Stroke services

Contact the service by:

• Phone: 03000 200 655 option 1

• Email: clcht.plannedcarebarnet@nhs.net and clcht.barneticsesd@nhs.net

In Hammersmith & Fulham we provide:

• Early supported discharge for stroke
• Community neuro-rehabilitation
• Stroke reviews

Early supported discharge for stroke

We provide early intensive rehabilitation for people with stroke, usually at the point of hospital discharge, for up to six weeks at the same intensity as they would receive in hospital. This includes access to a range of clinical specialities including:

• Physiotherapy
• Occupational therapy
• Speech and language therapy
• Psychology
• Rehabilitation assistants

We work in partnership with other community support services for people with stroke. If further rehabilitation is required at the end of six weeks, clients are automatically transferred to the community neuro rehabilitation service.

Services are provided in the most appropriate location for treatment (for example people's homes, residential homes and in other community locations). We work with clients to support them to reach agreed goals and provide early assessment, treatment and advice regarding:

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

Stroke reviews

We carry out holistic stroke reviews with people who have had a stroke and their carers' at six months post discharge from services. This allows us to identify any unmet needs, and enable clients to independently seek solutions. We will refer or signpost to other services as required.
Communication group and peer mentoring scheme.

Please contact the team directly to discuss what is available.

Core hours

The core hours for our community stroke services are Monday to Friday, 8.30am to 17.00pm.

Phone: 020 8102 3879

In Kensington and Chelsea and Westminster we provide:

• Early supported discharge for stroke
• Community neuro-rehabilitation
• Stroke reviews
• Stroke support worker

Early supported discharge for stroke

We provide early intensive rehabilitation for people with stroke, usually at the point of hospital discharge, for up to six weeks at the same intensity as they would receive in hospital. This includes access to a range of clinical specialities including:

• Physiotherapy
• Occupational therapy
• Speech and language therapy
• Psychology
• Rehabilitation assistants

We work in partnership with other community support services for people with stroke. If further rehabilitation is required at the end of six weeks, clients are automatically transferred to the community neuro rehabilitation service.

Services are provided in the most appropriate location for treatment (for example people's homes, residential homes and in other community locations). We work with clients to support them to reach agreed goals and provide early assessment, treatment and advice regarding:

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

Stroke reviews

We carry out holistic stroke reviews with people who have had a stroke and their carers' at six months post discharge from services. This allows us to identify any unmet needs, and enable clients to independently seek solutions. We will refer or signpost to other services as required.

Stroke support service

This service is open to all people who have had a stroke and their carers'. It is available in a range of community settings (including hospitals, client homes', and residential care homes). The service is provided for up to one year following the stroke and includes the provision of information, advice, advocacy, emotional support and signposting to other services.

Communication group and peer mentoring scheme

Please contact the team directly to discuss what is available.

Core hours

The core hours for our community stroke services are Monday to Friday, 8.30am to 17.00pm.

Phone: 020 8102 3879

Queries and referrals for stroke services in Kensington and Chelsea and Westminster:

Queries relating to our stroke services will be processed through the single telephone number 0300 033 0333. The 0300 033 0333 telephone number for is to be used for queries only.

Referrals for stroke services should be sent to:

• eFax: 0300 008 3251
• Email: CLCHT.SPA.Referral@nhs.net
• Further information: Single Point of Access (SPA)

Inclusion

• Have a confirmed acute stroke diagnosis (by MRI/CT scan or clinically by a consultant).
• Safe to be discharged home over the 24hour period (e.g. adequate equipment, cognitive or physical support, and continence needs managed in-between care calls).
• Barnet GP registered and resident.
• Patient cognitively able to engage with rehabilitation program and has rehabilitation goals.
• Able to transfer/mobilise with one person assisting.
• Patient is medically stable and able to manage nutritional requirements safely at home.

Exclusion

Patient not registered with a Barnet GP, non-Barnet resident and or medically unstable where patient may require intervention of medical staffing within 24hrs.

• Early supported discharge service: referrals to the service can be made by hospital therapists, consultants and other health and social care professionals. The referrals must be discussed and agreed for acceptance with the early supported discharge coordinators who are available to discuss referrals during Monday to Friday core working hours.
• Stroke reviews: referrals can be made by GPs, hospital services, and health and social care professionals. We also accept self-referrals from people who have had a stroke and their carers.

Phone: 020 8102 3879

• Early supported discharge service: referrals to the service can be made by hospital therapists, consultants and other health and social care professionals. The referrals must be discussed and agreed for acceptance with the early supported discharge coordinators who are available to discuss referrals during Monday to Friday core working hours.
• Stroke reviews and stroke support service: referrals can be made by GPs, hospital services, and health and social care professionals. We also accept self-referrals from people who have had a stroke and their carers.

Phone: 020 8102 3879

Clients will be discharged when they have reached their full rehabilitation potential, they have achieved their rehabilitation goals, or where there is no clinical benefit to continued rehabilitation. Clients can also be discharged back to the care of their GP if they fail to attend appointments.