Our community neurological (neuro) rehabilitation services are for adults, over 16, with a primary neurological diagnosis which is the reason for their referral.

We assess the patient's healthcare needs and work with them to plan and agree a rehabilitation programme to help them achieve their goals.
 

Hammersmith & Fulham, Kensington and Chelsea and Westminster service information

Our teams include the following clinical specialities:

  • Physiotherapy
  • Occupational therapy
  • Speech and language therapy
  • Psychology
  • Rehabilitation assistants
  • Stroke support workers

We provide assessment, treatment and advice to clients and carers regarding:

  • Indoor/outdoor walking practice
  • Promoting independence with daily activities, e.g. meal preparation, bathing
  • Swallowing, eating, drinking
  • Communication - speaking, understanding, reading, writing
  • Cognitive - e.g. memory and attention
  • Emotional difficulties
  • Fatigue management
  • Work, education and leisure

Early supported discharge (ESD) team for stroke

We provide early intensive multi-disciplinary rehabilitation for people with a stroke, at the point of hospital discharge, for up to six weeks at the same intensity as they would receive in hospital.

Referral to this service can be made by hospital therapists, consultants and other health and social care professionals. The referral will only be accepted following verbal discussion with an ESD coordinator. They can be contacted via our main office number on: 020 8102 3879.

Specialist neurological rehabilitation outreach service (SNROS)

We provide the specialist neurological rehabilitation outreach service (SNROS), in partnership with the Charing Cross neurological rehabilitation unit (CNRU). This service is for adults with more complex neurological rehabilitation needs who benefit from the increased intensity and access to the CNRU rehabilitation consultant and specialist nurse to support them to achieve their goals.

Referrals to SNROS should be made through the Badgernet online referral system for specialist rehabilitation or by calling 020 3311 1948.

Merton service information

Our community neuro-rehabilitation services are for people over the age of 18 years of age who have neurological conditions or have had a neurological event requiring rehabilitation.

We assess the patient's healthcare needs and work with them to plan and agree a rehabilitation programme to help them achieve their goals. Our services are provided for people with neurological impairments caused by conditions such as stroke, traumatic brain injury, multiple sclerosis, Parkinson's disease and motor neurone disease.
 

Who we are:

Our teams include, or have access to a range of clinical specialties including:

  • Physiotherapy
  • Occupational therapy
  • Speech and language therapy
  • Neuro rehabilitation specialist nurse
  • Parkinson’s disease specialist nurse
  • Rehabilitation assistants
  • Dietetics

Patient contact number: 0333 241 4242

Who can refer?

  • GPs
  • Inpatient and community healthcare professionals
  • Social services

Hammersmith & Fulham, Kensington and Chelsea and Westminster referral information

Referrals can be made via our Single Point of Access (SPA) team:

Phone: 0300 033 0333 - option 1
eFax: 0300 008 3251
Email: CLCHT.SPA@nhs.net
Further information: Single Point of Access (SPA).

Patient contact details:

Phone: 020 8102 3879

Merton referral information

Referrals should be made through the Merton Single Point of Access:

Phone: 0333 004 7555
Email: clcht.mertonspa@nhs.net

Referral forms:

Hammersmith & Fulham, Kensington and Chelsea and Westminster Inclusion and exclusion criteria

Inclusion:

  • Over 16 years of age
  • Registered with a GP in Hammersmith & Fulham, Kensington and Chelsea and Westminster
  • Patients with a confirmed neurological diagnosis
  • Patients who need specialist neurological rehabilitation

Exclusion:

  • Provision of equipment or housing adaptations
  • Needs best met through case management or social care
  • Primary needs relate to frailty or conditions of aging

Merton inclusion and exclusion criteria

This service is for:

  • Housebound patients although some outpatient clinics are available
  • Over 18 years of age
  • Registered with a GP in Merton
  • Patients where neurological diagnosis is the reason for the referral

Inclusion:

The main reason for referral is due to a new neurological diagnosis or deterioration in a long-term neurological condition.

Patients who require input from two or more neuro disciplines. However, uni-disciplinary referrals are accepted for occupational therapy for cognition or splinting, neuro physio for domi or outpatient clinic and referrals to our Parkinson’s disease nurse.

Exclusion:

  • People who require acute medical care
  • Referrals for vocational rehabilitation only
  • Referrals to vestibular rehabilitation only
  • Referrals for equipment only

This service is not for:

  • Provision of equipment or housing adaptations

Discharge criteria

Patients can be discharged when they have reached their full rehabilitation potential, have achieved their rehabilitation goals, or where there is no clinical benefit to continued rehabilitation. Patients will be discharged back to their GP if they fail to attend appointments without first contacting their treating therapist.

Merton additional information

We provide assessment, treatment and advice to clients and carers regarding:

  • Active rehabilitation (physical therapy) e.g. indoor/outdoor walking practice.
  • Balance group.
  • Interventions for prevention of secondary complications and health promotion, including BP, smoking cessation, cardiovascular risk factor assessment, urinary/bowel dysfunction and follow-up of medical needs following discharge from acute setting.
  • Home exercise prescription.
  • Re-education and pacing of activities of daily living.
  • Equipment provision, basic fitting and adjustment, and instruction in equipment use.
  • Education of service users and carers in condition management.
  • Relaxation and anxiety management.
  • Splinting.
  • Cognitive rehabilitation.
  • Other SLT interventions (e.g. communication therapy, dysphagia management).
  • Coordination of end of life care in line with health need, including advanced care planning

The teams include an early supported discharge for stroke service, providing intensive rehabilitation at home for up to four weeks following discharge from hospital. We carry out reviews of the needs of stroke survivors at six months after their stroke.

Locations and opening hours

Clients are seen in the most appropriate location to achieve their rehabilitation goals, which may be their homes, in outpatient facilities or other suitable community sites.

Hammersmith & Fulham Community Neurological Rehabilitation Team

Hammersmith Bridge Surgery, 1 Hammersmith Bridge Road, W6 9DU

Team Lead: Alex Henson
Phone: 020 8102 3879
Opening times: Monday to Friday, 9am – 5pm

Kensington & Chelsea Community Neurological Rehabilitation Team

World’s End Health Centre, 529 Kings Road, SW10 0UD

Team Lead: Bethanie Goodfellow
Phone: 020 8102 3879

Opening times: Monday to Friday, 9am – 5pm

St Charles Hospital

Exmoor Street, London, W10 6DZ

Westminster Community Neurological Rehabilitation Team

Lisson Grove Health Centre, Gateforth Street, London, NW8 8EG

Team Lead: Melissa Thomas
Phone: 020 8102 3879
Opening times: Monday to Friday, 9am – 5pm

Merton Community Neurological Rehabilitation Team

14th Floor Civic Centre, London Road, Morden SM4 5DX

Team Lead: Denise Meredith
Phone: 0333 004 7555
Opening times: Monday to Friday, 9am – 5pm