Thinking about providing live-in care
Live-in care can range from providing much-needed companionship and peace of mind, to intensive services which help people remain at home, rather than use residential care. It helps people who need support to stay in their own home through to end of life and, as such, is an important component of the full spectrum of home-based care.
People supported by homecare services may have physical or sensory needs that mean they require “round the clock” care, or have a condition such as dementia, Parkinson’s, MS or others that make it difficult for them to be on their own. Live in care also provides an answer to social isolation, with the worker acting more as a companion than a careworker.
During the COVID-19 pandemic, live in care enabled people to reduce the risk of infection, which is higher in hospital or residential care.
Live-in care was originally the preserve of a small number of specialist providers and agencies, but is increasingly being offered by homecare organisations that provide daily care, often in response to user demand.
So what issues should a provider consider before branching out into live in care?
Before starting up or expanding a business to offer live in care, the provider should thoroughly research the market. This is not easy as there is very little data specific to the live in care market, and it doesn’t usually feature separately in national statistics.
A would-be live in care provider should decide whether they are targeting their local care market, in which case an exploratory call to the local authority commissioning team might be a good idea, and looking to see whether there are already successful live-in providers in the local area. Providing services to health commissioners, via the relevant Integrated Care System, is another local option.
Alternatively a provider may want to cover a wider area, perhaps even the national market. The latter would need a more sophisticated analysis of the national market for live in care and would need to consider the fact that separate registrations may be needed with the appropriate care regulator.
Careful thought will be needed on the type of service provided. Do you want to give companionship or provide personal care, or support people with dementia or at end of life? Will your service extend to preventative care or complex care? The answer will depend on how you see your business model and the outcome of your local, or national research.
Live in care is usually provided either as a managed service, where workers are employed by the organisation, or as an introduction service - technically an employment agency - which introduces people to hirers to be employed by the hirer directly. Employment agencies are regulated by the Employment Agencies Act 1973 and the Conduct of Employment Agencies and Employment Businesses Regulations 2003, as revised.
The two different models of service have implications which need to be considered carefully.
A live in service operated as a managed service proceeds in the same way as a conventional homecare service. The organisation employs the worker, and the person receiving the service pays the organisation for the service. By contrast, the introduction service exists to introduce potential workers who can provide the service required by the person supported or “hirer”. The introductory (“employment agency” model) selects a suitable candidate, based in part on information supplied by the organisation, and the person employs or “hires” the worker directly. The agency does not become involved in the day-to-day supervision and control of the worker.
A crucial difference is who employs the worker and who is responsible for giving them directions, operating PAYE and national insurance and ensuring that working time and National Minimum Wage (NMW) rules are adhered to.
There are also differences in who is responsible for drawing up a care plan. A direct service provider will draw up a care plan. The employment agency may draw one up as a service to the person supported, but the person is not required to follow it (some people prefer to draw up their own list of tasks), and the agency mustn’t try and impose it on the careworker. It is also very important to note that not all introduction agencies are regulated services.
The extended hours worked by a live-in careworker (there will be times that they are working and other times when they are effectively on call) mean that you may choose to have a specific rota. You will need to bear in mind working time rules to ensure your staff have sufficient time off and breaks, and plan for staff sickness and holidays.
The rules and case law surrounding National Minimum Wage and National Living Wage are complicated to apply to homecare, especially sleep-ins and live in care. They change from time to time, as does the approach of HMRC to compliance.
If you are considering providing live in care, it is essential you take legal advice on the possible options for sleep-in and live-in arrangements, so you can develop a strategy for NMW compliance. Some options involve more risk of non-compliance than others.
The Homecare Association has a National Minimum Wage Toolkit and specimen Daily Average Hours Agreement, drawn up by our preferred solicitors Anthony Collins Solicitors LLP, available to member organisations. Members also have access to a legal helpline which provides a limited amount of free telephone advice, see below.
There may well be regulatory implications for the model of live in care chosen. For example, the introduction service model does not trigger regulation by the Care Quality Commission in England (but is likely to do so in the other UK administrations), unlike the conventional managed service model. Some organisations choose to operate both models side by side, which brings its own challenges for management and administration, and can result in complex legal arrangements. Whichever model is chosen, it is essential to note that with a “hybrid” arrangement, where an introduction agency manages services, it is much harder to prove compliance with regulatory, employment and revenue law.
Pure introductory agencies are bound by the Employment Agencies Act and the Conduction of Employment Agencies etc. Regulations. While these do not require registration with a specific regulator, there is an inspectorate (the Employment Agency Standards Inspectorate (EAS), which is part of the Department for Business, Energy and Industrial Strategy) who may come and inspect documentation etc.
Marketing of live in care tends to be different, with advertising in traditional “up-market” magazines which appeal to those who can afford to self-fund live-in care a popular choice. There are also growing online options for promoting your services. If you do take the plunge, please inform the Homecare Association so we can help market your service via our online directory of members and their services.
Overall, the introduction model is generally felt to be a less expensive service to run, because it does not involve employing a workforce, is less regulated and does not require on-going supervision and control.
However, if your intention is to provide a live-in care service, rather than run a business essentially introducing staff, then the managed service model is the more appropriate.
Whatever direction you take, it is a good idea to take proper advice on your plans, to ensure that your business planning and documentation are in order.
Homecare Association has two specimen contracts, drafted by our preferred solicitors, that can help Homecare Association members. One is a contract between a person purchasing their own homecare and an organisation, for a managed service: Specimen Terms and Conditions Relating to the Supply of Care Services
The other is a contract between an organisation and a person requiring homecare support to introduce a care worker for employment by the person: Specimen Terms and Conditions Relating to Careworker Recruitment Services
Homecare Association also offers members human resources advice and a legal helpline to give a limited amount of free telephone advice on business and regulatory issues. To be referred, call our member helpline on 020 8661 8188, option 4.
A word of caution. Live in care demands particular skills from careworkers, who need to be sufficiently trained and self-reliant to be able to function with less supervision than a daily careworker. So you will need to think carefully about pay rates, recruitment, training and supervision to make sure you have sufficient workers of the right calibre to offer the service. That is why a good many live in care specialists, who offer a managed service, invest heavily in developing their workforce and allocate the resources to do this.
So budget implications will form a very important part of your business planning when considering a move into live-in care, as will recruitment and checking the skillset of both staff and managers before venturing into that sector. With recruitment posing a challenge generally in homecare, you will need to be sure you can ensure a supply of suitably trained staff. Recent temporary changes to migration rules may assist, should you choose to recruit more widely.
If you decide to go ahead with live in care, you will be providing a service that is highly valued by people who need support and their families in helping to maintain independence at home.
Policy, Practice and Innovation Team