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


There are 1080 care homes in Scotland, 815 for older adults and a total of 37,300 places in care homes for older adults. 

The majority of the care homes in Scotland are commercial entities, whether established as an individual business, or as part of a larger parent company. All care organisations are required to be registered with the Care Inspectorate (CI)[5]; they are inspected by the CI on a regular basis, and all reports are published in the public domain. The CI has established Memoranda of Agreement, and has undertaken joint inspection processes with associated organisations such as Healthcare Improvement Scotland (HIS) for topic-specific inspections.

On 17 May 2020, Cabinet Secretary for Health and Sport wrote to the Executive Nurse Directors of NHS Scotland Boards to vary their roles and responsibilities in order that they may support the multi-professional oversight of care homes by being accountable for the provision of nursing leadership, support and guidance. This variance included the responsibility to review care home safety huddle data and:  

  • identify where specific nursing support may be required and to develop and implement solutions [to] include clinical input to ensure that there are effective community nursing arrangements in place
  • identify where specific infection control and prevention support may be required [to] include recommendations and review re cleaning to prevent transmission and the appropriate use of PPE
  • support the development and implementation of testing approaches …
  • identify and support sourcing of staffing … [6]

At the date of commission there were four care homes with recently reported outbreaks with high attack rates, wherein a high proportion of staff and residents had tested positive for SARS-CoV-2, and there had been a number of COVID-19 related deaths. The Cabinet Secretary for Health and Sport commissioned a rapid review to ascertain opportunities for learning and quality improvement, with identification of good practice for application across the health and social care spectrum and to support care homes in the effective management of virus transmission.

The continuing COVID-19 pandemic brings an imperative to spread learning and identify areas for systems improvement; this review has been undertaken using root cause analysis methodology, adapting the national adverse incident investigation process[7] to identify any common themes and learning which can be shared with other care homes, care home providers and oversight groups to help reduce the risk of further outbreaks. 

Stakeholders were identified from across a range of NHS, non-NHS, charitable, health and social care organisations, agencies and those directly impacted by the series of events. The client group at the centre of this review consists mainly, but not exclusively, of older people in care homes, many of whom have dementia, or cognitive disabilities. The review team took advice from care home managers and other senior staff as to the ability of their residents to engage with the review; confirmation was given that direct communication with residents would be inappropriate and upsetting. Similarly, it was considered that a direct approach to families, some of whom were very recently bereaved, would be insensitive; we took advice from Scottish Care[8] and sought an alternative approach to ensure we listened to the views of carers and families.

The review team was assisted by a Reference Group; membership consisted of professional clinical staff and experts from across the health and social care system. Its role was to review the process, methodology and list of stakeholders intended by the review team, and then to provide a sense-check of the high level findings and recommendations of the review process, prior to final drafting and submission to the Cabinet Secretary.

The following sections provide a narrative in relation to themes identified from the evidence reviewed, information arising from interviews, considerations made, and conclusions and recommendations.