Community Stroke and Neuro Rehabilitation Team (CSNRT)

Service Information

Specialist rehabilitation for patients aged 16+ or over with acquired brain injury including stroke or neurological conditions.

Who can refer?

How to refer

You can be referred by your hospital, GP, health or social care professional. Due to service capacity and demands over busy periods you may have to wait to be seen by the specific therapists required for your personal rehabilitation.

Referrals via Trafford Single Point of Access (SPOA).

• Tel: 0300 323 0303
• Email: tspoa1@nhs.net
• Mail referrals via SPOA, Meadway Health Centre, Sale M33 4PS

General enquiries about referrals can be made to the team from professionals via 0161 912 4141.

Referral form

CSNRT Referral Form [Word doc, 32KB]

Inclusion/exclusion criteria for CSNRT 

Acceptance and exclusion criteria and thresholds 

Stroke Pathway 

Referrals will be accepted if: 

• The patient is over 18 years old, however, exceptions may be made for 16–17-year-olds whose needs have been identified as being best met with the skills of the ICSS 
• The patient has a primary diagnosis of stroke  
• They are medically stable with appropriate medical investigations completed 
• Rehabilitation goals are identifiable 
• The patient consents to intervention by the team 
• For patients discharged alone to a private address they must be able to maintain their own safety independently 
• The category of patient disability accepted: ESD patients and non-ESD patients. 

Re-referrals of people with a stroke are accepted if there are specific rehabilitation goals which require specialist community stroke rehabilitation. 

Patients cannot be discharged to the ICSS until necessary care, equipment and transportation are in place which should be organised by the discharging stroke unit. 

Exclusion criteria 

All referrals will be triaged, assessment or treatment may not be provided for the following reasons: 

• No rehabilitation goals or interventions identified by the family, patient or service 
• The patient cannot or does not wish to participate in rehabilitation 
• There has been no significant change since last discharged from the service 
• Management of patients with Functional Neurological Diagnosis 

If any patients are deemed not appropriate for intervention by the ICSS, the team will provide advice and support to sign post to the most appropriate service. 

Neuro Pathway 

Referrals will be accepted if the person: 

• Is over 18 years old, however, exceptions where the patient is 16 years or older and whose needs have been identified as being best met with the skills of the community neurological rehabilitation team 
• Has a diagnosed neurological condition, and requires neurological rehabilitation within the community 
• Can participate in rehabilitation and has identifiable goals that are best met by the community neurorehabilitation team 
• Is medically stable with appropriate medical investigations completed 
• Consents to intervention by the team 

Patients may have uni-disciplinary and multi-disciplinary neurorehabilitation needs.  

Patients who have uni-disciplinary needs for dietetics or clinical psychology will be referred to a uni-disciplinary service. 

Patients who have a clear neurological presentation, and neurorehabilitation needs who are awaiting a neurological diagnosis may be eligible for specialist neurological rehabilitation following a clinical review and discussion with other local community services to establish the most appropriate rehabilitation pathway to meet the patient needs. 

Individuals with cognitive or psychological difficulties (e.g. those with dementia or intellectual disabilities) are eligible if they have needs arising from concurrent neurological disabilities and are able to participate in rehabilitation. 

For patients discharged alone to a private address they must be able to maintain their own safety independently, or with an appropriate support package. 

Patients cannot be discharged to the community neurorehabilitation team until necessary care, equipment (e.g. wheelchair) and transportation are in place which should be organised by the inpatient team.  

There must be an appropriate space in the person’s home (or in a clinic) so that the rehabilitation can be delivered safely. 

If the patient with a neurological condition is at a palliative stage of life or on an end-of-life pathway, then palliative goals are to be discussed and managed with the palliative care services to ensure appropriate input is provided by the most appropriate team. 

Re-referrals of people with a neurological condition are accepted if there are specific rehabilitation goals. The team may advise on ‘maintenance’ interventions that have a preventive rationale and may assess care needs and provide advice and information in response to changing needs but does not itself provide ongoing ‘care’. 

Exclusion criteria 

All referrals will be screened /triaged; however, assessment or treatment may not be provided for the following reasons: 

• If the overriding requirement is for management of symptoms rather than disabilities (e.g. pain, headache, or seizures) without additional rehabilitation needs being identified or where symptoms mean rehabilitation is not possible.
• If the dominant impairment is reduced cognition or mood or behavioural disorder without other neurological impairments being present (e.g. primary dementia or intellectual disability).
• Patients or their families cannot identify rehabilitation goals.
• The patient cannot or does not wish to participate in rehabilitation.
• There has been no significant change since last discharged from the service.
• Management of patients with Functional Neurological Diagnosis
• The service will not provide assessment or treatment for respiratory impairments
  experienced by service users.

If any patients are deemed not appropriate for intervention by the community neurorehabilitation team, the team will provide advice and support to sign post to the most appropriate service. 

Information last reviewed: February 2025