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Last updated: February 2022

Leaflet: Supporting you at home after a stroke

The Integrated Community Stroke Service (ICSS) supports you to get home from hospital as soon as possible and provides support for your recovery (rehabilitation) and specialist advice.

What happens before I leave hospital?

We will work with the hospital team to plan what you will need at home and will arrange any equipment, such as handrails or mobility aids. The team may need to look around your home before you leave and may take you along on this visit. The therapists and nurses will discuss your goals with us and what the next steps are in your care.

When will I be seen?

We will aim to see you on the day you get home from hospital so that we can check that you have everything you need and that we can work together to make a plan for your rehabilitation. If you have no rehabilitation needs then our nurse will offer you a review up to six weeks after you go home.

How long will you visit for?

We do not have a time limit on our service but we need to be flexible so that we can support more people out of hospital. We will continue to see you until: you do not have any more therapy goals; those goals can be worked towards without the team’s support; or goals are not
being achieved.

We will tailor our visits to your situation and this may change over time. For example, we may see you every day at first but this may reduce as you become more independent. We may see you face to face or occasionally over videocall or telephone. Before we stop our visits we will make sure that you have the strategies you need to set your own longer term goals and work towards them without our support.

We will link you to long term Life After Stroke services, eg Stroke Association/Bristol After Stroke.

If you are no longer seeing the team but have new appropriate stroke-related goals, then you can refer back into the service through your GP or self-referral.

What is rehabilitation?

Rehabilitation is a joint effort between you and your therapy team and aims to either improve function or to find strategies to make tasks easier. Not all rehabilitation looks the same. You may be doing physical exercises, everyday tasks such as washing and dressing, conversation practise, computer tasks or community activities such as catching the bus or finding ways to get back to a hobby.

The rehabilitation you do will be based on your individual goals so will look different for each person. We will work with you to find ways of using everyday tasks to make the most of your rehabilitation.

Who will provide rehabilitation?

A number of different team members may visit you at home including:
Nurses – help with medication, continence, lifestyle, sleep, sex and intimacy and any other stroke related medical issues.
Physiotherapists – help with movement including transfers, using your affected arm and leg, altered sensation, weakness or tightness in muscles, posture and positioning and provision of equipment to support independence in movement.
Occupational Therapists – help with tasks and activities that you need or want to do such as washing and dressing, cooking, hobbies, work, driving and also may see you for problems with thinking skills (cognition) or vision and hand and arm function.
Speech and Language Therapists – help with unclear speech or difficulty with thinking of words or forming sentences and also may help with reading and writing and eating and swallowing problems
Dietitians – help with maintaining a healthy weight and finding the best ways to be well nourished and have a well-balanced diet. They may also help with managing tube feeding.
Rehabilitation Support Workers – support the therapists and nurses to carry out personal care or therapy programmes, provide the majority of washing and dressing or meal preparation practise.
Life after Stroke Keyworkers – help with signposting to community support and activities, access to benefits, access to support from other stroke survivors and provide a review at six months after your stroke.

We often work together so you may sometimes see more than one of us at each visit.

What happens if I need help with my mood and wellbeing?

Feeling low in mood is common and we have a range of options to support you and your loved ones depending on your needs. You can ask any member of the team for support and we will regularly check how you are coping.

What happens if I need personal care?

If you need help with things like washing and dressing, using the toilet, meal preparation or taking medication then our support workers and therapists may see you to work specifically on this. We will review how you are progressing with these tasks regularly.

If you have a longer-term need for this support then we will work closely with you, yourfamily and social s ervices to make sure you have the care package that you need and how this will be funded.

Does therapy continue at the weekends?

The more you practise tasks the better, so you may be offered therapy or nursing sessions at the weekend. Assistance with personal care and meal preparation will be the same seven days a week.

If you would rather not have visits from us at the weekend or would prefer to do them on your own then just let us know.

How do I get in touch?

Call our administrator on 0300 1255951 who can help you or will put you in touch with the most relevant member of the team. If you find using the telephone difficult then we will find the best way for you to access information.

Privacy Notice:

We collect and process personal data in line with legislation for the purpose of healthcare. For further information visit our website ( and search ‘Privacy Policy’.

Useful links

Stroke Association
North Somerset Stroke Recovery Service
Verity Aldous:
07799 436024

My Stroke Guide

Bristol After Stroke
0117 964 7657

Different Strokes
0345 1307172

Messages from other stroke survivors

“Make sure you pace yourself and rest when you need to.”

“Keep thinking about the long term.”

“Everyone’s stroke is different”

“Don’t be afraid to ask questions. There’s no such thing as a silly question”