How to get 24-hour care at home, and who pays

The routes overlap. Your relative can claim Attendance Allowance while the council assessment and any NHS assessment are under way. If the NHS takes on the care, it pays for all of it and the council steps back. If it does not, the council's assessment decides what the council pays, and your relative pays the rest from their income, savings and any benefits.

It helps to know which kind of 24-hour care your relative needs, because the cost depends on it: one live-in carer if they sleep most nights, or a second carer awake at night if they do not. The 24-hour care guide explains the arrangements, and what 24-hour care costs prices each one.

1. 1

   Keep a note of the nights for a fortnight

   Start now

   Write down when your relative woke, how long they were awake, what help they needed and whether they were safe. Your notes are how the assessor learns what the nights are like.
2. 2

   Ring adult social care, or ask online

   Free

   Contact your relative's council and ask for a care needs assessment. Say that you think they need somebody there day and night, and ask for a carer's assessment for yourself at the same time.
3. 3

   Be there for the assessment

   At home

   The assessor asks how your relative manages washing, dressing, meals, the toilet and keeping safe. Answer for a bad day and a bad night, not a good one, and hand over your notes.
4. 4

   The financial assessment follows

   If needs are eligible

   The council looks at income and savings. In England, over £23,250 in savings means paying the full cost, and below £14,250 savings are ignored. The house is not counted while your relative lives in it.
5. 5

   A care and support plan with a personal budget

   In writing

   The plan lists the needs the council will meet and the personal budget it has set to meet them. Ask for a copy of the assessment and the plan, and check the nights are in both.

To be eligible, your relative's needs have to come from an illness or impairment, leave them unable to manage two or more everyday things, and have a significant effect on their wellbeing. The everyday things are set out in the eligibility regulations. They include eating and drinking, washing, using the toilet, getting dressed, using the home safely and keeping in touch with family. Be specific about which ones go wrong after dark. Our guide to the care needs assessment goes through the questions in more detail, and local authority funding covers the means test.

If you have been doing the nights yourself, the carer's assessment matters as much as your relative's. It looks at what caring is doing to you and what would help, and it is separate from your relative's own assessment. What is a carer's assessment? explains what to ask for.

You do not have to wait for the assessment to arrange care. If your relative cannot manage tonight, put help in place and keep going with the assessment alongside it. Tell the assessor what the carer is doing each day and night, and what would happen without them, so the assessment records the full picture of your relative's needs.

The Care Act statutory guidance, which councils have to act under, deals with this directly. When it decides how to meet somebody's needs, a council may take its own budget into account, and it may weigh up the total cost of different options case by case. Cost can be a factor in choosing between options that would each meet the needs. The guidance then sets limits on that. The council can consider cost in deciding how needs are met, but not whether they are met. It should not set arbitrary upper limits on what it will pay for care at home. And the choice "does not mean choosing the cheapest option; but the one which delivers the outcomes desired for the best value".

The chapter on personal budgets adds that councils should not have arbitrary ceilings on personal budgets that force people into care homes against their will.

So a council can say that care at home would cost much more than a care home and offer the care home instead. Age UK's factsheet on personal budgets says a council may not agree, for example, to a direct payment request that would cost twice as much as a care home. What it cannot do is apply a fixed cap without looking at your relative, ignore what they want, or decide that their needs will not be met at all.

On PrimeCarers, one live-in carer costs about the same each week as the average care home in the table above, and the gap opens up when a second carer is needed at night. If the council does raise cost, these steps help:

• Ask for the reasons in writing, with the figures the council compared and how it worked out the personal budget, which it must be able to explain.
• Check the assessment records all of the needs. A council only has to set the budget high enough to meet the needs it has agreed, so a need that was missed is money that was missed.
• Say clearly what your relative wants and why staying at home matters to them.
• If you still disagree, use the council's complaints procedure, and after that the Local Government and Social Care Ombudsman.

A care home is sometimes the better answer, and choosing one is not a failure. 24-hour care or a care home sets out how families weigh the two.

Age UK's factsheet on direct payments says the money can be used to contract with a self-employed person or an agency, without your relative becoming an employer. The statutory guidance adds that the council still has a duty to make sure your relative's needs are met, so plans for when a carer is off sick or on holiday belong in the care plan. Direct payments covers the conditions, the records and what to do if the council refuses, and direct payments by council collects each council's own rules.

This is where PrimeCarers can help. PrimeCarers is an introductory service, not a care agency. Carers on PrimeCarers are self-employed, set their own rates and agree terms directly with you. Before a carer appears on the platform we check their identity, their right to work and an enhanced DBS check (or PVG in Scotland, Access NI in Northern Ireland) issued within the last 2 years, and we interview them online. Separately from those checks, visits booked through PrimeCarers are insured, within the terms of the policy. We do not check qualifications, training or references, so references and reviews on a profile are unverified, and skills and training are for you to check with the carer. Invoices are compiled from the bookings you and the carer enter on the platform, so keep the bookings accurate and keep each invoice with your direct payment records.

When the funding is in place, you can search for carers near you and compare their rates, read what each says about their experience, and message two or three before you commit. A live-in carer costs from £1,050 a week on PrimeCarers, with our fee included, against about £1,400 a week through an agency, so the same budget can cover more weeks of care.

The test is whether your relative has a primary health need. The national framework that sets the rules looks at the nature of the needs and how complex, intense and unpredictable they are. It says eligibility is not decided by the setting where the care is given, so care at home qualifies in the same way as a care home. A diagnosis on its own does not decide it either way. Needs that change from hour to hour, or that put your relative at risk at night, are the kind the assessment weighs.

The framework has a passage on care at home that costs more than other options. The NHS can take cost and value for money into account, but the comparison has to use what each option would cost for your relative's own needs, not a standard care home price. It must not set arbitrary limits on care at home based only on what a care home would cost. Cost also has to be weighed against your relative's wish to stay in a family setting. The framework also notes that people are sometimes described as needing 24-hour care when what they need is ready access to help, and it asks the NHS to look at what the needs are.

If your relative is eligible, the NHS pays for all of their assessed care at home, but not rent, food or household bills. You can ask for a personal health budget, which can give your family more say over who provides the care. NHS Continuing Healthcare explains the twelve areas and how to appeal a decision, and personal budgets and personal health budgets explains how the money can be handled.

The fast track is for somebody whose condition is deteriorating rapidly and may be entering a terminal phase. It skips the checklist and the full assessment, and the framework says it should not be read narrowly or tied to a fixed amount of time left. Fast-track Continuing Healthcare covers how to ask for it.

If your relative is found not eligible, the letter must say how to ask for a review, and the council assessment is still open to them. A decision against Continuing Healthcare does not close off the other routes on this page.

Attendance Allowance is for people over State Pension age who need help with personal care, or somebody to keep them safe, because of an illness or disability. The lower rate covers help in the day or supervision at night. The higher rate covers the day and the night together, or somebody a doctor or nurse has said is nearing the end of life.

The night test in the law is specific. Your relative meets it if, at night, they need prolonged or repeated help with things like the toilet, turning or medicines, or if somebody needs to be awake for a long time or at frequent intervals to keep them safe. When you fill in the form, describe how often they wake, what they need each time and what would happen if nobody came. If your relative already gets the lower rate and the nights have got worse, tell the Department for Work and Pensions and ask for the higher rate.

Your relative must have needed the help for six months before the allowance is paid, except under the special rules for people nearing the end of life. They do not need a carer to claim. If the council charges for care at home, it can count Attendance Allowance as income in the financial assessment, but the statutory guidance says it should leave your relative enough to pay for disability-related costs the council is not meeting, such as care they arrange privately. Attendance Allowance walks through the claim form, and the funding guide puts every route in one place.

In Scotland, Pension Age Disability Payment is replacing Attendance Allowance. Care funding also works differently in Scotland, Wales and Northern Ireland.