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 RCA revealed certain factors, or root causes, that directly contributed to the increased vulnerability, in the care homes included in this review, to the spread of COVID-19. These factors have been found to be present in at least two or more of the care home included in this review. These are collectively summarised as including:

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 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 DPH reports (indicators included staffing data, single positive cases and self-reporting of these not sufficient to identify risk e.g. 100% compliance with IPC and PPE reported, but this was discovered not to be the case when inspected); 

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 re risk 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 did not have well-established relationships with the NHS boards, tended not to use 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, this warrants further investigation.

In summary, high community prevalence and slow confirmation of an outbreak after the first case was detected was a common cause of the high attack rate identified. Many of the positive cases were not identified quickly because they were asymptomatic or there was a lack of awareness in those interviewed of the wider spectrum of symptom presentation in older people. This resulted in testing not done in a timely manner. As a result additional control measures were put in place too late to stop the widespread transmission. Key to this is timely testing and reporting of results, in order that control measures can be put in place and so we must consider the system which may have created the optimal conditions for the virus to spread among older people in these care homes.The challenges with high community prevalence in the local areas, testing availability and turnaround times, combined with high 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. 

Once COVID-19 has been introduced into a care home, it has the potential to result in high attack rates among residents, staff members, and visitors, and this occurred in each of the homes within this review. It is therefore critical that all long-term care facilities (care homes, residential settings and community hospitals) implement active measures to prevent introduction of COVID-19, and are supported to do so.