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
2. Experience in first wave

2. Experience in first wave

None of the four homes included in the review had experienced a previous outbreak of COVID-19 in the first wave of the pandemic and one of the key roles for the review was to explore if those homes, not previously affected, were more at risk now. 'Those involved in managing incidents are expected to evaluate and report on the effectiveness and efficiency of their efforts. NHS boards, LAs and national agencies should share information on public health incidents with interested parties, so that the whole service can learn from the experience of others' (PHS 2020)[15] 

The Incident Management Team (IMT) chair for an investigation of an outbreak is responsible for identifying and following up key learning points. We learned a number of lessons, which had been identified locally through our interviews with the DPHs and with national bodies. We were informed that these were being shared informally at local level and with PHS in twice weekly calls during the pandemic. We found little collation of these for wider system sharing in formalised reports from the first wave or subsequently. Those interviewed, both at local and national level, told us this reporting was hampered by the nature of the pandemic, the number of concurrent outbreaks happening across a variety of settings, competing priorities and resource constraints.

A formal national lessons learned exercise in relation to reducing delayed discharges and hospital admissions was undertaken by COSLA and the H&SC partnerships after the first wave of the pandemic in March and April 2020.[16] The report examined delayed discharges, A&E attendances and hospital admissions, which all reduced significantly during March and April as the COVID-19 pandemic surge progressed in Scotland. The review identified a number of issues which pertain to this current review. The key themes related to the Terms of Reference for this review from the first wave were: distribution of PPE and changing guidelines for its use, confusion over changing testing guidance, impact on care sector staff who have been left feeling unappreciated and fatigued. These themes were also pointed to in the care inspectorate report on learning during the pandemic (2020)9.  Whilst PPE distribution has clearly improved in the intervening period, as it did not feature as a theme in this review; guidance production, timing, versions and dissemination continues to be a challenging theme. Care sector staff and their professionalism and wellbeing also feature as a theme in our review, as did the impact of multiple investigations of the care home in the context of outbreaks. 

The first wave report noted that mobilisation of NHS staff to support the sector in relation to IPC procedures, PPE use, and translation of guidance had been helpful, however it had 'muddled the oversight, accountabilities and governance'15. We found in our interviews for this review with the NHS boards that new governance and accountabilities had been put in place and were continuing to be refined in the light of the Cabinet Secretary letter to Executive Nurse Directors6. Partnership organisations expressed concern that IPC was making care homes into 'mini hospitals' and that there was a desire to return to recognising care homes are people's homes. This concern also featured in our discussions with the care home managers from the four homes currently experiencing large outbreaks in this second wave, and additionally it was raised by national organisations and by the family representatives. The importance of risk-based and proportionate IPC, inclusive of its application to visiting, is critical to the sector. Care homes need support for local risk assessment, and sharing of what works well, in terms of applying the national guidance in context in other care homes.

The Care Inspectorate report (2020)9 pointed to higher rates of suspected cases in larger care homes (comparing those with <10 places to those >60), and higher prevalence of suspected cases in homes which required nursing care, and in urban versus rural settings, mirroring the prevailing community prevalence. The report also highlighted issues in relation to staff shortages during the first peak, with 13% of care homes reporting issues at that time. Recommendations were made in relation to augmenting future inspection frameworks to include IPC measures, recognising the concerns raised by families and wider stakeholders about their concerns with the use of IPC measures during this time. The aspects of IPC being further augmented in future inspection frameworks and staffing shortages also feature in this review.

As mentioned previously, none of the four homes included in the review had experienced a previous outbreak of COVID-19 in the first wave of the pandemic. DPHs informed us that their focus of support had been on those homes with outbreaks, and the larger care homes in terms of wider preparedness, based on evidence from the first wave. It is therefore likely that those homes who previously had experienced an outbreak, also received focussed interventions, training and support and therefore may have been better prepared than those who had not experienced an outbreak to date. 

The challenges in the first wave centred on availability of PPE, and this was resolved by system connectedness to receive supplies from the NHS. Other issues included hospital admissions and ensuring testing and quarantine arrangements were in place, as well as ensuring IPC measures were reviewed; these areas have been strengthened with guidance and policies on testing and IPC in the intervening period. The issues being experienced in these four care homes in this second wave are different. New factors include: the introduction of COVID-19 via care workers who have travelled to areas within and beyond the UK with a high prevalence of COVID-19, better identification of the risk of asymptomatic cases via routine screening and testing, data availability, and testing capacity when needed.  In addition to the IPC there is a need to keep care home staff aware of the changing epidemiology and risks; we heard of the first positive case in one home being a returning care home worker from a holiday within the UK. The area was one with a high community prevalence, and care home staff and managers need to be aware of this risk. Raising awareness of the wider spectrum of symptoms in older people, which is the subject of guidance issued after the first wave, should also be helpful in early identification of residents at risk in care homes, to prevent spread.

PHS reported that there were differences in the challenges now, as compared to wave one. In wave one these were structural; there was still preparedness underway as the HPTs mobilised the resources they needed, and joined up HSCP working was strengthened to support the response. The challenges faced by care homes were about staffing, pay and conditions, and availability of PPE. Current challenges with control measures in wave two relate to: symptom vigilance; IPC training; physical distancing; car sharing; and understanding or managing risk that arises outside of the direct care environments in care homes, such as during break times. The DPHs also pointed to challenges with resourcing continuity, as the many staff deployed to create the surge capacity required earlier in the year, had been mobilised from services which had been paused, or from academia and under-graduate students, and those staff had now returned to those services or to their studies. 

PHS noted the importance of considering wider lessons learned from other population-level COVID-19 outbreaks, such as shared coach travel and holidays in areas of high prevalence of COVID-19 within and outside of the UK. This learning should translate to development of further guidance and care home managers considering their strategy for care home workers who return from leave in this context carefully, and managing the risk by ensuring uptake of staff testing remains high and is undertaken in a timely manner.

In considering the reasons for the high attack rate in these four homes, PHS suggested that there are a range of relevant hypotheses, including that these homes could be 'virus na├»ve' as they had not had an outbreak in the first wave and so may not have had the same level of preparedness and vigilance as to be alert to the on-going risk; wider use of PPE and variation in IPC adherence may be impacting transmission in specific homes, especially given the risk of asymptomatic spread. ARHAI Scotland reinforced this point highlighting on-going variation in care homes with respect to glove use, hand hygiene, and cleaning. There is also a theory that foot fall (number of people inclusive of visitors moving in a space) in larger homes may also account for how many of the outbreaks in the first wave occurred in the larger homes. 

Outbreak susceptibility and risk is a ubiquitous threat in all care homes during the pandemic.  A single case has the propensity to result in a very high attack rate throughout a care home. System vulnerabilities may be addressed by system leadership, safe staffing levels, and IPC adherence in the built environment in all long term care settings. In summary, all the international evidence points to the fact that once COVID-19 has been introduced into a care home, it has the potential to result in high attack rates among residents and staff members, and this is what occurred in each of the homes examined. 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.


  • Board level and national-level lessons learned for care homes are required to be continuously reported and shared in the pandemic with the care homes and the wider system
  • All long-term care facilities (care homes, residential settings and community hospitals) need to implement active measures to prevent introduction of COVID-19 and be kept up to date with the emerging epidemiology and IPC issues.
  • Additional factors found for consideration of further guidance and support include: travel associated risks in care workers, on-going variation in care homes with respect to glove use, hand hygiene, and cleaning
  • IPC, inclusive of its application to visiting, is critical to the sector. Care homes should have access to expert IPC advice to support local risk assessment and a mechanism should be developed to enable sharing of what works well, in terms of applying the national guidance in a local context