Peninsula Community Health

Stroke Rehabilitation Units

Elder Man With Headache 10974211

Community Stroke Service

The Community Stroke Service provides specialist care for Stroke and Transient Ischaemic Attack (TIA or mini stroke) patients, their families and carers. This includes specialist clinical assessment, treatment, rehabilitation and management post stroke or TIA.

After a Stroke or TIA you may spend some time in an Acute Hospital before returning to the Community Service for your care to continue:

  • In a Community Stroke Rehabilitation Unit
  • At home under the care of the Early Supported Discharge Team
  • At home under the care of the Community Stroke Care Co-ordination Service

What our patients think:

"Today I feel happy. If it wasn’t for the support and faith of the Team on the stroke unit then I wouldn’t have got as far as I got. Therapy is never easy but it paid off with hard work and dedication. There were days when I wanted to do nothing but cry and never thought I would do the things I am doing now, but they never gave up the hope and taught me that I must keep the faith and always believe."- Written by a patient on the Woodfield stroke unit (2013)

Stroke Rehabilitation Units

In Cornwall and the Isles of Scilly there are two specialist stroke rehabilitation units where a multi-disciplinary stroke team will care for you and provide further therapy to help prepare you for going home:

  • Woodfield Stroke Rehabilitation Unit at Bodmin Community Hospital - Ward Manager [office hours]: 01208 251392
  • Lanyon Stroke Rehabilitation Unit at Camborne Redruth Community Hospital - Ward Manager [office hours]: 01209 318017

You will be assessed on your arrival and your personal treatment plan will be reviewed and developed by the multi-disciplinary stroke team ensuring that:

  • Individual problems and issues are clearly identified
  • Measurable goals are agreed with you and included in the treatment plan
  • The multidisciplinary stroke team regularly review the individual treatment plan with you, your family and carers.

For those who need rehabilitation there is a range of therapy that includes Occupational therapy, Physiotherapy and Speech and Language Therapy.  Each patient will have an agreed personal development plan which includes their goals and the type / frequency of therapy required to achieve the goals.

When it is time for you to be discharged from hospital or when you reach the end of the care from the early supported discharge team, your ongoing care will be carefully planned by the specialist stroke team working closely with your GP and possibly the community health care team and social services.  You and your family and carers will be given information about your diagnosis, your likely prognosis and advice about care at home as well as helpful contact details in case you encounter any problems.

If necessary, a home assessment will be undertaken to make sure that any adaptations to your home are made before you arrive. The specialist stroke team of nurses, physiotherapists and occupational therapists will work with you and your carers to plan the details of the care you will need at home.  Some patients will have active input from a social worker who will help with the discharge from hospital, including those patients who are going to a nursing or residential home.  Some who are discharged home from hospital will require ongoing therapy from the rehabilitation team, or the specialist neuro occupational therapist, or the neuro physiotherapist. 

Your GP will also be able to help with any further support you may need. Your GP will be informed about your admission and your care needs when you return home. Following your discharge, they will then become the doctor responsible for your care.

Stroke Care Coordinators

The community stroke nursing service makes sure that all patients who have had a stroke or TIA (mini stroke) continue to have access to stroke assessment and appropriate care following their discharge home from hospital. The community stroke nursing service will monitor progress, provide follow up and risk assessment, recognise new symptoms related to stroke, refer patients that need to be assessed and continue to provide ongoing advice and support in relation to stroke and TIA. 

The local specialist stroke nurse (Stroke Care Coordinator) will be informed of your discharge and will contact you within one week.  They will then arrange to see you, according to your clinical needs, either at home, or in a local clinic. You will also have a formal review after six months.

The community Stroke Care Coordinator (stroke nurse) will:

  • Provide expert advice and support to patients following a stroke or TIA
  • Provide a clinical and social assessment on all adult stroke patients referred to the service
  • Provide the patient with an individualised care plan, using a combination of home visits, phone calls, clinics and lifestyle advice
  • Provide a specialist resource as required to other healthcare professionals who are working with the patient and work in partnership with other agencies
  • Work with the GP to prevent a further stroke or TIA
  • Facilitate recovery and promote self management of the patient’s condition
  • Act as a lifelong resource for individuals, their families and carers
  • Review the patient’s medicines and, where necessary, liaise with the GP over changes

Stroke patients will be given their own patient information and personal health record for stroke or TIA. This includes a personalised care plan for reducing and managing risk factors for stroke.

The Stroke Care Coordinator can also advise patients and carers about accessing support from a range of statutory, third sector and voluntary organisations in Cornwall.  Working with the local NHS and Cornwall County Council, these organisations provide a range of services to help stroke survivors and their carers live as active a life as possible at home and include:

  • Physical activity
  • Healthy eating and drinking
  • Emotional and mental wellbeing
  • Assistive technology
  • Vocational activity
  • Work
  • Volunteering
  • Carer Support Worker
  • Befriending and hospital visiting service
  • Support and advice
  • Social clubs
  • Exercise after stroke
  • Support for people with communication difficulties
  • Information and training for professionals 

TIA Clinic

The TIA Clinic is a one stop, multi-disciplinary, rapid access service for patients with Transient Ischaemic Attack (TIA or mini stroke) providing secondary prevention to reduce the incidence of stroke and to reduce unnecessary acute hospital admissions.

Clinics are held 7 days a week, rotating throughout the County at various venues and are staffed by a Consultant, Stroke Care Co-ordinator, Vascular Technician and Clinic Nurse. On receipt, referrals are triaged and patients scored as ‘high risk’ are seen and have diagnostic investigations within 24 hours, all other patients are seen within 7 days.

The local specialist stroke nurse (Stroke Care Co-ordinator) will be informed of your diagnosis and will arrange to see you for a follow up appointment according to your clinical needs, either at home, or in a local clinic. 

Gastrostomy Service

Information can be found HERE