Community Neuro Rehabilitation

The Hounslow CNRT team consists of specialist therapists and nurses:

• Clinical Service Manager
• Advanced Clinical Practitioner in Neuro Rehabilitation
• Allied Health Practitioner
• Physiotherapists
• Occupational therapists
• Rehabilitation assistants                      
• Speech and Language Therapy (SLT)
• Psychology
• Pharmacy
• Neurology Nurses (Multiple Sclerosis and Parkinson’s)

We work closely with other services including specialist neurology services, GPs, District Nursing, Continence Nurse Specialist, Podiatry, Dietetics and the Hounslow Community Services.

About our care in CNRT

We specialise in:

• Personalised care and support tailored to patient’s needs to help them regain their daily living skills
• Building independence through practicing everyday tasks such as self-care and meal preparation
• Providing support, education and advice to patients and their family/carers on their neurological condition
• Indoor or outdoor walking practice
• Support with difficulties in thinking and learning that may be experienced as a result of neurological condition
• Providing appropriate equipment and keeping patients informed about using it safely
• Providing advice on managing fatigue
• Support for any mood or emotional difficulties that may be experienced as a result of a neurological diagnosis
• Medication reviews
• Advice about returning to employment or voluntary work

Core Neurorehabilitation

For Individuals with acquired or long term neurological condition. 

Long term management

For individuals with long term neurological conditions.

Neuro Timely Service

This is a community neurorehabilitation service for people who have an acquired or long-term neurological condition and facilitates early discharge to home from hospital.

The team consists of a range of specialists who will provide rehabilitation for when people return home, like rehabilitation that they may have had when in hospital.

Our aim is to help people return to their usual activities and take care of themselves as well as possible. The team provides comprehensive neurological rehabilitation programmes for up to four weeks. If a patient has met their agreed goals before this time, they may be discharged. 

Parkinson Neurology Clinics

This is the community Parkinson Clinics for individuals who are diagnosed with Parkinson. Individuals will be reviewed in our clinics by a Neurology Nurse and Allied Health Practitioner. 

What we offer

• Education about clinical condition and self-management  
• Medication advice and monitoring drug treatments, including titration and modification of drug therapy as required.
• Medication review as required
• Lifestyle advice
• Telephone advice line
• Referral to other disciplines/health professionals and working within a MDT
• Education to health and social care professionals working with people with Parkinson’s
• Holistic reviews by Neurology Specialists (six to nine months after your appointment with Neurology Consultant)   
• Social activities and groups to support patients with Parkinson’s.

Multiple Sclerosis Neurology Clinics

The community Multiple Sclerosis clinics are for individuals who are diagnosed with Multiple Sclerosis (MS). Individuals will be reviewed in our clinics by a Neurology Nurse and Allied Health Practitioner.

What we offer

• Education about Clinical condition and self-management  
• Medication advice and monitoring drug treatments, including titration and modification of drug therapy as required.
• Lifestyle advice
• Telephone advice line
• Referral to other disciplines/health professionals and working within a MDT
• Education to health and social care professionals working with people with Multiple Sclerosis
• Annual Holistic reviews by Neurology Specialists 
• Social activities and groups to support patients with Multiple Sclerosis.

Discharge Criteria

Neuro rehab Pathway

CNRT provides specific, goal focused neurological rehabilitation programmes for up to 12 weeks.

Patients can be discharged before 12 weeks if 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 do not to attend appointments without first contacting their treating therapist.

Once therapy has been completed, we provide rehabilitation advice to help patients to maintain and continue progress. If needed, we may refer them to other services.

• Parkinson – Multiple Sclerosis neurology Clinics:

Individuals will be discharged after assessment.

Individuals will remain under monitoring waiting list. Service will contact individuals for their  next appointment.

HCNRT Acceptance criteria

• Adults (18 years and over) with a confirmed diagnosis of acquired or long-term neurological condition
• Adults who are Hounslow Residence and are registered with a Hounslow GP,
• Adults who are register with Hounslow GP and are living within one mile radius outside of Hounslow borough.
• Adults with confirmed diagnosis of Central nervous system lesion/diseases, such as
• Stroke
• Traumatic Brain injury
• Acquired Brain injury
• Parkinson’s Disease (PD) / Progressive Supranuclear Palsy (PSP) / Multi Systems Atrophy (MSA)
• Multiple Sclerosis (MS)
• Motor Neurone Disease (MND)
• Guillian Barre Syndrome (GBS)
• Polyneuropathies e.g. chronic inflammatory demyelinating polyneuropathy
• Brain Tumour
• Spinal cord Injury (SCI)
• Huntington’s Disease
• Cerebellar Ataxia
• Hereditary peripheral neuropathy e.g. Charcot Marie Tooth
• Functional Neurological disabilities
• Muscle dystrophy
• The main problem or identified need must relate to their neurological diagnosis.
• Clear rehabilitation goals/Clinical needs to be identified 
• The main problem identified must relate to their neurological diagnosis. 

HCNRT Exclusion Criteria:

• People whose primary diagnosis is:
  • Learning difficulties
  • Mental health problems
  • Substance misuse
  • Dementia
  • Traumatic injury or a new medical condition unrelated to their neurological condition e.g. fracture or pneumonia
  • Multiple active unresolved medical needs taking priority over their underlying neurological condition
  • Peripheral neuropathy
  • Single nerve palsy related to trauma
  • Nerve root involvement related to disc protrusion
  • Muscular dystrophy
• Individuals who do not have a Hounslow GP registration.
• Individuals who live more than one mile outside the London Borough of Hounslow.
• Individuals without confirmed neurological diagnosis or those not under the care of a consultant neurologist.
• Individuals that their identified need is not related with their neurological diagnosis

NOTE: This service is not an urgent care service. For any urgent care inquires, please liaise with your GP or emergency Services 111/999. 

Hounslow Neurology outpatient clinics for patients with Multiple Sclerosis

Our Multiple Sclerosis (MS) Community Healthcare clinics are for patients with MS. We provide assessment and advice to increase independence and quality of life for adults with Multiple Sclerosis (MS). 

Our Service provides

• Holistic assessment & Physical examination in our clinic or home visits (as appropriate)
• Information and support for patients, families, and carers -specific individual advice and information
• Support of Symptom control
• Complete a holistic assessment by members of the specialist team 
• Complete a physical assessment to determine how your weakness /stiffness affect you 
• Give an opportunity to voice concerns related to your condition 
• Identify how your condition affects your lifestyle and daily life activities
• Work together to identify realistic goals for intervention and future management 
• Work together to identify factors which could influence your condition in the future 
• Giving condition specific education 
• Following assessment in clinic the team may make onward referrals to local services, to other specialist regional services, provide advice to your G.P, complete further assessments, and work within Multi-Disciplinary Teams (MDT) to achieve holistic care.
• Education about Clinical condition and self-management  
• Medication advice and monitoring drug treatments including urgent steroid treatment for Replasing remitting MS.
• Medication review and prescribing as required
• Lifestyle advice
• Telephone advice line
• Referral to other disciplines/health professionals.
• Education to health and social care professionals working with people with Multiple Sclerosis
• Holistic annual reviews by Community Neurology Specialists
• Benefits and grant information

The Neurology Specialist Practitioners can provide

• Information and support for patients who have recently been diagnosed with MS or
• Information about treatments and medicines used.
• Teaching for other health and social care staff to help them understand MS.
• On-going support for people affected by MS, including their family and carers.
• Specialist assessment and advice on the management of MS.
• Links to other services that can support you in managing your MS.
• Input into service developments for people affected by MS. 

Meet Our Team

Specialist healthcare practitioners (Neurology Nurses, Pharmacist, Neurology Practitioner) are offering a holistic assessment to patients.

• Dr Sofia Nousi: Clinical Service Manager 
• Anju John, Allied Health Practitioner
• Chandni Bhardwa: Neurology Nurse Specialist
• Elsie Maphosa: Neurology Nurse
• Janet Taylor: Pharmacist

Contact Information

Hounslow Multiple Sclerosis Neurology Team

Telephone

0207 461 7266,

0207 461 7267 (admin)

Email: wlt.hounslowcommunityneurorehab@nhs.net

Address:

Heart of Hounslow Health Centre

Hounslow Neurorehabilitation team

92 Bath Road, Hounslow,

TW3 3EL

Referrals

The service is available for patients who:

• Are registered with GP in Hounslow and lives in Hounslow
• Have a confirmed diagnosis of Multiple Sclerosis

Important note: This is not an urgent care service. For any urgent care inquires please contact your GP or emergency Services 111/999. 

The first referral should be made by a healthcare professional through the Hounslow SPA. 

Email address:  wtl.hounslowadultspa@nhs.net

Working hours

Tuesday to Thursday 8.30 am to 4.30pm.

Hounslow Neurology Outpatient Clinics for patients with Parkinson Disease (PD)

Our clinics aim to improve Community Healthcare for patients with Parkinson's Disease. 

Our Service offers:

• Holistic assessment & physical examination in our clinic, virtually or home visits (as appropriate).
• Information and support for patients, families, and carers working along side the Parkinson’s UK society.
• Support of symptom control and self management of managing the long-term condition.
• Recognising worsening symptoms and identifying when you need earlier intervention.
• Assisting to improving symptom control in early Parkinson's Disease and provide information for the long-term management of the disease.
• Education about clinical condition and self management  
• Medication advice and monitoring drug treatments, including titration and modification of drug therapy as required.
• Medication review and prescribing as required
• Lifestyle advice
• Telephone advice line
• Referral to other disciplines/health professionals and working within a MDT
• Education to health and social care professionals working with people with Parkinson’s
• Holistic reviews by Neurology Specialists (six to nine months after your appointment with Neurology Consultant)   
• Benefits and grant information.
• Social activities and groups to support patients with Parkinson’s. 

The Neurology Specialist Practitioners can provide

• Information and support for patients who have recently been diagnosed with Parkinson’s or
• Information about treatments and medicines used.
• Teaching for other health and social care staff to help them understand Parkinson’s.
• On going support for people affected by Parkinson's, including their family and carers.
• Specialist assessment and advice on the management of Parkinson’s.
• Links to other services that can support you in managing your Parkinson’s.
• Input into service developments for people affected by Parkinson’s.

Meet Our Team

• Dr Sofia Nousi: Clinical Service Manager/ Advanced Clinical Practitioner
• Anju John: Neurology Specialist Practitioner
• Chandni Bhardwa: Neurology Nurse Specialist
• Elsie Maphosa: Neurology Nurse
• Janet Taylor: Pharmacist

Specialist healthcare practitioners (Neurology Nurses, Pharmacist, Neurology Practitioner) are offering a holistic assessment to patients.

Important note: This is not an urgent care service. For any urgent care inquires, please contact your GP or emergency Services 111/999. 

Contact Information

Telephone

0207 461 7266

0207 461 7267 (admin)

Email: wlt.hounslowcommunityneurorehab@nhs.net

Address

Heart of Hounslow Health Centre

Hounslow Neuro Rehabilitation Team

92 Bath Road, Hounslow,

TW3 3EL

Referrals

The service is available for patients who:

Hounslow residents (or those who live within a 1 mile radius outside of London borough of Hounslow) and are registered with GP in Hounslow. 

• Are Hounslow resident and are register with Ealing GP Practices below

• The Medical Centre, Cecil Road, Hounslow – Dr Mangat (**there is an increase in list size which the provider will monitor referrals against previous volumes)
• The Medical Centre, 23 Beaconsfield Road, Southall
• Berkeley Avenue Surgery, Cranford, Hounslow – Dr Sandhu
• Hammond Road Surgery, 95 Hammond Road, Southall
• The MWH Practice, Vincent Road, Hounslow – Dr Htoo
• The MWH Practice, The Broadway HC, Southall
• The Practice Chiswick 89 Southfield Road Chiswick – Dr Webber
• The Bedford Road Surgery 55 South Parade Chiswick W4 5LH
• Have a confirmed diagnosis of Parkinson’s
• Are already known to the service so self-referrals are accepted.
• Are experiencing problems associated with Parkinson’s

How to refer patients

The first referral should be made by a health professional  (Neurology Consultant, Nurse, GP, therapists or other Allied Health Professional ) through Hounslow  SPA.

Email: wtl.hounslowadultspa@nhs.net

Working hours

Tuesday to Thursday  from  8:30 am to 4:30 pm.

Referrals to the community neuro rehabilitation team should be made via  Hounslow Single Point of Access (SPA) using the SPA single referral form.

Email: wlt.hounslowadultspa@nhs.net

Referrals from hospital settings should be completed via the WMUH Discharge Hub.

Referrals for Neurotimely

Referral from hospitals only. Telephone triage to be completed when patient is medical fit for discharge  

Phone referral to 07947 944 179.

Hospital therapy team to call HCNRT Timely so Hounslow CNRT Clinician will complete initial triage. Hounslow Neuro Timely Service  is NOT a commissioned ESD service. 

Neuro Timely Service does not hold slots, acceptances are on a first come first served basis. It is the referrers responsibility to plan if there are no new patient slots available and consider referring for Neuro Core input if timely does not have capacity.

It is the referrers responsibility to call Neuro Timely to complete a telephone triage when the patient is identified as MFFD, with a confirmed EDD and PoC if identified.

If the referral is accepted, the referrer is to forward the NBA/Discharge summary to SPA wlt.hounslowadultspa@nhs.net and call Neuro Timely to advise of patients’ discharge or of any changes to their discharge as soon possible.

If no communication is received within 48 hours of telephone triage, the referral will be discharged, and a new telephone triage will need to be completed, and an updated NBA/Discharge summary will need to be sent.

Please note if a patient is referred for a Neuro Core Pathway, they will be seen if capacity allows. Hounslow Neuro Rehabilitation team is not an urgent service.