Publication - Independent report

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

Published: 3 Nov 2020

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.

Coronavirus (COVID-19): care home outbreaks - root cause analysis
12. Inspection arrangements

12. Inspection arrangements

The statutory duty for inspecting care homes in Scotland lies with the Care Inspectorate. The review team was able to review the most recently published inspection reports for each of the four homes, although further inspections in these homes were ongoing during the period of this review and we have therefore been unable to incorporate any further issues arising from these into the RCA report.

The inspection reports revealed, in the context of these outbreaks, ongoing issues related to the cleaning of the environment, staff IPC practice including correct use of PPE, management of waste and staffing numbers.  In addition, concerns about people social distancing, who cannot self-isolate due to living with dementia, and end of life care for individuals; these elements are commented on elsewhere in this report.

The review team heard from representatives of Healthcare Improvement Scotland, the Care Inspectorate, SSSC, and care homes in relation to experience of the inspection process. 

Whilst the CI has the statutory function to inspect care homes, it recognised that there are areas where additional expertise is required to ensure that a holistic approach, particularly of the clinical elements of infection prevention and control. We heard that the CI has in place a wide-ranging set of educational measures to support the preparedness of inspectors for their role, as does HIS, however inevitably there will be challenges to ensure that the most relevant clinical expertise in IPC is available to underpin the inspection and assurance processes. A Memorandum of Agreement is in place with HIS to undertake joint inspections with the Care Inspectorate, with HIS staff providing support for IPC and clinical considerations. It was clear to the review team however that the process is not fully integrated, and that the methodologies employed, grading and reporting structures for CI and HIS differ; this brought inconsistency and challenges in agreeing applicable grades for one of the care homes in this review. It also brought difficulties for those being inspected, and we heard of the impact of these inconsistencies of approach during inspection visits, which depended on the knowledge, role and approach of the individual inspector(s) involved in the process, differing advice offered, and treating the care home environment as if it was a clinical environment. These issues resulted in confusion for the care home staff and the intended actions they should implement.

Care homes operate within a wide range of governance structures, which range from single independent homes, to large UK wide corporations.  These structures impacted, both positively and negatively, on the capacity of individual unit managers to respond to COVID -19, with a range of support structures for the larger organisations, to the agility of the independent homes to quickly assimilate information. 

Care Inspectorate inspects care homes individually, however it may be helpful also to understand the culture, management process and impact of the overarching corporate approach or parent company, and we recommend that it is an area for further consideration.


  • Undertake a thorough review of the joint inspection process to ensure a truly integrated approach to inspection in care homes is in place 
  • Ensure that relevant professional national IPC expertise is at the centre of the process, to provide a consistent level of expertise and support 
  • At present the operation of the wider company structure is out with the scope of Care Inspectorate scrutiny, and consideration should be given to extending its remit to corporate entities