Mid Notts Stepped approach to an Integrated Community Stroke Service

Mid Notts Stepped approach to an Integrated Community Stroke Service featured image

I would like to put my team forward for a Fab award due to the continued hard work and dedication that they show as we continue to develop from an Early Supported Discharge Team to an Integrated Community Stroke Service (ICSS).

We have been very lucky to receive external funding which has allowed us to work on the expansion of the team, something that we recognise that our area has needed for a considerable amount of time. We recognise the gaps in community stroke services that the area has and we are working tirelessly to try to improve this and ultimately improve patient care.

We have worked successfully as an Early Supported Discharge Team since 2009 and I have been lucky that I have been with the team since its development. We are now expanding to an ICSS in order to allow us to help a greater number of stroke survivors. The criteria has been amended and the staffing structure looked at and increased in order to cope with these changes.

From initial project planning, to a huge recruitment drive, the team have pulled together to embrace all of these changes in a positive way. There have been frequent times where our processes have needed to be adapted and the team have coped with this professionally and calmly. A lot of our processes/systems such as IT systems for patient’s notes have had to be adapted/changed and at times changed multiple times. The team have coped well and supported each other through this, as they continue to do so.

The project has led to increased patient numbers, a growing waiting list and a large training need for new staff. Again this is something that the staff are working hard to improve on. The team continue to receive excellent patient feedback.


The team have commenced 6 month reviews, something which the National Stroke Guidelines recognise should be offered to all patients, again this is something that the team continue to tailor to ensure that it meets the needs of our patients and provides something meaningful for them.

We hope that we can continue to grow and develop and ultimately provide care for a greater number of patients.

You can read and download this comprehensive project report HERE

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  • Acute > Medicine > Rehab and elderly Medicine
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