CG Reports

CG REPORT 6: Effects of COVID-19 in Care Homes – A Mixed Methods Review

Download Full PDF | medRxiv | Summary & Key Findings

The COVID-19 pandemic disproportionately impacted those living in care homes at the highest risk for severe outcomes. However, the pandemic only highlighted and exacerbated a long-running problem: underfunding, poor structural layout, undertraining, under-skilling, under-equipping, and finally, lack of humanity in dealing with the most vulnerable members of society. Neglect, thirst, and hunger were – and possibly still are – the biggest killers.

This report aimed to address three main questions:

This report provides an up-to-date review of the global effects of the COVID-19 pandemic in care homes. We used a mixed methods approach to assess care home mortality by country, how the deaths compared with previous periods, and how excess deaths may be explained. We retrieved national datasets for 25 countries on mortality, 17 cohort studies assessing deaths compared to a previous period, and 16 cohort studies reporting interventions or factors associated with excess mortality.


Analysis of national datasets for 25 countries shows that care home deaths were, on average, 30% of the total COVID-19 deaths (range: 9-64%). The 17 cohort studies also point to excess mortality worsening during the pandemic, with excess mortality being reported for both COVID-19 positive and negative patients.

Several reported interventions or factors suggest the potential to mitigate the risk in care homes substantially. Interventions that could reduce mortality include improving the care home quality, increasing staffing levels, reducing the number of beds in the facility, employing staff confinement strategies with residents, and improving clinical care such as implementing daily examinations. Some care home solutions like US ‘Green House’ homes, which usually have fewer than 12 beds, may provide crucial insights into the care home problem compared with larger homes. Furthermore, care home residents faced barriers accessing emergency treatments during the pandemic waves. Finally, interventions targeting care homes should be subject to smaller trials given large effect sizes in some studies. 

Main Recommendations

Approximately one per cent of the global population resides in care homes, while care home residents account for nearly one-third of deaths attributed to COVID-19 in the 25 countries studied. Reducing this ratio requires analysing current care home infrastructures, funding models, and incentives for providing high-quality care. The scale of the problem in care homes requires robust evaluation and coordinated strategies to improve outcomes for those most vulnerable to COVID-19. Failure to address these systemic problems could mean global care home populations will be similarly affected by future crises and pandemics.

Quality of Evidence

Despite involving vast numbers of care homes around the globe, the quality of the evidence is not good. For example, the majority of the studies infer the cause of extra deaths from the observation window (mainly the spring of 2020) rather than through detailed investigations. This is why we do not make any one-to-one comparisons between countries or draw any clear conclusions about the causes of death, apart from noting their significantly high numbers. In addition, we did not review all policy actions since 2020 but note there has been a scarcity of studies since then – an indicator that interest in this problem has waned and likely not been addressed.