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 terms of reference (Appendix 1) detailed the key roles the review was required to fulfil and these determined the approach undertaken. These key roles were: 

  • Follow an adverse incident investigation process to identify any common themes and learning from recent care homes outbreaks
  • Consider COVID-19 outbreaks from August 2020 in care home settings identified to understand: 
    • the factors that led up to a COVID-19 care home outbreak; and
    • if there are shared new characteristics across these.
  • Understand the characteristics and risk factors of outbreaks in care homes and assess this against learning in the first half of 2020. This approach will ensure appropriate clinical and operational guidance can be prepared for the sector.
  • Review feedback and information from local incident management teams and other data sources e.g. safety huddle tool across all KPI's including workforce, DPH weekly returns, care inspectorate data, SSSC data, Scottish Care data. Review timeline of events so far from IMT minutes and documents related to these care homes.
  • Undertake interviews with local oversight teams and care homes.
  • Explore the hypothesis that care homes that were not affected by COVID-19 to June 2020 are more at risk this winter.
  • 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 to deliver within this context.

Root cause analysis is a methodology applied to support and add rigour to serious incident investigations by applying a systematic process, whereby the factors that contributed to an incident are identified. The principles in the national adverse event framework approach[3] were adapted to address the aim and cover the key roles identified for this review in the TOR. This was to enable the identification of common themes across the four homes reviewed, rather than a specific root cause analysis in each individual home, to be presented. This also enabled a broader perspective of identifying local common experiences and sharing of learning from the four homes and wider parts of the system, to inform national learning in line with the aim of the review.

A desk top evaluation of all the evidence supplied to the review team, as detailed in the TOR, was undertaken to inform a time line of events in each of the homes; detailing the events leading up to the first confirmed case of the outbreak and the events and process which followed thereafter. Emerging issues from that process were used to inform the interview process[4] and interviewees. An appreciative inquiry approach was adopted for the interviews. The intelligence from all the sources was synthesised using Ishikawa analysis and identifying common themes and root causes.

Recommendations from this review are made at the system level to address the specific factors identified in the evaluation of the events in the four homes collectively and the wider system factors identified in the review.