Mapping the Evidence on Care Home Decarbonisation: A Scoping Review Revealing Fragmented Progress and Key Implementation Gaps

As the present review aims to chart the evidence on decarbonisation in care home settings to identify knowledge gaps and priority areas for future policy, practice, and investigation, the manuscript provides a scoping review of the evidence, strategies, and research gaps in this area. Moreover, the topic is meaningful and important, particularly given the growing emphasis on sustainable healthcare and the unique energy demands of care home settings. The manuscript is well-structured, clearly written, and makes a valuable contribution to the field. Overall, the manuscript has identified several gaps in the existing evidence and has made a positive contribution to this field. The reviewer recommends that the manuscript be accepted after minor revision based on the following comment:  

Thank you for your helpful feedback. The comments have been addressed below.

(1) More quantitative description and analysis can be added regarding Figure 1. The PRISMA-ScR flowchart (Figure 1) effectively outlines the study selection process. However, the manuscript would benefit from a more detailed quantitative description and analysis of the screening and inclusion stages. For instance, it would be helpful to present and analyse the proportion of records excluded at each stage (e.g., percentage excluded after title/abstract screening, full-text review), and the primary reasons for exclusion (e.g., wrong setting, wrong outcomes, etc.).

That you for this suggestion. The description regarding the study selection process has been enhanced as below:

“The search strategy yielded 6735 results. This was reduced by 53% after duplicates were removed, leaving 3165 records for title and abstract screening. Following title and abstract screening, 3087 records were excluded (45.84%) as they did not meet the inclusion criteria, this was primarily due to records focused on the wrong setting (e.g. hospitals, healthcare clinics) or the wrong outcomes (e.g. interventions to prevent or better manage disease), many records were also editorial statements or commentary pieces, while four records could not be found. 75 records were therefore reviewed at the full text stage. At this point, a further 0.79% were excluded. Therefore, after the full-text review stage, 22 articles were deemed eligible and included in the final review. A PRISMA-ScR flowchart has been provided to summarise the study identification process in Figure 1.”

(2) There are a lot of acronyms throughout the whole manuscript. It would be helpful to add a table to summarise all the acronyms and full names.  

Thank you for this helpful suggestion.

We have an “Abbreviations” section at the end of the manuscript summarising all acronyms and their full names for reader clarity.

(3) Additionally, the authors are encouraged to outline a specific research agenda for future studies in this area. The significance and direction of future research can be stated in detail in the last part of the 5. Conclusions.

Thank you for this suggestion, the conclusions section has been adapted to better outline a research agenda for future studies in this area as below:

“This review has identified several gaps in existing evidence. Notably, there is a lack of routine baseline carbon footprints for care homes, limited data on the comparative effectiveness and cost-efficiency of interventions tailored to resource-constrained settings, and insufficient research on the potential for decarbonisation to enhance care quality and resident wellbeing. These gaps are particularly significant given the acute operational and financial pressures faced by this sector. Promising, emerging research areas which require further exploration include the integration of decarbonisation with climate adaptation, the use of digital technologies and smart systems, and circular economy approaches to procurement and waste.

Care homes are a critical, yet overlooked, sector in broader efforts to achieve healthcare decarbonisation and climate targets. The evidence base is fragmented, with substantial gaps remaining across all key emission scopes. Addressing decarbonisation in care homes requires co-ordinated focus on organisational change, staff and resident engagement, together with robust economic analysis and evaluation of health co-benefits. Unlocking co-benefits, such as improved health, climate resilience, and economic savings, may depend on the adoption of multi-disciplinary, systems-based strategies. Future studies should prioritise the development and piloting of scalable interventions that may be feasible for stretched care home budgets and are sensitive to care quality concerns. As climate risks and regulatory pressures increase, there is an urgent need for such care home tailored research, targeted policies, and dedicated guidance. This includes ensuring care homes are recognised within broader Net Zero healthcare frameworks and developing mechanisms for cross-sector learning from hospitals, hotels, and other 24/7 facilities with similar operational demands.”

The manuscript is methodologically rigorous, clearly structured, and makes a valuable contribution by synthesizing a fragmented evidence base. The use of the GHG Protocol scopes as an organizing framework is highly effective and provides immediate clarity. The discussion is insightful, moving beyond a simple summary to identify key gaps and provide strategic, actionable recommendations for research, policy, and practice. After a few minor revisions, the manuscript will be a significant addition to the literature. Here are some comments.

Thank you for this very helpful feedback. Your comments have been addressed below:

[1] Specify the number of databases searched in the methods sentence (e.g., “seven databases...”).

Thank you for this helpful suggestion. We have revised the sentence in the Methods section to explicitly state the number of databases searched. The revised sentence now reads:

“To identify potentially relevant studies, seven bibliographic databases were searched…”

[2] Add a sentence after introducing the GHG Protocol scopes (page 3) to more explicitly state the review's hypothesis that the evidence is likely uneven across these scopes, which this review will map.

Thank you for this helpful comment. We have added a sentence near the end of the paragraph introducing the GHG Protocol to make the review’s working hypothesis explicit.

The new text reads:

“Accordingly, this review sought to map and synthesise evidence across all scopes to identify areas of concentration and neglect. It was hypothesised that existing evidence on care home decarbonisation would be uneven across the three GHG Protocol emission scopes, with Scope 2 (purchased electricity) likely to be most represented.”

This addition strengthens the conceptual framing and clarifies the focus of the scoping review.

[3] Add the number of reports excluded at the full-text stage (n=53) to Figure 1 for completeness.

Thank you for highlighting this, the PRISMA-ScR figure has been updated with this addition.

[4] In the Scope 1 results section (3.2.1), add a sentence to starkly highlight the trade-off.

Thank you for this constructive suggestion.

We have added a sentence to the Scope 1 results section to explicitly emphasise the trade-off between reducing direct emissions and the potential increase in indirect electricity use.

The revised text now reads:

This finding highlights a critical trade-off, while low-carbon heating systems can reduce direct (Scope 1) emissions, the compensatory use of electric heating devices for psychological comfort may inadvertently increase indirect (Scope 2) emissions, thereby offsetting some of the anticipated environmental benefits.

[5] In the discussion, subtly reframe the health co-benefits to more explicitly connect them to the core business incentives of a care home (e.g., quality of care, resident and family satisfaction, operational stability).

Thank you for this helpful suggestion. We have added two sentences to the paragraph discussing health co-benefits to explicitly link these outcomes with care home business priorities.

The revised text reads:

“These co-benefits are not only important for resident health but also directly relevant to the operational goals of care homes [73]. Improved air quality, comfort, and wellbeing can enhance perceived quality of care, increase resident and family satisfaction, and contribute to organisational stability by reducing energy costs and creating healthier working environments for staff.”

[6] A final careful proofread is needed to catch minor typographical errors (e.g., on page 8, “energy analysis and energy analysis” is repeated; on page 11, the reference to Verges et al. 2024 uses the wrong citation number [51] which should be [56]).

Thank you for identifying these minor errors. We have carefully proofread the manuscript and corrected typographical and citation issues. Specifically, to remove the repetition of “energy analysis” on page 8, and the citation for Vergés et al. (2024) has been amended from [51] to [56]. A final proofreading check was completed throughout the manuscript to ensure accuracy and consistency.

The manuscript presents a comprehensive scoping review of existing evidence on decarbonization
in care homes, with particular attention to greenhouse gas (GHG) emission scopes 1–3. Guided by
the Joanna Briggs Institute (JBI) methodology and the PRISMA-ScR framework, the review
synthesizes 22 studies published between 2014 and 2025. The authors categorize findings by
emission scope and identify evidence gaps, particularly in Scope 1 (direct) and Scope 3 (supply
chain) emissions. The study provides actionable recommendations for policy, research, and
practice. However, further revisions are needed in several sections to improve the presentation
quality of this manuscript. Here are some comments.

Thank you for this feedback. We have addressed all points raised as detailed below.

[1] Replace the current title with a new one which could better show the main idea of this
manuscript.

Thank you for this suggestion, the title has been updated to highlight the main findings of the review:

“Mapping the Evidence on Care Home Decarbonisation: A Scoping Review Revealing Fragmented Progress and Key Implementation Gaps”

[2] In the “Abstract”, remove words like “Background” “Results” “Conclusions”. Rewrite the
abstract clearly presenting the research topic/research gap, method and data, results/conclusions,
and contributions.

Thank you for this helpful suggestion. We have revised the abstract to follow the standard unstructured format required by Sustainability. The subheadings “Background,” “Methods,” “Results,” and “Conclusions” have been removed.

[3] Delete numbers and “;”s in front of each keyword.

Thank you. The numbers have been deleted from in front of each keyword.

[4] Delete “nursing homes” in the Keywords.

This has now been deleted.

[5] The terms “care homes” and “care home” appear multiple times in the manuscript.
Standardize the usage and apply a single form consistently in the entire manuscript.

Thank you for this observation regarding the inconsistency in the use of “care home(s)”. We have revised our manuscript to ensure consistency with care home terminology, retaining “care home” and “care homes” as appropriate to the context; either the singular form "care home" when referring to an individual facility, or the plural “care homes” when discussing the sector or multiple facilities collectively. This ensures both linguistic precision and contextual clarity throughout the manuscript.

[6] Rewrite the “objectives” within one paragraph in the end of the Introduction.

Thank you for this suggestion, the objectives have now been incorporated into one paragraph at the end of the Introduction as below:

“Overall, the present review aimed to chart the evidence related to decarbonisation in care homes in order to identify knowledge gaps and priority areas for future policy, practice, and investigation, via the following objectives: (1) to chart the range of decarbonisation strategies evaluated in care homes; (2) To synthesise evidence from studies measuring energy performance, carbon footprint, and efficiency in care homes; (3) To examine how care home residents, staff, and owners perceive and experience decarbonisation interventions, including facilitators and barriers to their implementation; (4) To identify gaps in existing research regarding decarbonisation in care homes.”

[7] Clearly present the unique contributions of this manuscript to the literature.

Unique contributions have now been highlighted in the introduction and discussion as below:

Introduction:

“In long-term care settings, this evidence gap is especially acute, because food systems, pharmaceuticals, and disposable products are integral to everyday operations. Although policy momentum is growing, there is no comprehensive synthesis of decarbonisation strategies tailored for long-term care. Without such a synthesis, providers and regulators across diverse settings lack evidence-based guidance needed to inform practice, training, or regulatory design.

To date, existing reviews of healthcare sustainability and decarbonisation have focussed on hospitals or whole health systems [15,32,33], leaving care homes underrepresented despite their distinct energy use, procurement patterns, and contextual challenges. Accordingly, this review sought to map and synthesise evidence across all scopes to identify areas of concentration and neglect.”

Discussion/Implications:

“Existing evidence highlights several benefits to implementing decarbonisation in care homes. For example, the potential health co-benefits of decarbonisation, including enhancement of air quality, thermal comfort, and nutritional quality of meals [45,52,55,59,60]. Increasing awareness of these health benefits may help to increase engagement with decarbonisation strategies. There is a need for care-home specific decarbonisation guidance, which may go beyond current frameworks such as the CQC’s Single Assessment Framework [21]. For example, policy innovation, such as per-bed renewable quotas [54] or targeted financial incentives for care homes could enable sector-wide progress. …”

[8] Add the structure of the manuscript as the last paragraph in the “Introduction”.

Thank you for this suggestion, the following has been added to the Introduction section:

“The remainder of this paper is structured as follows. The Methods section outlines the scoping review protocol to include eligibility criteria, search strategy, study selection process, data extraction and synthesis approach. The Results section then presents the main findings of the included studies, mapped by GHG emission scope. The Discussion then interprets these findings in relation to the current literature, highlights research gaps and implications for policy and practice, and considers the limitations of the present review. Finally, the Conclusion section summarises the key contributions of this review and offers recommendations for future research in care home decarbonisation.”

[9] In the “Discussion/Limitation”, briefly expand on the implications of excluding grey
literature.

Thank you for this comment, we have expanded on this as below:

“The exclusion of grey literature such as policy reports, and other non-peer reviewed evidence may also limit insights into real-world practice and innovation. Omitting these sources may reduce the comprehensiveness of this review, and potentially overlook policy developments or implementation experiences which have not been reported in academic journals.”

[10] Expand discussion on systemic barriers to Scope 1 and 3 data collection and strategies for
integrated carbon accounting.

Thank you for this suggestion. We have now summarised the main findings of our review into a diagram (Figure 2. Proposed Model for Decarbonisation in Care Homes) which highlights the barriers.

Additionally, this has been discussed in further detail within the discussion.

“The proposed model (Figure 2) is the first to extend the WHO’s Operational Framework for Building Climate Resilient and Low Carbon Health Systems [28] to decarbonisation in the long-term care sector. This helps visualise how interventions and outcomes are moderated by operational, regulatory, psychological, and economic factors at multiple points, helping explain why decarbonisation remains challenging within the care home sector. By mapping these interactions, the proposed model offers a systems view of care home decarbonisation, shifting the focus from isolated technical fixes toward understanding of how concurrent, sequential, and conditional relationships shape real-world outcomes and identifies barriers that must be addressed for progress across all three emissions scopes.”

[11] Include a summary table of interventions with quantitative emission outcomes.

Thank you for this suggestion. We have now added a table (Table 1. Decarbonisation Strategies and Outcomes Across Emission Scopes) summarising the included studies which explored a decarbonisation strategy, including the quantitative outcomes.

[12] Strengthen linkage between evidence synthesis and international decarbonization
frameworks.

Thank you for highlighting this. As above, we have now proposed a model for care home decarbonisation based on our evidence synthesis which has been linked to the WHO’s Operational Framework for Building Climate Resilient and Low Carbon Health Systems. This has been discussed within the discussion as below:

“The proposed model (Figure 2) is the first to extend the WHO’s Operational Framework for Building Climate Resilient and Low Carbon Health Systems [28] to decarbonisation in the long-term care sector.”

Additionally, further links with decarbonisation frameworks are discussed with the implications section:

“There is a need for care-home specific decarbonisation guidance, which may go beyond current frameworks such as the CQC’s Single Assessment Framework [21]. For example, policy innovation, such as per-bed renewable quotas [54] or targeted financial incentives for care homes could enable sector-wide progress.”

“Recently published priorities to support local government action on health and climate change in England, for example, underscore the need for locally relevant research on the economic, health, and equity impacts of decarbonisation strategies [86]. In line with findings emerging from this review, this suggests meaningful engagement of residents, families, and staff in the design and evaluation of decarbonisation initiatives is essential for acceptability and uptake.”

[13] The title of section 3.3 could be “Strategies”.

Thank you for this suggestion. Section 3.3. has been updated accordingly.

[14] In the “Conclusions" section, structure the future research priorities more explicitly (e.g.,
using a list) for greater clarity and impact.

Thank you for this suggestion, future research priorities have been highlighted more explicitly within the Conclusions as below:

“Care homes are a critical, yet overlooked, sector in broader efforts to achieve healthcare decarbonisation and climate targets. The evidence base is fragmented, with substantial gaps remaining across all key emission scopes. Addressing decarbonisation in care homes requires co-ordinated focus on organisational change, staff and resident engagement, together with robust economic analysis and evaluation of health co-benefits. Unlocking co-benefits, such as improved health, climate resilience, and economic savings, may depend on the adoption of multi-disciplinary, systems-based strategies. Future studies should prioritise the development and piloting of scalable interventions that may be feasible for stretched care home budgets and are sensitive to care quality concerns. As climate risks and regulatory pressures increase, there is an urgent need for such care home tailored research, targeted policies, and dedicated guidance. This includes ensuring care homes are recognised within broader Net Zero healthcare frameworks and developing mechanisms for cross-sector learning from hospitals, hotels, and other 24/7 facilities with similar operational demands.”

[15] Conduct a final editorial proofread for hyphenation, acronyms, and formatting consistency.

Thank you for identifying these minor errors. We have carefully proofread the manuscript and corrected inconsistencies.

I have completed a review of your manuscript, “Decarbonisation in Care Homes: A Scoping Review of Evidence, Strategies, and Research Gaps.” The work presents an scope review of decarbonisation strategies in care homes, identifying knowledge gaps and priority areas for future policies, practices, and research. The manuscript's structure is very good. The following comments focus on increasing the impact, clarity, and strength of the arguments, particularly in the synthesis of key data that justify the urgency of addressing this sector.

Thank you for this very helpful feedback. Your comments have been addressed below:

(1) Inconsistency in the number of paper not retrieved: 4 papers are mentioned in the text (line 237) and 3 in Figure 1 (Reports not retrieved, n=3). Please align these numbers to ensure methodological transparency.

Thank you for highlighting this error, this has been checked and updated for accuracy.

(2) The statement "These emissions were composed of 11.78% Scope 1, 31.36% Scope 2, and 56.86% Scope 3, with the top three contributors coming from building energy (mainly electricity use) (47.25%), food and catering (15.41%), and water and waste (6.46%)". This is confusing for the reader as it suggests an inconsistency, given that Scope 2 is only 31.36 %. Please separate these figures into two sentences or clarify explicitly that the "Building energy" category is a functional category that sums Scope 2 (electricity) and the relevant portion of Scope 1 (gas).

Thank you for highlighting this. This sentence has been expanded for clarity as below:

“This comprised of health services, aged care services, and support services, with aged care found to contribute 47.81% of total greenhouse gas emissions. These emissions were composed of 11.78% Scope 1, 31.36% Scope 2, and 56.86% Scope 3. The top three contributors were from building energy (47.25%) which came mainly from electricity use (scope 2) and gas combustion (scope 1), followed by food and catering (15.41%) and, water and waste (6.46%)”

(3) The finding that aged care emissions (47.81 %) are comparable to health services emissions (49.16 %) is the central justification for the study. Although it is only mentioned in one reference. This critical data point must be included in the Conclusions section.

Additionally, I suggest including the percentage figures for Health Services and Support Services in Section 3.2 to properly contextualize the total organizational impact.

Thank you for highlighting this. We have now ensured to reference this within the conclusions section:

“Especially due to their comparable emissions with health services [45], care homes represent a critical, yet overlooked, sector in broader efforts to achieve healthcare decarbonisation and climate targets.”

Additionally, we have included the percentage figures for Health Services and Support Services in Section 3.2. to ensure this impact is contextualised:

“Aged care was found to contribute 47.81% of total greenhouse gas emissions of the health provider, while the health services and support services divisions contributed 49.16% and 3.03% respectively.”

(4) I recommend including the normalized intensity figure from study [42] in the Discussion. This contrast is essential to argue that the low perceived intensity has diverted attention from the high absolute volume of emissions, which represents a key barrier to investment and action in the sector.

Thank you highlighting this important contrast. We have now referenced this a number of times within the discussion:

“With the exception of one Australian study which measured Scope 1, 2, and 3 emissions of a health and aged care provider and found aged care contributed 47.8% of total greenhouse gas emissions, similar to the health services division [45]. This contradicts the assumption that health services have a higher carbon footprint than care homes, highlighting the substantial emissions of the care home sector and the need for equal attention to both health and aged care sectors in decarbonisation. Increased awareness of their comparable emissions may help to prioritise care homes within decarbonisation strategies.”

“Especially due to their comparable emissions with health services [45], care homes represent a critical, yet overlooked, sector in broader efforts to achieve healthcare decarbonisation and climate targets.”

(5) A commentary on demographic projections regarding global population aging is recommended, backed by data (e.g., UN projections). This would give the Introduction or Discussion of your manuscript a dimension of importance and urgency regarding energy consumption and GHG emissions in the aged care sector.

Thank you for this helpful suggestion. The following paragraph has been added to the introduction and referenced within the discussion:

“To date, most policy and research momentum has concentrated on hospitals and acute care facilities, where large-scale technical interventions (renewable energy, building retrofits, anaesthetic gas substation) have been documented and evaluated [3,14–17]. In contrast, long-term and residential care remains comparatively neglected in both research and policy, despite its expanding role in ageing societies worldwide. According to UN projections, the global population aged 60 years and older is expected to double from approximately 1.2 billion in 2024 to 2.1 billion by 2050, accounting for 26% of the population [18]. This will inevitably increase demand for residential and long-term care services, amplifying the energy consumption and greenhouse gas emissions of care homes.”

In this study, the evidence related to decarbonisation in care home settings were charted in order to identify knowledge gaps and priority areas for future policy, practice, and investigation. It mainly includes charting the range of decarbonisation strategies evaluated in care homes, synthesising evidence from studies measuring energy performance, carbon footprint, and efficiency in care homes, examining how care home residents, staff, and owners perceive and experience decarbonisation interventions, including facilitators and barriers to their implementation, and identifying gaps in existing research regarding decarbonisation in care homes.

The article has certain application value, but the research depth is slightly insufficient. Before publication, some contents in the manuscript still need further adjustment and improvement.

Thank you for this constructive feedback. We have carefully reviewed and addressed all points raised to enhance the depth, clarity, and overall quality of the manuscript. Specific revisions are detailed below.

The abstract is not written in a standardized manner, and does not conform to the standard writing style of a paper abstract. It is suggested to delete the words "Background:", "Methods:", "Results:", and "Conclusions:".

Thank you for this helpful suggestion. We have revised the abstract to follow the standard unstructured format required by Sustainability. The subheadings “Background,” “Methods,” “Results,” and “Conclusions” have been removed.

In the keywords, it is recommended to delete the serial numbers.

Thank you. These have been deleted from the manuscript.

The discussion of relevant research in the introduction is somewhat lacking in hierarchy. It is suggested to further enrich the review of the existing relevant research.

Thank you for this suggestion.

The introduction has been enhanced to incorporated increased relevant research, and improve the hierarchy and structure

The research methods adopted in this paper should be further elaborated in detail.

Thank you for this comment. The methods applied in this review were conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews and are fully documented in the registered protocol and PRISMA-ScR checklist. These resources ensure methodological transparency and reproducibility. Therefore, no major changes were required to the Methods section beyond clarifying this compliance in the manuscript.

The industry standards that appear in the text should be listed in the references.

Thank you for identifying this oversight.  We have carefully proofread the manuscript and corrected citation issues. A final proofreading check was also completed throughout the manuscript to ensure accuracy and consistency.

As a review paper, the number of references is insufficient. It is suggested to further increase the search and citation of relevant references.

Thank you for this comment. The numbers of studies identified, screened, and included are clearly reported in the Results section and summarised in the PRISMA-ScR flow diagram (Figure 1). Specifically, 6,735 records were identified across seven databases, 3,570 duplicates were removed, 3,165 records were screened, and 22 studies were included in the final review. The manuscript cites all eligible studies identified through this process in accordance with the Joanna Briggs Institute (JBI) methodology.

A broad search strategy was utilised to ensure potentially relevant literature was identified, however there are notable gaps in this under-researched area which this review has highlighted.

As a review, it is advisable to use as many tables and figures as possible to summarize the data and results of relevant studies and investigations.

Thank you for this suggestion. We have now summarised the main findings of our review into a diagram (Figure 2. Proposed Model for Decarbonisation in Care Homes). Additionally, a table (Table 1.) has been provided to summarise the interventions and associated outcomes synthesised within the included studies.

The conclusion should be further refined and appropriately expanded to include the future prospects related to this research.

Thank you for this suggestion. The conclusion has been expanded to include suggestions for future research as below:

“This review has identified several gaps in existing evidence. Notably, there is a lack of routine baseline carbon footprints for care homes, limited data on the comparative effectiveness and cost-efficiency of interventions tailored to resource-constrained settings, and insufficient research on the potential for decarbonisation to enhance care quality and resident wellbeing. These gaps are particularly significant given the acute operational and financial pressures faced by this sector. Promising, emerging research areas which require further exploration include the integration of decarbonisation with climate adaptation, the use of digital technologies and smart systems, and circular economy approaches to procurement and waste.

Care homes are a critical, yet overlooked, sector in broader efforts to achieve healthcare decarbonisation and climate targets. The evidence base is fragmented, with substantial gaps remaining across all key emission scopes. Addressing decarbonisation in care homes requires co-ordinated focus on organisational change, staff and resident engagement, together with robust economic analysis and evaluation of health co-benefits. Unlocking co-benefits, such as improved health, climate resilience, and economic savings, may depend on the adoption of multi-disciplinary, systems-based strategies. Future studies should prioritise the development and piloting of scalable interventions that may be feasible for stretched care home budgets and are sensitive to care quality concerns. As climate risks and regulatory pressures increase, there is an urgent need for such care home tailored research, targeted policies, and dedicated guidance. This includes ensuring care homes are recognised within broader Net Zero healthcare frameworks and developing mechanisms for cross-sector learning from hospitals, hotels, and other 24/7 facilities with similar operational demands.”

The author needs to clearly present the research objectives in the introduction.

Thank you for this comment. The research objectives are clearly stated at the end of the Introduction section. This paragraph outlines the purpose of the review and specifies the objectives, which are to chart and synthesise the evidence on decarbonisation strategies in care home settings, identify evaluated interventions, explore stakeholder perspectives, and highlight gaps to inform future policy, practice, and research.

This paper requires a more detailed theoretical review of the key concepts.

In addition, it is necessary to logically illustrate the flow of the research by visualizing how the related concepts are structured and what unique characteristics are derived, as well as how the study introduces new perspectives.

It is recommended to provide a conceptual map in the conclusion section to help readers better understand the presented content.

Thank you for these helpful suggestions.

We have now summarised the main findings of our review into a diagram (Figure 2. Proposed Model for Decarbonisation in Care Homes).

In addition, we have enhanced both the introduction and discussion sections of the manuscript to provide a more detailed theoretical review.

Although some visualization has been provided in the methodology section, the number of samples and the analytical methods should be described in a more coherent and systematic manner.

If possible, numerical evidence that can serve as objective support should also be included.

Thank you for this suggestion. Further numerical evidence has been presented in the results to articulate the sampling and screening process as below:

“The search strategy yielded 6735 results. This was reduced by 53% after duplicates were removed, leaving 3165 records for title and abstract screening. Following title and abstract screening, 3087 records were excluded (45.84%) as they did not meet the inclusion criteria, this was primarily due to records focused on the wrong setting (e.g. hospitals, healthcare clinics) or the wrong outcomes (e.g. interventions to prevent or better manage disease), many records were also editorial statements or commentary pieces, while four records could not be found. 75 records were therefore reviewed at the full text stage. At this point, a further 0.79% were excluded. Therefore, after the full-text review stage, 22 articles were deemed eligible and included in the final review.”

Additionally, numerical evidence for the included studies is included within the results synthesis. For example:

“First, however, one study measured scope 1, 2 and 3 emissions from a health provider in Australia across one year [46]. Aged care was found to contribute 47.81% of total greenhouse gas emissions of the health provider, while the health services and support services divisions contributed 49.16% and 3.03% respectively. The aged care division emissions were composed of 11.78% Scope 1, 31.36% Scope 2, and 56.86% Scope 3, with the top three contributors coming from building energy (mainly electricity use) (47.25%), food and catering (15.41%) and, water and waste (6.46%). Although it had been hypothesised that the health services division would have a higher carbon footprint, results showed health services and aged care divisions had comparable total emissions and therefore required equal emission reduction attention. Aged care showed some differences to the health services division. For example, food and catering (scope 3) was responsible for 15.41% of emissions in aged care compared to only 4.16% of health services. Additionally, water and waste accounted for a greater percentage of emissions in aged care (6.46%) than health services (3.06%).”

The manuscript presents a scoping review that effectively maps and synthesizes the fragmented evidence on decarbonization in care homes. The authors have carried out a methodologically rigorous review, and the work represents a timely and meaningful contribution to the literature. The revisions made in response to previous reviewer comments have clearly strengthened the manuscript. Here are some comments for final minor revisions before publication.

Thank you for your time and consideration of our manuscript. We have revised the paper in accordance with all comments and suggestions provided, which we believe has strengthened the quality and clarity of our paper.

We have addressed the minor revisions suggested as below:

[1] In the Abstract, provide a minor rephrase for precision, e.g., “The evidence was concentrated on strategies for reducing Scope 2 emissions..., with far fewer studies addressing Scope 1... and Scope 3...”.

Thank you for highlighting this, we have updated the phrasing in the abstract as below:

“The evidence was concentrated around Scope 2 emissions, through efforts to monitor and reduce electricity use, while Scope 1 (facility emissions) and Scope 3 (supply chain emissions) remain comparatively underexplored.”

[2] In line 333-334 “...others included care homes among other buildings...” The phrasing is slightly awkward. It could be “...other studies analyzed care homes within a broader sample of building types...”.

Thank you for this suggestion. We have updated the phrasing of this sentence as below:

“The others included care homes within a broader sample of varied building types”

[3] Add one or two sentences explaining that the “Effect Modifiers” (e.g., risk aversion, resident behavior) can either enable or hinder the “Interventions”, and that the “Mediation Pathways” (the emission scopes) are the mechanisms through which the interventions lead to the “Net Zero Outcomes”.

Thank you for this helpful suggestion, we have now added some information to better explain the proposed model:

“The main findings of this review have been synthesised into a model (Figure 2) to present the proposed decarbonisation interventions, and net zero outcomes, identified within the included studies. Effect modifiers such as emissions measurement, operational constraints, risk aversion, and resident behaviours can act as either facilitators or barriers to the successful implementation of decarbonisation interventions within care homes. The mediation pathways, corresponding to Scope 1, 2, and 3 emissions, represent the mechanisms by which these interventions influence the achievement of Net Zero Outcomes, including reduced emissions, lower costs, and associated health co-benefits.”

The authors have completed the revisions in accordance with the reviewers' comments and suggestions.

Thank you for your time and consideration of our manuscript. We have revised the paper in accordance with all comments and suggestions provided, which we believe has strengthened the quality and clarity of our paper.

Revision is done well.

Thank you for your time and consideration of our manuscript. We have revised the paper in accordance with all comments and suggestions provided, which we believe has strengthened the quality and clarity of our paper.