Neuro rehabilitation after a stroke

We work closely with several hospitals across the South East, providing expert neuro rehabilitation to stroke patients directly out of hospital. Our multi disciplinary team of therapists, specialist nursing and care staff are supported by a medical consultant and GP; providing integrated therapy and nursing care in one location at our state of the art  Care and Rehabilitation Centre

As part of the Surrey and Sussex Healthcare NHS Trust stroke pathway, patients from East Surrey Hospital receive up to 4 weeks inpatient neuro rehabilitation. They are then supported by the Early Supported Discharge team and receive ongoing therapy at home for 6 weeks, as part of a community re-ablement package. There is no gap in care provision as it is part of a single stroke rehabilitation pathway with a dedicated social worker for QEF clients. 

This varies for clients from other NHS hospitals. People who have had a relatively recent stroke generally receive a 4-6 week neuro rehabilitation plan and QEF can help coordinate follow on care for these clients prior to discharge.

What you can expect when you arrive: 

First Week
Within 48 hours of arrival each person is assessed by:
- a Physiotherapist to see how much independent movement they may have,
- a Speech and Language Therapist to determine their ability to swallow and what type of food they will be able to eat, and
- an Occupational Therapist who will determine their seating requirements. 
- A manual handling risk assessment is also completed so the care teams know how best to manage moving each person.

During the next few days, the client will be further assessed by:
- an Occupational Therapist to determine what support they require for personal care and feeding;
- a Speech and Language Therapist who will do further assessment around their communication needs, and
- a Clinical Psychologist who will assess their capacity to give consent, as well as their mood and cognitive abilities.

We then create guidelines for the care team (positioning, swallowing, behavioural, personal care etc), so there is a clear understanding of each person’s needs and abilities and a therapy timetable is developed based on individual needs. We aim to provide stroke clients with four to five sessions of Physiotherapy and Occupational therapy every week, whilst Speech and Language and Psychology are provided dependent on need.  

Each person is allocated a keyworker who is the main point of contact for families, as well as responsible for coordinating the current and onward care needs of the client.

Second week onwards

Therapists work with each person to establish what it is that they want to achieve from their rehabilitation programme, as they will then be motivated to work towards these goals. Therapists then set SMART* goals for therapy sessions that help each individual to achieve their aspirations.

The Multidisciplinary team meets every week to assess how each person is progressing towards their goals, and a medical ward round takes place every Tuesday with a GP and Rehabilitation consultant.

We also provide art, music activities and other therapy led groups which each person can join in with, such as gardening, cooking, relaxation and mindfulness. A dietitian is also available if needed to look at what food and supplements a person may require.  

*Specific Measurable Achievable Realistic Timely  

Discharge Planning

Discussions about onward care and discharge start early so that it isn’t rushed – usually in week one. This involves talking to families and the client about what they want to happen when they leave QEF, establish whether going home is realistic, how much community rehabilitation they will need or whether an onward referral for continued inpatient rehabilitation is more appropriate, either with us or at another centre.

The Occupational Therapy team will conduct either an access visit without the client or a home visit with the client to assess what equipment might be needed for the person to be safe at home, whether they may need a bedroom setting up downstairs for example and whether living at home is viable or not. Following this visit, the Occupational therapist will make recommendations around what equipment is required for a safe discharge home.