of infection prevention and control, and to understand the issues and challenges facing Care Homes in this pandemic and beyond.

Description of review team

The review team consisted of three members, all independent of Scottish Government.

  • Professor Jacqui Reilly;(Director of Nursing National Services Scotland (NSS) and Professor of Infection Prevention Control (IPC), Glasgow Caledonian University (GCU) Co-Chair
  • David Crawford; (former Director of Social Work) Co-Chair
  • Professor Donna O'Boyle;(Professional Adviser; regulation Chief Nursing Officers Directorate (CNOD)  investigation lead


  • Colin McKnight (Scottish Government Policy Manager)
  • Abbie Eddington (Scottish Government Business Manager)

Review timescales

This review was commissioned as a rapid investigation; the parameters of the review included attention to an ongoing pandemic response, therefore in order to apply lessons learned as soon as was practicable, timescales were truncated. 

The review was commissioned on Monday, 12th October, and given the pressing need to identify high level recommendations contained within a report for submission to the Cabinet Secretary for Health, this was expected by Friday, 30th October 2020. 

Scope and level of the review

The terms of reference for the review is attached as appendix 1. Key issues to be addressed:

  • Understand the characteristics and risk factors of outbreaks in care homes to ensure appropriate clinical and operational guidance can be prepared for the sector.
  • 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 within this context.

A mixed methodology was employed which included a table-top review and analysis of relevant information and data, complemented by interviews with stakeholders using an appreciative inquiry approach.  

Sources of information reviewed:

  • Care Inspectorate statutory inspection reports
  • TURAS Safety Huddle data 
  • Director of Public Health data returns
  • Information and outputs from local Problem Assessment Groups (PAG)/Incident Management Teams (IMT)
  • Lessons learned reports from wave one
  • Evidence from peer reviewed published international evidence

Interviews with representatives of:

  • Care Home managers and other senior staff
  • Care Home Relatives Scotland
  • Scottish Care
  • Directors of Public Health
  • Chair of Oversight Boards
  • Chair of Problem Assessment Group 
  • Executive Nurse Directors
  • Health and Social Care Partnerships
  • Integrated Joint Boards 
  • Trades' Unions
  • Scottish Government officials
  • Scottish Government Professional Advisers
  • Care Inspectorate
  • Healthcare Improvement Scotland
  • Public Health Scotland
  • ARHAI Scotland, National Services Scotland 
  • Scottish Social Services Council (SSSC)

Family and carer involvement

A broad range of stakeholders were identified; principle among these was consideration of how to incorporate the family and resident aspects within the review.

It was recognised that the families who have been directly affected by the events leading to this review may have been very recently bereaved, and it was considered inappropriate to intrude upon their grieving process. The majority of the residents across the four homes were older people, many of whom have dementia. Whilst it is not unusual to involve recently bereaved families in a root cause analysis that affects a single event, the multitude and complexity of affected families in this series of events, and across multiple organisations led the review team to consider how best to engage and hear relatives' views and take account of information relevant to residents in a sensitive manner. Advice was sought from Scottish Care (membership organisation representing 85% of Scottish Care Homes) and this led to engagement with Care Home Relatives Scotland.

The review team was further assisted by the establishment of a Reference Group, membership of which included representation of relevant professional expertise (and is further outlined in appendix 1). The terms of reference for the review (established by the Cabinet Secretary), together with the intended methodology were shared with the Reference Group; their comments further refined the intended approach and list of stakeholders. The Reference Group also agreed to confidentially review the findings and recommendations, prior to submission of the report to the Cabinet Secretary.    


09/10/20; invitation issued to review team members; review team established

12/10/20 – 13/10/20; review team commence work: establishment of Terms of Reference; documents; data; stakeholders identified. Briefing to Cabinet Secretary outlining intended approach. Table-top review of available information commenced.

14/10/20; Cabinet Secretary approval. Organisation of stakeholder interviews.

15/10/20; Initial Reference Group meeting to agree approach and representatives to be interviewed

16/10/20 – 21/10/20; interviews commence, commissioning of further evidence.

26/10/20; interviews concluded

27/10/20; Findings and recommendations shared with Reference Group

30/10/20; report updated and presented to Cabinet Secretary

Contributory system factors

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.

Assessment and findings

A full commentary of the review team's findings are appended below (from pages 11 to 35)

Review outcome

Contributory factors and root causes are identified and their impact examined in detail within the narrative report. These factors have been found to be present in at least two or more of the care homes included in this review and are summarised as:

  • High community prevalence of COVID-19 in the geographical region
  • Homes which had >20 resident places, were for older adults and had not experienced a COVID-19 outbreak previously and had high occupancy
  • Presence of asymptomatic cases and lack of awareness of the wider spectrum of symptom presentation in older people
  • Delays in testing and reporting of results
  • Slow confirmation of an outbreak 
  • Delays to initiation of additional control measures to stop the widespread transmission. 
  • Context specific challenges in the care home environment with IPC measures

Key to this is timely testing and reporting of results, in order that control measures can be put in place. The challenges with testing availability and turnaround times, combined with high community prevalence, occupant density, staff shortage indicators and the built environment risks re isolation or cohorting capability, placed care home residents at risk of the swift spread of COVID-19.

Wider system factors are also identified as themes from the intelligence received, from system data and interviews, as part of this review.

Opportunities for improvement are listed throughout the narrative, in the summary and in the recommendations table


Recommendations have been made and these are summarised in the Table of Recommendations at page 38.

Arrangements for sharing lessons or learning points

The high level messages and list of recommendations have been shared on a confidential basis with the Reference Group. Additionally, relevant portions of the report have been shared with stakeholders for factual accuracy checking. Consideration by the Cabinet Secretary will be given to the dissemination of learning points and date of publication for the report. The report should be shared with the whole system for learning. 



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