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


The COVID-19 pandemic has impacted on all aspects of life and society for people across the world. Evidence has emerged of the higher risk of developing severe illness with coronavirus being greater in people who are older and those who have pre-existing health conditions. There is also evidence, worldwide, of the rapid transmission possible within closed settings. Of particular concern are settings where older people, those with weak immune systems and those with long-term health conditions live in environments of multiple occupancy with shared facilities, hence the adverse impact on those who live in long term care facilities worldwide. Many of Scotland's care homes have already experienced outbreaks of COVID-19, particularly in March / April 2020 at the previous peak of the pandemic in the UK, and around 10% of care homes in Scotland have one or more cases of suspected COVID-19 [1], mirroring the current rise in community cases. 

The Cabinet Secretary for Health and Sport commissioned a rapid review of recent COVID-19 outbreaks in care homes; the primary aim of the review was to ensure that areas for improvement are identified, focussing on systems analysis and opportunities to enhance the support available for the delivery of care in the care home sector.[2] 'The aim was to collate and evaluate local level experiences and responses to the resurgence of COVID-19 outbreaks within care homes and to support learning and practice across the sector through the sharing of learning identified and approaches to improvement.' 

This review focussed on four care homes currently identified with outbreaks involving a high number of positive cases of COVID-19. These care homes may not be representative of the experience of other homes in similar circumstances, those homes who had outbreaks with fewer cases, or those with no outbreaks at all. In order to check if these findings were representative of other care homes and NHS Board experiences at this time, we reviewed safety huddle data and other intelligence in the system beyond these homes, and spoke with national organisations. This triangulation indicated these findings were in line with wider system issues. We also checked the findings with the review reference group, who were drawn from NHS Boards and sector partners beyond those four care homes included in the review, they confirmed these were issues in the wider system being experienced. 

Due to the fast-paced environment within which constant evaluation of relevant factors is being undertaken, within a multi-factorial approach involving many agencies, the review team recognise it is possible that work may already be underway to address elements of some of the recommendations we have made. In these circumstances, will serve to reinforce the need for development and progression of these existing work-streams.

The review team wish to record our thanks to everyone who has assisted us with this piece of work. From the outset it was clear that the timescales were demanding and we are grateful to everyone who made themselves available for interview, at extremely short notice. Gratitude is also extended to the members of the Reference Group for contributing their thoughts and ideas and to all who responded willingly to our many requests for data and information. 

We hope the report does justice to the quality of the contributions we received, and helps to build on the substantial improvements which have been made in recent months, by providing clarity on the key issues and highlighting the next critical steps in improving the safety and well-being of care home residents and staff.