This report sets the context and describes the growth of concern about the treatment of residents at Stoke Place Mansion House and Stoke Green House, two establishments run by Longcare Ltd. The report then gives details of the investigation carried out by the Social Services Department Inspection Unit and the conclusions which have been drawn from this extensive exercise.
The investigation centred on two registered homes for adults with a learning disability in the Stoke Poges area: both are operated by a company, Longcare Ltd. The Managing Director was Gordon Rowe until last year when his son, Nigel Rowe, assumed this role. The other Director is Angela Rowe, who is Gordon Rowe's wife. A number of staff at the homes are also family members and the registered manager is Ray Cradock who is married to Gordon Rowe's first wife.
Although not registered as the manager until May 1993, he was in full-time employment with the Company from September 1992; prior to this, he was employed as a consultant by Longcare.
One home is called Stoke Place Mansion House and is a large country house with extensive grounds, leased from South Bucks District Council; another part of the building is used as a Country Club and Conference Centre by a seperate enterprise. The home was initially registered under the name of Gordon Rowe in November 1983, to accommodate up to 38 adults with a learning disability.
The other home is known as Stoke Green House and is registered to accommodate up to 28 adults with a learning disability. It was first registered in April 1987, and is a large house with substantial grounds.
The majority of residents are sponsored by London Boroughs and the counties surrounding London. The oldest resident is in his 70's and the youngest are in their early twenties. Some residents have an additional disability such as blindness, but the impression is that many are fairly capable.
HISTORY OF CONCERNS
There is reference in the file to the fact that at the time of the initial application for registration of Stoke Place Mansion House in 1983, Gordon Rowe shared with this Department that serious allegations had been made about him by the owner of the home where he had previously worked.
Information in the file is limited but does indicate that this was followed up by the Department's registration officer at the time whocontacted Somerset Police. They had found no evidence of misconduct.
In April 1991, a serious complaint was passed to this Department by another authority about the treatment of one of their clients by Gordon Rowe. She alleged that on New Year's Day, she had been physically dragged out of the house by her arm, hair and clothes and thrown to cold and wet ground. Gordon Rowe stood over her for more than an hour and would not let her get up. This allegation was subsequently thoroughly investigated by an officer of this Department, Anthony Barker, and he subsequently advised Gordon Rowe that he found it difficult to understand why there had been so much physical violence in dealing with a resident who appeared to be so much physically inferior in both weight and strength.
Between December 1992 and February 1993, a total of six telephone calls were made to the Inspection Unit by three different individuals, expressing concern about the treatment of residents in general and making specific allegations in respect of named residents. Two of these callers presented as very frightened people who wanted to remain anonymous for fear.
These calls were followed in April 1993, with a written complaint made initially to the Berkshire Inspection Unit by an ex-member of staff. The allegations made included physical assault by Gordon Rowe, a resident forced to eat meals outside and residents confined to bed for prolonged periods. In July 1993, another ex-member of staff contacted this Department to share concerns.
The Police were immediately involved and a meeting was held the following day with representatives from both Social Services and Police to agree a way forward. Interviews were conducted by the Police and involving a member of the Inspection Unit. A third person, at the time a current employee of Longcare, also contacted the Police and made a statement which included a suspicion of buggery. The Police investigation concluded that there was insufficient evidence for them to pursue an investigation further.
INVESTIGATION BY THE
In November 1993, the Inspection Unit embarked on an extensive information gathering exercise. The unit was advised that both Gordon and Angela Rowe had voluntarily suspended themselves in November 1993 on being advised of the allegations, as understood by Mr Cradock.
A total of 70 initial interviews were conducted. A deliberate decision was made not to interview residents. . . because it was felt that if the regime was as described, then residents would not feel able to talk because of the fear of recriminations and further suffering. (There was a) perception of Gordon Rowe as a very powerful figure who had many influential connections, including some in the Police force, and who did not hesitate to use physical force.
All three Directors and Mr Cradock were interviewed. . . apart from making reference to some situations which they felt could have been misinterpreted, all of the substantive allegations were denied.
Some of those spoken to were literally terrified of the consequences if they were to share concerns. At least one of those who made a statement subsequently received an anonymous threatening 'phone call. Several witnesses explained that entries in report books were censored. Some report books did have pages removed and in some cases entries had been altered after the application of thick Tippex. The individual files kept in respect of residents were almost all in new files. The vast majority of the contents in each file related to DSS correspondence with little or no material relating to the welfare needs of residents during their time at Longcare. There were a number of instances when serious incidents were recorded in the day report book but no details included in the individual's file.
In the statements obtained, over 40 instances of physical assault by Gordon Rowe have been described by 13 different individuals. One striking feature about these is the consistency of the description of Gordon Rowe's aggressive behaviour. The assaults described vary in severity from a kick or blows to the head to severe physical assault. Several individuals also refer to Gordon Rowe's habit of forcibly moving residents around by their hair; while another described what would happen to one resident, MS, if he was out of his room without Gordon Rowe's permission: he would be 'physically bounced/dragged/pushed/kicked back to his room (by Gordon Rowe) which could be some distance away' (written statement from witness T).
The majority of the allegations of physical abuse involved Gordon Rowe but the statements also include allegations of physical abuse of residents by five other members of staff, three of whom are still employed at the home. In addition, one witness has also described Angela Rowe being physically violent towards a female resident. Angela Rowe is also described as being verbally abusive.
The consistency in the descriptions of the assaults cannot be overlooked and it is the view of the investigating officers that the witnesses are, in the main, credible.
Our understanding of what has been shared with us is that there was a culture in which physical assaults were seen as acceptable practice. Three witnesses spoke of having witnessed Gordon Rowe physically assault a resident and then advised that this was how to keep residents under control.
Apart from a few allegations in respect of Angela Rowe. . . allegations about sexual abuse revolve around Gordon Rowe. Many people refer to the fact that there were a group of female residents (about eight in number) who were Gordon Rowe's 'favourites'. There have been many references to the fact that he has been seen kissing them. The information from staff indicates that five different female residents spoke to them at different times and on different occasions and related things which Gordon Rowe had done to them sexually.
It was disturbing to read a number of entries which indicated that some residents were described as 'abusers'. One entry indicated that a particular resident (BM) had abused 8-10 residents in the previous few days.
Notes in another individual's file (TR's) indicated that he had buggered at least two residents - but again there was no indication of any involvement of any outside agency (either the Police or relevant social worker). There were, however, references in the report books to several male residents who consistently had bleeding from the anus, and one female resident who had bruising around the anus.
There is deep concern that a culture may have existed in which abuse was seen as a minor infringement by the perpetrator and insignificant in the life of the victim.
The extensive investigation which has been carried out has resulted in a considerable body of information which indicates that for many years the homes operated a totally unacceptable regime which meant that a substantial group of vulnerable people were at times denied some of their most basic human rights, as shown in the following paragraphs.
It isdifficult to distill the information given and still convey the enormity and scale of humilation, deprivation, torment and punishment to which residents were subjected. PK is a gentleman who is blind, as well as having a learning disability. Descriptions of assaults on him include 'Gordon lying in wait and pouncing', and being deliberately dragged downstairs by the hair or ear and being deliberately pushed into furniture. He was often made to sit in a designated chair for days on end (one witness referred to two months) and belted around the head by Gordon Rowe whenever he went past. Being blind, he must have been in constant fear. Another person described how PK would be punched by Gordon Rowe as an 'example' to other residents. Yet another person described the physical injuries sustained by this blind gentleman when having been buggered by another resident.
JG is described as a very affectionate lady with Downs Syndrome who was mentioned by virtually everyone. It would appear that some problems developed with JG's eating (one person told us it was because she was moved from Stoke Green House to Stoke Place Mansion House and she was unhappy about this move). Allegations in respect of the way this was handled include JG being held upright by the hair and force fed by both Gordon and Angela Rowe; JG being dragged/kicked/ pushed out of the dining room for being too slow at eating; JG being forbidden to eat in the dining room and having to eat out of doors, including in winter wearing only indoor clothes. The situation reached the stage when JG would herself take her meal outside to eat and refuse to eat in the dining room (presumably her logic was that she would end up outside anyway and this way she avoided a beating).
Two residents, DHS and BM, were described as being used as servants by Gordon and Angela Rowe. DHS and BM apparently cleaned the house, looked after the Rowe's son and cooked meals. Another group of residents - known as 'the working lads' - formed a work gang which was used to work on building work on Gordon Rowe's new house in Windsor and elsewhere.
As mentioned previously, there are extensive grounds associated with both houses. Numerous individuals raised concerns about the way in which the gardens were used as an 'activity'. Many referred to the inadequate clothing worn by residents who were expected to garden in atrocious weather conditions when 'no sensible person would garden'. The tasks given to residents were often meaningless and repetitive. MB & MS would be forced to go and work in the garden until their 'behaviour was better', despite pleas for a change of occupation. Many also described how MB was forced to garden in the cold, wearing shorts with open, weeping sores on his legs (self-inflicted).
Again, many spoke of the inadequacies of the clothing available to residents. 'Decent' clothes were kept in a locked room and residents were only allowed to wear them when they had contact with the outside world, for example the outing to Butlins. Staff were frequently having to dress residents in other people's clothing, including underwear.
There were times when there was no toilet paper available: witnesses T and H both described how PC would use his flannel when there was no paper available and T witnessed Gordon Rowe rub PC's face 6 the soiled flannel as punishment. Witness M has described being unable to get any toilet paper for residents even during the period of the investigation.
A common punishment was to send residents to bed - witness R refers to residents TE and L being locked in rooms for days. Other witnesses mention MS as spending a lot of time in his room as a punishment while TE told witness N she had been sent to bed for 2 days for not drying the dishes.
Deprivation of personal possessions was another way in which residents were punished - according to a report book, JR had his drawing pencils and pencil sharpener removed because 'he caused many problems this afternoon' (275.90) and when he asked for them back twice the following day, he was sent to his room. Witness H described seeing GG tied to a tree as a punishment.
Concerns about the way in which residents' money was managed on their behalf was raised by a large number of individuals. Allegations included the fact that residents were charged for a full portion of fish & chips each week but most only got half a portion of sausage & chips. Residents' money was used to buy admission tickets to Mirage (a night club) for staff and family friends. All residents were charged pounds 1 each for the hire of a video in an evening; the videos provided were loaned from Gordon Rowe's own collection. Residents were also charged for trips out they did not make.
All aspects of residents' lives were controlled for them - what they wore, what they ate, when they washed, how they spent their days and evenings, what chair they sat in, and even what time they were allowed to go to the toilet.
A number of individuals raised concerns about the standard of health care. These concerns ranged from the continual ignoring of symptoms which subsequently turned out to be serious to the fact that residents who were observed to be ill were not allowed to remain in bed during the day but had instead to go to the classroom/workshop. The standard response to a resident saying he/she felt ill or had a pain was to describe that individual as 'playing up' or 'putting it on'. Physical symptoms were often recorded several times before any action was taken - for example, PC's visit to the doctor on 24.1.92 was after severe anal bleeding being recorded for days. Nor was there any follow up to the doctor's visit, merely an entry saying 'to doctor this morning for rectal examination. Screamed the place down and examination had to be aborted. Will examine here'. Neither was there any record in the individual's file about this. Another element of the entries in the report books which caused concern was the number of times that residents who had epilepsy were referred to as 'pretending to fit' and told off.
The descriptions of the disturbance shown by individuals was horrific - one lady banged holes in the plaster work in her bedroom with her head, whilst the response of staff was frequently both crass and insensitive in the extreme.
There are also a number of allegations made against Lorraine Field, the Care Supervisor. These make reference to her ineptitude, her unpleasant attitude and mistreatment of residents. Witnesses have stated that Lorraine has hit or manhandled residents roughly on 3 occasions. For example, she was observed hitting one resident (JW) around the head and forcibly undressing and manhandling another resident (S) into the bath. Another resident (FK) confided to a witness that he was scared about upsetting Lorraine and making her angry; he wept, recalling one incident when she had hit him. Witnesses have also described 5 situations where Lorraine showed lack of care towards residents. For example two witnesses described situations in which they brought to Lorraine's attention residents (ST and PM) who were not well in each case they were sent to the workshop or classroom. Both residents worsened during the day and one was eventually admitted to hospital in the night with a thrombosis. Lorraine is also alleged to have sent a resident (MS) to bed as a punishment and to have chased another (JL) into the garden, throwing his slippers after him. In addition, Lorraine was also described as domineering, intimidating and as being too quick tempered and over-reacting to minor disturbances. It was stated that she harassed staff in the same way as she did residents.
To summarise, the conclusions from this investigation are that for many years Longcare Ltd not only failed to adequately safeguard the welfare of a number of vulnerable and handicapped adults but allowed them to be continually subjected to a catalogue of abuse, deprivation, humiliation and torment. The majority of the allegations of specific assault and abuse refer to Gordon Rowe while his wife Angela Rowe is referred to in a few instances. Angela Rowe was responsible for aspects of the management of the home such as the provision of residents' clothing, toiletries and household supplies.
It will be apparent from the above that Gordon Rowe has, assisted by his wife, run the homes in a manner which shows in the clearest possible terms that neither are fit and proper persons for such a task. As has been indicated earlier in this Report, both have been removed from day to day care of the residents and they have in fact moved home so no longer live, as formerly, in a cottage in the grounds of the homes. At the moment the Inspectors do not consider that sufficient effort has been made to ensure that Gordon and Angela Rowe remain disassociated from the homes if indeed they are to remain as Registered homes.
Head of Inspection
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