Staffing 24-Hour Care: Why It Takes Five Workers, Not Three

Families who are setting up round-the-clock care at home rarely realise how many people this involves. The sense of the problem is that three eight hour shifts make one day and three people will cover the arrangement.

There are 168 hours in a week. Full-time work is approximately 38 hrs. 168 hours equals more than 4 full-time equivalents prior to leave, illness, training or turnover. After deducting the annual leave, sick leave and public holidays, and realising that no employee is on duty every week of the year, a truly continuous staffing level requires five or more people turning up.

This is not a detail. It is why most 24 hour placements don't work, and it doesn't work at the care, it works at the roster.

The Arithmetic

Solve it correctly.

168 hours a week to cover. That's 38 hours (4.4 FTE) before everything.

Four weeks per worker per year of annual leave takes out about eight percent of the capacity over a year.

In care work, people can't come in sick, and personal and sick leave removes more, hence it's used.

The public holidays must still be paid at a premium rate and must be taken.

Turnover. The aged care sector and disability industry is high turnover and each time someone leaves there is someone who needs to be trained in their place.

Availability constraints. There are other clients, study and families to which workers devote part of their time. There are very few available for all shifts and all days.

In reality, the requirement for 168 hours is covered by 5 to 7 members of the rotation, two or three of whom will work nights and weekends.

In most homes this is more than they want in their home and more than their financial resources can provide, hence the fact that almost no one has continuous cover, and why arrangements are constructed as a combination of funded hours, sleepovers and family care.

Why the Roster Is Where It Breaks

Families expect a clinical challenge. In reality, it's simpler.

Someone resigns. With 3 people, if one resigns, that removes a third of the cover, there is no extra cover to move in to cover the loss.

Two take leave during the same 2 weeks. The classic is January.

A worker who has become sick at 6am is scheduled to work from 7am.

Availability changes. A worker gets another client and begins with another course, relocates to another suburb.

The arrangement expands. The need to add more hours into the process exceeds what the current team can handle.

All of these are completely predictable. They are both the reason for an arrangement that sounds great for eight months, but falls apart in the ninth.

Continuity Versus Coverage: the Real Trade-Off

This is the tension no one manages to resolve nicely.

Having more employees can provide greater resilience. An absence gets absorbed, and the vacancy does not become a crisis; it's a mere inconvenience.

Continuity is better with fewer workers. A person who knows the individual well is aware of changes, needs less direction and, especially in dementia care, can cause less distress.

Both are important and the balance will vary from individual to individual.

If dementia or cognitive impairment is severe, opt for fewer, familiar workers. Distress and escalation are caused by unfamiliar faces, especially during personal care. Having 3 or 4 people who are consistent is usually better than 7 even if that means reducing resilience.

When the clinical complexity is high, take the side of more. High intensity or palliative care supports must have competency sign-off, often from a registered nurse: if there is only one trained worker, then the arrangement ends completely if that person is not available. The typical goal is to have three workers signed off for every support.

If needs are certain and cognitive function is intact, then a larger pool is sufficient, and will provide you with the strongest setup.

The usual arrangement for most families is a nucleus of 3 or 4 steady workers who put in the hours, with a couple more occasional workers willing to work just to have someone they know and are available to call on in case of emergencies.

This latter is important. However, if a person was trained eighteen months ago and has never worked a shift, then they are not a working backup. Rotate them in once every week or two.

Night Staffing Specifically

Nights have their rules.

Not all of the employees will work during the night. The number of available employees for a 24 hour shift is greatly reduced, and the most frequent bottleneck at night is availability.

Fatigue is an issue of safety. A worker who works consecutive night shifts, or a shift from day to night, is a risk factor for the person and for themselves. Even though a roster might seem efficient on a spreadsheet, it's not necessarily safe in reality.

The difference between sleepover and active is everything. If an active shift is not feasible, a sleepover shift (up to two hours of active support) can be staffed easily, is cheaper and more sustainable for staff. When the night becomes a ‘sleepover’, the cost and staffing issue both get smaller.

Handovers are more important at night. It's hard for a night worker if they don't know how the day has gone, and the ramifications reveal themselves at 3am.

Handovers: Where Information Gets Lost

The weakest link is the flow of information in rotations of five or six people. This is well established in the health care sector overall, things are misplaced at the interfaces of people, not in their hands.

What reduces it:

A common, updated, not supplemented, written record. Contradictions occur when there are multiple versions in circulation.

A verbal handover at every change of duty, or a written handover if this is not possible, which is read.

A rule concerning changes. Any change, a new medicine, doctor's instructions, a fall, a change of routine, is passed on to the entire team prior to the next shift, not next review.

One-page practical brief that can be read by the new or occasional worker prior to their first shift: the work routine, the person's preference, how they communicate pain and refusal, what to look out for, who to call. This is the one most important document in any arrangement and typically it doesn't exist.

Building a Team That Lasts

The 5 key differences between stable arrangements and fragile ones.

Forecast recruitment requirements and plan accordingly. Train and introduce the fourth and fifth worker when the first three are still present. The worst time to hire is when there is a gap and the worst matches are the ones that are recruited during a gap.

Take advantage of the backups frequently. Familiarity has to be maintained.

Treat workers well. The biggest danger to a 24-hour arrangement is turnover, which is triggered largely by people's experiences. Accurate rostering, reasonable notice of changes, getting paid properly, on time, a healthy and respectful workplace that supports workers' mental health, and a verbal pat on the back when something has turned out well. Households that do this retain workers for years in their household.

Don't be an idealist when it comes to rates. Australian support jobs are not high-paid occupations. If an arrangement relies on goodwill of the worker, whether that's staying late unpaid, covering for others at short notice frequently, it's tenuous and will come to an end without warning.

Make plans for the predictable. Discuss leave plans several months in advance. Be familiar with who is responsible for covering for illness. Be aware of what will occur when a worker is admitted to hospital, and what will happen when workers miss a shift and might take on additional clients, because discussing it beforehand avoids having to rebuild from the ground up on discharge.

When the Workforce Simply Is Not There

In regional areas, or in certain combinations (overnight, weekend, a particular language, a particular gender, high-intensity competencies), the workers may simply not be found in the region.

Options that help:

Expand who you think of. It's better to find someone excellent and willing to be trained, rather than waiting for a perfect match who never comes along.

Minimise hours required. Equipment, sensor technology and clinical changes which transform an active night into a sleepover reduce the most challenging shifts to staff.

Run a hybrid. High intensity or registered supports from a registered provider, and everything else from directly engaged workers, which widens the pool for the majority of hours.

Speak the truth about the ceiling. If there is no safe arrangement at your home, this is part of the consideration of sustainable home care, not something that is taken on for an indefinite time by the family.

The Bottom Line

A week is 168 hours before leave, illness or turnover, which is greater than 4 full-time equivalents. True continuity requires five or more people on duty, including a couple of the staff to work nights and weekends.

The majority of 24 hour, long-term care services don't succeed at the care, they succeed at the roster. The protections aren't pretty: hire them early enough, use them, document anything in their heads, inform others of changes prior to the next shift, treat workers well enough that they are not going to leave.

But where the night turns out to be a clinical sleepover and not an active shift, the cost and staffing issue becomes starkly manageable, and in fact that's the first question to ask before any other one.

Onboarding a New Worker Properly

You will be continuously introducing new workers with 5 or 6 people rotating. Taking two hours to do it well is well worth your while.

Submit the one page brief prior to the first shift. Routine, preferences, communication, things to look out for, escalation. A worker who has read it comes in handy, not as a passenger.

If the first shift is to be overlapped with another shift, have another worker that the person is familiar with on that shift. Not to pass out the ball at the door, but actually pass it off with someone who knows what to do. This is hugely important in dementia as the stranger shows up alone and is unsettling.

Introduce them at the best time. Most often, in the morning, not the late afternoon.

Take them around the house. Where the things are, how the shower works, the bed controls, where supplies are stored, where the documentation is stored.

Explicitly cover the practicalities. Parking, access, may they use the kitchen, where to sit during quiet times, what to do with the notes.

Check in after 2nd and 4th shift. If the problem is raised early most of them can be easily resolved, if not, it is a resignation.

What Good Providers Do Differently

For those who are engaging through a provider and not directly, these questions will help separate them.

How many workers will be assigned to us and will they be consistent?

Are workers in our vicinity or are they sent? This is the distinction between on time performance and regular tardiness in a dispersed city.

Who covers when our regular worker is not available and have they met us before?

With this type of work, what is your turnover rate?

What are your procedures for passing the job between employees?

What do you do to help employees when they are stressed out? It's not about their stability, but about yours, as unsupported workers walk out the door.

Is there a time to meet with workers as they are starting and can we change them if it is not working?

If someone says that they will find a provider, it's not a plan, it's a hole.

What It Looks Like When Staffing Is Working

A helpful picture of the desired outcome, rather than a list of cautions.

The core. A number of regular workers, who work the majority of the hours. Each has been in place for at least six months. The person is familiar and comfortable with all three.

The backups. Two other workers who work a shift every 2 to 3 weeks just so they are ‘familiar and available’. Both have undergone the same induction as the main team.

The night. Two of the five will work at night, enough to arrange a sleepover four nights a week with a fallback plan.

The documentation. A plan of support in one place. A one-page ‘brief’ which any one of the five can work from. All complete a shift log.

The rhythm. Two months' leave will be discussed in advance. Regular monthly standing check-in. Nominated leader who plans and directs.

The test. Last winter when one worker switched jobs, the replacement was placed in the slot, another worker was brought on and it took more than a month to get her started, and the family never missed a single shift.

That's five people, one document and the habit of hiring before you need to. It's not hard to understand. It's very seldom done, as creating redundancy when something is working feels like solving a problem you don't have.

The Cost of Turnover, Quantified

It's better to know what it costs to lose a worker, because knowing that makes the effort to retain them worthwhile.

Time of recruitment and matching (for a provider, days of coordinator time; for a self-managing family, the same work done by you).

Onboarding and orientation: at least one, if not more, overlaps in this regard.

Competency training, with high intensity supports, cannot be skipped, and days to weeks is the time frame.

Lost knowledge: all the knowledge that the departing worker knows but never documented. The preferences, the triggers, the early warning signs of this person.

Disruption to the person, in dementia this often can be a significant increase in distress and resistance for weeks.

Higher risk in the gap, where the family covers, or if the previous person wasn't familiar with the area and a new person is taking over.

In contrast, these are the low cost aspects that keep employees: reliable rosters, notice of change, correct and timely payment, being treated with respect, and being informed when things are going well. It is better to do it purposefully than to wish for it.

Frequently Asked Questions

How many staff are really required for 24 hour care?

For truly continuous cover, 5 or more in rotation. The number of hours in a week is 168, just over four full-time equivalents, prior to leave, sick time and public holidays or turnover. There are three workers who cannot sustainably cover it, so most families opt for a combination of funded hours, sleepovers, and family care.

Should there be fewer or more workers?

This is subject to the individual. Fewer, more familiar workers minimise distress; three to four familiar people are often fine when dementia is significant. Where competency sign-off is required, more is safer, as with only one trained worker the support shuts off when they are not around. A typical house will be on a group of 3 to 4 people, with 1 to 2 people as backups.

What causes 24-hour plans to fail?

Very rarely is it not at the workforce. A worker gives up, two staff members go on holiday at short notice, a worker is unwell on short notice, or one of the staff is away for some reason. The small group has no slack to take it and the family takes it up until they can't.

What should be done to prevent the loss of workers?

Accurate rostering, foreseeable change, proper and punctual pay, positive work culture and recognition on positive behaviours. How people are treated is a key determinant of turnover, and households that do this well retain their employees for years.

What can we do when our regular worker goes on leave?

This should be more of a months-long process than a week-long one. Discuss leave arrangements, get a named contact that is already aware of the individual, and change those who are taking the leave periodically so they are not starting from scratch.

Is it possible for one worker to make a live-in arrangement?

Live-in care involves a single worker working in the home and having fixed hours, breaks and a sleep period, with a second worker working in their place when away. It cuts the cost of shift rotation by a day, and it's more convenient for continuity reasons, but it is delicate, one resignation and everything goes out the window, and there needs to be a spare bedroom.

Why is it difficult to have night workers?

Less labour will be available for night shifts, reducing the workforce. Fatigue is also considered a real safety concern, and consecutive night shifts or a night shift after a day shift should be avoided even when a worker is willing.

What should be in a handover document?

The actual, not written, routine; the individual's preferences; their signs of pain or refusal; the early warning signs specific to them; equipment information; escalation plan (after hours). One page that a new employee can read prior to their first shift.

We are in a regional area and have a shortage of labour. What now?

Think about employing people who are trainable, not experienced, and make fewer hours available by using equipment and clinical modifications, and employ a mix of work hours. But be forthright if there really is no feasible local staffing situation, as that is part of the home care sustainability decision.

Does a bigger provider address the staffing issue?

Not automatically. A bigger provider will have a larger staff of people on their books and may be swapping them around, so you won't be getting continuity. The question to ask is not how many workers are assigned to you, but how many workers are actually assigned to you, whether they live in close proximity to you, and what is happening when you don't have any of your regular workers available.

Support Network's aged care services and home support help families to create a team instead of relying on one person, and to recruit members of their team who are their own choice. See our 24 hour care services or call 1300 671 931.

Sources and further reading

• NDIS Pricing Schedule 2026-27, sleepover and overnight support rates
• Social, Community, Home Care and Disability Services Industry Award (SCHADS)
• My Aged Care, Support at Home services