The short answer
- Three therapies follow the stroke homePhysiotherapy, occupational therapy and speech and language therapy, through one community stroke team with a named contact.
- The therapists are not there for most of the weekNICE asks for at least three hours of therapy a day on at least five days a week. Everything around those sessions is home practice.
- A carer carries the plan and does not write itPractising the transfer the way the physiotherapist set it, prompting the exercises, serving meals at the texture the speech therapist advised.
- A block of therapy ending is not the end of rehabThere is a stroke review at six months and then every year, and somebody who has stopped improving can be referred back.
Carers on PrimeCarers charge £18 to £25 an hour with our fee included, against £28 to £35 at an agency. Therapy is a separate cost and we do not publish rates for it.
Who comes
The people who turn up at the house, and what each one is for
Rehabilitation after a stroke is run by the NHS, not by a care company. Knowing which professional decides what saves a lot of ringing round in the first month.
The community stroke team
Takes over from the ward
The physiotherapist
Movement and walking
The occupational therapist
Everyday activities
The speech and language therapist
Talking and swallowing
A stroke key worker or another named member of the team should be given to you as the contact. If nobody has told you who that is, ask, and put the name and number somewhere the whole family can find it. There should also be a social care assessment before the move home, which looks at care needs, benefits and housing. The first weeks home after a stroke covers the discharge itself.
Alongside therapy, a council may offer reablement, the free six weeks of short-term help aimed at getting somebody doing things for themselves again. Intermediate care and reablement have to be free for the first six weeks under the Care and Support (Preventing Needs for Care and Support) Regulations 2014, and community equipment and minor adaptations are free with no limit.
Where the gaps are
How much therapy is meant to happen, and what the rest of the week looks like
There is a national standard for how much rehabilitation somebody should be offered after a stroke. Set it against the size of a week and the problem becomes clear.
3 hours a day
NICE asks for needs-based rehabilitation of at least three hours a day, on at least five days of the week, covering physiotherapy, occupational therapy and speech and language therapy. Where somebody cannot manage three hours, the therapy they do need should still be offered five days a week.
NICE guideline NG236, stroke rehabilitation in adults, recommendations 1.2.16 and 1.2.17.
Three hours a day, five days a week, is fifteen hours. A week has 168 hours. Even where a service meets the standard in full, most of the week is not therapy, and after the first weeks the sessions come further apart. What fills the hours in between decides how much of the programme turns into recovery, because exercises only work if they are repeated. That is the part the family is left holding, on top of work, children and the shock of what has happened. Post-operative rehabilitation at home covers the same problem after surgery.
What a carer does
A carer carries the therapist's plan, and does not change it
The line between the two matters, and it is worth being clear about it before you book anybody. A carer is not a therapist. Physiotherapist, occupational therapist and speech and language therapist are protected titles held by the Health and Care Professions Council, and only somebody on that register may use them.
Physiotherapy
Standing up, transferring, balance and walking
What the therapist sets
The exercises and how many of each, how a transfer is done, how far to walk, and what the weaker arm and leg need through the day.
What a carer can carry through the week
The same transfer done the same way every time, walking alongside at the pace the physiotherapist set, the exercises on the days there is no therapy visit, and a note of how each one went.
Only the therapist
Assessing the movement, deciding an exercise has become too easy, adding a harder one, and fitting or changing a walking aid or a splint.
Occupational therapy
Washing, dressing, the kitchen, and the equipment at home
What the therapist sets
How dressing is done with one working hand, which aids to use, how the bathroom and kitchen are laid out, and how to pace a day around fatigue.
What a carer can carry through the week
Laying the clothes out the way the occupational therapist showed, standing by while the person dresses themselves, using the equipment as it was set up, and keeping the routine the same.
Only the therapist
Assessing the home, ordering or changing equipment, and deciding that a task can now be done alone.
Speech and language therapy
Talking, understanding, and swallowing safely
What the therapist sets
The communication practice, the words and pictures to work on, and the textures of food and drink that are safe to give.
What a carer can carry through the week
The practice done daily, time given for the person to find their own word rather than having it finished for them, and meals served at the texture set, sitting upright, watched from start to finish.
Only the therapist
Assessing speech and swallowing, changing the texture of food or drink, and deciding when the practice moves on.
The three therapies and what each covers follow NICE guideline NG236 on stroke rehabilitation in adults. The split on the right of each row is the general shape of a home rehabilitation plan rather than a rule about any one person. Your relative’s plan, and the therapist who wrote it, says what theirs is.
The pattern is the same in all three rows. The therapist assesses, decides and progresses, and a carer repeats, at the right time and in the way they were shown, on the days nobody from the NHS is coming. If an exercise has become too easy or too hard, that is a message to the therapist rather than a change made at home.
NICE asks speech and language therapists to coach the people around the person, including family members and carers, in supportive communication. Half an hour of a therapist showing a carer how to give your father time to find a word changes every conversation he has that week. Aphasia and communication after a stroke goes further into that.
Under the agreement between a client and a carer, the carer keeps professional discretion over how they work and agrees not to take on work they feel unqualified to do. A care plan you write is information rather than instruction, so have the practical conversation: here is the sheet the physiotherapist left, here is how the transfer is done, can you do this, and will you say so if you are not comfortable. Writing a care plan together and what carers are not allowed to do cover the rest.
If you want somebody to carry the therapist's plan through the rest of the week, you can search for carers near you and compare their rates and experience before speaking to anybody. Booking the same person for those slots matters more here than in most arrangements, because the value is in somebody who remembers how last Tuesday went. The same carer every visit explains why.
Helping without taking over
Care that supports recovery, and care that replaces it
The exercises and the everyday tasks are the treatment, so a carer who does everything removes the practice the programme depends on. Say this out loud when you book somebody. No carer minds being told what the therapist is working towards.
What keeps the recovery going
- Waiting while they do the part of the task they can do, however long it takes
- Setting out the clothes and aids the way the occupational therapist showed, then standing by
- Prompting the exercises at a set time each day, so it becomes a routine rather than a request
- Giving time for a word to be found, and letting the person finish their own sentence
- Writing down what was done and what was hard, for the therapist to read
What takes it over
- Dressing somebody because it is quicker than watching them dress themselves
- Doing the transfer a different way from the physiotherapist because it feels easier
- Filling in the end of every sentence, which removes the practice speech recovery needs
- Adding exercises, repetitions or distances that nobody has assessed
- Changing the texture of food or drink because the person asked
Fatigue after a stroke is not ordinary tiredness and it does not respond to encouragement. NICE asks teams to consider a standardised fatigue assessment early in rehabilitation and again at the six-month review. A carer who understands that an hour of effort can cost the afternoon will plan the day around it, and stop when it arrives rather than push through. Fatigue with MS behaves the same way, and building a day round MS fatigue covers the pacing and the jobs worth handing over.
Mood is checked at the six-month and annual reviews, and where something new or persisting is found the person should be referred on for assessment and treatment. A carer who sees somebody several times a week may be the first to notice a change, and should tell you and the GP. Mental health in later life covers what help exists, and transfers with one-sided weakness goes through the method itself.
When therapy stops
The block of therapy ends, and rehabilitation does not have to
A block of therapy can be wound up without much being said about what follows it. Something does follow it, and there are two doors back in.
- Leaving hospital
Therapy continues at home
Where early supported discharge is offered, NICE says therapy should continue at the same intensity and level of support as in hospital.
- The weeks after
Sessions come further apart
The team works to goals set early and reviewed as they go. Rehabilitation should continue for as long as it keeps helping the person reach those goals.
- The block ends
You are given a home programme
Ask three things before the last visit: what should be practised and how often, what would count as going backwards, and who to ring if it does.
- Six months
The stroke review
A structured health and social care review, covering the person and the needs of the people caring for them, including whether anyone needs more training. Fatigue and mood are checked.
- A year, then yearly
The reviews carry on
It happens again at a year and then annually. Communication problems still there at a review should go back to a speech and language therapist.
The reviews are one door back in. The other is self-referral: NICE tells services to explain that people can refer themselves back, usually with support from somebody in primary care such as a GP or a social prescriber, or from the named contact at the stroke service. Ring the named contact first, and the GP if there is none left.
Between those doors the practice still has to happen, and that is the argument for a carer through the middle months: the therapist decides, and the repetition is a job that can be booked. The Stroke Association supports stroke survivors and families and is worth a call for what runs near you (stroke.org.uk), and the NHS page on recovering from a stroke is the plain summary of what to expect.
Paying for more
Paying for a carer, and paying privately for therapy
These are two different costs and they are easy to run together. A carer is paid for hours at home. A private therapist is paid for an assessment and a programme, and there are far fewer of those hours.
| What you are buying | What it costs | Where to look | |
|---|---|---|---|
| A carer for the daily practice | Hours at home: personal care, meals, prompting the exercises, walking alongside, a lift to appointments. | £18 to £25 an hour on PrimeCarers with our fee included, and £18 an hour is common for a single visit of six hours or more. Agencies charge £28 to £35. | Search by postcode, read the profiles, interview the ones you like. |
| A private physiotherapist | Assessment, a programme, and reviews that change it as your relative improves. | Set by the therapist. We do not publish rates for private therapy. | The Chartered Society of Physiotherapy runs a directory for the public. |
| A private speech and language therapist | Assessment and treatment for speech, understanding or swallowing, and advice for people at home. | Set by the therapist. We do not publish rates for private therapy. | The Association of Speech and Language Therapists in Independent Practice lists independent therapists. |
A carer for the daily practice
- What you are buying
- Hours at home: personal care, meals, prompting the exercises, walking alongside, a lift to appointments.
- What it costs
- £18 to £25 an hour on PrimeCarers with our fee included, and £18 an hour is common for a single visit of six hours or more. Agencies charge £28 to £35.
- Where to look
- Search by postcode, read the profiles, interview the ones you like.
A private physiotherapist
- What you are buying
- Assessment, a programme, and reviews that change it as your relative improves.
- What it costs
- Set by the therapist. We do not publish rates for private therapy.
- Where to look
- The Chartered Society of Physiotherapy runs a directory for the public.
A private speech and language therapist
- What you are buying
- Assessment and treatment for speech, understanding or swallowing, and advice for people at home.
- What it costs
- Set by the therapist. We do not publish rates for private therapy.
- Where to look
- The Association of Speech and Language Therapists in Independent Practice lists independent therapists.
Check anyone you find is on the Health and Care Professions Council register before they start, and tell the NHS team about private therapy so the two programmes agree.
Those two are the Chartered Society of Physiotherapy and the Association of Speech and Language Therapists in Independent Practice, and registration is checked on the HCPC register. Paying for a private assessment and doing the work at home with a carer in between spreads a budget: the assessment is the expensive part, and the repetition is what needs somebody there.
Attendance Allowance is paid at two weekly rates depending on how much help somebody needs, is not means-tested, and is not affected by savings or a pension. A council can help after a needs assessment and a financial assessment, with savings of £23,250 or more in England meaning the cost falls to your relative, which local authority funding explains. Where needs are mainly health needs, NHS Continuing Healthcare can pay for the whole package, and what care costs where you live gives a local figure.
Questions
Questions families ask about rehab at home
That depends on the plan your relative is given, and it changes as they improve. NICE sets the standard at needs-based rehabilitation of at least three hours a day on at least five days a week, covering physiotherapy, occupational therapy and speech and language therapy together. Ask the community stroke team what your relative has been assessed as needing, and ask for it in writing.
A carer can do the exercises the physiotherapist has set, at the times they were set, in the way they were shown, and write down how each one went. A carer cannot assess the movement, decide an exercise has become too easy, add a new one, or change a walking aid. Anything that needs to change is a message to the therapist.
You should be left with a home programme, and rehabilitation is meant to continue for as long as it keeps helping your relative reach their goals. There is a structured stroke review at six months, again at a year, and then annually. NICE also tells services to explain that people can refer themselves back, usually with support from a GP, a social prescriber or the named contact at the stroke service.
We cannot tell you that. We check identity, right to work and an enhanced DBS on the Update Service, and we interview every carer online. We do not check qualifications, training or references. What a carer says about their stroke experience is their own account on their profile, for you to ask about and check with them. Carers are self-employed and insured while they work.
Yes. Check the person is on the Health and Care Professions Council register first, because physiotherapist and speech and language therapist are protected titles, and tell the NHS team what you have arranged so the two programmes do not pull against each other. We do not publish rates for private therapy, so ask the therapist what it costs.
It depends on the programme and on what else your relative needs help with. A daily visit covering washing and dressing, breakfast and the exercise sheet is about an hour, which is seven hours a week, or £126 to £175 at PrimeCarers rates. What fits in one hour, two hours, half a day.